The Write Stuff: selected study module in medical writing

Really Good StuffNew ideas in medical education

A peer-reviewed collection of reportson innovative approaches to medical education

Edited by M. Brownell AndersonAssociation of American Medical Colleges

Really Good Stuff

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489

Contents

Introduction to Really Good Stuff

M. Brownell Anderson

Pre-Clinical Education

Teaching ultrasound of the abdomen and the pelvic

organs in the medicine curriculum in Vienna

Interdisciplinary clinical conferences: a response to the

challenge of integrating basic science education within

a traditional curriculum

From classroom to bedside: a curriculum for first year

medical students

How does the introduction of computers and wall-

mounted plasma screens impact small group tutorials?

Preliminary results

Management and delivery of the gross anatomy curri-

culum with decreased course time: the importance of

structured teaching activities

Developing Professional skills

The Write Stuff: selected study module in medical

writing

Communicating during procedures: development of a

rating scale

Can �performing� a procedure help students explain it to

their patients?

Teaching professional development in undergraduate

medical education

Setting our own standards: a student-led professional-

ism curriculum for preclerkship students

Clinical Education

Training and testing competence in direct ophthalmo-

scopy

Development of a competency-based neurology clerk-

ship

Graduate Medical Education

A sharing programme to improve women’s health

education in a veterans’ hospital clinic

The three-headed mentor: rethinking the classical

construct

�My question is…� – learner-centred precepting

Continuing Professional education

A novel means of feedback for the Emergency Response

Team

A brief but multi-faceted approach improves clinicians’

domestic violence confidence, competence and clinical

performance

Casting anxiety in small group facilitation: faculty

development via role play

Really Good Stuff474


Introduction to Really Good Stuff

The title �Really Good Stuff� was created for this section

of the journal to encourage projects not yet completed,

not fully evaluated, and sometimes not even successful.

The section is itself a work in progress and continues to

evolve and change to reflect the changes facing medical

education, much as the reports printed here represent

new approaches to managing and conducting medical

education today.

The reports presented in this issue provide a glimpse

at the breadth of issues medical educators face today,

and the creative ways they are tackling the issues across

the continuum of medical education. Because �Really

Good Stuff� represents medical schools throughout the

world, it offers a snapshot of the universal nature of the

problems faced by medical educators. One of the

challenges we face as editors of the section is to define

the kinds of reports to include in �Really Good Stuff�.The collection reports on approaches no more than

three years old that have not been reported elsewhere in

the peer-reviewed literature. The new approaches –

whether a curriculum unit, an evaluation tool, a record

keeping system, or any other element of medical

training – must have been implemented, although they

may be pilot programmes. We recognise that it often

takes years for a new programme, even a small one, to

be introduced, refined, and assessed, and for a report of

that assessment to be published – and during that time,

programme creators and implementers have trouble

finding out what other institutions are doing.

�Really Good Stuff� was created to help medical

school faculty members and administrators find infor-

mation about new programmes at other institutions and

to be useful to people whose �day job� is the education

of medical students, residents, and physicians.

Interest in �Really Good Stuff� remains high, as

demonstrated by the number of submissions received.

However, many schools do not submit anything. There

are hundreds of medical schools throughout the world.

At almost every one of these schools there is consid-

erable activity underway in medical education innova-

tions. Yet these schools are not represented here

because they did not submit anything. My hope is that

future issues will feature 100 or more different medical

schools and⁄or institutions.

I want to acknowledge the important contributions

made by each of the reviewers, both in shaping the

contents of this issue and in shaping the direction of

�Really Good Stuff�. During the past three years, the

reviewers have provided substantive suggestions for

changes in the review process, the review form, and the

nature of the �Really Good Stuff� section. Without their

thoughtful suggestions and their commitment of time

and energy to the review process, there would be no

feature called �Really Good Stuff�.My particular thanks go to the staff of Medical

Education, especially Julie Brice and Liz Baker, for their

unflagging support and guidance in the production of

�Really Good Stuff�.

M. Brownell AndersonAssociation of American Medical Colleges,

Washington DC, USA

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489 475

Really Good Stuff

Correspondence: M Brownell Anderson, Association of American

Medical Colleges, 2450 N Street NW, Washington DC 20037-1127,

United States of America.

Tel.: (202) 828 0562; Fax: (202) 828 0972;

E-mail: [email protected]

New ideas in medical education

Teaching ultrasound of the abdomen and thepelvic organs in the medicine curriculum inVienna

Waltraut Wicke, Peter C Brugger & Wilhelm Firbas

Context and setting Medical students in Vienna often

criticise the anonymous and non practice-orientated

way they are taught. Thus, an optional course on

ultrasound anatomy of the abdomen and pelvis was

initiated at the Department of Anatomy after the

anatomy examination. Groups of 6–7 students (in their

third to 12th semester) are trained by a teacher who is

either a medical doctor (generalist, internist, ortho-

paedist, radiologist) or a well instructed senior student.

Why the idea was necessary Ultrasound is widely

used as an imaging method and this course demon-

strates how the anatomical knowledge acquired during

dissection courses may be put into practice.

What was done Throughout the whole semester the

students learn the theoretical and practical aspects of

ultrasound imaging. The practical part comprises 10

weekly, 3-hour sessions, where students become familiar

with the apparatus and the anatomical specialities of

abdominal and pelvic ultrasound images. As they

perform sonography on each other, they learn by doing

and improve their anatomical knowledge. In addition,

lectures with audiovisual aids are held once a week,

where each group presents a special chapter to the others.

Students who are preparing lectures have access to the

library, which is equipped with books, CD-ROMs,

videotapes and slides. The lectures cover the physical

basics, anatomy and corresponding ultrasound images.

Other imaging methods including computer tomography

and the most common pathologies, are also dealt with. As

not all students have passed the pathology examination,

the emphasis lies on anatomy and physiology.

Because the number of places available for this

optional subject is limited, students have to undergo a

selection procedure. The criteria used are their

performance at the anatomy examination and their

progress in the curriculum. Thus, the participants

have progressed to the clinical section of the curricu-

lum, so clinical aspects can be introduced to enrich

discussions.

In the oral examination at the end of the semester,

students are required to answer questions on the theory

of ultrasound, demonstrate their skills in the acquisition

and storage of ultrasound images and interpret normal

ultrasound anatomy.

Evaluation of results From the winter semester

2000 to the summer semester 2002, between 58 and

69 students per semester (16%) attended this course

(dropout rate: 0Æ6–4Æ1%). From the winter semester

2000 onwards, the Department circulated question-

naires among participants in order to gain student

feedback on the course concept and instructors.

Analysis of the 175 returned questionnaires showed

that 93% of participants considered the course very

important or important for their curriculum, 96%

were very content or content with their active

involvement and 89% evaluated their instructors as

very competent or competent. The majority (80%)

wished to attend further courses. The most frequent

complaint was the lack of additional places on this

course.

Encouraged by these positive results, we plan to

expand our capacity in order to give more students

access to this course. Moreover, we now successfully

offer a course on joint ultrasound.

Correspondence: Waltraut Wicke MD, Department of Anatomy,

University of Vienna, Waehringerstrasse 13, 1090 Vienna, Austria.

Tel: 00 43 1 4277 61149; Fax: 00 43 1 4277 61142; E-mail:

[email protected]

Interdisciplinary clinical conferences:a response to the challenge of integratingbasic science education within a traditionalcurriculum

JoAnn Wood Jarvis, Rebecca Crump & Gail Haynes

Context and setting The University of Louisville is

a 200-year-old School of Medicine currently under-

� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489 476

Really Good Stuff

going vertical and horizontal curricular revision.

