Joong Hiong Sim

Students’ performance in the different clinical skills assessed in OSCE: what does it reveal?

Introduction The purpose of this study was to compare students’ performance in the different clinical skills (CSs) assessed in the objective structured clinical examination. Methods Data for this study were obtained from final year medical students’ exit examination (n=185). Retrospective analysis of data was conducted using SPSS. Means for the six CSs assessed across the 16 stations were computed and compared. Results Means for history taking, physical examination, communication skills, clinical reasoning skills (CRSs), procedural skills (PSs), and professionalism were 6.25±1.29, 6.39±1.36, 6.34±0.98, 5.86±0.99, 6.59±1.08, and 6.28±1.02, respectively. Repeated measures ANOVA showed there was a significant difference in the means of the six CSs assessed [F(2.980, 548.332)=20.253, p<0.001]. Pairwise multiple comparisons revealed significant differences between the means of the eight pairs of CSs assessed, at p<0.05. Conclusions CRSs appeared to be the weakest while PSs were the strongest, among the six CSs assessed. Students’ unsatisfactory performance in CRS needs to be addressed as CRS is one of the core competencies in medical education and a critical skill to be acquired by medical students before entering the workplace. Despite its challenges, students must learn the skills of clinical reasoning, while clinical teachers should facilitate the clinical reasoning process and guide students’ clinical reasoning development.

Thinking about thinking: changes in first-year medical students’ metacognition and its relation to performance

Background Studies have shown the importance of metacognition in medical education. Metacognitive skills consist of two dimensions: knowledge of metacognition and regulation of metacognition. Aim This study hypothesizes that the knowledge and regulation of metacognition is significantly different at the beginning and end of the academic year, and a correlation exists between the two dimensions of metacognitive skills with academic performance. Methods The Metacognitive Skills Inventory comprising 52 Likert-scale items was administered to 159 first-year medical students at the University of Malaya. Students’ year-end results were used to measure their academic performance. Results A paired sample t-test indicated no significant difference for knowledge of metacognition at the beginning and end of the academic year. A paired sample t-test revealed significant difference for regulation of metacognition at the beginning and end of the academic year. A very strong correlation was found between the two dimensions of metacognition. The correlation between knowledge and regulation of metacognition with students’ academic result was moderate. Conclusions The improvement in students’ metacognitive regulation and the moderate correlation between knowledge and regulation of metacognition with academic performance at the end of the academic year indicate the probable positive influence of the teaching and learning activities in the medical program.

Representational Competence in Chemistry: A comparison between students with different levels of understanding of basic chemical concepts and chemical representations

Abstract Representational competence is defined as “skills in interpreting and using representations”. This study attempted to compare students’ of high, medium, and low levels of understanding of (1) basic chemical concepts, and (2) chemical representations, in their representational competence. A total of 411 Form 4 science students (mean age = 16 years) from seven urban secondary schools in Malaysia participated in this study. Data were collected from three instruments namely the test of chemical concepts, the test of chemical representations, and the test of representational competence. The Statistical Package for the Social Sciences was used to analyze the data. Findings showed students with a high level of understanding of (1) chemical concepts and (2) chemical representations had significantly higher overall level of representational competence compared to both the medium and the low groups, at p < 0.001. However, students with medium and low levels of understanding of (1) chemical concepts and (2) chemical representations showed no significant difference in their overall levels of representational competence. Findings also showed that students’ overall level of representational competence had a higher dependence on their level of understanding of chemical concepts than their level of understanding of chemical representations.

