The Benefits and Challenges of Clinical Work-based Surface Anatomy Learning Among Preclinical Medical Students

@#Knowledge on surface anatomy enables medical students and graduates to locate anatomical structures exteriorly, improve their clinical and procedural skills and interpret ultrasonographic and radiographic images. Hence, a standard surface anatomy knowledge is essential for attainment of clinical skill competency. Nevertheless, there is lack of attention given on surface anatomy in the medical curriculum as it is usually delivered didactically or during selfstudy by the students. Owing to limitations in cadaveric dissection in many institutions, lecture-based instruction, e-learning materials, living anatomy models, radiological imaging and anatomy software are used in teaching surface anatomy; however, none of these methods proved to be effective over the others. Furthermore, some of these teaching resources lack clinical relevancy, possibly impeding students’ appreciation on learning surface anatomy. Hence, integrating clinical input during surface anatomy teaching by involving patients in an actual clinical environment is pertinent. This article demonstrates the benefits and challenges of teaching surface anatomy in the clinical setting to medical students and highlights the need to design an evidence-based framework of work-based surface anatomy learning.

The Outcomes of Team-based Learning on Test Performance, Cognitive Engagement and Motivation in Preclinical Anatomy Practical Classes

@#Introduction: Designing an engaging teaching strategy that enhances the clinical application of anatomy knowledge is important for effective learning. Hence, this study was carried out to evaluate the outcomes of team-based learning (TBL) approach on students’ learning during gross anatomy practical classes. Method: A randomised-controlled trial was conducted on 215 pre-clinical year medical students, who were divided into TBL and control groups. Both groups attended the same anatomy lecture before the practical session. The TBL group underwent three phases of activities, which were pre-practical assignment (Phase-1), individual and team readiness assurance tests followed by a debriefing session (Phase-2), and group application task (Phase-3). Concurrently, the control group received a reading material as their pre-practical assignment and attended a practical session in the form of an anatomy model demonstration. Pre- and post-practical assessments were measured 30 minutes before and after the practical sessions. The students’ cognitive engagement and motivation were also measured after the practical sessions. Results: The TBL group among the Year-1 students outperformed the control group in all the test performance measures. The TBL group of the Year-1 students was also found to have greater improvement of test scores compared to their control counterparts. The TBL group was found to have significantly higher cognitive engagement scores only among the Year-2 students. However, the internal motivation scores were not significant in both cohorts. Conclusion: These results indicate that the TBL session contributes positive outcomes to students’ learning in anatomy context.

Psychometric properties of the secondary school stressor questionnaire among adolescents at five secondary schools

This study aimed to evaluate the construct, convergent, and discriminant validity of the Secondary School Stressor Questionnaire [3SQ] as well as its internal consistency among adolescents in Malaysian secondary schools. A cross-sectional study was conducted on 700 secondary school students in five secondary schools. Stratified random sampling was used to select schools and participants. The confirmatory factor analysis was performed to examine its construct, convergent, and discriminant validity. The reliability analysis was performed to determine its internal consistency. The results showed that the original six-factor model with 44 items failed to achieve acceptable values of the goodness of fit indices, indicating poor model fit. A new five-factor model of 3SQ with 22 items demonstrated acceptable level of goodness of fit indices to signify a model fit. The overall Cronbach's alpha value for the new version 3SQ was 0.93, while the five constructs ranged from 0.68 to 0.94. The composite reliability values of each construct ranged between 0.68 and 0.93, indicating satisfactory to high level of convergent validity. The construct validity of the original version of 3SQ was not supported. We found the new version 3SQ showed more convincing evidence of validity and reliability to measure stressors of adolescents. Continued research is required to verify and maximize the psychometric credentials of 3SQ across institutions and nationalities

DEAL-based intervention for the reduction of depression, denial, self-blame and academic stress: a randomized controlled trial