Courses are generating learning objectives and we

have begun a process of integrating basic science

education into all 4 years of training. Like many

schools, the challenge is to integrate the basic and

clinical sciences while maintaining a traditional cur-

ricular format.

Why the change was necessary Although adult

learning theory supports the use of multiple teaching

modalities and experiential instruction, lectures remain

the primary teaching modality. Interdisciplinary clinical

conferences (ICCs) were developed in response to the

need for a greater range of teaching modalities. The

ICC concept focuses on three goals:

1 to demonstrate the importance of basic science

knowledge to practising physicians;

2 to foster mentor)mentee relationships between first

year students and practising physicians, and

3 to demonstrate the importance of teamwork to

clinicians.

A guide for the creation of future ICC sessions has

been developed to allow these sessions to be used as

tools for further curricular integration at the University

of Louisville, such as in our standardised patient and

human patient simulation programmes.

What was done Interdisciplinary clinical confer-

ences were piloted within the first year curriculum as

a section of the clinical practice sciences course. The

conferences are now scheduled 15 times throughout

the year. Twelve clinical teachers from the depart-

ments of surgery, internal medicine, paediatrics and

family medicine mentor the teams. A master educator

provided training in small group instruction and

problem-based learning before the ICCs were piloted

(Special thanks to Frank Stritter, Ph D, University of

North Carolina at Chapel Hill for his mentorship).

Faculty development is key to the overall success of

this initiative as clinical faculty agreed to participate in

exchange for scheduled medical education training.

Each ICC session is explicitly developed to include

basic science and clinical content (biostatistics, patient

communication, ethics and physical examination

skills, for example). Students earn points by comple-

ting a team task. Student performance in timekeeper,

observer and recorder roles is also evaluated, using a

form that reflects third year clerkship evaluation forms

in an effort to acclimate students to the evaluations

used in clinical rotations. Multiple teaching modalities

have been employed within the ICCs, including the

use of standardised patients and human patient

simulation.

Evaluation and impact of results A liaison com-

mittee with a student representative elected from each

team meets quarterly with an outside evaluator. Stu-

dents also complete team evaluations for each ICC.

The mentor)mentee relationship will be assessed by

students, who will complete evaluation forms, at the

conclusion of each semester. Preliminary data from the

first liaison committee meeting indicate that student

opinions of the ICCs are positive; this tool has assisted

with assimilation of basic science learning objectives

and regular exposure to clinical faculty members is

beneficial. Team assessment evaluations are currently

being reviewed. Future research will compare current

third year clerkship evaluations with those of students

who participated in the ICC sections as first year

students.

Correspondence: JoAnn Wood Jarvis MD, FAAP, Assistant Professor

of Paediatrics and Internal Medicine; Section Leader, Clinical

Practical Sciences Course; University of Louisville School of

Medicine, Office of Curriculum Development and Evaluation,

Instructional Building B, Room 306, 500 South Preston Street,

Louisville, Kentucky 40292, USA. Tel: 00 1 502 852 8695; Fax: 00

1 502 852 2368; E-mail: [email protected]

From classroom to bedside: a curriculum forfirst year medical students

P Basaviah, L French & J Muller

Context and setting The Clinical Interlude (CI)

programme was designed as a 4-day curriculum

occurring 3 months into medical school and intended

to introduce first year medical students to the culture of

the inpatient setting and to provide them with a context

for the classroom material they were learning. Specific

goals included:

1 allowing students to observe patient)clinician rela-

tionships through an integrated approach to patient

care;

2 providing a basic awareness of inpatient setting

processes and the dynamics of health care teams;

3 enabling student learning about the hospital

experience from a patient’s perspective, and

4 facilitating development of students’ abilities to

function effectively with other health care provi-

ders.

Why the change was necessary Students can

have significant difficulty in adapting to ward

culture. Further, medical students often complain

Really Good Stuff 477


that they do not see the clinical relevance of basic

science instruction, which they see as impeding their

motivation for learning. The CI curriculum func-

tioned as an early immersion experience that provi-

ded direct relevance and application for student

learning.

Description Clinical Interlude was implemented

in December 2001 at the University of California

(UCSF) for all 142 first year medical students. Each

student was assigned to an inpatient setting in one of six

hospitals, to one of 11 clinical areas (medicine, cardi-

ology, ICU, CCU, surgery, paediatrics, NICU, PICU,

neurology, obstetrics, anaesthesiology), and to one of

10 health care professional categories (nurses, pharma-

cists, social workers, physical therapists, occupational

therapists, nutritionists, spiritual services representa-

tives, phlebotomists, radiology technologists, respirat-

ory therapists). The curriculum consisted of five key

components:

1 an orientation, including a large group discussion led

by a physician describing the challenges of being a

patient with a chronic illness;

2 a day of observation and interaction with inpatient

teams during work rounds, bedside rounds and

didactic sessions led by attending physicians and⁄or

residents;

3 a one-to-one interview with and basic physical

examination of a hospitalised patient;

4 a session with a non-physician health care provider,

and

5 a small group reflection session led by faculty

facilitators.

Evaluation and discussion The overall course

evaluation was positive (rating scale 1 ¼ poor to

5 ¼ excellent) in terms of its having achieved its

goals. Results indicated the course was positively

received, with respondents reporting the following

experiences as highly useful to their education: obser-

ving a health care professional (mean 4.20); inter-

viewing a patient (mean 4.05); quality of clinical

experience (4.07), and overall quality of the clinical

interlude (mean 3.80). In addition, the course direc-

tors asked students to complete a written narrative

assessment on their experience. A total of 91% of

students reported that the curriculum helped them to

recognise that:

1 non-physician health care professionals play integral

roles in patient care;

2 communication between members of the health care

team and with patients is important to function

effectively, and

3 students themselves can have control in defining the

kind of physicians they will become.

In conclusion, early clinical experiences provided first

year medical students with new insights and motivation

for learning. Medical school curricula can promote the

professional development and maturation of students in

clinical contexts early in their careers.

Correspondence: Preetha Basaviah MD, Box 0120, 505 Parnassus,

UCSF - University of California, San Francisco, California 94143,

USA. Tel: 00 1 415 514 2095; Fax: 00 1 415 514 2094; E-mail:

[email protected]

How does the introduction of computers andwall-mounted plasma screens impact smallgroup tutorials? Preliminary results

B Price Kerfoot, Barbara A Masser & Janet P Hafler

Context and setting Educational technology has

advanced remarkably over the last decade, but its

impact on teaching and learning is unclear. At our

institution, medical students who would usually use

textbooks as reference materials during problem-based

learning tutorials have been provided with a computer

with Internet access and a 50-inch, wall-mounted

plasma screen in each tutorial room.

Why the idea was necessary While the technology

is state-of-the-art and the institutional investment is

substantial, the question remains as to how this

technology will affect tutorials.

What was done The study’s design included both

qualitative and quantitative research methods. Appro-

val was obtained from the Harvard Medical School

Institutional Review Board (IRB). The first courses in

the medical school’s Year 1 and 2 classes were selected

for study. A stratified random group of tutorials was

observed for 21 1-hour sessions to document the

patterns of use of the new technologies. Based on these

observations, survey questions were developed and

field-tested on a focus group of nine medical students.

