Marina Sawdon

‘You’re judged all the time!’ Students’ views on professionalism: a multicentre study

Medical Education 2010: 44: 814–825

Peer estimation of lack of professionalism correlates with low Conscientiousness Index scores.

Context  Measures of professionalism in undergraduate medical students are generally subjective in nature, and based on limited observations of behaviours in observed settings. We have previously described an objective scalar measure of conscientiousness over many occasions, and shown that it correlates with independent faculty estimates of students’ professionalism. In this study we test the hypothesis that these measures of conscientiousness relate to independent peer estimates of professionalism, and explore the relationships between conscientiousness, and gender and educational background.

The clinical conscientiousness index: a valid tool for exploring professionalism in the clinical undergraduate setting.

Purpose The need to develop effective tools to measure professionalism continues to challenge medical educators; thus, as a follow-up to a recent examination of the “Conscientiousness Index” (CI, a novel measure of one facet of professionalism) in one setting with preclinical medical students, the authors aimed to investigate the validity of the CI as a proxy measure of professionalism in a different context and in the clinical phase of undergraduate medical education. Method In academic year 2009–2010, the authors collected data similar to those collected for the original preclinical study. In an effort to create a Clinical Conscientiousness Index (CCI) score, they collected the following information on 124 third-year medical students completing their clinical rotations: attendance, timeliness of assessment submissions, and completion of rotation evaluations. Then, they compared the resultant CCI scores with faculty views on professionalism and with formal assessments of students’ professionalism (i.e., their portfolios and objective structured clinical examinations [OSCEs]). Results The authors demonstrate significant correlations between CCI scores and faculty views on professionalism (rS = 0.3; P = .001), and between CCI scores and OSCE score (rS = 0.237; P = .008), but not between CCI scores and portfolio assessment (rS = 0.084; P = .354). The authors also present relationships between CCI scores and demographics. Conclusion The CCI is a practical, valid proxy measure of professionalism, achieving good correlation with faculty views on professionalism and clinical competency examinations, but not portfolio assessment, in one clinical undergraduate setting.Purpose: The need to develop effective tools to measure professionalism continues to challenge medical educators; thus, as a follow-up to a recent examination of the “Conscientiousness Index” (CI, a novel measure of one facet of professionalism) in one setting with preclinical medical students, the authors aimed to investigate the validity of the CI as a proxy measure of professionalism in a different context and in the clinical phase of undergraduate medical education. Method: In academic year 2009–2010, the authors collected data similar to those collected for the original preclinical study. In an effort to create a Clinical Conscientiousness Index (CCI) score, they collected the following information on 124 third-year medical students completing their clinical rotations: attendance, timeliness of assessment submissions, and completion of rotation evaluations. Then, they compared the resultant CCI scores with faculty views on professionalism and with formal assessments of students’ professionalism (i.e., their portfolios and objective structured clinical examinations [OSCEs]). Results: The authors demonstrate significant correlations between CCI scores and faculty views on professionalism (rS = 0.3; P = .001), and between CCI scores and OSCE score (rS = 0.237; P = .008), but not between CCI scores and portfolio assessment (rS = 0.084; P = .354). The authors also present relationships between CCI scores and demographics. Conclusion: The CCI is a practical, valid proxy measure of professionalism, achieving good correlation with faculty views on professionalism and clinical competency examinations, but not portfolio assessment, in one clinical undergraduate setting.

The Effects of Primary Thoracic Blast Injury and Morphine on the Response to Haemorrhage in the Anaesthetised Rat

Primary thoracic blast injury causes a triad of bradycardia, hypotension and apnoea mediated in part via a vagal reflex. Blast casualties may also suffer blood loss, and the response to progressive simple haemorrhage is biphasic: an initial tachycardia followed by a vagally mediated reflex bradycardia which can be attenuated by μ opioid agonists. The aims of this study were to determine the effects of thoracic blast injury on the response to subsequent haemorrhage, and the effects of morphine, administered after blast, on the response to blood loss. Male Wistar rats, terminally anaesthetised with alphadolone‐alphaxolone (19‐21 mg kg−1 h−1 I.V.), were allocated randomly to one of three groups: Group I, sham blast; Group II, thoracic blast; Group III, thoracic blast plus morphine (0.5 mg kg−1 I.V. given 5 min after blast). Blast (Groups II and III) resulted in significant (P < 0.05, ANOVA) bradycardia, hypotension and apnoea. Sham blast (Group I) had no effect. Ten minutes later, haemorrhage (40% of the estimated total blood volume (BV)) in Group I produced a biphasic response comprising a tachycardia followed by a peak bradycardia after the loss of 33% BV. Arterial blood pressure did not fall significantly until the loss of 13.3% BV. In Group II the haemorrhage‐induced tachycardia was absent and the bradycardia was augmented: peak bradycardia was seen after the loss of 23% BV. Mean arterial blood pressure (MBP) began to fall as soon as haemorrhage commenced and was significant after the loss of 10% BV. Morphine (Group III) prevented the haemorrhage‐induced bradycardia and delayed the significant fall in MBP until the loss of 30% BV. It is concluded that the response to thoracic blast injury augments the depressor response to haemorrhage while morphine attenuates this response.

