Factors affecting pharmacology learning in integrated PBL in diverse medical students: a mixed methods study.

INTRODUCTION: Problem-based learning (PBL) was introduced to address passive teaching limitations. However, it is not fully characterised as a teaching modality in pharmacology. The present study investigated the factors affecting pharmacology learning in an integrated PBL-based curriculum in diverse learners. METHODS: Year 1 undergraduate medical students from two cohorts at St. George's University of London and University of Nicosia, participated. Statistical analysis of pharmacology knowledge scores, at the beginning (pre-test) and end of the academic year (post-test), investigated readiness to benefit from PBL based on diverse student characteristics (educational background, age, gender, country of origin, ethnicity, native language, PBL experience). Focus groups/interviews and a survey investigated aspects of integrated PBL impacting learning in depth. RESULTS: Pre- and post-test scores were positively correlated. Students with biomedical sciences degrees performed better at the pharmacology pre- and post-tests, while post-graduate degree holders performed better only at the pre-test. Effect size was of moderate magnitude. However, progress in learning (post-test performance after controlling for pre-test scores) was unaffected. Qualitative analysis revealed three major themes: 1) PBL as a learning environment; 2) PBL as a learning environment in pharmacology; and 3) PBL as a learning environment and confidence in prescribing. Under theme one, skill development, knowledge acquisition through collaboration and self-directed learning, group dynamics and preferred teaching methods were discussed. Under theme two, contextual learning, depth of knowledge and material correctness were raised. Under theme 3, students expressed variability in prescribing confidence. They perceived that learning could be improved by better integration, further references earlier on, more lectures and PBL facilitators with greater content expertise. The survey findings were consistent with those from focus groups/interviews. CONCLUSION: Pharmacology learning in a PBL-based curriculum is facilitated by constructive, collaborative and contextual learning. While baseline pharmacology knowledge may be advantageous, the other aforementioned characteristics studied may not affect readiness to benefit from PBL. However, further instructional scaffolding is needed, for example through further resources, lectures and self-assessment. The results from our study can inform evidence-based curriculum reform to support student learning further. Addressing learning needs could ultimately contribute to reducing medication errors through effective training of future prescribers.

Seasonal variation in the distribution of daily stepping in 11-13 year old school children.

PURPOSE: Seasonality studies in adolescent's physical activity (PA) tend to report total PA (e.g. steps/day) rather than more specific detail such as steps/hour. This study compared the detailed changes in PA between seasons. METHODS: Thirty three adolescents (baseline age 12.2 ± 0.3y) wore the activPAL activity monitor for 8 days on two occasions. RESULTS: Steps/day were higher in summer (Mdn = 12,879) than winter (Mdn = 10,512), p<.001. Steps/hour were significantly higher in summer compared to winter between 17:00 and 21:00 (p<. 044). No steps/day differences were found between boys and girls at either time point (p>.05), however, boys had significantly higher step counts in summer between '13:00-14:00' (p=.023), '19:00-20:00' (p=.032) and '20:00-21:00' (p=.023). CONCLUSION: Total steps/day masked sex differences within specific hours of the day, particularly evening times. Detailed daily patterns of PA are required to fully understand differences between sexes and across seasons.

The prevalence of upright non-stepping time in comparison to stepping time in 11-13 year old school children across seasons.

Evidence suggests that behaviours such as standing are beneficial for our health. Unfortunately, little is known of the prevalence of this state, its importance in relation to time spent stepping or variation across seasons. The aim of this study was to quantify, in young adolescents, the prevalence and seasonal changes in time spent upright and not stepping (UNSt(time)) as well as time spent upright and stepping (USt(time)), and their contribution to overall upright time (U(time)). Thirty-three adolescents (12.2 ± 0.3 y) wore the activPAL activity monitor during four school days on two occasions: November/December (winter) and May/June (summer). UNSt(time) contributed 60% of daily U(time) at winter (Mean = 196 min) and 53% at summer (Mean = 171 min); a significant seasonal effect, p < 0.001. USt(time) was significantly greater in summer compared to winter (153 min versus 131 min, p < 0.001). The effects in UNSt(time) could be explained through significant seasonal differences during the school hours (09:00-16:00), whereas the effects in USt(time) could be explained through significant seasonal differences in the evening period (16:00-22:00). Adolescents spent a greater amount of time upright and not stepping than they did stepping, in both winter and summer. The observed seasonal effects for both UNSt(time) and USt(time) provide important information for behaviour change intervention programs.

Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students?

INTRODUCTION: The transition to full-time clinical studies holds anxieties for most medical students. While graduate entry medical education has only recently begun in the UK, the parallel undergraduate and graduate entry MBBS courses taught at our school allowed us to study how 2 differently prepared groups perceived this vital time at a comparable stage in their training. METHOD: An anonymous questionnaire collected demographic data and graded anxiety in 13 statements relating to starting full-time clinical attachments. Two open questions allowed free text comment on the most positive and negative influences perceived during this time. Both a statistical analysis and a qualitative assessment were performed to compare the 2 groups of students. RESULTS: The 2 groups were similar with respect to gender but the graduate entry students were significantly older. The graduate entry students were significantly less anxious about most aspects of the transition period compared to the undergraduates. These course differences remained after adjusting for age and sex. When adjusted for course and age, male students expressed less anxiety. The main positive qualitative statements related to continual clinical and communication skills training in the graduate entry group. The main qualitative concerns in both groups related to 'fitting in' and perceived lack of factual knowledge. DISCUSSION: These data support the early introduction of clinical skills teaching, backed up by a fully integrated clinically relevant curriculum with continued assessment, in preparing students and reducing levels of anxiety before they start full-time clinical attachments. These course design differences appear to be more important than any differences in maturity between the 2 groups.

Student attitudes towards anatomy teaching and learning in a multiprofessional context.

CONTEXT: We carried out a survey of attitudes to learning anatomy amongst students from a range of health care disciplines in a multiprofessional context. SETTING: A joint course called the Common Foundation Programme (CFP) presented by a hospital medical school and a joint university faculty of health and social care sciences in the UK in the first term of the students' courses. PARTICIPANTS: Students following degree courses in biomedical science, medicine, nursing, physiotherapy, diagnostic radiography and therapeutic radiography. OBJECTIVES: To assess student attitudes to cadaveric work, learning anatomy and multiprofessional learning, and to compare student performance between degree courses in an anatomy assessment. DESIGN: A questionnaire was designed that requested demographic information and the students' attitudes to cadaveric work, anatomy learning and multiprofessional learning on a Likert scale. All students sat the same anatomy assessment at the end of the first term. RESULTS: The biomedical science and medical students were the most apprehensive about entering the dissecting room. The biomedical science students enjoyed working in a multidisciplinary group the most. Assessment results varied widely and the physiotherapy and medical students scored more highly than students in other disciplines, although all students had participated in the same course. CONCLUSIONS: It was possible to teach anatomy in the context of the shared learning experience of the CFP, although performance varied widely. Reasons for the differences are discussed and suggestions for the design of multiprofessional courses involving anatomy are made.

Selecting performance assessment methods for experienced physicians.

BACKGROUND: While much is now known about how to assess the competence of medical practitioners in a controlled environment, less is known about how to measure the performance in practice of experienced doctors working in their own environments. The performance of doctors depends increasingly on how well they function in teams and how well the health care system around them functions. METHODS: This paper reflects the combined experiences of a group of experienced education researchers and the results of literature searches on performance assessment methods. CONCLUSION: Measurement of competence is different to measurement of performance. Components of performance could be re-conceptualised within a different domain structure. Assessment methods may be of a different utility to that in competence assessment and, indeed, of different utility according to the purpose of the assessment. An exploration of the utility of potential performance assessment methods suggests significant gaps that indicate priority areas for research and development.

Is insight important? measuring capacity to change performance.