The questions were then distributed to the students as

part of a computer-based, end-of-course evaluation

instrument. Separate paper-based surveys were distri-

buted to all tutors at the end of both courses. Students

and tutors were asked to:

1 rank on a 5-point scale the impact (positive or

negative) the computers and wall-mounted plasma

screens had on tutorials;

2 list examples of how the plasma screens were used in

a manner that positively or negatively affected the

tutorials, and



3 suggest any changes that might increase the useful-

ness of this technology.

Observational field notes were qualitatively analysed

for themes. Analysis of the survey data was descriptive.

Evaluation of the impact Survey response rates

were excellent among second year students (97%) and

tutors (77%), but more limited among first year

students (61%) and tutors (60%). The technologies

were rated as having a very positive impact on tutorials

by all groups: first year students and tutors gave mean

ratings of 1.61 (SD 0.71) and 1.93 (SD 0.89),

respectively; second year students and tutors gave

mean ratings of 1.64 (SD 0.91) and 1.95 (SD 0.89),

respectively. The plasma screens were used an average

of 13.50 minutes (median 10.00 minutes, SD 13.25)

per 1-hour tutorial observation. Resources utilised

included Internet sites (48% of total use time), Pow-

erPoint presentations by students (28%), and course-

specific postings (24%). The majority of tutors (53%)

cited multimedia capabilities (pertinent video clips,

anatomy animations and PowerPoint presentations) as

examples of how the technologies made a positive

impact on tutorials. Tutorial observations revealed the

potential for the technologies to interrupt the flow of

the tutorial process. On average, there were 1.45

(median 1.00, SD 1.82) significant interruptions per

1-hour tutorial observation, each lasting a mean of

3.86 minutes (median 3.00, SD 5.19). Examples of

interruptions included a lull in discussion during

attempts to find an educational resource on the Internet

or web-searching by an individual that resulted in the

termination of the conversation. Survey data confirmed

this finding. These preliminary data will be used to

develop workshops and guidelines for faculty on how to

use this new technology in order to gain the greatest

educational benefit.

Correspondence: B Price Kerfoot MD, EdM, Department of Surgery

(Urology), Veterans Administration Boston Healthcare System,

1400 VFW Parkway, West Roxbury, Massachusetts 02131, USA.

Tel: 00 1 617 323 7700 6585; Fax: 00 1 617 363 5567; E-mail:

[email protected]

Management and delivery of the grossanatomy curriculum with decreased coursetime: the importance of structured teachingactivities

N S Vasan

Context and setting In the last 20 years, curricular

density in medical education, especially during the

preclinical years, has increased due to the inclusion of

new courses and other academic activities. This has

resulted in reduced curriculum time for all courses.

Furthermore, to encourage independent learning, the

number of lectures in each course has been reduced,

favouring problem-orientated, small group teaching.

Why the idea was necessary The gross anatomy

(GA) programme, which has visibly larger course time,

became a natural target and suffered a disproportionate

reduction in allotted time.

What was done In teaching GA, we have addressed

the challenge of an approximately 20% time reduction

by restructuring the course and delivery of materials,

decreasing the emphasis on minutiae and focusing on

clinical integration. The laboratory teaching took place

in small groups of 22 students per teacher. In addition,

the course director and a senior faculty member rotated

through all the teaching laboratories and conducted

interactive clinical integration teaching. The faculty

member provided well structured pre-laboratory in-

structions, focusing on the �big picture�. The pre-

laboratory presentations uniformly emphasised the core

material specified in the syllabus, and at the same time

allowed faculty members to maintain their creative

teaching styles. In addition, the teachers provided an

interactive post-laboratory review that focused on

clinical integration. The course co-ordinator conducted

weekly reviews to integrate embryology, radiology,

gross anatomy and problem solving of clinical cases in

an interactive format. These reviews served to reinforce

a large amount of material in a clinical context. The

author also introduced E-mail quizzes with clinical

vignettes as well as �clinical conditions� taken from the

National Board of Medical Examiners’ �content out-

line�. These often led to oral presentations by students

picked at random during subsequent laboratory ses-

sions. Since 1997, the Physical Medicine and Rehabil-

itation faculty and residents have taught

musculoskeletal and neuromuscular aspects of clinical

anatomy during laboratory time. These small group

sessions are interactive and have enhanced students’

understanding of anatomy in a clinical context.

Evaluation of results Faculty members and stu-

dents expressed extreme satisfaction with the new

course format. The reduction in the number of lectures

encouraged faculty members to be selective on lecture

topics and motivated them to present their material in a

clinical context. Student attendance of these clinically

integrated lectures increased from 40% to 90% of the

class. In 1997, 25% of the multiple choice questions on

the GA examinations included problem-orientated

clinical items; this was gradually increased to 90% by

1999. In the first of three written examinations, the



class average was 76.46% 9.66%; by the third it had

risen to 83.36% 8.30%. The students’ performance on

the standardised national board test, which is also

clinically orientated, showed a dramatic increase from a

class average of 73.1% 6.8% in 1997 to 83.9% 6.5%

in 2000. We attribute these improved test scores to

students’ increased affinity for the application of

anatomical knowledge to clinical problem solving.

Correspondence: N S Vasan, DVM, PhD, Department of Cell Biology

and Molecular Medicine and UMDNJ Master Educator Guild,

UMDNJ - New Jersey Medical School, Newark, New Jersey 07103,

USA. E-mail: [email protected]

The Write Stuff: selected study module inmedical writing

Peter Cross & Sabina Dosani

Context and setting A successful 4-week selected

study module (SSM) in writing skills for medical

students took place at Bart’s and the London School

of Medicine and Dentistry during August 2002. Selec-

ted study modules provide an opportunity to explore an

area of interest outside the core curriculum. As far as it

is known, this is the first time this sort of course has

been offered to medical students.

Why the idea was necessary Good writing skills

are a prerequisite for anyone wishing to have a career

in medicine. In the process of learning how to

research, market and write publishable pieces, stu-

dents improved skills essential for a doctor. Skills

were gained in writing newspaper copy crossover and

improving letters, reports and case note entries.

Students learned techniques pertaining to time man-

agement and working to deadlines ) editors do not

give extensions!

What was done The course was designed and

piloted by writer and journalist Peter Cross, whose

work has appeared in most broadsheet titles and

numerous magazines and specialist journals. He

hypothesised that any motivated medical student has

the necessary writing skills to produce publishable

prose for a national broadsheet. To test this, he took a

group of 13 medical students through the creative

process. They were shown techniques for generating

ideas, told where to find newspaper contact details

and advised how to approach specific editors. They

were helped to draft, write and improve articles and

features.

Students produced interview features, book reviews

and a think-piece, entitled The NHS in Crisis?

Inspired by an in-course visit to the National Portrait

Gallery, students wrote a review of the visit aimed at

a particular publication. There were other activities,

such as a trip to see a trial at the Old Bailey, a talk

and interview with a nursing journal’s news editor

and another with the editor of an international

medical student magazine. The informal teaching

encouraged individual learning and self-motivation.

There were frequent opportunities to apply new

knowledge and skills, with daily written assignments

coupled with peer and tutor feedback. Students also

generated their own topics, reflecting individual

interests and aspirations.

Evaluation and feedback The course was evalu-

ated in three ways. General satisfaction was ascer-

tained through end-of-module questionnaires and

interviews. Changes in knowledge were apparent

from student evaluations and tutor observations.