A study to investigate the effectiveness of SimMan® as an adjunct in teaching preclinical skills to medical students

BackgroundFollowing the GMC’s report on Tomorrow’s Doctors, greater emphasis has been placed on training in clinical skills, and the integration of clinical and basic sciences within the curriculum to promote the development of effective doctors. The use of simulation in the learning environment has the potential to support the development of clinical skills in preclinical medical students whilst in a ‘safe’ environment, but currently there is little evidence on its effectiveness.MethodsSeventy nine year one medical students were divided into two groups. A pre-test was conducted by both groups, after which one group performed chest examination on their peers whilst the other group examined the SimMan® manikin. Both groups subsequently performed a mid-test and crossed over so that the group that conducted peer examination examined the manikin and vice-versa. Finally a post-test was conducted. The students were scored for formative feedback whilst performing examinations. Students completed a feedback questionnaire at the end of the session. Data were analysed using a one-way ANOVA, independent t-test and 2- proportion Z test.ResultsWhen the two groups were compared, there was no significant difference in their pre-test and post-test knowledge scores, whereas mid-test knowledge scores increased significantly (P < 0.001), with the group using SimMan® initially scoring higher. A significant increase in the test scores was seen in both groups after using SimMan® (P < 0.001). Students’ confidence increased significantly in differentiating between normal and abnormal signs (P < 0.001). Students highly valued the use of the manikin in the session with 96% of students reporting that it enhanced their learning experience.ConclusionsThe study demonstrated a significant improvement in the students’ knowledge after examining the manikin and students also reported an increase in their confidence. Students’ feedback was generally very positive and they perceived the incorporation of manikin-based examinations useful to prepare them for future patient contact. The use of simulation in this context supports an integrated learning approach when used as an adjunct to peer examination, and can benefit the acquisition of clinical skills in preclinical medical students.

Relating professionalism and conscientiousness to develop an objective, scalar, proxy measure of professionalism in anaesthetic trainees

BackgroundThe concept of professionalism is complex and subjective and relies on expert judgements. Currently, there are no existing objective measures of professionalism in anaesthesia. However, it is possible that at least some elements of professionalism may be indicated by objective measures. A number of studies have suggested that conscientiousness as a trait is a significant contributor to professionalism.MethodsA ‘Conscientiousness Index’ (CI) was developed by collation of routinely collected data from tasks expected to be carried out by anaesthetic trainees such as punctual submission of holiday and ‘not-on-call’ requests, attendance at audit meetings, timely submission of completed appraisal documentation and sickness/absence notifications. The CI consists of a sum of points deducted from a baseline of 50 for non-completion of these objective and measurable behaviours related to conscientiousness. This was correlated with consultants’ formal and informal subjective measures of professionalism in those trainees.Informal, subjective measures of professionalism consisted of a ‘Professionalism Index’ (PI). The PI consisted of a score developed from consultants’ expert, subjective views of professionalism for those trainees. Formal, subjective measures of professionalism consisted of a score derived from comments made by consultants in College Tutor feedback forms on their views on the professionalism of those trainees (College Tutor feedback; CT). The PI and CT scores were correlated against the CI using a Pearson or Spearman correlation coefficient.ResultsThere was a negative, but not statistically significant, relationship between the CI and formal, subjective measures of professionalism; CT scores (r = -0.341, p = 0.06), but no correlation between CI and consultants informal views of trainees’ professionalism; the PI scores (rs = -0.059, p = 0.759).ConclusionsThis may be due the ‘failure to fail’ phenomenon due to the high stakes nature of raising concerns of professionalism in postgraduate healthcare professionals or may be that the precision of the tool may be insufficient to distinguish between trainees who generally show highly professional behaviour. Future development of the tool may need to include more of the sub-facets of conscientiousness. Independently of a relationship with the construct of professionalism, a measure of conscientiousness might be of interest to future employers.

