Members’ papers presented in parallel sessions

Arts & Humanities Why medical students should read Victorian novels: Middlemarch by George Eliot J Morrissey

V Patel Assessment Evaluation of assessments to predict ranking for Foundation posts J Franks

J Dacre I Taylor

Can judges conceptualise the borderline student when applying the Modified Angoff method? S Fowell R Fewtrell D C M Taylor

The use of simulation in the assessment of performance of consultant anaesthetists whose performance has given cause for concern

M Rhodes M Campbell K Haire P McAvoy D O'Leary

Measuring professionalism: the conscientiousness index J McLachlan G Finn J Macnaughton

A postgraduate Diploma in child health: do examiners and candidates agree on what it assesses?

A Reece L Davis P Todd M Bellman S J Newell

Simulated patients versus clinical examiners: an assessment of rater stringency/leniency in consultation skills scores assessed in OSCEs

A Hastings V Shah R Wright

Criterion referencing judges: who are the best predictors? S Newell P Kumar R Dinwiddie L David A Muir-Davis G Muir

A comprison of the passing standards for a written examination at two UK medical schools A Blythe J Hancock

Introducing feedback for OSCEs J King H Sweetland R Marshall

Developing selection methodology for entry into postgraduate training; Validity, utility and candidate reactions

F Patterson S Gregory B Irish S Plint

Patient feedback for medical students - towards multisource feedback in undergraduate assessment

J Rees O Lyons J Archer

Predictive validity of Team Objective Structured Bedside Assessment (TOSBA): evaluating the clinical competencies of final medical year

F Meagher S D W Miller M W Butler R W Costello R Conroy N G McElvaney

Patterns and demographics of 11 years of GMC Fitness to Practice referrals A Sturrock K Boursicot H Spencer J Dacre

Basic Science Education Will Nursing Students surpass their Medical Peers? D M Fanning

G Chadwick

The science underpinning medical decision making by junior doctors S Bull K Mattick

Is anatomy different? Exploring anatomy tutors' views on the character of anatomical knowledge and the most effective ways to teach it

K Mattick S Regan de Bere

Learning anatomy from the living body: a modern approach to anotomical teaching D Patten J L Donnelly P M White G Finn J C McLachlan

Clinical Skills Whither Clinical Skills? R K McKinley

R B Hays

Right-left discrimination: a cautionary tale for undergraduate medical teachers G Gormley R Best M Dempster

Evaluation of a Nephrology Outpatient Clinic designed for teaching medical students R Al-Jayyousi

Development of a pre-operative assessment service as a key learning opportunity for medical students

S Cregan J Botfield A Walsh A Hassell

Communicating clinical information: the four point presentation J Morrissey R Nair V Patel

Alphabet strategy for diabetes care: an international evidence-based, patient-centered medical education approach for long-term conditions

V Patel J Morrissey L Varadhan A Gopinath J D Lee S Shaikh D James P Sear J Wilson T Ritchie R Nair

Peer Physical Examination: A Qualitative analysis of student perceived problems viewed with the lens of activity theory

P Bradley C Rees A Wearn A Vnuk

Communication with patients: does performance at the start of medical education predict students' skills in the clinical years?

A Hastings S Petersen R McKinley

The "Trialogue": A new model metaphor for understanding clinical teaching and learning and developing skills

J McKimm

Assessment of a novel objective structured video examination for the assessment of clinical competence in paediatrics

E A Webb V Nanduri L Davis G Muir S J Newell

A quasi-experimental trial of interprofessional education (IPE) of resuscitation skills P Bradley S Cooper F Duncan

Teaching Communication Skills in Mental Health: Interprofessional Learning S Abbott J Attenborough A Cushing M Hanrahan A Korszun

Continuing Education Working as a newly appointed consultant: an investigation into the transition from Specialist Registrar to Hospital Consultant

J Brown I Ryland N J Shaw D Graham

Onlining or flatlining? The challenge of internet CME provision J Pearson Curriculum Planning Evidence for the acceptability and academic success of an innovative remote and rural extended placement

J Cleland M Wilson

Undergraduate ethics: theory and practice in the clinical years R Knight

Eliciting students' preferences for teaching in ophthalmology: a conjoint analysis approach A King A J Foss

Delivering online computer aided learning in gastroenterology to a large multi-campus medical school: an exploration of student attitudes

N Khan O Epstein

Qualitative evaluation of specialist oncology training - unexpected tails I J Robbe M Button

Developing a national strategy for undergraduate education in psychiatry N Dogra S Hardy

Clinical teachers' views on barriers to undergraduate teaching A Akkad S Bonas D Heney

Education on the move: a survey of medical students experiences of m-learning I Bickle P K Hamilton G Gormley S Bridgett A Davey P Stirling

Professional Ethical and Legal Awareness of Students in the Medical and Health Sciences Fields: a Cohort Study

S Abdul Rahman N Muhammad M Ahmad Mansur J K Candlish

Swallows, Amazons and Mayan Peoples: Learning Outcomes, Curricular Objectives and the Hiden Curriculum

R Talbot M Talbot

Management/Administration Using action research to improve and administer the child health teaching programme for Warwick Medical Students

