Communication skills learning through role models in Nepal; what are medical students really learning? A qualitative study.

BACKGROUND: Communication skills (CS) are important and teachable, however, many Asian medical schools' curricula do not incorporate them. Patan Academy of Health Sciences in Nepal identifies CS within its' aims and curriculum. CS are taught from commencement of medical school and re-emphasised throughout preclinical learning (first 2 years). There is no explicit CS teaching in clinical years but placements allow students to learn through observation. These 'role-modelling' interactions form part of CS learning and development. METHODS: This study is a qualitative evaluation of CS learning in PAHS, through participants' experiences. Through purposive sampling, twenty medical students from 2nd, 4th and Intern years were selected for inclusion. Data were collected via audio recorded, semi-structured interviews, employing a piloted schedule. Transcripts were manually coded and analysed thematically. Codes were organised into themes and subthemes. This paper discusses themes related to role-modelling. RESULTS: The majority of participants described role-modelling in CS learning, recounting both positive and negative incidents, reflected in the themes of; Positive and Negative experiences. Subthemes of Personal Qualities and Inspiring, emerged from positive experiences, describing students' desire to imitate or aspire to be like their role models. Learners reported predominantly negative experiences and interns exclusively so. From these emerged subthemes of; Good doctors but.., Contradictory messages, How not to behave, Unprofessional behaviour and Affect-Emotional Distress. Learners received conflicting messages from observing behaviour contradictory to explicit CS teaching. Many identified learning "how not to behave" from such incidents, however, several described feeling distressed. DISCUSSION: Role-modelling is a powerful and important CS learning tool, seen as positively reinforcing or negatively contradicting explicit CS teaching. Negative modelling created internal conflict, confusion and distress amongst learners, despite its' potential for positive learning. The worldwide problem of negative role-modelling is also prevalent in Nepal. Medical educators need to ensure the explicit curriculum aligns with implicit learning. Clinical tutors must be alerted to their powerful role-model position and supported in developing intentional modelling skills. Learners' reflections upon their experiences should be facilitated, enabling them to critically evaluate observations and hence consciously adopt or reject role-modelled behaviour and attitudes.

Communication skills teaching and learning in Nepal; what are medical students' perceptions and experiences? A qualitative study.

BACKGROUND: Communication skills (CS) are vital for doctors. Indeed, as the most important element of consultations, are highly valued by patients. CS are core, teachable skills, however, have not been widely taught in South Asian medical schools, unlike their western counterparts. Patan Academy of Health Sciences, is one of the first in Nepal to have CS central to its' aims and curriculum. CS are taught from the first weeks of medical school and re-enforced during preclinical study (first 2 years). Our study seeks to explore students' perceptions and experiences of CS teaching in this South Asian, Nepal context. METHODS: This study is a qualitative evaluation of a CS course in Nepal, exploring the experiences and perceptions of participants. The study aims to also identify aspects that were helpful or not for student learning and areas for potential development. A purposive sample of twenty: second, fourth and Intern year students was selected for interview. Data were collected through audio recorded semi-structured interviews following a piloted schedule. Interview transcripts were manually coded and thematically analysed. Codes were arranged into themes and subthemes. RESULTS: The two main themes: 1. Positivity 2. Experiential learning. Results demonstrate participants' positive perceptions of CS teaching: believing it is important, effective, relevant and valuable for personal development. Participants identified experiential learning features as valuable for CS acquisition. Intern students recognised CS relevance and requested expanding teaching to clinical years,incorporating challenging communication scenarios. DISCUSSION: This study shows that PAHS' CS course is well perceived and valuable to learners. Experiential learning is powerful for CS development. Expansion of formal, structured CS teaching through all years in a spiral curriculum, should be considered. Violence towards doctors in South Asia is increasing. Students recognised CS teaching's significance in addressing this. CONCLUSION: CS teaching,still in its' infancy in South Asia, is a pressing issue for medical educators here. Our study provides evidence it is well perceived with positive impacts in this context, particularly when employing experiential learning. Medical schools in south Asia should be encouraged to incorporate and strengthen their CS teaching curriculum. .