Changes in performance were evident: written work

produced at the end of the course was dramatically

better than earlier efforts. Five of the 13 students

submitted essays for external medical student essay

competitions. Four students stated that this sort of

writing was something they had never considered.

The tutor’s contribution has been recognised by the

medical school, with the result that he has been

invited to teach essay writing skills to the entire

fourth year.

Correspondence: Peter Cross, 154 The Circle, Queen Elizabeth Street,

London SE1 2JL, UK. Tel: 00 44 207 234 0476; E-mail: peter-

[email protected]

Communicating during procedures:development of a rating scale

Debra Nestel, Jane Kidd & Roger Kneebone

Context and Setting: Most undergraduate medical

communication programmes focus on developing

patient-centred skills within a medical interview.

Although this is an appropriate starting point for

learning the skills of gathering and imparting informa-

tion, it does not take account of the specialised

communication skills required during clinical proce-

dures on conscious patients.

We have developed a technique of scenario-based

assessment, where medical students integrate technical

with communication skills in a quasi-clinical setting.

Participants conduct �procedures� (such as suturing or

urinary catheterisation) on simulated patients who are

attached to benchtop clinical models. This provides a



safe environment within which to examine and teach

procedure-related communication. We observed that

some students were unable to maintain their patient-

centred communication skills while conducting such

clinical procedures.

Why the idea was necessary: Rating scales are

often used in formative assessments but do not take

account of the specific communication skills required

during an invasive procedure. Although the opening

and closing stages of such a procedure demand skills

common to all medical interviews (skills such as

establishing a rapport, exploring the patient’s anxieties

and establishing an agreed action strategy), communi-

cation during the actual procedure serves an additional

function. Monitoring the patient’s well-being is para-

mount, and the clinician must be vigilant in observing

facial expressions, body movements, changes in the

patient’s voice and requests, and also be sensitive to the

patient’s feelings, adept in voicing empathic statements

and making effective use of silence.

What was done: A literature search showed that little

has been published in this field. We therefore developed

a rating scale for procedure-related communication

skills. In Section 1, 14 checklist items are presented

sequentially. Before the procedure, each student is

expected to cover the following: greet the patient,

introduce him⁄herself by name and role, check the

patient’s comfort, state the purpose and explain the

procedure, assess the patient’s understanding and

establish consent. After the procedure the student

should state what was done, what will happen next,

check the patient’s understanding and ask for questions.

Section 2 presents seven key competencies, each

rated on a 5-point global scale. These are: the use of

non-verbal communication, response to patient’s verbal

and non-verbal cues, appropriate use of silence, use of

unexplained jargon, making empathic statements and

showing warmth.

The rating form is used in scenario-based format-

ive assessments as described above. Observers rate

each procedure in real time, using closed-circuit

video equipment. Immediately after the procedure,

the student who conducted it uses an identical form

to rate a videotaped recording of his or her

procedure.

Evaluation: The current version of the rating form

is the result of progressive refinement based on group

interviews with participants. Observational and inter-

view studies using standard qualitative methods show

that the form has helped to raise students’ awareness of

the unique nature of procedure-related communication

skills by focusing their attention on key areas. A feature

of the form is its applicability to many clinical proce-

dures. Establishing reliability and validity and piloting

the form in summative assessments is planned.

Correspondence: Debra Nestel, Centre for Medical & Health Sciences

Education, Building 15, Monash University, Clayton, 380, Aus-

tralia. Tel.: 61(3) 9905 4401; E-mail: [email protected].

edu.au

Can ‘performing’ a procedure help studentsexplain it to their patients?

Roger Kneebone, Debra Nestel & Paula Taylor

Context and setting When an investigative proce-

dure is scheduled, the patient often asks an inexper-

ienced member of the medical team (such as a

medical student) to explain what will happen. While

most students will have witnessed investigations such

as flexible colonoscopy, they will almost certainly

never have performed the procedure themselves.

Although practical details often concern patients most,

these are the very issues that students know least

about.

Why the change was necessary We hypothesised

that the experience of �performing� a procedure might

enhance students’ ability to meet the patient’s need for

information. We used a commercially available virtual

reality (VR) endoscopy device, originally developed for

clinical training. This allows learners to carry out the

steps of flexible colonoscopy, manipulating a real

endoscope while watching a high fidelity display that

closely approximates clinical reality.

What was done Volunteer third year undergra-

duate students in a London teaching hospital were

randomised into one of three intervention groups for

a 1-hour learning session using either a VR simula-

tor, a factual CD-ROM or written material, or a

control group. Each student then underwent a 10-

minute interview with a simulated patient (SP),

during which they explained an impending flexible

colonoscopy.

Students completed evaluation forms before and

after the consultation, rating their confidence, com-

petence and anxiety about explaining endoscopy.

Standardised patients rated their satisfaction with

the information they were given and how it was

delivered. Group interviews with students and SPs

were recorded and analysed using standard qualitative

methods.

Evaluation of results Twenty-two undergraduate

medical students participated in the study (groups of 6,

6, 6, 4). All felt engaged by the process and found it

valuable.



Before the SP consultation, intervention group stu-

dents felt less confident than control group students in

their ability to provide appropriate information. After

the consultation, however, intervention group students

felt greater confidence than the control group in their

knowledge of technical aspects of the procedure. There

were no differences between groups in self ratings of

confidence, competence and anxiety.

Students in the VR simulator group were rated more

highly by SPs than students in the other groups.

Overall, SPs were satisfied with the students’ abilities

in giving information, although they identified specific

areas for improvement, including: assessing the level of

information needed; avoiding unexplained jargon;

summarising key information; using signposting; check-

ing understanding; improving the ending of the con-

sultation, and increasing sensitivity and making

empathic statements.

Students reported that the SP consultations raised

their awareness of the wide range of information that

patients require about forthcoming procedures. De-

tailed technical knowledge of the procedure, while

clearly necessary, was effective in meeting only a small

part of the patients’ need for information.

State-of-the-art VR training devices have consider-

able potential for widening and deepening students’

understanding of complex procedures, providing

insight into practical issues that are of particular

concern to patients yet are seldom taught. The

practice of arranging consultations with SPs alongside

simulator-based experience allows students to develop

specific skills pertaining to patient-centred explan-

ation.

Further work will apply this concept to a range of

endoscopic and interventional radiology procedures

where suitable VR technology exists. This will include

bronchoscopy, endoscopic retrograde cholangiopan-

creatography and cardiac catheterisation.

Correspondence: Roger Kneebone, Senior Lecturer in Surgical Educa-

tion, Department of Surgical Oncology and Technology, Imperial

College London, 10th Floor QEQM Wing, St Mary’s Hospital, Praed

Street, London W2 1NY, UK. Tel: 00 44 207 8867930; E-mail:

[email protected]

Teaching professional development inundergraduate medical education

Hamish Wilson, Tony Egan & Rose Friend

Context and setting Starting with the intake of

preclinical second year students in 1997, the Otago

Medical School in New Zealand made a number of

educational changes to the curriculum, placing greater

emphases on small group teaching, communication

skills, and self-directed learning. A new module called

�Professional Development� was included when the

1997 cohort of students reached their first clinical year

in 1999.

Why the change was necessary The only previ-

ous teaching in professional development consisted of

a 1-day seminar for final year students on occupational

health issues, substance abuse and critical incident

debriefing. The new curriculum allowed an opportun-

ity to expand on those topics in response to changing

societal expectations of practitioners, the need for self-

regulation by the profession and the recognised

occupational stresses of undergraduate medical stu-

dents.