T Bindal E Peile

Multi-professional Education Enhancing confidence in practising and teaching communication skills - impact of a Masters level module

M Barnett J Kidd

Early interprofessional interactions: does student age matter? E Anderson L Thorpe

Should medical students learn about patient safety with other students? A comparative study E Anderson L Thorpe S Petersen

Learning together in practice - evaluating the impact of undergraduate, interprofessional learning using the Leicester Model of Interprofessional Education

E Anderson A Lennox S Petersen

Working with the patient voice: developing teaching resources for inter-professional education S Kilminster S Fielden C Carney A Onafowokan

Developing professional identity: a study of the perceptions of the first year Medical, Nursing, Dental and Pharmacy students

S Morison A O'Boyle

New Technologies The Internet in medical education: A realist review G Wong

T Greenhalgh R Pawson

Connected but not connecting? An interactive "blog" website within a PBL curriculum D Maxton S T Creavin

Factors influencing clinical teachers' (dis)engagement with their own on-line training C Morris J McKimm

Postgraduate Education How successful is the Foundation Programme? Views of trainees, consultants and nurses in NHS Scotland

F French J Wakeling C Rooke K McHardy G Bagnall

Electronic portfolios for surgical trainees: educational emancipation or regulatory suppression? L Pugsley L Allery M MacDonald S Brigley

Moving the goal posts and hitting the targets: reflections on researching in a change context L Pugsley L Allery M MacDonald S Brigley

What can attachments in public health add to training programmes in general practice? T Swanwick J Reynolds J Wills

Selection Admissions to graduate-entry medicine - validity and equity of selection tools P Garrud Staff Development Producing highly effective interprofessional educators: A postgraduate level Continual Professional Development Programme

E Anderson D Cox L Thorpe

Beyond consultation: the role of reflection in creating institutional change – let the students teach the teachers

M Kelly S O’Flynn M McCarthy I Bairre

A Scott

Moving beyond teacher competence: the case for educational leadership as a core element to accredited faculty development activity

J McKimm C Morris

Teaching about specific subjects Attitudes of medical students to caring for patients approaching the end of life: a cross-sectional study in the University of Cambridge

S Barclay J Benson D Wood J Brimicombe E Summers T Quince

Teaching and Learning Learning Approaches and Learning Styles of Medical and Nursing Students - A Comparative Analysis

D M Fanning G Chadwick

Does the Strategic Learning Approach promote inactive Doctors? D M Fanning G Chadwick

Learning Style Theory - Reflective versus Activist Doctors D M Fanning G Chadwick

An intercalated BSc degree is associated with higher marks in subsequent medical undergraduate degree examinations

J Cleland A Milne H Sinclair A Lee

Medical students with educational problems: who and how to help R Hays M Lawson

Is a supervised on-call session a valuable and effective learning tool for final year medical students?

R Isba C Marshall K Rothwell G Byrne P O'Neill

Peer teaching "pepped up" P Stark A Walker M F Peerally J Connors E Weston N Bax

Support for breadth of repertoire of learning styles T Quince J Benson J Brimicombe Z N Djuric D Wood

DVD clips as an adjunct to PBL sessions: do they improve outcomes? R Isba D Gore M Ahmed B Woolley G Byrne P O'Neill

"In six months' time ……. the patient will be happier because I have the title doctor": medical student and junior doctor reflection on pelvic examination skill learning

A Carson-Stevens A N Fiander I J Robbé

Systematic review of the role of intercalated BScs in medical education M Jones S Singh

Learner Centred Programme Evaluation T Dornan

C Boggis J Graham N Lown A Scherpbier H Boshuizen A Muijtjens

"I think therefore I am".... I think? Medical students' changing personal epistemology in a problem-based curriculum

G Maudsley

Pot Pourri Who's got the power - the SP or the student? A linguistic analysis of conversational dominance in communication skills assessments

A de la Croix

The Experiences of UK, EU, (Non-UK) and Non-EU Medical Graduates Making the Transition to the UK Workplace

C Kergon J Illing G Morrow B Burford A Bedi

The Prehospital Care Programme - the Medical Student's Story E Lightbody

Two years’ experience of a large-scale, peer-led education programme in Leicester Medical School

