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Transcript of 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
� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489
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:
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
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� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489
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:
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
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� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489
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:
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
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� Blackwell Publishing Ltd MEDICAL EDUCATION 2003;37:473–489
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-
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
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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.
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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:
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
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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:
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
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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;
E-mail: [email protected]
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-
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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.
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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:
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:
�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-
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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.
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• 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;
E-mail: [email protected]
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%.
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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]
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