Understanding medical students' empathy based on Enneagram personality types / 한국의학교육

PURPOSE@#High self-awareness can promote communication and empathy. The Enneagram is a well-known personality tool to enhance self-awareness. We evaluated differences in empathy among medical students using the Enneagram typology.@*METHODS@#This cross-sectional study included first and second grade students at the Inje University College of Medicine. The Jefferson Scale of Empathy was used to measure empathy and the Korean Enneagram Personality Type Indicator was used for examining personality characteristics. Empathy scores were analyzed according to the Triads, Hornevian group, Harmonic group, and each Enneagram type.@*RESULTS@#The Instinctive triad, the Withdrawns, and the Positive outlook group were the most common, and the Feeling triad, the Assertives, and the Emotional realness group were the least common. Students in the Feeling triad and the Dutifuls had higher compassionate care (CC) scores as compared to their counterparts. Type 2 and 6 students showed the two highest empathy and CC scores. The empathy score of type 3 students was the lowest. Type 7 had the lowest CC score but the highest perspective taking score.@*CONCLUSION@#These differences in empathy according to Enneagram personality types can be applied to medical education to maintain and improve medical students' empathy.

Understanding medical students' empathy based on Enneagram personality types / 한국의학교육

PURPOSE: High self-awareness can promote communication and empathy. The Enneagram is a well-known personality tool to enhance self-awareness. We evaluated differences in empathy among medical students using the Enneagram typology. METHODS: This cross-sectional study included first and second grade students at the Inje University College of Medicine. The Jefferson Scale of Empathy was used to measure empathy and the Korean Enneagram Personality Type Indicator was used for examining personality characteristics. Empathy scores were analyzed according to the Triads, Hornevian group, Harmonic group, and each Enneagram type. RESULTS: The Instinctive triad, the Withdrawns, and the Positive outlook group were the most common, and the Feeling triad, the Assertives, and the Emotional realness group were the least common. Students in the Feeling triad and the Dutifuls had higher compassionate care (CC) scores as compared to their counterparts. Type 2 and 6 students showed the two highest empathy and CC scores. The empathy score of type 3 students was the lowest. Type 7 had the lowest CC score but the highest perspective taking score. CONCLUSION: These differences in empathy according to Enneagram personality types can be applied to medical education to maintain and improve medical students' empathy.

Assessing clinical reasoning abilities of medical students using clinical performance examination / 한국의학교육

PURPOSE: The purpose of this study is to investigate the reliability and validity of new clinical performance examination (CPX) for assessing clinical reasoning skills and evaluating clinical reasoning ability of the students. METHODS: Third-year medical school students (n=313) in Busan-Gyeongnam consortium in 2014 were included in the study. One of 12 stations was developed to assess clinical reasoning abilities. The scenario and checklists of the station were revised by six experts. Chief complaint of the case was rhinorrhea, accompanied by fever, headache, and vomiting. Checklists focused on identifying of the main problem and systematic approach to the problem. Students interviewed the patient and recorded subjective and objective findings, assessments, plans (SOAP) note for 15 minutes. Two professors assessed students simultaneously. We performed statistical analysis on their scores and survey. RESULTS: The Cronbach α of subject station was 0.878 and Cohen κ coefficient between graders was 0.785. Students agreed on CPX as an adequate tool to evaluate students' performance, but some graders argued that the CPX failed to secure its validity due to their lack of understanding the case. One hundred eight students (34.5%) identified essential problem early and only 58 (18.5%) performed systematic history taking and physical examination. One hundred seventy-three of them (55.3%) communicated correct diagnosis with the patient. Most of them had trouble in writing SOAP notes. CONCLUSION: To gain reliability and validity, interrater agreement should be secured. Students' clinical reasoning skills were not enough. Students need to be trained on problem identification, reasoning skills and accurate record-keeping.