A Batchelder

Arts and Humanities

Why Medical Students Should Read Victorian Novels : Middlemarch by George Eliot J Morrissey, V Patel J Morrissey, Diabetes Centre, George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire CV10 7DJ, United Kingdom Context and setting Second-year students at Warwick Medical School are required to undertake a Special Studies Module. We report on one, a reading group on the novel Middlemarch by George Eliot. In Nuneaton we have a special affinity with Eliot, since she was born here and our hospital is named after her. Middlemarch, published in 1871-2, is her undisputed masterpiece and arguably the finest of all Victorian realist novels. It is notable for its narrative sweep, high moral purpose and the author’s empathy with her large cast of characters. Why the idea was necessary Advocates of teaching humanities to medical students argue that it encourages reflection and enhances the ability to enter imaginatively into the lives of others. Middlemarch is ideal for this purpose. One of the leading characters is a doctor, Tertius Lydgate. As a physician and researcher he is talented, dedicated and progressive: he is first in the town to use a stethoscope and proposes establishment of a medical school. However, his ambitions remain unfulfilled since he is unable to apply in his personal life the insight and moral integrity he exhibits in his professional one. What was done The group consisted of seven students and ourselves, and we met fortnightly. Each student selected a theme raised by the book and wrote a short assignment. The themes chosen were: • From Middlemarch to modern medicine • George Eliot’s subtle sermon: medicine and faith together • The choices of Doctor Lydgate • Medical reform in Middlemarch • How Eliot communicates the theme of political instability in Middlemarch • The women of Middlemarch • The relationships and potential relationships of Dorothea Brooke Results and conclusions The students developed many important insights on such themes as professionalism, spirituality, gender roles and ambivalent attitudes towards progress, amongst others. With regard to Lydgate one wrote “His lack of social awareness and poor choices cost him his dreams. (The module) made me reflect on what success actually is.” Another noted a parallel between Lydgate’s descent into debt and the debts accumulated by medical students who “may be tempted to higher paying but less benevolent positions.” Lydgate’s struggle to modernise medical practice teaches us “that change is not always appreciated” wrote a third. The final word goes to a fourth: “Studying Middlemarch encourages reflection about the importance of a successful doctor-patient relationship and increases awareness of human nature.”

Assessment

Evaluation of Assessments to Predict Ranking for Foundation Posts J Franks, J Dacre, I Taylor J Franks, Division of Surgical & Interventional Sciences, Royal Free & University College Medical School, University College London, 74 Huntley Street, London, WC1E 6AU Introduction The appointment of medical students to Foundation posts requires medical schools to divide year groups into quartiles. This process relies on accurately predicting a student’s quartile in the final examination (Year 5) at the end of Year 4. Methods A retrospective analysis of the 347 medical students who sat medical finals at UCL in the summer of 2007. The final quartile of each student was compared with the quartile predicted by the Year 3 and 4 assessments to evaluate accuracy of prediction Results The written papers in Year 3 correctly predicted 52% of students final quartile. Only 38% of students final position was correctly predicted by the Year 3 OSCE (P=<0.05). Combining the Year 3 & 4 results increased the predictive power of the assessment methods such that 59% of students were correctly ranked in finals. Individual assessments from Year 3 could not predict as accurately as the Year 3&4 combined results the students who would gain honours in finals. The Year 3 written paper did not place 22% of students who gained distinction in finals in the top quartile compared with an average of 4% predicted by the Year 3&4 combined results. In addition 33.3% of students who failed finals were not predicted to be in the bottom quartile by the Year3 written papers as compared with 13% predicted by the Year 3&4 combined results Discussion The medical students are used to assessments dominated by written papers & factual recall- “knows”. The greater predictive power of the written assessment in Year 3 is probably a reflection of the student’s familiarity with this type of assessment method. The Year 3 OSCE has a significantly lower power of prediction. It aims to test the “shows how”- this requires the students to develop a range of new study skill techniques as well as demonstrate newly acquired clinical competencies. The accuracy of quartile prediction can be improved by combining assessment methods to produce the strongest predictive validity. Combined assessments from Year 3&4 show a consistently greater accuracy of prediction. The range of assessments reduces the disadvantage that all individual methods have on students and allows triangulation. Conclusions The accuracy of prediction of final year quartile positions influences the allocation of Foundation posts. Regular evaluation of this assessment process is vital as these high stakes assessments have a direct bearing on career progression.

Can judges conceptualise the borderline student when applying the Modified Angoff method? S L Fowell, R Fewtrell, D C M Taylor S L Fowell, School of Medical Education, 2nd Floor, Cedar House. Ashton Street. Liverpool, L69 3GE The concept of the borderline or minimally competent candidate that represents the lowest level of acceptable competence is key to standard setting. Concerns have been raised regarding the ability of judges participating in these methods to conceptualise the borderline candidate and accurately predict their performance,1 and anecdotal evidence suggests that many judges do find this aspect of standard setting difficult. Assessment in the Liverpool MBChB includes exam papers based on the extended matching question (EMQ) format and short answer questions (SAQ).2 All summative written assessments are now routinely standard set using the modified Angoff method.3 For EMQ-based papers, judges are require to estimate the percentage of borderline candidates who would be expected to correctly answer the question, for SAQ-based papers, judges estimate the number of marks that borderline candidates should be expected to obtain for each part of the question. Preliminary analysis of EMQ-based assessments has shown that there is a statistically significant correlation between the percentage of students in the lower third of the class (based on performance on the paper overall) that answer the question correctly and the median of the judges’ rating of the questions. This correlation increases after the discussion stage of the Modified Angoff method. Suitable measures of question difficulty for SAQ-based papers will be described, and the analysis will be extended to all assessments throughout the course to see whether these findings apply to different assessments formats and different years of the course. References:

1. Zieky MJ. So much has changed: How the setting of cut scores has evolved since the 1980s. In: Cizek GJ, ed. Setting performance standards: Concepts, methods and perspectives. Mahwah, N.J: Lawrence Erlbaum Associates; 2001.

2. Fowell S, Fewtrell R, McLaughlin P. Estimating the minimum number of judges required for test-centred standard setting on written assessments. Do discussion and iteration have an influence? Advances in Health Sciences Education 2008;13(1):11-24.