Development of an instrument to measure medical students’ perceptions of the assessment environment: initial validation

Introduction Assessment environment, synonymous with climate or atmosphere, is multifaceted. Although there are valid and reliable instruments for measuring the educational environment, there is no validated instrument for measuring the assessment environment in medical programs. This study aimed to develop an instrument for measuring students’ perceptions of the assessment environment in an undergraduate medical program and to examine the psychometric properties of the new instrument. Method The Assessment Environment Questionnaire (AEQ), a 40-item, four-point (1=Strongly Disagree to 4=Strongly Agree) Likert scale instrument designed by the authors, was administered to medical undergraduates from the authors’ institution. The response rate was 626/794 (78.84%). To establish construct validity, exploratory factor analysis (EFA) with principal component analysis and varimax rotation was conducted. To examine the internal consistency reliability of the instrument, Cronbachs α was computed. Mean scores for the entire AEQ and for each factor/subscale were calculated. Mean AEQ scores of students from different academic years and sex were examined. Results Six hundred and eleven completed questionnaires were analysed. EFA extracted four factors: feedback mechanism (seven items), learning and performance (five items), information on assessment (five items), and assessment system/procedure (three items), which together explained 56.72% of the variance. Based on the four extracted factors/subscales, the AEQ was reduced to 20 items. Cronbachs α for the 20-item AEQ was 0.89, whereas Cronbachs α for the four factors/subscales ranged from 0.71 to 0.87. Mean score for the AEQ was 2.68/4.00. The factor/subscale of ‘feedback mechanism’ recorded the lowest mean (2.39/4.00), whereas the factor/subscale of ‘assessment system/procedure’ scored the highest mean (2.92/4.00). Significant differences were found among the AEQ scores of students from different academic years. Conclusions The AEQ is a valid and reliable instrument. Initial validation supports its use to measure students’ perceptions of the assessment environment in an undergraduate medical program.

Humanising medicine: taking our first step

What problems were addressed? Whereas medicine is a science, the practice of medicine is an art. Over the years, medical practice becomes increasingly dehumanised. Medical schools assess their students mainly on medical knowledge and clinical skills, and neglect the humanist aspects of medicine. This approach will not facilitate the development of clinicians who can express themselves clearly, and who listen attentively to their patients, show empathy and possess good bedside manners. Although humanist qualities are powerful healing tools that can help in the cultivation of strong patient–doctor relationships, there is, sadly, an absence of humanism in the culture of modern medicine. Changes in medical training are required. What was tried? Our medical school provides an early introduction to the humanities in medicine with the aim of educating students in humanism and the art of medicine. In our revised medical curriculum, the ‘Language in Medicine’ component is introduced at the commencement of Year 1. Four themes are highlighted in this component: Icons in medicine; Good science, bad science; When there is no doctor, and Death and dying. The first theme introduces students to local and international icons in medicine. The second theme exposes students to uncertainty and scepticism in medicine. The third theme emphasises that the provision of health care represents a team effort and exposes students to health care that does not involve doctors. In the fourth theme, students are introduced to palliative care and end-of-life issues. They learn about compassion, empathy and the art of breaking bad news. Blended learning is facilitated through activities on an e-learning platform, lectures and show-and-tell sessions in which patient volunteers share their experiences. Interspersed with this, students visit six centres, including an emergency department and a community clinic. Communication skills workshops equip students with essential skills for communicating with patients. Students are encouraged to reflect on their activities throughout the week and to write about their experiences as a group. Learning is supported by feedback provided through online forums, online resources and formative assessments. What lessons were learned? The introduction of Language in Medicine has raised awareness among students of the humane aspect of medicine. Group assignments hone students’ team skills and communication skills training enhances their ability in history taking and interpersonal interaction. The Death and dying theme emphasises the fact that although doctors cannot always heal, they can always care. Tutors in subsequent basic science blocks commented that the revised curriculum has made students more inquisitive and has improved communication between tutors and students. Despite the efforts and enthusiasm contributed by everyone involved in implementing the many useful activities, some students commented that the time might be better spent on learning medicine. After a review, the 12-week component was condensed to 8 weeks for subsequent cohorts. Curriculum review and transformation helped us to humanise our undergraduate medical curriculum. Over time and with continuous feedback for improvement, a change in the student learning experience is slowly taking shape.

