Natalie Radomski

Integrated Case Learning: teaching clinical reasoning

Learning how to ‘think like doctors’ can be difficult for undergraduate medical students in their early clinical years. Our model of collaborative Integrated Case Learning (ICL) and simulated clinical reasoning aims to address these issues. Taking a socio-cultural perspective, this study investigates the reflective learning interactions and practices of clinical thinking that emerged in the ICL environment. We also explore how third year medical students perceived their ICL experiences in relation to the clinical situations encountered in the hospital setting. The context for the inquiry is a rural Clinical School in North West Victoria, Australia. We used a qualitative case study methodology following eight third-year medical students over an academic year. Individual and group interviews were conducted, together with observations and document/artefact analysis. Data was analysed using content and narrative methods. The ICL program was well received. Findings suggest that the group-based, simulated clinical reasoning process appears to help undergraduate medical students to rehearse, articulate and question their clinical decision-making pathways. We argue that the ICL process offers a professionally challenging, but supportive group learning ‘space’ for students to practise what it might mean to ‘think’, ‘talk’ and ‘perform’ like doctors in real settings. The ICL environment also appears to create a connective bridge between the ‘classroom’ and clinical practice.

Performance pressure: simulated patients and high-stakes examinations in a regional clinical school.

OBJECTIVE To investigate the effects and challenges of being a simulated patient (SP) in a high-stakes clinical examination context in a regional setting. DESIGN Mixed methods, using a written survey, focus groups, and a retrospective postal survey. SETTING A university clinical school in a Victorian regional city. PARTICIPANTS Nineteen SP volunteers (from an existing database of 55 people) who had been involved in mid-year, summative Objective Structured Clinical Examination (OSCE) role-play performances. MAIN OUTCOME MEASURES Challenges of the OSCE role-play experience and the reported effects on SPs. The implications of these factors have an impact on the sustainability of SP programs in regional settings. RESULTS Physical and emotional effects like exhaustion were reported, as well as empathy and concern for the medical students. The retrospective postal survey indicated that the SPs had no long-term negative effects from their high-stakes examination experiences. Participants also reported that a level of decision making and improvisation was needed in the performance of their OSCE role plays. CONCLUSIONS Our study reveals the complexity and demands on SPs in performing in high-stakes clinical examinations. The results highlight that SP roles involve more than the transfer of scripted information. SPs should be considered as members of the examination team when preparing and implementing high-stakes examinations to assist in maintaining standardised performance during and across OSCE role plays. Relationships between SPs and educational institutes need to be nurtured to ensure that the ability to continue high-stakes OSCEs in a regional setting is maintained.

Written feedback and continuity of learning in a geographically distributed medical education program

Background: The provision of effective feedback on clinical performance for medical students is important for their continued learning. Written feedback is an underutilised medium for linking clinical performances over time. Aims: The aim of this study is to investigate how clinical supervisors construct performance orientated written feedback and learning goals for medical students in a geographically distributed medical education (GDME) programme. Methods: This qualitative study uses textual analysis to examine the structure and content of written feedback statements in 1000 mini-CEX records from 33 Australian undergraduate medical students during their 36 week GDME programme. The students were in their second clinical year. Results: Forty percent of mini-CEX records contained written feedback statements. Within these statements, 80% included comments relating to student clinical performance. The way in which written feedback statements were recorded varied in structure and content. Only 16% of the statements contained student learning goals focused on improving a students clinical performance over time. Very few of the written feedback statements identified forward-focused learning goals. Conclusion: Training clinical supervisors in understanding how their feedback contributes to a students continuity of learning across their GDME clinical placements will enable more focused learning experiences based on student need. To enhance student learning over time and place, effective written feedback should contain focused, coherent phrases that help reflection on current and future clinical performance. It also needs to provide enough detail for other GDME clinical supervisors to understand current student performance and plan future directions for their teaching.

What non-technical skills competencies are addressed by Australian standards documents for health professionals who work in secondary and tertiary clinical settings? A qualitative comparative analysis

Objectives At minimum, safe patient outcomes are recognised as resulting from a combination of technical and non-technical skills. Flin and colleagues provide a practical framework of non-technical skills, cognitive, social and interpersonal, that complement technical skills, with categories identified as situational awareness, communication, team working, decision-making, leadership, coping with stress and managing fatigue. The aim of this research was to explore the alignment of categories and elements of non-technical skills with those in the published standards documents of several health professions in Australia. Design A qualitative comparative analysis using document analysis and deductive coding examined, extracted and interpreted data from competency standards documents focusing on non-technical skills categories and elements. Participants A purposive sample of 11 health professions competency standards documents required for registration in Australia. Findings The 11 competency standards documents contained 1616 statements. Although standards documents addressed all non-technical skills categories, there was limited reporting of managing stress and coping with fatigue. Of the 31 elements included in the non-technical skills framework, 22 were not common to all health professions and 3 elements were missing from the standards documents. Additionally, the documents were composed differently with no common taxonomy and multifaceted statements. Conclusion While commonalities identified in the standards documents related to non-technical skills categories are likely to support patient safety, gaps in associated elements may undermine their effectiveness. The notable lack of reference to stress and fatigue requires further attention for health professional well-being in Australia. A shared taxonomy with clear statements may offer the best support for collaborative practice and positive patient outcomes. Competency standards need to be flexible to respond to the emerging demands of current healthcare practice along with consumer and health service needs.