Naloxone does not inhibit the attenuation of the response to severe haemorrhage seen after simulated injury in the anaesthetized rat

Severe haemorrhage leads to a reflex bradycardia and hypotension. This is thought to be protective, but is attenuated by both concomitant musculoskeletal injury and exogenous morphine. The aim of this study was to determine whether the injury‐induced attenuation of the response to severe haemorrhage could be blocked by naloxone. Male Wistar rats, terminally anaesthetized with alphadolone/alphaxalone (19–20 mg kg−1 h−1i.v.), were randomly allocated to one of four groups. In groups I and IV, haemorrhage was simple [40% of estimated total blood volume (BV)], while in groups II and III it was initiated 10 min after the onset of bilateral hindlimb ischaemia (a model of musculoskeletal injury). Groups I and II received 20 μl of 0.9% saline intracerebroventricularly (i.c.v.) immediately before haemorrhage, while groups III and IV received 20 μg of naloxone i.c.v., in the same volume. In group I, the bradycardia reached its peak after the loss of 32.8 ± 0.3% BV (mean ±s.e.m.). Blood pressure did not fall significantly until the loss of 15.0 ± 3.0% BV. The response in group IV was not significantly different from group I. By contrast, the bradycardia was absent after similar blood losses in groups II and III, while hypotension was attenuated. These results indicate that naloxone, at a dose known to be effective in blocking μ‐opioid receptors and preventing other aspects of the response to injury, does not prevent the injury‐induced attenuation of the response to severe haemorrhage. Thus the attenuation of the response to blood loss by injury is unlikely to be mediated via the μ‐opioid receptors.

Thomas the Tank Engine significantly improves the understanding of oxygen delivery and hypoxaemia

Despite apparent adequate background knowledge many physiological concepts are poorly understood1. Analogous imagery can describe such concepts2, 3. Thomas the Tank Engine has previously demonstrated an enhanced understanding of hypoxaemia4, 5. The effectiveness of such imagery has not been evaluated in medical student education. Two 30-minute Microsoft Power Point lectures entitled “Oxygen delivery and hypoxaemia” were delivered to Year One Medical Students at the Universities of Newcastle and Durham. The control lecture was a conventional presentation; the study lecture contained additional images of Thomas the Tank Engine4, 5. Local Research Ethics approval was advised as being unnecessary and HiT Entertainment UK granted permission to use the imagery of Thomas the Tank Engine. Course tutors randomised students into 4 groups (A-D.) Groups A and B received the control lecture, C and D the study lecture. A and C undertook a pre-lecture multiple choice questionnaire (MCQ) of 20 questions on oxygen delivery and hypoxaemia to assess background knowledge and monitor for “priming.” Pre and post-lecture MCQ scores for groups A and C were compared to assess for lecture effectiveness (A vs. A and C vs. C) and for differences between the control and study lecture (pre-MCQ A vs. C and post-MCQ A vs. C.) The effect of priming was assessed by comparing post-lecture MCQ scores (A vs. B and C vs. D.) Students also completed a post-lecture qualitative evaluation of eight aspects of lecture quality scored 1 to 5: strongly agree/ agree/ undecided/ disagree/ strongly disagree (figure 1.) All scores were collected using an ARS-KEEpad system and compared using the Mann-Whitney U-test for non-parametric data. A p value <0.05 was regarded as significant. Group numbers were A n=73, B n=56, C n=59, D n=53. Both lectures significantly improved post-lecture MCQ scores (p<0.001) with group A having significantly higher pre-lecture MCQ scores compared to group C (median 16 vs. 12, p<0.001), there was no difference post-lecture (median 18 vs. 17, p=0.4). Post-lecture MCQ scores were not different between A and B (median 18 vs. 18, p=0.14) or C and D (median 17 vs. 17, p=0.6.) The imagery also made the lecture significantly more organised (p=0.006), interesting and stimulating (p<0.001) and improved qualitative understanding (p<0.001.) Figure 1. Images of Thomas the Tank Engine can significantly improve the understanding of oxygen delivery and hypoxaemia in Year One Medical Students. A pre-lecture MCQ does not create a priming effect.