3. Case SM, Swanson DB. Constructing written test questions for the basic and clinical sciences. National Board of Medical Examiners.1996.

The use of simulation in the assessment of performance of consultant anaesthetists whose performance has given cause for concern M Rhodes, M Campbell, K Haire, P McAvoy, D O’Leary M Rhodes, National Clinical Assessment Service (NCAS), Market Towers, 1 Nine Elms Lane, Vauxhall, London, SW8 5NQ Introduction ‘High Fidelity’ simulation is used in the training of undergraduates and postgraduates worldwide and simulation has been used to assess anaesthetists up to accrediting examinations. This is the first report of the use of simulation as part of the assessment of accredited specialists whose performance had given cause for concern. Method Through an iterative process, simulated scenarios were developed aided by specialists from the Simulation Centre at Chelsea and Westminster Hospital, the Royal College of Anaesthetists and Anaesthetic Consultants who are National Clinical Assessment Service (NCAS) assessors. The latter experienced the simulations during their development and were then trained during a pilot session where senior trainee anaesthetists acted as practitioners undergoing assessment. Several instruments for recording the observations of the assessors and consequent judgements were trialled and modified during the piloting of the scenarios. Ultimately, an instrument based on the NOTTS surgical observation in theatre was used. Results Assessments have been planned to be conducted on consultant anaesthetists referred to the General Medical Council and NCAS. Judgments will be made by assessors in the domains of:-

• Situational awareness • Technical competence • Leadership • Teamworking • Relationships with patients

contributing to the assessment reports. Conclusion High fidelity simulations will allow anaesthetists to be assessed on critical areas of practice unlikely to be observed in usual workplace based assessments. It will be reported on how useful they were in their contribution to the overall assessment.

Measuring Professionalism: the Conscientiousness Index J C McLachlan, G Finn, J Macnaughton J C McLachlan, Associate Dean of Undergraduate Medicine, School of Medicine and Health, Durham University, Queen's Campus, Stockton-on-Tees TS17 6BH Undergraduate medical student behaviour and performance may correlate with later measures of professionalism. 1-3. However, it is not clear how undergraduate performance can be quantified in an objective and scalar manner that would allow early interventions to be made. We have been collecting routine data on student performance over a number of domains, including attendance, timely submission of work, participation in evaluation, and fulfilment of class requirements with regard to submission of personal details, feedback, and attendance at career development events. Each data point is objective in nature, and can be completed by support staff, rather than requiring expert judgement by Faculty members. These are collated into a ‘Conscientiousness Index’, again by support staff. This Index showed good scalar properties, acting as a discriminator between students within a cohort, and showing almost identical distributions between years. This suggests that a specific and consistent trait is being measured. Validity of this approach as a surrogate for the concept of professionalism was explored by inviting Faculty familiar with the cohorts and with the concept of professionalism as established by the General Medical Council to grade students with regard to their approach to professionalism, without access to information on the Conscientiousness Index scores. These gradings were compared to the Index, and a strong positive correlation was observed. Moreover, a strong correlation was observed with Critical Incident Reporting data, which again was collected through a completely independent process. Reliability was explored by comparing scores from year to year, and again strong correlations were observed. Practicality (in terms of cost and ease of collection of data) was also high, suggesting that this might be a useful measure. Predictive validity of this measure can only be explored over time. Currently, therefore, the Index is not being used neither in a summative nor a formative way. Instead, it is regarded as ‘Informative’, in that records will be kept for future analysis. The observations indicate that a specific and measurable trait might be related to the more complex construct of ‘professionalism’ as understood by experienced staff familiar with the individual students. References:

1. Papadakis MA, Hodgson CS, Teherani A, Kohatsu ND. Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board. Academic Medicine. 2004; 79:244-9.

2. Papadakis MA, Teherani A, Banach MA, Knettler TR, Rattner SL, Stern DT, Veloski JJ, Hodgson CS. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005; 353:2673-82.

3. Teherani A, Hodgson CS, Banach M, Papadakis MA. Domains of unprofessional behavior during medical school associated with future disciplinary action by a state medical board. Academic Medicine. 2005; 80(Suppl):S17-20.