Experience of clinical skills assessment in the Busan-Gyeongnam Consortium / 한국의학교육

PURPOSE: The purpose of this study is to judge the quality of clinical skills assessment in Busan-Gyeongnam Consortium. METHODS: Fourth grade medical school students (n=350 in 2012 and n=419 in 2013) in the Busan-Gyeongnam Consortium were included in the study. The examination was consisted of 6 clinical performance examination (CPX) and 6 objective structured clinical examination (OSCE) stations. The students were divided into groups to take the exam in 4 sites during 3 days. The overall reliability was estimated by Cronbach alpha coefficient across the stations and the case reliability was by alpha across checklist items. Analysis of variance and between-group variation were used to evaluate the variation of examinee performance across different days and sites. RESULTS: The mean total CPX/OSCE score was 67.0 points. The overall alpha across-stations was 0.66 in 2012 and 0.61 in 2013. The alpha across-items within a station was 0.54 to 0.86 in CPX, 0.51 to 0.92 in OSCE. There was no significant increase in scores between the different days. The mean scores over sites were different in 30 out of 48 stations but between-group variances were under 30%, except 2 cases. CONCLUSION: The overall reliability was below 0.70 and standardization of exam sites was unclear. To improve the quality of exam, case development, item design, training of standardized patients and assessors, and standardization of sites are necessary. Above of all, we need to develop the well-organized matrix to measure the quality of the exam.

Differentiation Strategy of Graduate Entry Programme / 한양의대학술지

Graduate medical students have been expected to have different characteristics and backgrounds. If it is true, our strategy to educate them should be differentiated. However, basic medical education for graduate entrants in Korea now is not much different from those for non-graduate entrants. Therefore, I investigated the differences between graduate entry and schoolleaver students. Herein, I reviewed their demographics, academic backgrounds, career choice motivation, moral reasoning ability, learning styles and strategy, academic achievement, quality of school life, and outcome after graduation. Also I tried to suggest the differentiated strategy for effective education according to curriculum, teaching and learning, assessment, student support system, and admission selection policy.

Learning Curve for a Laparoscopic Appendectomy by a Surgical Trainee

PURPOSE: The laparoscopic appendectomy has been a basic part of the principal of a more complex laparoscopic technique for the surgical trainee. As the number of laparoscopic appendectomies performed by surgical trainees has increased, we are trying to check the stability of, which is controversial, and the learning curve associated with a laparoscopic appendectomy. METHODS: We studied the demographics, histologic diagnoses, operative time, the number of complicated cases, and hospital duration of one hundred and three patients who underwent an open appendectomy (group A, 53) or a laparoscopic appendectomy (group B, 50) retrospectively through a review of their medical records. The learning curve for the laparoscopic appendectomy was established through the moving average and ANOVA methods. RESULTS: There were no differences in the operative times (A, 64.15 +/- 29.88 minutes; B, 58.2 +/- 20.72 minutes; P-value, 0.225) and complications (A, 11%; B, 6%; P-value, 0.34) between group A and group B. Group B was divided into group C who underwent the operation in the early period (before the learning curve) and group D who underwent the operation in the later period (after the learning curve). The average operative time for group C was 66.83 +/- 21.55 minutes, but it was 45.25 +/- 10.19 minutes for group D (P-value < 0.0001). Although this difference was statistically significant, no significant difference in the complication rate was observed between the two groups. CONCLUSION: A laparoscopic appendectomy, compared with an open appendectomy, performed by a surgical trainee is safe. In this study, the learning curve for a laparoscopic appendectomy was thirty cases.

Experience of Implementation of Objective Structured Oral Examination for Ethical Competence Assessment / 한국의학교육

PURPOSE: We developed an objective structured oral examination (OSOE) case to assess the medical ethics of students. The aim of this study was to assess the reliability of OSOE with generalizability theory. METHODS: One 10-minute OSOE that contained key questions was developed. The evaluation sheet consisted of 4 domains: moral sensitivity, moral reasoning, decision making, and attitude. The total number of items was 13. The numbers of checklist items and global rating items were 11 and 2, respectively. Items and key questions were validated by 6 professionals. Standardization of the raters and the pilot study was performed before the OSOE. Fifty-four third-year medical students participated in the OSOE. The OSOE was duplicated, and 2 professors assessed 1 student independently. Each station lasted 8 minutes and was followed by a 2-minute interval,during which raters completed the checklist forms. We analyzed the reliability of the OSOE with the GENOVA program. RESULTS: The reliability (generalizability coefficient) was 0.945, and the interrater agreement was 0.867. The type of item, checklist or global rating, was the largest variance component. The reliability of the checklist alone was 0.668 and that of the global rating alone was 0.363. CONCLUSION: The OSOE is reliable and can be used to assess ethics. More research should focus on achieving validity.