Enhancing the quality and safety of care through training generalist doctors: a longitudinal, mixed-methods study of a UK broad-based training programme.

OBJECTIVE: Changing patient demographics make it ever more challenging to maintain the quality and safety of care. One approach to addressing this is the development of training for generalist doctors who can take a more holistic approach to care. The purpose of the work we report here is to consider whether a broad-based training programme prepares doctors for a changing health service. SETTING AND PARTICIPANTS: We adopted a longitudinal, mixed-methods approach, collecting questionnaire data from trainees on the broad-based training (BBT) programme in England (baseline n=62) and comparator trainees in the same regions (baseline n=90). We held 15 focus groups with BBT trainees and one-to-one telephone interviews with trainees post-BBT (n=21) and their Educational Supervisors (n=9). RESULTS: From questionnaire data, compared with comparator groups, BBT trainees were significantly more confident that their training would result in: wider perspectives, understanding specialty complementarity, ability to apply learning across specialties, manage complex patients and provide patient-focused care. Data from interviews and focus groups provided evidence of positive consequences for patient care from BBT trainees' ability to apply knowledge from other specialties. Specifically, insights from BBT enabled trainees to tailor referrals and consider patients' psychological as well as physical needs, thus adopting a more holistic approach to care. Unintended consequences were revealed in focus groups where BBT trainees expressed feelings of isolation. However, when we explored this sentiment on questionnaire surveys, we found that at least as many in the comparator groups sometimes felt isolated. CONCLUSIONS: Practitioners with an understanding of care across specialty boundaries can enhance patient care and reduce risks from poor inter-specialty communication. Internationally, there is growing recognition of the place of generalism in medical practice and the need to take a more person-centred approach. Broad-based approaches to training support the development of generalist doctors, which is well-suited to a changing health service.

Work-based assessments: making the transition from participation to engagement.

Work-based assessments (WBAs) were only recently introduced into medicine. However, since their introduction, they have rapidly grown in popularity. WBAs are now a routine part of medical training. As WBAs are being implemented, the practical difficulties with their use have come to light. A major problem is failure of the trainees, trainers and training programmes to adequately engage with them. In this review, the reasons for this and how these can be overcome are discussed.

Clinical teaching: widening the definition.

BACKGROUND: In all medical specialities, trainees are increasingly encouraged to develop teaching skills alongside their clinical professional development. However, there have been few empirical UK-based studies that have examined trainees' attitudes and understanding of their own engagement with educational activities. This study therefore aimed to explore this in the context of general practitioner (GP) training using a qualitative approach. METHODS: Twenty GP registrars from the North Western Deanery were recruited to four focus groups. The data obtained using a semi-structured topic guide were analysed for thematic content, and the rigour of this methodology was increased by peer checking of the coding. Participation was voluntary and ethical approval was obtained. RESULTS: The majority of registrars interviewed initially presumed that teaching role development was only in relation to educating those junior to them, and thus followed a vertical hierarchical structure; however, during focus group discussions, the registrars started to recognise a range of other teaching modalities that they had not previously noted. These included peer-to-peer teaching sessions, examination preparation groups and, indeed, the everyday education of patients during consultations. DISCUSSION: Although this study has been conducted in the context of GP training, it is plausible to suggest that skewed perceptions from trainees as to what constitutes teaching may indeed exist in other speciality training schemes. There is therefore a need to shift current thinking around teaching engagement away from the traditional senior-junior relationship, and instead widen the definition of what it means to be involved in teaching activities.

The motivation to teach as a registrar in general practice.