A postgraduate Diploma in Child Health; do examiners and candidates agree on what it assesses? A Reece, L Davis, P Todd, M Bellman, S J Newell A Reece, Department of Paediatrics, Watford General Hospital, Vicarage Road, Watford, Hertfordshire, WD18 0HB Aims To examine views of examiners and candidates on whether a Postgraduate Paediatric Diploma is a good assessment of clinical skills. Background and Methods The Diploma in Child Health (DCH), of the Royal College of Paediatrics and Child Health (RCPCH), was taken by 437 candidates in 2007. It aims to assess the expected competency of a newly appointed General Practitioner after 4-6 months training in paediatrics. There are 8 stations of 5 or 13 minutes testing communication, history taking, clinical examination, child development, clinical knowledge and judgement in common paediatric problems. In 2007 as part of quality audit, a questionnaire survey of hosts, candidates and examiners was collated. Both quantitative and qualitative data were described. Results Data from 13 sittings in 12 centres were obtained. This included 37 examiners (Paediatricians, Child Psychiatrists, Paediatric Surgeons and General Practitioners) and 211 candidates. Over 60% of candidates were female. Most had qualified in medicine 3-7 years previously (range 1-31 years). 83% of candidates felt that the examiners were helpful and not intimidating. 70% of candidates felt the exam had fairly and accurately assessed their ability. Areas identified as problematic by candidates: variability in examiner demeanour, short timing of clinical stations and high level of clinical case difficulty. Examiners generally agreed. Examiners and candidates agreed that the exam was a good assessment of history taking skills, communication skills, clinical examination skills, child development knowledge and competence. However, consistently more examiners (93.6%), compared to candidates (69.4%) on average rated each skill area fit for purpose. Chi square test on grouped data for these responses showed there was a significant difference between examiners and candidates in levels of agreement (Χ² = 43.08; df = 1; p = 0.001). Conclusion The DCH remains a popular qualification for doctors working in General Practice and specialities looking after children. The RCPCH ensures regular quality assessment and audit. Its popularity, based on the increasing numbers of candidates, reflects an agreed view that most stations are fit for purpose. There are areas where candidates consider that it is a less good assessment of certain skills. The importance of seeking feedback from candidates and examiners is clear and will allow continuing review to further enhance the validity and reliability of the DCH to maintain its overall high regard by candidates and examiners alike. Reference:

1. http://www.rcpch.ac.uk/Examinations/DCH. Royal College of Paediatrics and Child Health. Accessed 13th March 2008.

Simulated Patients Versus Clinical Examiners: An Assessment of Rater Stringency/Leniency in Consultation Skills Scores Assessed in OSCEs V Shah, A Hastings, R Wright

A Hastings, Department of Medical and Social Care Education, Maurice Shock Medical Sciences Building, University of Leicester, PO Box 138, Leicester, LE1 9HN Background Simulated Patients (SPs) have been used widely in OSCEs, in both portraying clinical scenarios and also rating student performance1. Extensive work has shown that the reliability of SP raters is comparable to that of physician raters2-4. However, raters may differ in their relative leniency or stringency, bringing an undesired source of variance in candidate scores. This is traditionally known as the ‘hawk-dove’ problem5. This paper seeks to answer the following questions:

What is size of the hawk-dove effect when SPs are used to rate history taking skills compared with physicians?

Are SPs more or less stringent raters than physicians?

Do history taking skills as measured by the Leicester Assessment Package show case generalisability?

Methods The Consultation skills of 270 undergraduate Medical Students will be examined using 2 OSCE stations of a possible 6. Performance will be rated using a modified version of the Leicester Assessment Package (LAP)6. Each candidate will be rated by both a Simulated Patient and a Physician. We shall conduct Multi-faceted Rasch modelling of the paired judgments to calculate rater stringency/leniency. The model will also allow us to isolate other sources of error variance introduced to the OSCE such as Case and Item, and will generate an adjusted mark with the effects of these components removed7.

Conclusions Previous studies investigating the hawk-dove problem in clinical OSCEs have reported varying estimations of the size of the effect on candidate score5.8. The effect is highly dependant on the level of selection, monitoring and training provided to examiners. We anticipate that whether the SPs or physicians are used as raters, only a small proportion of the variation in candidate scores would be due examiner stringency/leniency behaviour. We would not anticipate the size of the hawk-dove effect to be higher in one group over the other.

Previous work suggests that SP raters may score students higher than physicians when assessing physical examination9, however we may not observe such a difference in assessing generic skills like communication and history taking10. We would not anticipate SPs to be any more or less lenient than physicians in our study.

Assessment of physical examination skills is known to be highly case-specific. However, it has been recently shown that generic skills like communication are independent of cases8. We would therefore expect our findings to show that this is also true for history taking skills as measured by LAP.

The analysis will also provide valuable information regarding which of the LAP items are the most useful discriminators when assessing history taking skills. References:

1. Adamo G Simulated and standardized patients in OSCEs: achievements and challenges 1992-2003. Med Teach. 2003 May;25(3):262-70.

2. Swanson DB, Stillman PL. Use of standardised patients for teaching and assessing clinical skills. Eval Health Prof. 1990; 13:79-103 3. Tamblyn RM, Klass DK, Shnabl GK, Kopelow ML Factors associated with the accuracy of standardized patient presentation. Acad

Med. 1990 Sep; 65(9 Suppl):S55-6. 4. Vu NV, Barrows HS, Marcy ML, Verhulst SJ, Colliver JA, Travis T Six years of comprehensive, clinical, performance-based

assessment using standardized patients at the Southern Illinois University School of Medicine. Acad Med. 1992 Jan; 67(1):42-50. 5. IC McManus, M Thompson and J Mollon. Assessment of examiner leniency and stringency ('hawk-dove effect') in the MRCP(UK)

clinical examination (PACES) using multi-facet Rasch modeling. BMC Medical Education 2006, 6:42 6. Hastings A, McKinley RK, Fraser RC Strengths and weaknesses in the consultation skills of senior medical students: identification,

enhancement and curricular change. Med Educ. 2006 May; 40(5):437-43. 7. Applying the Rasch Model. Fundamental Measurement in the Human Sciences. Bond T, Fox CM (2001). New Jersey: Lawrence