Experience of Clinical Performance Examination in Ethical Dilemma / 한국의학교육

PURPOSE: Ethics objective structured clinical examination (OSCE) scenarios was developed and were applied to medical students to see whether it would be suitable for assessing the students' ethical behaviors. METHODS: The data for this study were gathered from the end-of-clerkship patient-doctor-society OSCE, involving third-year medical students along the academic year of 2006. 54 students who participated in the ethics OSCE, which consisted of three stations, responded. Nine standardized patients (SPs) participated in the evaluation. The SPs were trained for 4 hours to conduct the medical interview and for 2 hours for evaluating students' performance using the checklist for each station. RESULTS: The consistency (Cronbach's alpha) of the SPs was 0.796. Mean score was 57.33. There was no difference among circuits and gender. CONCLUSION: We found that the ethics OSCE was adequate for evaluating students' performances.

Using Medical Error Cases for Patient Safety Education / 한국의학교육

PURPOSE: To draw attention to patient safety and increase its awareness among medical students, we developed a program that teaches patient safety based on common medical error cases. The aim of this study is to introduce this program and improve student receptivity to it. METHODS: As part of the "Patient, Doctor, and Society" course, third-year medical students participated in 8 hours of a medical error education program. Students discussed recent, typical medical lawsuits that were generated from internal medicine, surgery, pediatrics, obstetrics and gynecology, neurosurgery, medication, anesthesia, and blood transfusion cases. Students weighed these issues in small groups, using various discussion methods. After finishing the program, students completed a course evaluation questionnaire. RESULTS: The students rated this program as satisfactory, highly motivating, and helpful in preparing their future practices. They responded that although the cases were interesting, some were difficult. They stated that the small group discussion techniques encouraged them to take active part in the discussion and to consider the cases more deeply. CONCLUSION: Small group discussion of medical error cases is an effective method for students to study patient safety.

Abdominal Computed Tomography in Patients with Right Lower Quadrant Pain

PURPOSE: This study was performed to evaluate the usefulness of abdominal computed tomography (CT) for patients with right lower quadrant (RLQ) pain. METHODS: Between January 2006 and July 2008, 191 consecutive patients with RLQ pain underwent abdominal CT (CT group). Forty-two patients who had undergone abdominal ultrasound (US group) and 52 patients without abdominal CT or abdominal ultrasound for RLQ pain (clinical Dx group) underwent emergent operations. Using the Alvarado scoring system, we scored all patients. The abdominal CT was performed in the abdominal and pelvic area with contrast. RESULTS: One hundred twenty-one (63.4%) of the 191 patients in the CT group were preoperatively diagnosed as having acute appendicitis and underwent surgery. There were three cases of negative appendectomy (1.6%). In the US group and the clinical Dx group, the negative appendectomy rates were 4.8% and 3.8%, respectively. The sensitivity of the abdominal CT was 96.7%. In the CT group, in addition to acute appendicitis, colitis, nonspecific enteritis, diverticulitis, urinary stone, ovary, uterine, and diseases were indentified. CONCLUSIONS: In this study, abdominal CT scans in patients with RLQ pain were useful for the diagnosis acute appendicitis and for the differential diagnosis of other diseases presenting with RLQ pain. The false positive rate was significantly lower in the CT group than in the other groups.

The Assessment of Medical Students' Learning Styles using the Kolb Learning Style Inventory / 한국의학교육

PURPOSE: The purpose of this paper was to assess if there is a relationship between Kolb learning styles and learner variables including age, gender, and grade retention among medical students. METHODS: The Kolb Learning Style Inventory(LSI) is used at many educational levels to determine the learning preferences of medical students and clinicians. The students' learning styles were analyzed for associations with learner variables. The Kolb LSI was administered to 164 Kangwon medical students. They were categorized based on learner variables. RESULTS: Kolb's 'assimilator' was the preferred learning style type of the study group(55.2%). 'Accommodator'(17.8%) and 'diverger'(16.0%) were next, followed by 'converger'(11.0%). Learning style preferences of medical students did not vary significantly according to age, gender, and grade retention. CONCLUSION: No statistically significant relationships were identified between the Kolb learning styles and learner variables. The assessment of medical students' learning styles categorized based on Kolb LSI is expected to provide educators with skills to plan teaching strategies, employ a variety of teaching methods, and facilitate academic performance.