This study aimed to evaluate effectiveness of a DEAL-based based intervention on medical students' depression symptoms, coping strategies and perceived stressors. A parallel randomized controlled trial was conducted on a government medical school in Malaysia. A total of 171 medical students consented to participate in the study. A 4-h educational workshop that was designed based on the DEAL model was conducted on the medical students. Depression, coping strategies and perceived stressors were measured by Beck's Depression Inventory, Brief COPE and Medical Student Stressor Questionnaire respectively. The mixed model ANCOVA was applied to determine the effect of intervention. Partial eta squared [h2 partial] was used to estimate effect size. 171 medical students were randomized into study groups by draw lots [control = 83 and intervention = 88]. 18 medical students withdrew from the study before 32nd week, leaving 153 medical students [control = 80 and intervention = 73] for analysis. The intervention group significantly experienced lower depression symptoms [p = 0.017, eta[2] partial = 0.037], less frequent of denial [p = 0.002, eta[2] partial = 0.063], less frequent of self-blame [p = 0.002, h2 eta[2] = 0.064] and lower perceived academic stress [p = 0.009, h2 eta[2] = 0.044] than the control group. The results support the positive impacts of the DEAL-based intervention on the medical students' mental health. It is a promising intervention to be adopted by medical schools due to it consumes minimal amount of time, money, training and man power as well as simple to be implemented

Interventions on medical students' psychological health: a meta-analysis

Three systemic reviews reported that, although many studies echoed the importance of stress management programs in medical curricula, yet very few high quality studies provided convincing evidence of their effectiveness. So far, none of meta-analysis study was done to appraise their effectiveness on medical students' psychological health. The author conducted a meta-analysis to quantitatively appraise and summarize all studies of stress management interventions on medical students' psychological health that include general psychological distress, stress, anxiety and depression symptoms. The author planned, conducted and reported this study according to the PRISMA standard of quality for reporting meta-analyses. The author yielded 23,921 relevant articles based on search terms and eventually, after critical appraisal, only 13 articles were included in the meta-analysis. Stress management interventions were associated with moderate, statistically significant improvement of medical students' psychological health [-0.335 [95% CI, -0.423, -0.246], P <0.001] with low inconsistency among the studies [I[2]= 30.46%]. Subgroup analyses demonstrated there were consistent interactions with the duration of intervention [Qvalue [df]= 15.56 [3], p=0.001] and research design [Qvalue [df]=4.93 [1], p= 0.026]. Sensitivity analyses did not change the study conclusions. Stress management interventions were associated with moderate effects on medical students' psychological health compared with no intervention. Brief to medium-duration intervention demonstrated significant larger effects than long-duration intervention. Likewise, RCT studies showed larger effects than non-RCT studies. Future research with RCT design should directly compare different types of stress management interventions based on a sound theoretical basis.

Difficulty index, discrimination index, sensitivity and specificity of long case and multiple choice questions to predict medical students' examination performance

The competency assessment of tomorrow's doctors plays a vital role to offer insight into their clinical abilities and overall achievement. This study explores difficult index, discrimination index, areas under ROC curve, sensitivity and specificity of assessment components employed in the pediatric examination in Universiti Sains Malaysia [USM]. A retrospective record review of medical undergraduates' examination performance was done. The target population were fourth-year medical students in 2012 [n = 210] and 2013 [n = 177] academic year that sat for the pediatric end posting examinations after completing a 6-week rotation. Each of the examinations comprised of MCQ and Long Case. The difficulty index of MCQ ranged from 0.67 to 0.79, which is considered as optimal level. The difficulty index for Long Case ranged from 0.89 to 0.91, which is considered as less optimal level. The MCQ demonstrated higher discrimination index [0.58-0.76] than the long case [0.20-0.23], suggesting the MCQ was better able to discriminate poor and good students than the long case. MCQ has more evidence to support its discriminant validity and optimal difficulty level than the long case for both cohorts of medical students. The MCQ has good psychometric credentials which may results of the broad sampling of knowledge over short duration of time, while the long case seems to have poor psychometric credentials which may results of the assessment subjectivity

Mental health of medical students before and during medical education: a prospective study