BACKGROUND: Some doctors who perform poorly appear not to be aware of how their performance compares with accepted practice. The way that professionals maintain their existing expertise and acquire new knowledge and skills - that is, maintain their 'currency' of practice - requires a capacity to change. This capacity to change probably requires the individual doctor to possess insight into his or her performance as well as motivation to change. There may be a range of levels of insight in different individuals. At some point this reaches a level which is inadequate for effective self-regulation. Insight and performance may be critically related and there are instances where increasing insight in the presence of decreasing performance can also cause difficulties. OBJECTIVE: This paper presents an exploration into the nature of insight, its relationship to professional performance and its measurement as part of performance, reflecting the combined experiences of a group of experienced education researchers and the results of literature searches on insight and performance. CONCLUSION: There may be individuals in whom insight is so lacking that they are beyond remediation. If there is a dichotomy between adequate and inadequate levels of insight, testing this could be a cost-effective way of determining where efforts for remediation should be focussed.

The assessment of poorly performing doctors: the development of the assessment programmes for the General Medical Council's Performance Procedures.

BACKGROUND: Modernization of medical regulation has included the introduction of the Professional Performance Procedures by the UK General Medical Council in 1995. The Council now has the power to assess any registered practitioner whose performance may be seriously deficient, thus calling registration (licensure) into question. Problems arising from ill health or conduct are dealt with under separate programmes. METHODS: This paper describes the development of the assessment programmes within the overall policy framework determined by the Council. Peer review of performance in the workplace (Phase 1) is followed by tests of competence (Phase 2) to reflect the relationship between clinical competence and performance. The theoretical and research basis for the approach are presented, and the relationship between the qualitative methods in Phase 1 and the quantitative methods in Phase 2 explored. CONCLUSIONS: The approach is feasible, has been implemented and has stood legal challenge. The assessors judge and report all the evidence they collect and may not select from it. All their judgements are included and the voice of the lay assessor is preserved. Taken together, the output from both phases forms an important basis for remediation and training should it be required.

The General Medical Council's Performance Procedures: the development and implementation of tests of competence with examples from general practice.

OBJECTIVE: This paper describes the development of the tests of competence used as part of the General Medical Council's assessment of potentially seriously deficient doctors. It is illustrated by reference to tests of knowledge and clinical and practical skills created for general practice. SUBJECTS AND TESTS: A notional sample of 30 volunteers in 'good standing' in the specialty (reference group), 27 practitioners referred to the procedures and four practitioners not referred but who were the focus of concern over their performance. Tests were constructed using available guidelines and a specially convened working group in the specialty. METHODS: Standards were set using Angoff, modified contrasting group and global judgement methods, as appropriate. RESULTS: Tests performed highly reliably, showed evidence of construct validity, intercorrelated at appropriate levels and, at the standards employed, demonstrated good separation of reference and referred groups. Likelihood ratios for above and below standard performance based on competence were large for each test. Seven of 27 doctors referred were shown not to be deficient in both phases of the performance assessment.

Training the assessors for the General Medical Council's Performance Procedures.

From July 1997, the General Medical Council (GMC) has had the power to investigate doctors whose performance is considered to be seriously deficient. Assessment procedures have been developed for all medical specialties to include peer review of performance in practice and tests of competence. Peer review is conducted by teams of at least two medical assessors and one lay assessor. A comprehensive training programme for assessors has been developed that simulates the context of a typical practice-based assessment and has been tailored for 12 medical specialties. The training includes the principles of assessment, familiarization with the assessment instruments and supervised practice in assessment methods used during the peer review visit. High fidelity is achieved through the use of actors who simulate third party interviewees and trained doctors who role play the assessee. A subgroup of assessors, selected to lead the assessment teams, undergo training in handling group dynamics, report writing and in defending the assessment report against legal challenge. Debriefing of assessors following real assessments has been strongly positive with regard to their preparedness and confidence in undertaking the assessment.

The General Medical Council's Performance Procedures: peer review of performance in the workplace.

The General Medical Council procedures to assess the performance of doctors who may be seriously deficient include peer review of the doctor's practice at the workplace and tests of competence and skills. Peer reviews are conducted by three trained assessors, two from the same speciality as the doctor being assessed, with one lay assessor. The doctor completes a portfolio to describe his/her training, experience, the circumstances of practice and self rate his/her competence and familiarity in dealing with the common problems of his/her own discipline. The assessment includes a review of the doctor's medical records; discussion of cases selected from these records; observation of consultations for clinicians, or of relevant activities in non-clinicians; a tour of the doctor's workplace; interviews with at least 12 third parties (five nominated by the doctor); and structured interviews with the doctor. The content and structure of the peer review are designed to assess the doctor against the standards defined in Good Medical Practice, as applied to the doctor's speciality. The assessment methods are based on validated instruments and gather 700-1000 judgements on each doctor. Early experience of the peer review visits has confirmed their feasibility and effectiveness.