Students' Perception of Their Achievement of Clinical Competency for Patient Safety / 한국의학교육

PURPOSE: The aim of this study is to evaluate the students' clinical competency from the patient safety perspective. METHODS: We conducted this evaluation in 2006 at College of Medicine, Kangwon National University. We surveyed 50 fourth-year medical students after finishing all clinical clerkships. 49 Students evaluated their achievement with 5-Likert score scale. The questionnaires were composed 6 domains: communication skills, prevention & management of adverse events, using evidence and information techniques, teamwork & leadership, medical ethical behaviors, and procedural skills. The each domains were constituted several items. Total 53 items was evaluated. RESULTS: The students' preparedness was relatively low in 28 items of the total 53(difficult communication, detecting and managing medical errors, using evidence and information technique, understanding of complex systems, autonomy, and procedural skills). CONCLUSION: The items with low achievement were closely related with medical errors and patient safety. These findings suggest that the clinical education is insufficient for preventing medical errors by students. For patient safety, we should understand the importance of achievement of competency related with patient safety and establish a systematic clinical curriculum with explicit learning outcomes.

Implementation of Student Internship with Intern-Level Responsibility / 한국의학교육

PURPOSE: The aim of the study is to evaluate the possibility of giving student interns intern- level responsibilities and to discuss the various obstacles. METHODS: Modifications were made to the student internship program, including rotations through major departments, for 4th-year medical students and was conducted at the College of Medicine, Kangwon National University. We surveyed 49 students for the evaluation of the program, administered a checklist evaluation for their performance, and interviewed two focus groups of faculties and residents to find out the obstacles of the program. RESULTS: Most of the students answered that the program was satisfactory and necessary. Of the students, 71.4% performed as an acting intern. The mean score of the students' performance was 84.1. The students had the most difficulty with time management and making diagnostic and management decisions. Initially, at the start of the program, both students and residents were somewhat confused about the student interns' duties. They suggested that definite learning objectives, legal and institutional support to students' clinical practice, and announcements to patients and hospital staff should be put in place prior to the implementation of such a program. CONCLUSION: We discovered that it was possible for student interns to perform at the level of interns. We suggest that systemic improvements continue for the establishment of such student internship program.

Effect of Practice based Program for Procedural Skills / 한국의학교육

PURPOSE: To evaluate the educational effectiveness of practice-based program for procedural skills at Kangwon National University College of Medicine. METHODS: In 2005, we conducted the training program composed of 19 procedural skills for third-year medical students during their first semester clerkship. The 14-week training used simulation models and was held for 3 hours per week, one hour for didactic session and 2 hours for practical exercise. A lecture was given only for wound dressing. OSCE, consisting of four 5-minute stations, was administered to analyze the students' achievement. 53 third-year students were given a survey following skills training and OSCE. RESULTS: Most students reported that the practice-based program was interesting and helpful in learning procedural skills. Students preferred practice to didactic medium. Students were satisfied with the faculty's instruction, but suggested that the training should be providedprior to clerkship. OSCE had an overall reliability coefficient (Cronbach's alpha) of 0.78. The mean score in the dressing case was lower than those in other cases. CONCLUSION: The practice-based program for procedural skills was effective in motivating students' learning as well as improving theirtechnical skills. Self-directed exercises and appropriate feedback are more effective training tools than lectures.

Expression of CD43 in Colorectal Adenocarcinom

BACKGROUND: CD43 is a sialoglycoprotein that is highly expressed on most leukocytes, except on B lymphocytes and dendritic cells. CD43 has been reported to be involved in the adhesion and apoptosis of lymphocytes. Although the aberrant expression of CD43 antigen in non-lymphoid tissues has been reported, the expression of the CD43 antigen in gastrointestinal malignancies is not well studied. Here, we studied the expression of CD43 in colon adenocarcinoma using the anti-CD43 monoclonal antibody developed in our laboratory. METHODS: Thirty patients who had undergone surgical resection for colorectal carcinoma were recruited. The expression of CD43 molecule was determined by analyzing the formalin-fixed, paraffin-embedded specimens immunohistochemically using our newly developed anti-CD43 mAb (K06). The results obtained by the immunohistochemical analysis correlated to the clinicopatho-logical parameters. RESULTS: The expression of CD43 were found in 20 out of 30 colorectal carcinoma cases. The expression of CD43 antigen is higher in well differentiated adenocarcinomas than poorly or moderately differentiated adenocarcinomas. CONCLUSIONS: The new anti-CD43 mAb might be helpful for the detection of the expression of CD43 on colorectal carcinoma cells. Further studies are required to assess the relationship between the CD43 expression and the colorectal carcinogenesis.