The mental health of prospective medical students has been associated with ethnic group, extracurricular activity, parents' educational level and previous academic achievement in some studies but not in others. The aim of this study was to explore relations between medical students' socio-demographic profiles and mental health before and during the first year of medical education. A cohort of medical students in Malaysia was studied prospectively. Stress, anxiety and depression symptoms were measured on the 21 -item Depression Anxiety Stress Scale during the interview before the onset of medical education [time 0], after 2 months [time 1], 4 months [time 2] and 6 months [time 3] and at the final examination [time 4]. A repeated-measure ANOVA was performed to determine factors associated with mental health over the five intervals. Significantly lower scores were found for stress, anxiety and depression with higher father's educational level and lower scores for stress and anxiety with extracurricular activity and higher mother's educational level. Malay students had more anxiety symptoms than students of other races, and female students had lower scores for depression than males. Measures should be provided to prevent these symptoms and support medical students' well-being

A Study of Psychological Distress in Two Cohorts of First-Year Medical Students that Underwent Different Admission Selection Processes

Background: Medical training is often regarded as a stressful period. Studies have previously found that 21.6%–50% of medical students experience significant psychological distress. The present study compared the prevalence and levels of psychological distress between 2 cohorts of first-year medical students that underwent different admission selection processes. Methods: A comparative cross-sectional study was conducted by comparing 2 cohorts of first-year medical students; 1 group (cohort 1) was selected based purely on academic merit (2008/2009 cohort) and the other group (cohort 2) was selected based on academic merit, psychometric assessment, and interview performance (2009/2010 cohort). Their distress levels were measured by the General Health Questionnaire, and scores higher than 3 were considered indicative of significant psychological distress. Results: The prevalence (P = 0.003) and levels (P = 0.001) of psychological distress were significantly different between the 2 cohorts. Cohort 1 had 1.2–3.3 times higher risk of developing psychological distress compared to cohort 2 (P = 0.007). Conclusion: Cohort 2 had better psychological health than cohort 1 and was less likely to develop psychological distress. This study provided evidence of a potential benefit of multimodal student selection based on academic merit, psychometric assessment, and interview performance. This selection process might identify medical students who will maintain better psychological health.

Stability of Usmeq-I In Measuring Emotional Intelligence In Medical Students

Objective: Emotional Intelligence (EI) is described as the ability to perceive, express, understand, motivate, control and regulate emotion. The USM Emotional Quotient Inventory (USMEQ-i) was designed to measure EI and it was found to be a reliable and valid tool in a sample of prospective medical students. The objective of this study is to determine stability of the USMEQ-i to measure EI at different time and occasions. Methods: A prospective cohort study was done on 196 first year medical students. It was administered to the medical students at four different intervals. The Cronbach’s alpha and intra-class correlation analysis were applied to measure the internal consistency and agreement level across the intervals. The analysis was done using Statistical Package for Social Sciences (SPSS) version 18. Results: A total of 196 first year medical students participated in this study. Its overall Cronbach’s alpha value across intervals ranged between 0.94 and 0.97. The Cronbach’s alpha values of emotional control, emotional maturity, emotional conscientiousness, emotional awareness, emotional commitment, emotional fortitude, and emotional expression scale ranged between 0.59 and 0.91. The Cronbach’s alpha value for the faking index scale ranged from 0.76 to 0.89. The ICC coefficient values for EI total score was 0.83, EI domain score ranged between 0.62 and 0.76 and the faking index score was 0.76. Conclusion: The USMEQ-i has demonstrated a good level of stability and internal consistency to measure EI at different time and occasions. It is a promising psychometric instrument that can be used to measure EI

Effects of A Brief Stress Reduction Intervention On Medical Students' Depression, Anxiety And Stress Level During Stressful Period

Objective: The objective of this study was to evaluate whether students exposed to a brief stress reduction intervention would have lesser stress, anxiety and depression levels compared to their non-exposed classmates during stressful events. Methods: The Ex Post Facto design was applied in this study. Students who were exposed and not exposed to a brief stress reduction intervention were surveyed during a continuous examination and during the final examination. The Depression Anxiety Stress Scales (DASS) was used to examine effects on anxiety, stress, and depression levels. Results: The exposed students statistically had lower anxiety and depression scores than the non-exposed students during the stressful period. Reduction of stress, anxiety and depression scores was sustained during the stressful period. Conclusion: The significant reduction of anxiety and depression scores suggested that brief intervention was effective in the enhancement of the psychological wellbeing of exposed medical students during stressful period.

