Susie Schofield

Breaking bad news in amyotrophic lateral sclerosis: The need for medical education

Abstract The manner in which physicians deliver difficult diagnoses is an area of discontent for patients with amyotrophic lateral sclerosis (ALS). The American Academy of Neurologys Practice Parameter for care of the ALS Patient recommended teaching and evaluating strategies for disclosing the diagnosis (10). Our objective was to examine residents’ ability in and perceptions of communicating the diagnosis of ALS. Twenty-two resident physicians were videotaped and rated by two ALS neurologists as they delivered an ALS diagnosis to a standardized patient (SP) during an objective structured clinical examination (OSCE). Residents self-rated immediately after the OSCE, again after viewing their videotape, and completed a survey regarding the OSCE and delivering difficult diagnoses. OSCE performance was suboptimal, particularly for communication skills and empathy. The two examiners’ scores correlated except for the empathy subscore. Residents’ self-assessments did not align with the examiners’ scores either before or after watching their videotape. The survey uncovered residents’ apprehension and dissatisfaction with their training in diagnosis delivery. The results highlight a need for resident education in delivering an ALS diagnosis. The lack of correlation between residents’ and examiners’ scoring requires further study. Evaluation of empathy is particularly challenging. Residents agreed that OSCE participation was worthwhile.

How we encourage faculty development

Most clinicians enjoy teaching medical students, but many have had little training as clinical teachers. The General Medical Council (GMC) in ‘Good Medical Practice’ states ‘if you are involved in teaching you must develop the skills, attitudes and practices of a competent teacher’ (GMC 2006). Mclean et al.s (2008) AMEE guide on faculty development outlines practice points for those responsible for developing their facultys educational skills. In this article, we look at one health region, Tayside in East Scotland, where the University of Dundee, NHS Education for Scotland (NES) and NHS Tayside are collaborating to implement these practice points. This combined approach has proved to be effective in progressing staff development and recruiting additional clinical colleagues to develop their teaching role.

Assessment and feedback dialogue in online distance learning

What problems were addressed? Residents are expected to learn and demonstrate competency in using medical literature to guide their practice. Although medical students are instructed on the principles of constructing appropriate questions and searching through literature to identify solutions, it is difficult to observe and assess these skills in an objective manner, especially among doctors-in-training in whom it is particularly critical to establish good practices. Objective structured clinical examinations (OSCEs) present the appealing potential to assess a range of aptitudes in the setting of a realistic scenario of patient interaction. What was tried? Twenty-four obstetrics and gynaecology residents in postgraduate years (PGY) 1–4 participated in a five-station OSCE that assessed a range of abilities through a set of scenarios involving standardised patient (SP) interactions and focused skills testing. In the medical literature station, the patient presented for counselling after her sister had been diagnosed with a BRCA-1 gene mutation. The residents were given instructions to use the materials available through the online medical library to locate evidence to facilitate educating the patient about her risk for cancer and the effect of riskreducing surgery. The station had three parts: a literature review by the resident (8 minutes); interaction with the SP (8 minutes), and feedback with a faculty member (5 minutes). Using a remote desktop software program, a faculty member, who is also a clinical librarian, observed the resident’s search. Following the interaction with the patient, the faculty member discussed the framing query used by the resident and provided feedback. The faculty member rated the search according to source of information, framing query and strength of data based on a 3point scale (Does not meet expectations, Meets expectations, Exceeds information). The data were analysed using IBM SPSS Version 19 (IBM Corp., Armonk, NY, USA). Interactions at the station were videotaped so that they could be used for further training and research. What lessons were learned? All residents were able to complete the station and received ratings of at least ‘Meets expectations’ on all items. Residents received a rating of ‘Exceeds expectations’ if they used PubMed Clinical Queries, EMBASE or the Cochrane Library of Systematic Reviews and demonstrated a systematic approach to gathering data by using a real clinical question, or located prospective studies or clinical reviews. For all 24 residents, the mean standard deviation (SD) score for ‘Exceeds expectations’ was 37 35%; mean SD scores by PGY group were 44 39% for PGY-1 residents, 47 29% for PGY-2 residents, 41 41% for PGY-3 residents, and 18 31% for PGY-4 residents. Although these results are not statistically significant given the small sample size, it is notable that junior residents performed better than senior residents, and that the range of performance varied greatly among individual residents. This shows us that residents’ use of the medical literature may be assessed using an OSCE format, and that it may be worthwhile to perform an objective assessment of this skill in order to evaluate residents’ ability in this important area. Further evaluation of this method will help to refine the scoring system and establish the validity of the assessment, in addition to determining the areas in which additional evidencebased training is needed.