Characteristic Findings and Their Clinical Appraisal of Proctography and Cinedefecography in Patients with Pelvic Outlet Obstructive Disease

PURPOSE: We were assessed the characteristic findings of defecography and cinedefecography in patients with pelvic outlet obstructive disease, and compared the characteristic physiologic findings between proctography and cinedefecography. METHODS: Physiologic findings of 196 patients who were performed at least two items of physiologic tests were retrospectively evaluated. Patients were categorized as rectocele (Group I: n=119), nonrelaxing puborectalis syndrome (Group II: n=58), rectoanal intussusception (Group III: n=16), significant sigmoidocele (Group IV: n=3). The proctographic and cinedefecographic features were analyzed according to disease categories. The sensitivity, specificity, accuracy, false positive rate, false negative rate, diagnostic rate, and reproducibility were calculated, and we analyzed the difference between proctography and cinedefecography according to the disease groups. RESULTS: On the proctographic examinations; 1) 112 patients were confirmed as a clinically significant rectocele (n=128, sensitivity; 94%, specificity; 79%, accuracy; 88%, false positive rate; 21%, false negative rate; 6%, kappa; 0.749). 2) A clinically significant nonrelaxing puborectalis were 36 patients (n=73, sensitivity; 62%, specificity; 73%, accuracy; 70%, false positive rate; 27%, false negative rate; 38%, kappa; 0.328). 3) 12 patients were confirmed as significant rectoanal intussusception (n=31, sensitivity; 75%, specificity; 89%, accuracy; 88%, false positive rate; 11%, false negative rate; 25%, kappa; 0.425). 4) 3 patients were confirmed as clinically significant sigmoidocele (n=15, sensitivity; 100%, specificity; 94%, accuracy; 94%, false positive rate; 6%, false negative rate; 0%, kappa; 0.316). On the combination of proctography and cinedefecography; 1) 117 patients were confirmed as a clinically significant rectocele (n=122, sensitivity; 98%, specificity; 94%, accuracy; 96%, false positive rate; 6%, false negative rate; 2%, kappa; 0.925). 2) A clinically significant nonrelaxing puborectalis were 50 patients (n=64, sensitivity; 86%, specificity; 90%, accuracy; 88%, false positive rate; 10%, false negative rate; 14%, kappa; 0.738). 3) 16 patients were confirmed as significant rectoanal intussusception (n=22, sensitivity; 100%, specificity; 97%, accuracy; 97%, false positive rate; 3%, false negative rate; 0%, kappa; 0.826). 4) 3 patients were confirmed as clinically significant sigmoidocele (n=9, sensitivity; 100%, specificity; 97%, accuracy; 97%, false positive rate; 3%, false negative rate; 0%, kappa; 0.488). As compared with combined study (proctography plus cinedefecography), the proctography show decreased diagnostic rates in the evaluation of rectocele (P<0.05), nonrelaxing puborectalis (P<0.01), and rectoanal intussusception (P<0.05). And, the proctography also show increased false positive rate in the evaluation of rectocele (P<0.01), nonrelaxing puborectalis (P<0.01), and rectoanal intussusception (P<0.05). CONCLUSIONS: In our study, proctography showed a tendency to overdiagnosis. Therefore, the combined study of proctography and cinedefecography should be taken as a diagnostic tools for pelvic outlet obstructive disease. Adhering to these findings, other anorectal physiologic studies should be added for the clinically significant diagnosis.