What was done A multidisciplinary group devel-

oped specific attitudinal, skill and knowledge objec-

tives, and planned relevant activities for fourth to sixth

year students. Key decisions included: ensuring men-

tors did not participate in summative assessment of

their students; ensuring that topics were directly rele-

vant to student experience, and taking a developmental

approach over 3 years. Whole class sessions reviewed

student experiences of patient suffering, clinical uncer-

tainty, clinical teamwork and the stresses of undergra-

duate medical life. We increased student participation

by: minimising didactic input; encouraging participa-

tion and questioning, and using role-plays and vi-

gnettes. These methods encouraged multiple

perspectives and created conditions in which self-

awareness and the capacity for critical thinking could

develop.

These goals were also pursued individually by

students writing �thought provoking episode reports�(TPERs) and discussing them in mentored groups.

Thought provoking episode reports are similar to

critical incident analyses and have helped students to

systematically review their clinical and learning experi-

ences. From this work, students became more aware of

their personal reactions; they progressed from �mulling

over� to critical analysis and in the process discovered

underlying ethical issues. Regular review of TPERs

gave students practice in critical thinking, a skill as

important as medical history taking. The mentor’s role

has been to facilitate this.

We now employ over 30 mentors, all of whom are

practising doctors and none of whom are involved in

summative assessment of their students. Mentors meet

with groups of four students in the fourth and fifth years

to discuss their TPERs. In the final year, students meet

their mentor individually four times, reflecting the

students’ increasing clinical responsibilities. Mentors



attend regular training and review sessions to define

their role and develop their skills.

Evaluation of results Yearly student and mentor

evaluation data have indicated increasing participation

in these activities since the first cohort started in 1999.

In 2003, 11 final year students (one-fifth of the class)

will receive monthly mentoring; this pilot scheme will

be closely evaluated with respect to expectations and

experiences. Mentors have provided students with a

non-assessed forum for personal support and critical

thinking; many have commented on the lack of such

structures in their own training. Overall, we are

developing a growing appreciation of the role of

structured mentoring within medical education.

Correspondence: Dr Hamish Wilson, Dunedin School of Medicine,

University of Otago, Box 913, Dunedin, New Zealand. Tel: 00 64 3

479 7430; Fax: 00 64 3 479 7431; E-mail: [email protected]

Setting our own standards: a student-ledprofessionalism curriculum for preclerkshipstudents

Jennifer Rockfeld, Margaret Horlick & Adina Kalet

Context and setting At New York University School

of Medicine, the Professionalism Committee, consist-

ing of three second year students and a faculty advisor,

was formed in response to dissatisfaction on the part of

both administration and students with the lack of clarity

about expectations of medical students’ standards of

professionalism. We generated and led a curriculum for

first year students to provide the skills to recognise,

analyse and respond appropriately to conflicts between

professional values and the daily pressures of medical

school. Eventually this work will lead to the develop-

ment of fair and clear criteria with which to judge

professional behaviour.

Why the idea was necessary Physicians have the

right and responsibility to regulate the standards of

conduct of their profession; medical students, however,

are rarely prepared to take on this responsibility.

What was done During orientation week, students

shared their views of professionalism by first writing

about them and then talking them over in small groups.

Later in the year, the students attended a workshop to

learn about professional values as they apply to the

preclerkship years. Our student leaders developed five

case studies of unprofessional behaviour in the pre-

clerkship years; one, for example, involved an uninter-

ested student whose lack of participation and humorous

comments undermine the learning in a small group

conference. Volunteer second year students were

trained to lead the case discussions with first year

students. At the conclusion of each case discussion, the

group was asked to agree upon expectations for

professional behaviour for themselves and their class-

mates. Students completed a confidential self-assess-

ment questionnaire to set personal goals for

improvement at the end of the workshop. They placed

the questionnaire in a self-addressed, sealed envelope,

which was returned to them 3 months later for review.

The committee conducted a similar workshop during

clerkship orientation, using clinical scenarios created by

an advisory group of students based on their real

experiences and concerns.

Evaluation of results and impact This rich

curriculum prepared students to behave professionally,

engaged them in setting standards, led to an unprece-

dented level of open discussion about their behaviour,

and was run by well-prepared and effective student

facilitators who also benefited. When asked during

orientation to list the attributes of professionalism, the

students struggled to apply broad values (honesty,

compassion, integrity and respect) to specific preclin-

ical settings. The professionalism workshop challenged

them to agree on explicit, behavioural applications of

these values. Their responses ranged from being

accountable for personal actions to improving educa-

tional quality for future medical students through

constructive feedback to faculty. This year we will

conduct similar activities, analyse the data from these

sessions to develop evaluation criteria for all levels of

medical education, and conduct a peer assessment

workshop using role play to practise giving and

receiving fair and constructive feedback. Students and

faculty should collaborate on fostering development of

the highest standards of professionalism and teaching

the necessary skills to apply them early in medical

training.

Correspondence: Jennifer Rockfeld, Education Coordinator, Division of

Primary Care, Department of Medicine, NYU School of Medicine,

462 First Avenue, Old Bellevue D401, New York, New York 10016,

USA. Tel: 00 1 212 263 8895; Fax: 00 1 212 263 8234; E-mail:

[email protected]

Training and testing competence in directophthalmoscopy

A Levy & A J Churchill

Context and setting The final MBChB examination

at Bristol is a summative assessment of the degree



programme as a whole, with emphasis on the clinical

aspects of the curriculum. It is also intended as a test to

ensure that the student is fit for a post as a pre-

registration house officer (PRHO). The 15-station

objective structured clinical examination (OSCE)

forms part of a battery of examinations that previously

included interpretation of retinal photographs to indi-

cate competence in ophthalmology.

Why the change was necessary Most students

consider themselves to be competent direct ophthalm-

oscopists, yet surprisingly few seem able to use an

ophthalmoscope effectively. The ability to recognise

retinal disease patterns is not useful if the retina cannot

be seen in the first place, but there is little incentive for

students to master the technique if the presence of

inadequately dilated pupils, involuntary patient eye

movement and other clues to potential retinal pathol-

ogy, such as the presence of diabetes or hypertension,

allow bluff and bluster to compensate for lack of

competence.

What was done We developed a highly realistic

manikin in which the globe is constructed from a table

tennis ball painted on the inside surface via a 1-cm

diameter hole with two coats of orange matt emulsion.

A cut-out of the optic disc and major retinal blood

vessels is glued to the inside of the ball. Word targets (in

3-point Helvetica plain text) are positioned at the

macula and at six other locations. The model is

completed by closing the hole with the lens and

diaphragm assembly from a single-use camera. A

binocular stand with a plywood face profile and further

table tennis balls as �sockets� secures the model during

use and encourages the use of the appropriate hand and

eye for examination of each side. To view the targets,

the student has to look through a lens and diaphragm

and use the ophthalmoscope light and integral lens

system to bring each of the words into focus over a 120�range.

Evaluation of the results In the OSCE, students

were given 5 minutes to read the words and record

their positions on a printed mark sheet. Scores for

recording each word correctly were 30% for the

macula word and 10% for each additional word, with

a 10% bonus for entering all the words correctly. Of

133 students who took the examination, 100 scored

100% and a further 24 scored at least 50%. The

remaining nine students, two of whom scored zero,

were able to recognise their failings and seek further

training and help. Feedback was very favourable, with

one student attributing her competence to practising

with the manikin. All the manikin components are

readily available in the high street at very low cost.