Stress, Stressors And Coping Strategies Among House Officers In A Malaysian Hospital

highly stressful environment to doctors. This article described findings on stress, stressors and coping strategies among house officers in a Malaysian hospital. Methods: A cross-sectional study was conducted on house officers in a Malaysian hospital. The 12 items General Health Questionnaire (GHQ-12), General Stressors Questionnaire (GSQ) and Brief COPE inventory were administered to measure perceived stress, sources of stress and coping strategies among house officers respectively. Data was analysed using SPSS version 12. Results: Forty two house officers participated in this study. This study found that approximately 31% of the house officers were in distress. The top five stressors were fears of making mistakes that can lead to serious consequences, work overload, working with uncooperative colleagues, doing work that mentally straining and feeling of being underpaid. The most frequent coping strategies used by house officers were religion, acceptance and self-distraction. Conclusion: This study found that there was a high percentage of distressed house officers. It also found that major stressors were related to performance pressure. The main coping strategy used by house officer was emotion-focused copin

Prevalence and Sources of Stress among Universiti Sains Malaysia Medical Students

Background: Being in medical school has always been regarded as highly stressful. Excessive stress causes physical and mental health problems. Persistent stress can impair students’ academic achievement and personal or professional development. The aim of this study is to explore the nature of stress among medical students by determining the prevalence, sources and pattern of stress and the factors affecting it. Methods: We chose a cross-sectional study design utilizing validated questionnaires, the 12 items General Health Questionnaire (GHQ-12) and Medical Student Stressor Questionnaire (MSSQ), to evaluate stress levels and stressors. School and ethical committee clearance were obtained prior to the study. Data were analysed using SPSS version 12. Results: Of the medical students who were administered the questionnaire, 761 (72%) respondents participated in this study. The prevalence of stress among the medical students was 29.6%. The top 10 stressors were academic-related. Prevalence of stress for the first, second, third, fourth and fifth year students was 26.3%, 36.5 %, 31.4%, 35.3% and 21.9%, respectively. Year of study was the only significant factor affecting stress among medical students (P-value < 0.05). Conclusions: The prevalence of stress among medical students in USM is high. Academicrelated problems were the major stressor among medical students. Year of study was the factor most significantly associated with medical students’ stress. There was a bimodal pattern of the stress level throughout the year of study.

Big Sib Students’ Perceptions of the Educational Environment at the School of Medical Sciences, Universiti Sains Malaysia, using Dundee Ready Educational Environment Measure (DREEM) Inventory

Background: A cross-sectional descriptive study was conducted among Big Sib students to explore their perceptions of the educational environment at the School of Medical Sciences, Universiti Sains Malaysia (USM) and its weak areas using the Dundee Ready Educational Environment Measure (DREEM) inventory. The DREEM inventory is a validated global instrument for measuring educational environments in undergraduate medical and health professional education. Method: The English version of the DREEM inventory was administered to all Year 2 Big Sib students (n = 67) at a regular Big Sib session. The purpose of the study as well as confidentiality and ethical issues were explained to the students before the questionnaire was administered. Results: The response rate was 62.7% (42 out of 67 students). The overall DREEM score was 117.9/200 (SD 14.6). The DREEM indicated that the Big Sib students’ perception of educational environment of the medical school was more positive than negative. Nevertheless, the study also revealed some problem areas within the educational environment. Conclusion: This pilot study revealed that Big Sib students perceived a positive learning environment at the School of Medical Sciences, USM. It also identified some low-scored areas that require further exploration to pinpoint the exact problems. The relatively small study population selected from a particular group of students was the major limitation of the study. This small sample size also means that the study findings cannot be generalised.