Erlbaum Publishers Mahwah. 8. Harasym PH, Woloschuk W, Cunning L Undesired variance due to examiner stringency/leniency effect in communication skill scores

assessed in OSCEs. Adv Health Sci Educ Theory Pract. 2007 Jul 3 9. McLaughlin K, Gregor L, Jones A, Coderre S. Can standardized patients replace physicians as OSCE examiners? BMC Medical

Education 2006, 6:12 10. Rothman AI, Cusimano M: A comparison of physical examiners' standardized patients', and communication experts' rating of

international medical graduates' English proficiency. Acad Med 2000, 75:1206-1211

Criterion Referencing Judges: Who are the Best Predictors? P Kumar, R Dinwiddie, L Davis, A Muir-Davies, G Muir, S J Newell S Newell, Royal College of Paediatrics and Child Health, 5-11 Theobalds Road, London, WC1X 8SH Introduction The Royal College of Paediatrics and Child Health use criterion referenced assessment (Angoff methodology) to set the standard for the Part II written paper of the Membership exam (MRCPCH Part II). Seven judges independently review each question of the paper and estimate the percentage of borderline candidates who will answer the question correctly (homework grade). On the “Angoff day”, held shortly after the examination is taken, the individual judgements are shown and the panel discuss them. Each judge scores again. The candidates’ performance in the actual exam is then revealed and the judges give final estimates, the aggregate mean of which becomes the ‘consensus Angoff rating’. Our judging panel is unique, comprising both senior examiners and post membership trainees (SpR). We hypothesised that the senior examiners are better at predicting the candidates’ exam performance. Methods In 2007, 3 examination papers were criterion referenced. We analysed a total of 8000 judgements. Judges’ homework grades and the consensus Angoff rating were analysed for each exam paper, to test if there was a difference between examiners and SpRs. For both groups we also calculated the percentage change between judges’ homework grade and the final consensus grade (bias). Results

• In 2007, 33% of the judges were examiners, 67% were SpRs. • 2007.1 and 2007.2 papers: There was no difference between the homework grades of the examiners and

SpRs and the consensus Angoff rating (median 60%) (p>0.05). Bias was very similar in both groups (-3.16% for 2007.1 and -3.96% for 2007.2).

• 2007.3 paper: The median homework grade was 50% for examiners and 70% for SpRs. The bias for examiners was -13.3% and +6.67% for SpRs.

• Overall, examiners gave a slightly lower final pass mark grade (63.3%) than SpRs (66.7%). • The average percentage change in grades between judges’ first and final vote was +13.33% for examiners

and +6.67% for SpRs. Conclusion There appears to be little difference in the median gradings between the examiners and SpRs, suggesting they have similar ability to predict final scores. The data suggest that SpRs are better able to predict consensus scores and candidates’ performance. The modified Angoff method works well, and these data strongly support our policy of including trainees as judges in the Criterion Referencing of this high stakes postgraduate examination.

A comparison of the passing standards for a written examination at two UK medical schools A Blythe, J Hancock A Blythe, Senior Teaching Fellow, Department. of Community-Based Medicine, University of Bristol, Cotham House, Cotham, Bristol, BS6 6JL This research project, which is in progress, has three aims:

1. To compare the passing standards expected of students at two medical schools 2. To compare the distribution of marks achieved by students at these two medical schools 3. To compare the chances of a student failing or passing an examination at the two schools

UK medical schools are responsible for assessing the standards of their own graduating students. However, there is no literature comparing performance in written examinations across different medical schools. There is a small amount of research looking at clinical examinations and this suggests that standards do vary amongst UK medical schools1. There are several reasons for demanding that schools set comparable standards: the GMC states that “in legal terms every primary UK qualification is equal”2; consistent standards are important to medical students3 (partly because foundation posts appointments are determined by their quartile rankings); and patients expect that all doctors - wherever qualified – achieve the same basic level of competency. The project is based on examinations at two medical schools, Oxford and Bristol. In the penultimate clinical year of the undergraduate course at these schools there is module which consists of teaching in Primary Care, Dermatology and Care of the Elderly. At each school this module is partly assessed using a written paper which includes extended matching questions (EMQs). In order to make a comparison between the two schools the authors have selected some EMQs which they have embedded within the written examination at each school. The authors will record what passing score for the group of common EMQs is set by the usual panel of examiners at each school. One school uses the Ebel method, the other school uses the Angoff method in order to set the passing score. The authors will describe the distribution of scores achieved by the students at each school. They will use the χ2 test to compare the scores achieved by the students at each medical school and will use Fisher’s exact test to compare the pass rate at each school. This will enable them to comment on the whether the medical schools have equivalent examination standards. References:

1. Boursicot, KAM, Roberts, TE & Pell, G. Using borderline methods to compare passing standards for OSCEs at graduation across three medical schools. Medical Education 2007;41:1024-1031

2. General Medical Council. Assessing student performance and competence http://www.gmc-uk.org/education/undergraduate/undergraduate_faqs.asp#6 (23 December 2007)

3. Khan KZ and Sear JW. A national online survey of final year medical students’ opinion on the General Medical Council’s proposed reforms to the undergraduate medical assessment system. Postgrad. Med. 2007; 83: 606 - 609.

