Tim Dornan

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review #

Review date: Review period January 1992–December 2001. Final analysis July 2004–January 2005. Background and review context: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. Objectives of review: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research. Search strategy: Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of: Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology. Criteria: Definitions: • Experience: Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. • Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included. Exclusions: Not empirical; not early; post-basic; simulated rather than ‘authentic’ experience. Data collection: Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation. Headline results: A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention. Conclusions: Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

How can medical students learn in a self-directed way in the clinical environment? Design-based research

Aim  This study aimed to establish whether and under what conditions medical students can learn in a self‐directed manner in the clinical environment.

The diabetes educator : trying hard, but must concentrate more on behaviour

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self‐efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients’ sense of self‐efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self‐management. These conclusions have implications for future research and clinical practice.

An electronic learning portfolio for reflective continuing professional development.

Objectives  These were to measure the uptake and use of an electronic learning portfolio to support reflective continuing professional development, and to characterize attitudes towards its use and obstacles to its adoption.

Gender and the clinical usefulness of the albumin: creatinine ratio

One hundred and eighty‐seven diabetic and 105 control subjects collected timed overnight urine samples to measure the inter‐individual variation in creatinine excretion rate and its determinants, and to test the relationship between albumin excretion rate (AER) and two ‘surrogate measures’, the albumin concentration and albumin:creatinine ratio. Creatinine excretion was 55 % higher in men than women (geometric mean 8.9 μmol min−1 (95% confidence limits 4.7–17.0) compared with 5.7 (3.0–10.9); p < 0.001). Gender accounted for 31% of the variation in creatinine excretion and body mass index 1.4%; neither age nor the diabetic state had a significant effect. The relationships between AER and the two surrogate measures differed between diabetic subjects and controls such that relationships constructed from non‐diabetic data would not hold true for diabetes. Likewise, the relationship between AER and albumin:creatinine ratio differed between men and women such that a ratio of 4.0 mg mmol−1 corresponded to a predicted AER of 35 μg min−1 in men and 23 μg min−1 in women. The albumin:creatinine ratio outperformed albumin concentration in terms of sensitivity and specificity and its performance was better in women than men. We conclude that the albumin:creatinine ratio is a better surrogate for AER than albumin concentration. If ‘action levels’ are to be defined for screening programmes, they should be derived from diabetic and not non‐diabetic data and should be different in men and women. We propose a direct rather than screening role for the albumin:creatinine ratio in the management of diabetic nephropathy.

How do people with Type 2 diabetes perceive and respond to cardiovascular risk

Objectives To explore how people with Type 2 diabetes perceive cardiovascular risk, and how those perceptions might affect their motivation to make lifestyle changes.

Three cases of macroprolactinaemia

A woman with hirsutism but otherwise symptom-free was found to have a raised serum prolactin and a pituitary microadenoma. The hyperprolactinaemia persisted despite bromocriptine therapy and subsequent pituitary surgery, which yielded a non-functioning adenoma. After a further 15 years with persistent hyperprolactinaemia but no symptoms, macroprolactinaemia was diagnosed. Such cases might account for part of the failure rate of pituitary microsurgery for prolactinoma. Testing for macroprolactinaemia is advisable in a woman with hyperprolactinaemia, especially if her ovulatory cycle is normal. Two other cases are reported in which macroprolactinaemia was associated with menstrual disturbances and other hormonal effects: in these, treatment with dopamine agonists suppressed the hyperprolactinaemia and restored normal menstrual cycles.

Towards valid measures of self-directed clinical learning

Aim  To compare the validity of different measures of self‐directed clinical learning.

Capillary and Venous Blood Glucose Measurements Using a Direct Glucose‐sensing Meter

The aim of the study was to evaluate the precision and accuracy of the ExacTech home blood glucose meter when used with either capillary or venous blood and to compare this with a reference whole blood glucose assay. Non‐fasting glucose measurements were used since a validation study showed no capillary‐venous differences between fasting and postprandial states. In a cross‐sectional study, blood was taken from 182 patients and measured in duplicate on three batches of strips. Altogether we analysed 1089 readings. The regression of the data from capillary blood samples (meter vs reference method) had a correlation coefficient of 0.93, and a mean bias of 0.2 mmol l‐1. The corrected 90% confidence interval was ± 1.5 mmol l‐1 overall, and ± 0.9 mmol l‐1 for readings under 7.0 mmol l‐1. Regression of the data from venous blood samples (meter vs reference method) had a correlation coefficient of 0.93 and a slope of x 1.1. The corrected 90% confidence interval was ± 1.7 mmol l‐1. Thus venous blood may be used even though the meter is calibrated for capillary samples but the value must be corrected by dividing by 1.1. Error‐grid analysis showed that day‐to‐day clinical decisions could be made on the basis of ExacTech readings, although a diagnosis of borderline diabetes may not be possible.

Pathology and the OSCE: insights from a pilot study

Undergraduate medical education in Manchester is undergoing wholesale revision, with the introduction of problem‐based learning (PBL) in each successive year of the curriculum, as the cohort of students who joined the faculty in 1994 advances through the course. This cohort has now entered year 3, which is primarily hospital‐based. In preparation for this, we have explored the development of an OSCE, not only to assess core interpersonal skills such as history taking, clinical examination, and the ability to explain things to patients, but also to integrate the examination of important skills relating to investigational sciences. These include the correct choice of laboratory tests, accurate interpretation of data, and appropriate selection of clinical responses to test results.