Prevalence and sources of stress among postgraduate medical trainees: initial findings

Objective: Postgraduate medical training has always been regarded as a highly stressful environment to students. This article described an initial finding on prevalence and sources of stress among postgraduate students. Method: This is a cross-sectional study conducted on postgraduate students in the School of Medical Sciences, Universiti Sains Malaysia. Sample size as calculated for this preliminary study was 38 and convenient sampling method was applied. The 12 items General Health Questionnaire (GHQ-12) and Postgraduate Stressors Questionnaire (PSQ) were administered during a workshop involving postgraduate students. Data was analysed using SPSS version 12. Results: Thirty three participants participated in this study. This study found that the prevalence of distressed postgraduate students was 36.4%. The top ten stressors were tests and examinations, large amount of content to be learnt, time pressure to meet deadlines, doing work beyond ability, work overload, unfair assessment by superior, fears of making mistakes that can lead to serious consequences, doing work that mentally straining, work demands affect my personal and home life, and lack of time to review what have been learnt. Conclusion: This study found that there was a high prevalence of distressed postgraduate students. It also found that the Introduction Postgraduate medical training environment has always been regarded as highly stressful to students. The stressors of medical training and its associated negative consequences to the mental, emotional and physical health, particularly for undergraduate medical students, have been described in many studies [1-10], however, for postgraduate students there is very limited data on this. It is noteworthy that generally excessive and ASEAN Journal of Psychiatry, Vol.11 (2): July – December 2010 major stressors were related to academic and performance pressure

Stress, stressors and coping strategies among secondary school students in a Malaysian government secondary school: initial findings

Objective: In the process of growing, adolescents experience stress either good or bad depending on how they cope. School training further adds to this stressful situation. It is noteworthy that persistent over stress will impair students’ academic achievement, personal and professional development. This preliminary study is meant to obtain initial data on the stress prevalence, stressors, and coping strategies among secondary school children in Malaysia. Data gained from this preliminary study provides valuable data for subsequence research in the future. Methods: This is a cross-sectional study involving 100 secondary school students from a Malaysian government secondary school. The validated Malay version 12-item General Health Questionnaire (GHQ-12), Soalselidik Stressor Sekolah Menengah (SSSM) and Malay version of Brief COPE were used to identify stress level, stressors, and coping strategies. Results: A number of 90 (90%) students participated in this study. The prevalence of stress among secondary school students was 26.1%. It was found that the main stressors were related to academic. The top five coping strategies were religion, positive reinterpretation, active coping, planning, and use of instrumental support. Conclusion: The prevalence of stress among secondary school students in a Malaysian stressor among the students. The most frequent coping strategies being used by the students were positive coping strategies.

The validity of two malay versions of the general health questionnaire (GHQ) in detecting distressed medical students

Objective: To compare the sensitivity, specificity and reliability between the Malay GHQ-30 and the Malay GHQ-12 in detecting distressed medical students. This study determined which version is more sensitive, specific and reliable in detecting distressed medical students. Methods: Three validated instruments, the Malay version GHQ-30, the Malay version GHQ-12 and the Malay version Beck Depression Inventory-II (BDI-II), were administered to a total of 187 medical students. Distress diagnoses were made based on the Malay version BDI-II. ROC curve analysis was applied to determine the sensitivity and specificity of the both GHQs by testing against the BDI-II. Reliability analysis (Cronbach’s alpha) was applied to test internal consistency of the GHQ. The analysis was done using SPSS version 12. Results: 141 (75.4%) medical students participated in this study. The GHQ-30 sensitivity and specificity at cut-off point of 6 was 87.5% and 80.6% respectively with positive predictive value (PPV) of 70% as well as area under ROC curve was 0.93. The GHQ-12 sensitivity and specificity at cut-off point of 4 was 81.3% and 75.3% respectively with PPV of 62.9% as well as area under ROC curve was 0.82 The Cronbach’s alpha value of the GHQ-30 and GHQ-12 was 0.93 and 0.85 respectively. The Kappa value for the GHQ- 12 and GHQ-30 was 0.65 (p < 0.001). Conclusion: This study showed the Malay GHQ-30 had better ability to discriminate between distressed and non-distressed medical students compared to the Malay GHQ-12. The shorter version was found to be as reliable as the long version GHQ-30 in detecting distressed medical students. The optimum threshold score for the GHQ-30 and GHQ-12 to detect distressed medical students were 6 and 4 respectively. The GHQ-12 and GHQ-30 showed a good level of agreement in detecting distressed medical students.