The General Medical Council (GMC) states that teaching should be an integral part of the doctor's role and the Royal College of General Practitioners (RCGP) have incorporated teaching outcomes into the GP training curriculum. However, there are suggestions that the teaching role of a GP trainee declines as they move from hospital posts to the registrar community year. Using doctors in training as near-peer tutors offers multiple advantages. Trainees themselves benefit as teaching others is a strong driver of the tutor's own learning. In addition there are also practical incentives to mobilising this under-utilised pool of primary care clinical teachers given the continuing shift of focusing medical education in the community. This study forms part of a larger body of work exploring the attitudes and perceived learning needs of GP registrars with regards to developing a teaching role. A primary area of investigation was trainees' motivation to teach. This paper describes our attempts to establish: a) how strongly motivated are GP registrars to take on teaching roles? b) in consequence how strongly motivated are they to learn more about teaching? c) what are the factors which affect motivation to teach? Three themes emerged from the data. First, teaching was felt to be of low priority in comparison to competing clinical learning needs. Secondly, the clinical dominance to both formative and summative assessment during training further compounded this situation. Thirdly, registrars identified a number of practical barriers and incentives that influenced their teaching engagement. This included potential negative views from trainers as to their trainee's ability and requirement to be involved with teaching activities.
By understanding and addressing these issues, it is hoped that GP trainees' engagement with teaching activities can be better engendered with subsequent benefits for both the trainee and those they teach.

Teach practical skills.

Healthcare professionals have a key role to play in achieving consensus on the essential stages involved in undertaking practical and procedural skills. Providing opportunities for the trainee to practise is vital, as is regular critical scrutiny of performance, coupled with constructive feedback. Teaching procedural skills is a core role for many healthcare teachers. It is vital that trainers consider approaches to teaching skills, and the requirements for achieving skill mastery to ensure patient safety and ensure the training of competent clinicians for the future.

Counting quality because quality counts: differing standards in master's in medical education programmes.

BACKGROUND: In the United Kingdom the medical teacher role is being formalized. One result is that Masters level programmes in medical education are proliferating; however little or no attempt has been made to capture any differences in quality offered by them. A small scale project (Allery et al. 2006) set out to rectify this omission. AIM: Drawing on data from that study, this paper considers the variation in standards across programmes. Specifically research methods training provided in MMEd courses and levels of support for researchers is investigated. METHOD: A secondary analysis of the data generated by the evaluative study and gathered via review of programme web sites, semi structured interviews with MSc course directors and case studies in two sites, identified from purposive sampling. RESULTS: Variations in both taught and research elements were identified. The quality of the research experience was compromised for some students many of whom were poorly prepared to undertake educational research and the question of standards raised in respect of those institutions where the examination process lacked real academic rigour. CONCLUSIONS: The variance in research methods training and support raises a number of issues in relation to quality standards. The medical education community needs to engage in open and critical dialogue around the whole constellation of paradigms, methods and activities that pertain in educational research. Unless or until we address these deeper concerns, research into medical education will suffer through a lack of design flair, implementation and rigour.

Making a difference: researching master's and doctoral research programmes in medical education.

CONTEXT: The Association for the Study of Medical Education states that its aim is to improve the quality of medical education. As a consequence, it commissioned through its Education Research Group a small-scale project to explore the quality of the research methods elements in currently available UK master's and doctoral programmes. OBJECTIVE: This study aimed to explore the breadth, depth and diversity of the research methods provision of those programmes currently available to course participants. METHODS: The study comprised a 3-phase approach which utilised: a web-based search of curricula format and content; semi-structured interviews with key informants, and case studies and site visits to conduct documentary analysis of dissertations and in-depth interviews with core personnel. RESULTS: The study revealed wide variation across taught programmes. These discrepancies applied to length of course, requirements for the dissertation in terms of both length and time allowed to complete the study and, crucially, a wide variance in the quality and quantity of the levels of supervision provided for students during this research phase. DISCUSSION: This study raises concerns about the aims and functions of courses offering qualifications in medical education. It identifies a number of obstacles to the development of educational researchers who are skilled in the philosophical underpinnings of research activity or equipped to undertake educational research that is of a quality sufficient to withstand the scrutiny of the authors' scientific and clinical counterparts. We argue that if research into medical education is to thrive, it requires the full commitment of all those who are engaged in teaching the topic and supporting researchers.