Patient-oriented learning: a review of the role of the patient in the education of medical students.

AIM: To explore the contribution patients can make to medical education from both theoretical and empirical perspectives, to describe a framework for reviewing and monitoring patient involvement in specific educational situations and to generate suggestions for further research. METHODS: Literature review. RESULTS: Direct contact with patients can be seen to play a crucial role in the development of clinical reasoning, communication skills, professional attitudes and empathy. It also motivates through promoting relevance and providing context. Few studies have explored this area, including effects on the patients themselves, although there are examples of good practice in promoting more active participation. CONCLUSION: The Cambridge framework is a tool for evaluating the involvement of patients in the educational process, which could be used by curriculum planners and teachers to review and monitor the extent to which patients are actively involved. Areas for further research include looking at the 'added value' of using real, as opposed to simulated, patients; more work on outcomes for patients (other than satisfaction); the role of real patients in assessment; and the strengths and weaknesses of different models of patient involvement.

The personal tutor system: an evaluation.

The stressful nature of medical student training is being increasingly recognized. This study describes a questionnaire survey of the long running personal tutor system (intended to help with social as well as educational needs of clinical students), at a London medical school. Just over one half of students and one third of tutors were highly satisfied with the system. Satisfaction in students was linked with regularity, but not frequency, of meetings, being 'chased' by tutors, and engaging in social as well as educational activities. A small but worrying percentage of students reported that they would not be able to share personal or academic difficulties with tutors, highlighting the need for other avenues of support/counselling to be made available to students.

A survey of medical undergraduate community-based teaching: taking undergraduate teaching into the community.

This article summarizes the findings of a survey investigating the extent to which medical schools in the United Kingdom have developed community-based undergraduate teaching: the types of courses being run and their content; whether they are being evaluated; and how the students are assessed. Courses have been categorized under four main headings: (1) based in general practice, for teaching about general practice as a clinical specialty or using practice patients for teaching general medicine and basic clinical skills; (2) community-oriented, led by GP or community tutors; (3) specialist teaching led by hospital consultants; and (4) agency-based teaching. Twenty-eight schools responded to a written request for information and details of 83 courses were received.

Glycoproteins of trypanosomes: their biosynthesis and biological significance.

1. Trypanosomes are unicellular parasites that cause human sleeping sickness in Africa and Chagas' disease in South America. Glycoproteins are important components of their plasma membrane. 2. The bloodstream form of the extracellular salivarian African trypanosome (e.g. Trypanosoma brucei) has the ability to express on its cell surface a repertoire of variant surface glycoproteins (VSGs) and in so doing, evades the immune response of the host (antigenic variation). 3. The VSG is probably synthesized initially in a manner like that of the membrane-bound glycoproteins of mammalian systems, but it also undergoes some novel post-translational modifications. 4. The stercorarian South American trypanosome (Trypanosoma cruzi) is an intracellular parasite which expresses different glycoproteins on its plasma membrane at various stages of its life-cycle, but does not exhibit antigenic variation. 5. The biosynthesis and functions of trypanosomal glycoproteins are compared with those of mammalian glycoproteins, and are discussed with particular reference to potential targets for chemotherapy and immunotherapy of trypanosomiasis.

Lipid composition of bloodstream forms of Trypanosoma brucei brucei.

The qualitative and quantitative lipid composition of bloodstream forms of Trypanosoma brucei brucei S42 was compared with that of rat plasma and erythrocytes. The concentrations of lipid-bound phosphate and lipid-bound sialic acid in the trypanosomes were markedly higher than those of the rodent tissues. There was no trace in the trypanosomes of dolichol or dolichol phosphate. Trypanosomes contained two unidentified lipids: an acidic phospholipid and a highly polar glycolipid.