Impact of medical student well-being workshop on the medical students' stress level: A preliminary study

Objective: Medical training has always been regarded as a highly stressful environment to students. This article described a preliminary data on impact of a stress-management programme on medical students’ stress level. Methods: This is a quasi-experimental before after comparison study design. The programme was run over half-day and convenient sampling method was applied. Sample size as calculated for this preliminary study was 38. The 12 items General Health Questionnaire (GHQ-12) was administered prior to the programme and four months later. Data was analysed using SPSS version 12. Results: 34 participants were involved in this study. This study found that there was a significant difference in participants’ GHQ-12 scores before and after the programme (p<0.001). It also found that the percentage of distressed participants to have significantly reduced after they went through the programme (p<0.05). Conclusion: This study showed that the programme is a promising stress-management programme with the evidence of positive impact on the medical students’ mental health by improving and reducing their stress level. Apart from that it is a well accepted programme by the medical students. Perhaps similar approach can be considered relevant to be incorporated in other set up.

The sensitivity, specificity and reliability of the malay version 12-items general health questionnaire (GHQ-12) in detecting distress medical students

Objective: To determine the sensitivity, specificity and internal consistency of the Malay version GHQ-12 among medical student population. This study determined the appropriate GHQ-12 score to detect distressed medical students. Methods: The Malay version of GHQ-12 was derived based on two sources which were the original version GHQ-12 and the validated Malay version 30-items GHQ. The GHQ-12 and the Malay version Beck Depression Inventory-II (BDI-II) were administered to a total of 141 medical students. Distress diagnoses were made based on the Malay version BDI-II. ROC curve analysis was applied to determine the sensitivity and specificity of the GHQ-12 by testing against the BDI-II. Reliability analysis (Cronbach’s alpha and item total correlation) was applied to test internal consistency of the GHQ-12. The analysis was done using SPSS version 12.Results: The GHQ-12 sensitivity and specificity at cut-off point of 3/4 was 81.3% and 75.3% respectively with positive predictive value (PPV) of 62.9% as well as area under ROC curve more than 0.7. The Cronbach’s alpha value of the GHQ-12 was 0.85.Conclusion: This study showed the Malay version GHQ-12 is a valid and reliable screening tool in detecting distressed medical students. The GHQ-12 score equal to or more than 4 was considered as significant distress.

The development and validity of the medical student stressor questionnaire (MSSQ)

Objective: To determine the construct validity and the internal consistency of the Medical Student Stressor Questionnaire (MSSQ) among medical students hence in the future it could be used as a valid and reliable instrument to identify stressors among medical students. Methods: The blueprint for the development of MSSQ was developed after a review of literature on the subject and a discussion with experts in the field. It comprised of 40 items with six hypothetical groups. The face validity of the questionnaire was established through discussion with 141 final year medical students whereas content validity was established through discussion with experts from field of Medical Education and Psychiatry. It was administered to a total of 761 medical students. Data was analysed using Statistical Package Social Sciences (SPSS) version 12. Factor analysis was applied to test construct validity of the MSSQ. Reliability analysis (Cronbach’s alpha and item total correlation) was applied to test internal consistency of the MSSQ. Results: The total Cronbach’s alpha value of the MSSQ was 0.95. All the preliminary 40 items were included in the MSSQ as the items had item total correlation value of more than 0.3. The items were loaded nicely into the six pre-determined hypothetical groups as their factor loading values were more than 0.3. Conclusion: This study showed that MSSQ had good psychometric value. It is a valid and reliable instrument in identifying stressors among medical students.