A Trial of Surgical Clerkship for Developing Clinical Competency

PURPOSE: The surgery clerkship, focusing on the clinical competency, including critical thinking, problem solving, self-directed learning, autonomy and professionalism, were revised. The purposes of this study were to evaluate the students' assessment of the revised surgery clerkship program in order to improve the quality of surgical education. METHODS: Clinical competency was classified into 6 dimensions: intelligence, skill, relationship, attitude, problem solving performance, and autonomy. Problem based learning (PBL), procedural skill training, surgical anatomy, case discussion, pre-diagnosis at outpatient clinics, quiz, clinical performance assessment (CPA) and modified essay question (MEQ) were performed. Forty-nine 3rd year medical students participated during 2002. All students were asked to rate how far they had progressed in the 6 dimensions, in order to evaluate the course, and each program, and to suggest improvements at the end of the rotation. RESULTS: The students responded extremely positively and became been more motivated. They evaluated that the new clerkship had helped them increase their abilities in clinical reasoning, self-directed learning, problem solving and clinical techology, and to develop professionalism and autonomy. Most of students revealed that the PBL, case discussion, pre-diagnosis at outpatient clinics, CPA and MEQ programs were very helpful. They felt that procedural skill training and surgical anatomy programs required further improvements. CONCLUSION: The implementation of the new surgery clerkship was successful. The PBL, case discussion, pre-diagnosis at outpatient clinics, CPA and MEQ were valuable learning tools. More tools should be developed for procedural skill training and surgical anatomy education.

A Trial of Surgical Clerkship for Developing Clinical Competency

PURPOSE: The surgery clerkship, focusing on the clinical competency, including critical thinking, problem solving, self-directed learning, autonomy and professionalism, were revised. The purposes of this study were to evaluate the students' assessment of the revised surgery clerkship program in order to improve the quality of surgical education. METHODS: Clinical competency was classified into 6 dimensions: intelligence, skill, relationship, attitude, problem solving performance, and autonomy. Problem based learning (PBL), procedural skill training, surgical anatomy, case discussion, pre-diagnosis at outpatient clinics, quiz, clinical performance assessment (CPA) and modified essay question (MEQ) were performed. Forty-nine 3rd year medical students participated during 2002. All students were asked to rate how far they had progressed in the 6 dimensions, in order to evaluate the course, and each program, and to suggest improvements at the end of the rotation. RESULTS: The students responded extremely positively and became been more motivated. They evaluated that the new clerkship had helped them increase their abilities in clinical reasoning, self-directed learning, problem solving and clinical techology, and to develop professionalism and autonomy. Most of students revealed that the PBL, case discussion, pre-diagnosis at outpatient clinics, CPA and MEQ programs were very helpful. They felt that procedural skill training and surgical anatomy programs required further improvements. CONCLUSION: The implementation of the new surgery clerkship was successful. The PBL, case discussion, pre-diagnosis at outpatient clinics, CPA and MEQ were valuable learning tools. More tools should be developed for procedural skill training and surgical anatomy education.

Huge Exophytic Atypical Medullary Breast Cancer

A medullary carcinoma of the breast is an uncommon breast cancer subtype, but has a fair prognosis. The histopathological criteria for a medullary carcinoma were delineated by Ridolfi et al. in 1977, and most pathologists use these criteria. The authors experienced a huge carcinoma of the breast, which was diagnosed as an atypical medullary carcinoma. A 47-year old female visited our clinic due to a breast mass of six months duration. The mass was 16 cm in size and exophytic in the left lower breast. There had been necrosis, with a foul odor in most of the mass. A large fixed axillary lymph node was noted, but there was no evidence of distant metastasis. A radical mastectomy was performed due to invasion of the pectoralis major. On pathological examination, the tumor was diagnosed as an atypical medullary carcinoma.

Huge Exophytic Atypical Medullary Breast Cancer

A medullary carcinoma of the breast is an uncommon breast cancer subtype, but has a fair prognosis. The histopathological criteria for a medullary carcinoma were delineated by Ridolfi et al. in 1977, and most pathologists use these criteria. The authors experienced a huge carcinoma of the breast, which was diagnosed as an atypical medullary carcinoma. A 47-year old female visited our clinic due to a breast mass of six months duration. The mass was 16 cm in size and exophytic in the left lower breast. There had been necrosis, with a foul odor in most of the mass. A large fixed axillary lymph node was noted, but there was no evidence of distant metastasis. A radical mastectomy was performed due to invasion of the pectoralis major. On pathological examination, the tumor was diagnosed as an atypical medullary carcinoma.