Introducing Feedback for OSCEs J King, H Sweetland, R Marshall J King, Division of Medical Education, Cardiff University, University Hospital of Wales, Heath Park Campus, Cardiff, CF14 4XN Introduction When long and short cases were used at Cardiff University to examine clinical skills, students were given immediate face to face feedback by their examiners. With increasing class sizes past the 300 mark and the introduction of OSCE exams in 2003 it was no longer possible to give personal feedback for these summative exams. The students for the past five years have received their standard set mark and were asking for more. It was felt that the students should be given some feedback on their clinical skills which needed to be prompt and meaningful but also easy to create. Method Each element of the OSCE marking sheets are given one of five domains: communication skills, diagnostics and integration, practical procedures, examination and applied knowledge. These were then programmed into the computerised marking system and feedback for each domain was created as a percentage. These were posted out to the student for last year’s 3rd and this year’s 4th year OSCEs with the definitions of the domains and their standard set marks. The explanations were also posted on the student information web site. Student evaluation was sought using an online survey. Results Clinical tutors shown examples of the feedback informally could see the benefits immediately, as could recently qualified doctors from Cardiff who had not received feedback as students. The students however were less convinced. Half of those who replied to the survey could recognise some benefit for their future study plans. The rest wished to receive personal feedback from each examiner and copies of the OSCE mark sheet. They also showed they had not read the information provided by comments they had made. “There was inadequate explanation of what the results meant” Discussion Students do not always read information given to them and would prefer to be spoon fed. They may therefore have difficulty seeing the usefulness of the feedback provided. The feedback also has the benefits of being easy to produce for this class size. Allowing it to be given promptly to the students (although not immediately). Following the evaluation of the new feedback we plan to explain the point of the feedback in person, and to publish some of the general comments about the class already collected on examiner evaluation forms. The on line survey will then be repeated and we will report on the new findings among the students following their education and compare the response.

Developing selection methodology for entry into postgraduate training: Validity, utility & candidate reactions F Patterson, S Gregory, W Irish, S Plint F Patterson, 1 Bramcote Road, Beeston, Nottingham, NG9 1AG

Objectives Selection of doctors into postgraduate training is an under-researched area and it is currently a topic of fierce debate1. This paper reports on the development and validation of a new national 3 stage selection system for General Practice in the UK. Initial research using job analysis produced a valid model of selection criteria2. These criteria are assessed in the selection system which comprises (Stage 1) ‘long-listing’ and eligibility checks; (Stage 2) short listing via two machine-marked tests a clinical problem-solving test and situational judgement test (SJT) to assess non-clinical domains (e.g. empathy) and; (Stage 3) a selection centre comprising work relevant simulations (consultation, group & written exercises). This represents a significant innovation beyond the use of traditional application form and interview selection methods. For example, although the SJT methodology has been validated for use in medical school admissions3,4 this is the first application in postgraduate selection. Approach There are approximately 9,000 applicants per year for training in GP in the UK. We present validation data over 3 years (2005-8) focusing on 7 core issues.

1. Content/predictive validity: Are some selection criteria more readily assessed using a specific method? What is the relative accuracy of each tool?

2. Construct validity: e.g. Is there evidence the methods are actually measuring empathy? 3. Test format/instructions: How should candidate instructions be presented and what effect does this have on

the response process? 4. Fairness issues: How do we minimise adverse impact in the design process? 5. Susceptibility to coaching: What are the issues regarding coaching/social desirability? What strategies can

be applied? 6. Cost-effectiveness: What is the net gain in cost efficiency of using one method over another? 7. Fairness & candidate reactions: Do candidates perceive this as a fair and legitimate selection system?

Outcomes Results show the selection system to be a psychometrically valid and efficient selection methodology. The most effective combination of methods at each stage is identified and empirical evidence of incremental validity is provided. Candidate reactions are generally positive although areas for improvement are recognised. Evidence of procedural and distributive justice for the selection system is presented. Conclusions Best practice development of selection methodology is discussed for entry into post-graduate training and is linked to research in medical school admissions5. Results have major implications for international policy development for selection of doctors across all specialties. A future research agenda is presented. References:

1. Tooke J. Aspiring to Excellence. 2007. 2. Patterson et al. A competency model for GP; Implications for selection & development. 2000, BJGP, 50, 188-193. 3. Lievens F, et al. The operational validity of a video-based situational judgment test for medical college admissions: Illustrating the

importance of matching predictor and criterion construct domains. Journal of Applied Psychology, 90, 442-452, 2005. 4. Patterson F, et al. (under review) Evaluation of three short-listing methodologies for selection into post-graduate training: the case of

General Practice in the UK. Medical Education. 5. Patterson, F. & Ferguson, E. Selection into medical education and training. 2007, ASME monograph; Understanding Medical

Education .