Unlike with commercial models, it is not possible to

see the target words or to guess the target identity in

our manikin without using an ophthalmoscope. Pat-

tern recognition is easily taught using retinal photo-

graphs, but a student who is unable to read the words

is unable to use an ophthalmoscope.

Correspondence: A Levy, University Research Centre for Neuroendo-

crinology (URCN), Bristol University, Jenner Yard, Bristol BS2

8HW, UK. Tel: 00 44 117 928 3326; Fax: 00 44 117 928 3315;


Development of a competency-basedneurology clerkship

David Lee Gordon & S. Barry Issenberg

Context and Setting: A required four-week clinical

clerkship in neurology.

Why the change was necessary: Historically, the

University of Miami School of Medicine (UMSOM)

third-year neurology clerkship consisted of ward

rounds, weekly clinics, and faculty-driven lectures.

Students rarely received neurologic examination train-

ing. Student assessment consisted of a summative

cognitive multiple-choice exam at the end of the

clerkship with no testing of clinical skills. Student

evaluations indicated a variable ward experience that

depended on the patients seen and the willingness to

teach of residents and attendings. In July 2001, the

UMSOM implemented an outcomes-based neurology

clerkship designed to provide a standardised core

curriculum for medical students.

What was done: Learning objectives include the

knowledge, skills and attitudes students should possess

at the end of the neurology clerkship. These are

consistent with the neurology clerkship core curriculum

guidelines endorsed by the American Academy of

Neurology. Twenty computer-based case vignettes

comprise a core clinical curriculum in neurology,

including 10 common neurologic problems such as

headache and dementia and 10 neurologic emergencies

such as stroke and seizures. Didactic components of

these cases are available to the students on the internet.

Students attend 10 2- h sessions, each covering 2 cases

presented as unknowns and led by a faculty member or

neurology resident. After each session, a 5-question

quiz focuses on the learning objectives for that day’s

session. Faculty members review and discuss the

quizzes in three sessions. The quizzes provide formative

feedback to the students and also contribute to their

overall grade.

On the first day of the clerkship, students are

taught how to perform an essential neurologic exam-



ination using a multimedia computer program and

small-group sessions with standardised patients (SPs).

Two additional SP sessions emphasize performance

of focused neurologic examinations. In one session,

each student has 15 min to examine an �aphasic� SP.

In another session, each student has 5 min to

examine a �comatose� SP and 10 min to discuss the

condition with his �relative.� After each of these

sessions, the students review and discuss their video-

taped performances with the actors, an instructor,

and each other.

Assessment of student competence includes: a final

written exam based on the 20 case-vignette learning

outcomes; a final OSCE in which students have

10 min to perform a neurologic exam on a normal

patient while being assessed by a faculty member

with a skills checklist; computer simulation-based

outcome measures in bedside neurology skills, writ-

ten and oral presentations of patients seen in wards

or clinics; attendance and effort; and ward perform-

ance.

Evaluation of the Impact: To date, student ques-

tionnaires reflect overwhelming satisfaction with the

clerkship. Students feel their assessment is fair and

consistent with their learning experience. All students

complete the clerkship competent in performing an

essential neurologic examination. Pre- to post-test

scores from more than 150 students on the computer-

based outcome measures show an increase from 38.4%

to 84.2%, respectively. Future work includes studying

the retention of these skills and need for remediation

prior to graduation.

Correspondence: S. Barry Issenberg, MD, Centre for Research in

Medical Education, University of Miami School of Medicine, 1430

North-west 11th Avenue, Miami, Florida, 33136, USA. Tel.: 305-

243-6491; Fax: 305-243-6136; E-mail: [email protected]

A sharing programme to improve women’shealth education in a veterans’ hospital clinic

Sally G Haskell

Context, Setting and why change was necessary: In

the ambulatory clinic, the Accreditation council for

Graduate Medical Education requires that an Internal

Medicine resident’s patient panel beat least 25%women.

This requirement poses specific difficulties for Internal

Medicine Residency programmes that utilise veterans’

affairs (VA)hospitals for training sites,where themajority

of patients have traditionally been male. Residence

programmes that utilise VA hospitals for outpatient

training must make creative changes to accommodate

this need for improved women’s health education.

Description: Several years ago, our VA hospital

opened a women’s health clinic. The Women’s Health

Clinic is a site within the VA hospital, where women

can receive primary care, and gender specific care such

as pap smears and breast exams in a private, comfort-

able, secure environment. This setting is an ideal one

for educating residents in women’s health. It provides a

number of advantages including the availability of

Internal Medicine attendings who have a special inter-

est and expertise in women’s health and the opportun-

ity for residents to interact with sub-specialists in

women’s health areas. We designed a programme to

incorporate Internal Medicine residents into the Wo-

men’s Health Clinic by scheduling them to see patients

in the Women’s Health Clinic, instead of in their usual

primary care clinic, every fourth week.

The most challenging problem was to increase the

numbers of women patients available to be seen by

residents in the Women’s Health Clinic. In an effort to

increase the numbers of female patients utilising the

Women’s Health Centre, a �Sharing Programme� was

negotiated with the affiliated University Department of

Medicine. The purpose of the programme was to devise

a way for the wives of veterans to be able to receive care

at the VA Women’s Health Centre. In this programme,

the wives of veterans who have either Medicare or

private insurance are seen in the VA Clinic by Univer-

sity Faculty members who are also VA staff physicians,

along with residents.

The patients are registered by computer, into the

University billing and scheduling system and the VA

Women’s Health Centre is treated as if it were a satellite

clinic of the University Medical Group. The patients

are then seen at the VA but billed by the University

Medical Group for the care they receive. The VA

subsequently bills the University Department of Medi-

cine, on a per visit basis, for the �cost� to provide care for

each patient.

Evaluation: this programme has been in existence

for 10 months. There are three Internal Medicine

physicians participating on a part time basis, as well as

37 medical residents. So far 124 patients have enrolled

in the programme. The patients are interested based on

the convenience of receiving their care in the same

location as their husbands, comfort with the VA system

and confidence in the physicians. Based on the new

patients from this programme, as well as the constant

gradual influx of women veterans, the residency pro-

gramme will be able to meet its goal of 25% women for

all medical resident panels.



Correspondence: Sally G Haskell, MD, Women’s Health Centre,

VA Connecticut, 950 Campbell Avenue, New Haven, CT 06516,

USA, Tel. 203 9325711, ext 5400; Fax: 203 9374395; E-mail:

[email protected]

The three-headed mentor: rethinking theclassical construct

Rachel B. Levine, Randy S. Hebert, & Scott M. Wright

Context and setting: Mentoring relationships are

invaluable for the professional growth of physicians.

Mentors provide teaching, guidance and moral sup-

port. Those pursuing a career in academic medicine

will rely on mentoring relationships to promote their

development, and in turn will be expected to act as

mentors themselves.

Why the idea was necessary: Faculty and fellows

rarely receive formal training in mentoring skills. We

surmised that a shared mentoring experience would

provide fellows with an opportunity to learn and

practice skills related to effective mentoring. We also

hypothesised that a shared approach would help to

overcome common barriers by increasing the total time

available for mentoring, providing a broader range of

skills, and exposing mentees to multiple styles, per-

spectives, and teaching philosophies.