How do postgraduate qualifications in medical education impact on health professionals

Abstract Background and Purpose: The number of degree-awarding programmes in medical education is steadily increasing. Despite the popularity and extensive investment in these courses, there is little research into their impact. This study investigated the perceived impact of an internationally-renowned postgraduate programme in medical education on health professionals’ development as educators. Methods: An online survey of the 2008–12 graduates from the Centre for Medical Education, University of Dundee was carried out. Their self-reported shifts in various educational competencies and scholarship activities were analysed using non-parametric statistics. Qualitative data were also collected and analysed to add depth to the quantitative findings. Results: Of the 504 graduates who received the online questionnaire 224 responded. Participants reported that a qualification in medical education had significantly (p < 0.001) improved their professional educational practices and engagement in scholarly activities. Masters graduates reported greater impact compared to Certificate graduates on all items, including ability to facilitate curriculum reforms, and in assessment and feedback practices. Masters graduates also reported more engagement in scholarship activities, with significantly greater contributions to journals. These qualifications equally benefited all participants regardless of age. International graduates reported greater impact of the qualification than their UK counterparts. Conclusion: A postgraduate medical education programme can significantly impact on the practices and behaviours of health professionals in education, improving self-efficacy and instilling an increased sense of belonging to the educational community.

Translating evidence-based guidelines to improve feedback practices: the interACT case study

BackgroundThere has been a substantial body of research examining feedback practices, yet the assessment and feedback landscape in higher education is described as ‘stubbornly resistant to change’. The aim of this paper is to present a case study demonstrating how an entire programme’s assessment and feedback practices were re-engineered and evaluated in line with evidence from the literature in the interACT (Interaction and Collaboration via Technology) project.MethodsInformed by action research the project conducted two cycles of planning, action, evaluation and reflection. Four key pedagogical principles informed the re-design of the assessment and feedback practices. Evaluation activities included document analysis, interviews with staff (n = 10) and students (n = 7), and student questionnaires (n = 54). Descriptive statistics were used to analyse the questionnaire data. Framework thematic analysis was used to develop themes across the interview data.ResultsInterACT was reported by students and staff to promote self-evaluation, engagement with feedback and feedback dialogue. Streamlining the process after the first cycle of action research was crucial for improving engagement of students and staff. The interACT process of promoting self-evaluation, reflection on feedback, feedback dialogue and longitudinal perspectives of feedback has clear benefits and should be transferable to other contexts.ConclusionsInterACT has involved comprehensive re-engineering of the assessment and feedback processes using educational principles to guide the design taking into account stakeholder perspectives. These principles and the strategies to enact them should be transferable to other contexts.

What's in a name? Word inflation, punctuation, abbreviation and cloud formation.

The title of a journal paper offers a crucial portal into any scientific field. It determines whether interested readers locate the paper and whether others have enough interest sparked to lead them to read the abstract. This article looks at authored journal paper titles in Medical Education over its first 50 years (n = 6357) of publication and Medical Teacher over its first 35 years of publication, revealing both trends in areas of interest and how those interests are worded. Word clouds per decade showed a shift from teaching to learning and from examination to assessment, and new foci on learning, patients, research and feedback in both journals. The average length of title in Medical Education peeked in the 2000s, dropping to 70 characters in the 2010s, with no titles being longer than 140 characters (the length of a tweet) in this last decade. Abbreviations were used sparingly. The use of humorous titles, although not common, has increased in recent years. The use of the colon showed a marked increase in the 1980s, dropping a little in the 2000s but resurging in the 2010s. Titles posed as a question increased steadily, appearing to plateau in the 2000s at 11%. The use of humour and questions suggests that the authors of these articles are submitting papers to be selected by the human rather than just the virtual eye. We also hypothesise that the use of humour may indicate a maturation of medical education as a subject.