Licence to commence clinical day: the L-Plate test

What problems were addressed? Personal and professional development (PPD) is an important aspect of the training of future doctors. Learning how to be a good doctor, one who is competent, professional and ethical, takes time. Medical students are expected to recognise the code of professional conduct and public expectation of doctors, as well as familiarity with the relevant medical law. Sadly, this aspect of the curriculum is often taken lightly by medical students, who tend to focus on the core content of the curriculum – the basic and clinical sciences. Although PPD was part of our previous medical curriculum, it was not separately assessed. Students’ performance in the PPD module was not identified and they would not be penalised if they chose to neglect this module. What was tried? In the new University of Malaya Medical Programme (UMMP) in collaboration with the University of Sydney, students are given early clinical exposure, beginning in Year 1. Before students commence study in a clinical setting, they must understand some important ethical and legal basics related to patients and their health information. The L-Plate test was introduced as a required formative assessment for Year 1 medical students under the PPD theme. The test covers content areas pertaining to medical law and ethics. After attending a series of lectures on relevant sections of medical law, the code of professional conduct and essential ward behaviour, students took a written test comprising multiple-choice questions. Although only basic knowledge of medical law and ethics was assessed, students must have acquired adequate knowledge of the content areas to pass the test. Those who failed at their first attempt were allowed to resit. With only lectures as the mode of delivery, informal interviews with students revealed that they found medical law and ethics interesting and useful. Nonetheless, some students admitted that without the L-Plate test, they probably would not have appreciated medical law and ethics. What lessons were learned? Assessment of professionalism is critical yet challenging. The mandatory pass in the L-Plate test before they are allowed access to patient-care areas left the students with no option but to learn sufficiently well, as a pass in the test is equivalent to a licence to commence clinical day. Although the L-Plate test has sent an explicit message to students that professionalism has a considerable place in their training, a one-off written test is not warranted. Professionalism should be continually monitored and assessed on a broad range of evidence from across the programme. Ideally, professionalism should be embedded in the values of medical school from the beginning, and continue to be assessed and monitored while being taught using multiple teaching modalities. In order for it to be embodied in student behaviour, professionalism should be implicitly introduced and reinforced throughout the programme. From Year 1 to Year 5 in the UMMP, the PPD theme (mainly attitude and conduct) makes up one of four themes that students must pass in order to progress.

Using written text-based approach to promote reflection: Does it work?

The article by Andrews (2014) enlightened me. The author’s vivid description of her attempts at using reflection with preclinical students was very real and illuminating. The students’ ability to follow Donald Schon’s three-step model of reflective practice was amazing. Yes, reflections need to be real – from real encounters with real people. The author identified ‘‘engagement’’ as the key element that provided the students with real experiences and they in return, responded with genuine reflections. I wish to share an example of using reflection where students had no direct access to real experience. Yet they felt connected and demonstrated engagement. In our new medical curriculum, Year 1 students were introduced to the concept of reflective writing. Literature on reflection in medical education revealed written text-based approaches do not appeal to the ‘‘net generation’’ of learners and suggested the creative use of multimedia for reflection. To strike a balance, three resources – HIV/AIDS, organ donation, dengue (in Malaysia) were uploaded and resource links were provided. As a formative assessment, students had to login to access the online resources, selected one of the resource and wrote a short reflective essay about it. General guidelines were provided. Several questions that could prompt reflection were given. All the 179 students submitted the essays online. Although not all the essays fit the description of a structured, thoughtful piece of academic writing that displayed reflective ability and cultural sensitivity, students’ engagement with the resources were evident. Students responded with much thought and insights, and reacted with strong emotions. Phrases like ‘‘I was totally amazed/deeply disappointed’’, ‘‘It worried me’’, appeared repeatedly throughout their essays. Some students had even gone through the three phases of reflection: noticing, processing and future action. Excerpts from an essay to illustrate: ‘‘. . . this is what I never think about before . . .’’ (noticing); ‘‘. . . do you ever think of donating your organs?’’ (processing); ‘‘. . . our decisions to become organ donors which my parents and I are now’’ (future action). Although real experience is desirable, online written textbased resources can promote reflection, perhaps particularly so if assessment-related. Through guided reflection and a structured approach, pre-clinical students can learn to reflect.