What was done: We developed a �three-headed�approach to mentoring. Our team included two

General Internal Medicine fellows (one first and one

third year) and a faculty member. Together, we

mentored an intern and a third year resident on two

separate research projects over an 18-month period.

Residents met with the entire team or with individual

mentors depending on time constraints. Prior to

starting the research projects, the mentors reviewed

the mentoring process, discussed strategies, and set

goals. The mentors met periodically to debrief experi-

ences and reflect on ways to improve the model.

Residents were asked to provide feedback on the

experience from their viewpoint. The model was

refined accordingly.

Evaluation: We performed a qualitative analysis of

the experience. Mentors and residents were asked to

comment on their initial goals for the experience and

how the multiple mentor approach helped or hindered

the research.

Both fellows wanted to gain experience in mentor-

ing a junior physician on a research project and

recognised that they did not yet have the skills and

resources necessary to do so. The fellows wanted the

opportunity to observe an experienced mentor and

�pick up tips� in the process. The faculty mentor

wanted to meet the goals of the residents by helping

them to complete a successful research project. He

wanted to role model important skills and behaviors

critical to mentoring such as �setting specific goals,

being available and approachable, and responding

promptly�. All three mentors were committed to

observing one another �mentoring-in-action� and pro-

viding feedback. All believed that the approach was

time saving, fun, effective (producing quality research)

and resulted in greater reflection about the mentoring

process.

Both residents wanted to learn about conducting

research and complete a successful project. They

commented that the multiple mentor approach helped

to model teamwork and communication skills. The

third year resident described her experience: �I was able

to get many perspectives and learn from each of the

mentor�s strengths.’ The residents valued meeting with

the individual mentors but also wanted the whole

research team to meet periodically.

Based on the initial success of this intervention, we

believe that there may be a role for expanding the

mentoring relationship to include more than one

mentor. This commentary represents the first report

documenting the effectiveness of such a model to train

mentors and to more thoroughly support mentees in

their scholarly work.

Correspondence: Rachel B Levine MD, Division of GIM, B2N, Johns

Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore,

MD 21224, Tel.: 410-550-1862; Fax: 410-550-3403; e-mail:

[email protected]

�My question is…� – learner-centred precepting

Linda Pinsky

Context & Setting: A pilot of learner-centred pre-

cepting (LCP) was undertaken in an academic medical

centre general internal medicine continuity clinic that

has approximately 40 residents and 15 faculty mem-

bers.

Need for change: Several studies note discrepancy

between residents’ perceived learning needs and faculty

assessment of those needs when using traditional

precepting techniques. The objective of the LCP

approach is to increase teaching effectiveness by

encouraging learners and preceptors to co-construct

their learning encounter.

What was done - strategy and implementation:

A �learner-centred precepting� case presentation tem-



plate consists of 3 �moves�. Firstly, at the outset of a

patient case presentation, learners frame their general

learning need as a question: �My question is…� along

with describing the context of the patient’s presentation

(including the chief complaint). The second move

consists of conveying pertinent patient information to

the preceptor. The third involves clarifying the know-

ledge, skills or logistical information needed by the

learner to care for the patient.

LCP begins with the learner making a diagnostic

commitment and encourages the attending physician

to diagnose the learner in parallel with diagnosing

the patient, similar to the teaching principles used in

the �microskills of teaching.� In LCP, however, the

learner is an active partner in the teaching⁄learning

process and the process is explicit. Asking the

learner to frame a question about a perceived

knowledge deficit allows learners to gain skills in

self-assessment. It also enables the preceptor to

identify efficiently the learner’s perceived need, and

to diagnose better the learner’s understanding based

on the sophistication of the question asked. For

example, the presentation of a man with diabetes

might begin with the question �What are the relative

advantages of glargine vs. ultralente insulin?� thus

directing the teaching to the perceived need and

avoiding teaching that duplicates the learner’s exist-

ing knowledge of diabetic care.

LCP has the added benefit of modelling and

reinforcing techniques physicians use in patient-centred

care, i.e. establishing the patient’s agenda and attribu-

tion. Similarly, LCP begins with the learner’s statement

of agenda and attribution of the learning needs. Having

an explicit question in LCP provides a starting point for

discussion if the preceptor disagrees with the learner’s

perception of the case, teaching by example analogous

techniques for negotiation between physicians and

patients.

Training using videotaped examples and role-plays

was provided in separate groups for residents and

faculty. The residents practised identifying possible

categories of questions they might have. Attending

physicians, concerned about the possible loss of control

with the technique, practised techniques for redirection

of resident assessments.

Evaluation: Response after 18 months as assessed

by focus groups was very positive. Learners report that

this technique assists them in organising their thoughts

and decreases the number of learner-precepting teach-

ing mismatches. Preceptors report better understanding

of learners’ needs. Some preceptors’ initial hesitations

about the possibility of missing important clinical

information when relying on resident-directed discus-

sion have not been born out. A formal evaluation is

planned to look at the concordance of learner and

preceptor learning needs assessment. Future plans

include assessment of question type by learner levels

and impact of this approach on patient satisfaction.

Correspondence: Linda Pinsky, MD, Associate Professor of Medicine,

Department of Medicine, University of Washington, Campus Box

354760, 4245 Roosevelt Way NE, Seattle, WA 98103 USA.

Tel.: (206) 598–5527; Fax: (206) 598–5952; E-mail: lpinsky@

u.washington.edu

A novel means of feedback for the EmergencyResponse Team

Gautam Ramakrishna, Nicola E Schiebel & Henry J.

Schultz

Context and Setting: The Emergency Response

Team (ERT) at most teaching institutions has tradi-

tionally been vested with the responsibility of treating

patients in cardiac and⁄or respiratory arrest. At our

institution, the ERT responds to not only cardiac

and⁄or respiratory arrest, but also to a variety of other

emergencies such as severe gastrointestinal haemor-

rhage and non-cardiogenic syncope, on a 24- h needs-

available basis.

Our teaching hospital’s ERT consists of a senior

internal medicine resident and the cardiology intern on

call. The ERT also includes a pharmacist, specialised

nursing staff, phlebotomists, as well as critical care

service fellows who provide airway management.

Need for and Description of the Code Review

Session: Although ERT situations may build confid-

ence in residents, experience alone is by no means an

assurance of improvement in skill. Thus, we have

instituted a monthly ERT review session for residents

on the cardiology rotation to provide prompt feed-

back on management of ERT situations. To our

knowledge, such a forum has not been previously

described.

Case presentations by the senior residents are com-

plemented by feedback from the audience which

consists of cardiology interns, senior residents, and

cardiology and emergency medicine faculty. Presenters

are encouraged to present cases in stepwise fashion and

to prompt the audience for the next action at key

branch points. The review of a case includes:

• Reason for ERT activation and relevant details of the

patient’s clinical history

• Arrhythmia interpretation. When available, telemetry

recordings are presented for the audience to inter-

pret.



• Quality assurance, including the timing and role of

ancillary support

• Overall assessment of team dynamics and leadership

skills.

• Outcome of interventions, follow-up on intensive

care unit course, decisions to cease resuscitative

efforts, and discussion of ethical dilemmas.

Evaluation and Assessment of Impact: To

assess the clinical and quality improvement impact of

the ERT review sessions, we hope to analyse a variety

of pre- and post intervention outcome and process

measures. At the completion of ERT care for each

patient, a detailed pharmacy data sheet, a written

narrative by the ERT Leader, and a Continuous

Improvement Data sheet are all generated. Data may

also be extrapolated from AED data cards, the

inpatient medical records, and discussions during each

review session. Using these resources, such factors as

arrival time of the ERT, time to first defibrillation, and

immediate outcome of interventions may be extracted.