How do junior doctors in the UK learn to provide end of life care: a qualitative evaluation of postgraduate education

BackgroundThe fundamental importance of good end of life care has been well documented however recent national publications have high-lighted inadequacies in training in this area. For many patients dying in the UK today care is provided in hospital and the number of inpatient deaths is forecast to climb significantly in future. The demands of providing medical care for these patients by junior doctors will continue to rise. However, there is currently only limited research on training for doctors in this setting.MethodsA qualitative study using semi-structured interviews of trainees working in general medicine analysed utilising a grounded theory approach.ResultsEleven medical trainees from nine different medical schools participated. They had worked in fifteen different UK hospitals in the course of their careers. All of the doctors interviewed felt generally confident in managing a dying patient. This had developed at postgraduate level and increased when working in certain key specialties. Emerging themes fell into five main categories: perceived ability in clinical management, different learning opportunities experienced, the impact of variations in approach to end of life care, the role of the specialist palliative care team and suggestions for improvements to training. All participants felt further teaching would be beneficial.ConclusionsThis study identified key areas where training could be improved. This included small changes in everyday practice to shift the emphasis for trainees to education. There also needs to be focus on end of life care in the curriculum, formal teaching programmes and assessment of junior doctors. The specialist palliative care team played a vital role in training as well as service provision. For those working in this specialty, every clinical encounter provides an opportunity for education. Specifically targeting junior doctors will not only improve patient care today but empower the consultants of the future.

Docemur Docemus: Peer-Assisted Learning Improves the Knowledge Gain of Tutors in the Highest Quartile of Achievement but Not Those in the Lowest Quartile.

OBJECTIVES Peer-assisted learning (PAL) is a form of collaborative learning where members of a peer group act as teachers for each other. A reciprocal PAL program was designed to investigate whether there were differential gains in knowledge acquisition among tutors compared with tutees. DESIGN Bayesian statistical analysis was used to quantitatively assess the effect of tutor status on performance in a knowledge-based examination. Subgroup analysis according to student achievement and question difficulty was performed. PARTICIPANTS AND SETTING Final year undergraduate medical students in a 5-year degree program (n = 126). RESULTS The overall probability of getting a correct answer on the knowledge examination was 49.7%. For questions on topics where a student had acted as a tutor this improved to 57.3%. However, students who performed in the upper quartile had a greater percentage gain in the probability of a correct answer in topics that they had taught vs students who performed in the lowest quartile. CONCLUSIONS There was demonstrable overall knowledge gain associated with acting as a tutor in a PAL program but the greatest gain occurred in students of highest academic ability.

E-Learning in Global Surgery

E-learning – the use of the Internet and multimedia technology – is completely transforming the learning environment of the twenty-first century. The global penetration of computers, smart phones, and access to the Internet is reaching even the remotest parts of the least developed countries. As learner-educators, global surgeons can take advantage of new technologies by accessing existing online learning resources or developing their own. E-learning tools have unique advantages in distance learning, such as allowing learners to be engaged synchronously with an online lecture, or review and respond through an asynchronous discussion board. This chapter discusses e-learning instructional design and describes successful projects, evaluation approaches, and future directions for e-learning in global surgery. Formal online courses, webinars, and remote telementoring all provide examples of surgical leadership and north-south partnerships in surgical education. Evaluation of surgical e-learning partnership initiatives will provide opportunities for bilateral mutual learning and “reverse innovation.” Globally minded surgeons are on the cutting edge using innovation and new technology to teach their craft.

Professional Development for Medical Educators

Dundee University Medical School, on the east coast of Scotland, delivers a 5-year undergraduate medical program with about 160 students per year. Approximately 15% of the students are from Dundee and the surrounding area, 50% from the rest of Scotland, and 25% from England, Wales and Northern Ireland, with the remaining 10% being international students.