Process measures such as efficacy of ERT Leader’s

supervision and delegation of responsibility and task

performance in following ACLS algorithms can all be

evaluated.

Conclusion: We anticipate that this unique model

for ERT review sessions will serve to enhance the

effectiveness of this critical response team and improve

clinical outcomes. This also serves as an open forum for

discussion of quality improvement as well as oppor-

tunity to debate the clinical approaches taken. Such an

interactive forum as an ERT review session may be the

critical inclusion in a resident’s curriculum to ensure

that experience with ERT situations is complemented

by timely feedback.

Correspondence: Gautam Ramakrishna, MD, 200 First Street SW,

Rochester, MN 55905. Tel.: 507-255-5123; Fax: 507-284-4200;


A brief but multi-faceted approach improvesclinicians’ domestic violence confidence,competence and clinical performance

Kathleen Haney, , Elizabeth Kachur & Sondra Zabar

Context and setting: Domestic Violence (DV) against

women is a common and devastating public health

problem. Although most professional organisations

recommend universal screening of female patients, it

is rarely done in clinical practice. Gouverneur Health

Center in New York City serves a highly diverse patient

population. Thus, the already difficult task of inquiring

about DV is complicated further by language and

cultural barriers.

Why the idea was necessary: A review of sequen-

tial charts of new female patients indicated that only

29% of new female patients were screened at intake.

Although our centre has highly competent DV social

workers, physicians were not fully accessing their

services.

What was done: Twenty-two clinicians (physicians,

nurse practitioners and physician assistants) partici-

pated in a 3-h workshop led by a Primary Care Internist

and a Clinical Social Worker who specializes in DV to

model a team approach. The workshop incorporated a

variety of teaching modalities to enhance participants’

knowledge, skills and attitudes: a videotape of DV

victims telling their stories; brainstorming to elucidate

clinicians’ barriers to inquiring about DV; interactive

mini-lectures on techniques for asking about DV and

how to proceed if the DV screen is positive; interview

and counselling practice with standardised patients

(SPs) in groups of 3–4 led by a trained facilitator. SP

cases reflected the ethnically diverse patient population.

After skills practice, clinicians discussed their experi-

ences, asked further questions and were provided with

DV hotline number cards, a referral resource list and

diagnostic and treatment algorithms.

Participants were surveyed via questionnaire to assess

their attitudes and level of confidence regarding DV

before and after the workshop and their satisfaction

with the programme afterwards. They also completed a

pre- and postintervention Objective Structured Clinical

Exam (OSCE), which included a DV station. A chart

review after the programme was compared with the

preintervention results.

Evaluation of results: Even prior to the workshop,

the majority of clinicians (90%) believed that all new

female patients should be screened for DV, and that

routinely asking about DV should be part of the annual

physical exam. However, 73% said that they usually

forgot to ask and 41% believed they had inadequate

training in this area. Only half felt very confident in

their ability to assist DV victims. After the workshop,

confidence improved markedly, with 95% stating that

they had adequate training to ask about DV and that

they were very confident in their ability to assist victims.

Only 14% still felt they lacked time to inquire about

DV, compared to 41% prior. In the DV OSCE station

there was significant improvement in most skills

assessed. Of particular importance, participants were

more likely to offer the DV hotline phone number

(P ¼ 0.0002) and assess social support systems

(P ¼ 0.0001). Direct inquiry about DV increased

from 60% to 100%.



Satisfaction with the programme was high; all

participants agreed that what they learned would

enhance their practice. Most importantly, the postpro-

gramme chart review indicated a 17% increase in

screening.

A relatively short workshop on DV can significantly

affect clinicians’ attitudes and performance and influ-

ence their everyday practice.

Correspondence: Kathleen Hanley MD, Women’s Health Cross-

Training Project, Gouverneur Health Systems, 227 Madison Street,

New York, NY 10002, USA. Tel.: (212) 238–7408; Fax: (212) 238–

7668; E-mail: [email protected]

Casting anxiety in small group facilitation:faculty development via role play

Sara Kim, Nancy G. Stevens & Linda Pinsky

Context and Setting: Clinical faculty members often

lead small group discussions in teaching rounds, case

discussions, and more formal teaching settings. The

University of Washington Family Practice Residency

Network’s faculty development programme has

developed training sessions for new and experienced

teachers.

Importance of Small Group Teaching: Learners

in small group settings can benefit from peers’ per-

spectives and opportunities to engage in self-assessment

and reflection of one’s learning. Specific strategies can

lead to successfully facilitating small groups, such as (1)

setting ground rules around learning goals; (2) eliciting

learners’ characteristics including prior experiences and

expectations; (3) using questions to prompt reflections;

(4) incorporating resources (e.g. video clips) to trigger

discussions; and (5) promoting dialogues when disa-

greements occur. These small group facilitation skills

are not explicitly taught during medical training.

Implementation: We designed a two-hour faculty

development session in small group facilitation. Faculty

members first share their experiences in managing small

groups in both teaching and non-teaching settings.

Then, faculty members engage in role-play based upon

scenarios exemplifying challenging group dynamics

involving dominant or non-participatory residents or

polarising views among residents. The pilot scenarios

involve, respectively, faculty seeking residents: (a) input

on a newly implemented geriatric rotation; (b) views

about patient-centred communication after watching a

video vignette; and (c) opinions about recommending a

mammogram for a 40-year-old-woman. Faculty train-

ees take the roles of facilitators, consultants, observers,

or residents.

A sample scenario for a small group facilitator reads,

�You designed a new geriatric rotation at your pro-

gramme and wish to receive feedback regarding resi-

dents� experiences. The facilitator is paired with a

consultant who provides assistance when difficulties in

group discussions remain unresolved. The rest of the

faculty members assume the following sample roles as

residents:

• You initially express your positive view about the

rotation. However, when other residents share their

frustrations with the rotation, you feel less encour-

aged to speak up even when prompted to.

• You strongly voice your opinion that the rotation was

bad and don’t understand why you need this rotation

in the curriculum in face of competing educational

demands.

• You haven’t done the rotation but upon hearing how

bad it is, you join the bandwagon.

• You try once to help the person who gave positive

feedback about the rotation but don’t sustain it.

Both facilitator and consultant are blind to the

specific roles other trainees play. An observer records

the facilitators’ behaviour during discussion. Following

the role-play, the group discusses the facilitator’s

behaviour in handling particular tensions and generates

tips for small group facilitation. Lastly, handouts on key

principles in small group facilitation are reviewed.

Evaluation: Twenty faculty trainees have partici-

pated in this training and completed evaluation ques-

tionnaires. Eighty percent of trainees rated the overall

teaching effectiveness as excellent and 75% found the

video clips and handouts very good or excellent. They

found the role-play interactive, experiential, comfort-

able and fun. The session was the highest rated faculty

development offering in several years. Participants

suggested using scenarios based on real examples

faculty trainees face in their own teaching.

Correspondence: Sara Kim, PhD, Assistant Professor, Box 356390,

Department of Family Medicine, School of Medicine, University of

Washington, Seattle, WA 98195. U.S.A. Tel.: 206-543-9425; Fax:

206-543-3821; E-mail: [email protected]



The Write Stuff: selected study module in medical writing

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