Patient Feedback for Medical Students – Towards Multisource Feedback in Undergraduate Assessment O Lyons, J Archer, J Rees J Rees, Sherman Education Centre, 4th Floor Southwark Wing, Guy’s Hospital, London, SE1 9RT Introduction Multisource Feedback (MSF) is now used extensively in postgraduate education and appraisal1,2,3 in the UK but there has been relatively little published work utilising MSF in undergraduate medical students4,5. We are not aware of the development of any patient assessment tool for specific use with undergraduates. We set out to develop and then test the feasibility and reliability of a patient assessment tool for use by medical students after interaction with hospital patients. Method In order to test the feasibility of patient feedback in the undergraduate setting we constructed a patient feedback questionnaire, mapped to core objectives of the General Medical Council’s “Good Medical Practice”, “Medical students: professional behaviour and fitness to practise”, “Tomorrow’s Doctors”, and the King’s College London Medical School handbook. The questionnaire focused on student-patient communication, professionalism, and patient education. Likert scales were used to record responses along with basic demographic data and one free-text box for further comments. During a 13 week medical clinical placement 37 students in their first clinical year were each given 10 forms and were asked to give forms to ward patients after they had clerked them. Patients completed the forms in private and placed them in a pre-addressed envelope which was then posted by ward staff (via the hospital internal mail) to the study investigators. Forms were scanned and analysed using SPSS. Following completion of the clinical placement, focus-group work will be undertaken with medical students and nursing staff, examining attitudes towards this form of assessment. Results Outcomes will include analysis of the focus groups, the reliability of patient assessment results, and comparison of these scores to professional evaluations by consultant firm heads and Objective Structured Clinical Examination results. Variability with patient gender and ethnicity will be examined. Discussion This project aims to demonstrate the feasibility, reliability and acceptability of a novel patient assessment questionnaire for use by medical students in a hospital setting. References:

1. Archer JC, Norcini J, Southgate L, Heard S, Davies H. mini-PAT (Peer Assessment Tool): a valid component of a national assessment programme in the UK? Adv Health Sciences Education. 2006:http://dx.doi.org/10.1007/s10459-006-9033-3.

2. Crossley J, Davies H, McDonnell J, Cooper C, Archer JC, McAvoy P. A district hospital assessing its doctors for re-licensure: can it work? Medical Education. 2008;42:359-63.

3. Chisholm A, Askham J. What do you think of your doctor? A review of questionnaires for gathering patients' feedback on their doctor. Oxford, UK: Picker Institute; 2006.

4. Arnold L, Willoughby L, Calkins V, Gammon L, Eberhart G. Use of peer evaluation in the assessment of medical students. J Med Educ. 1981 Jan;56(1):35-42.

5. Rees C, Shepherd M. The acceptability of 360-degree judgements as a method of assessing undergraduate medical students' personal and professional behaviours. Medical Education. 2005;39:49-57.

The Predictive Validity of the Team Objective Structured Clinical Examination (TOSBA): Evaluating the Clinical Competencies of Final Year Medical Students F M Meagher , M W Butler, S D W Miller, R W Costello, R W Conroy, N G McElvaney FMeagher, Department of Medicine, Royal College of Surgeons in Ireland, Medical School, Education and Research Centre, Beaumont Hospital, Beaumont Road, Dublin 9, Ireland Objective This study was conducted to investigate the value of the TOSBA as a predictor of student performance in the Final Clinical Examination. Background We have previously described the TOSBA1 which is an adaption of the previously described TOSCE(2) to a ward-based ‘real’ patient setting. Methods The clinical competencies of 191 Final year students were formatively assessed during the 2005/6 academic year using the TOSBA. The overall performance of these students was analysed and compared with their performance in the Final Examination. Data were analysed to assess the contribution of the TOSBA assessments to the prediction of the Final Examination result. We also examined the correlation of another formative assessment tool, the OSLER3, with the Final Examination result. Clustering around latent variables (CLV) analysis of the various components of the Final Examination was used to evaluate the validity of the TOSBA Results A relatively low correlation was found between student performance in the OSLER and the Final Examination (r2=0.053). In comparison, a moderate correlation was found between the TOSBA and the Final Examination (r2

=0.53). Nine of the 11 students who failed the Final Examination also failed the TOSBA,. (sensitivity 82%, (95% CI 48% -98%). However, there were 47 failures on the TOSBA, so the predictive value of failure was low, at 19% (95% CI 9% to 33%). Of the 17 students who failed the clinical component of their final examination, eight had failed the TOSBA, giving a sensitivity of 47%, 95% CI 23% to 72%. However, the predictive value was again low, at 17%, 95% CI 8% to 31%. There was a clear grade of association between the failure and honours rates categorised by TOSBA result. Conclusion The analysis suggests that the TOSBA requires a more stringent definition of failure and a more liberal definition of honours if it is to be a potential means of identifying problem students on one hand and students of excellence on the other. The CLV analysis provided insights into assumptions made about what we are testing in our assessments – the TOSBA grouping with other patient-centered assessments. References:

1. Miller SDW, Butler MW, Meagher FM, Costello RW, McElvaney NG. Team Objective Structured Bedside Assessment (TOSBA): A Novel and Feasible Way of Providing Formative Teaching and Assessment. Med Teach 2007; 2: 156 -159.

2. Singleton A, Smith F, Harris T, Ross-Harper R, Hilton S. An Evaluation of the Team Objective Structured Examination (TOSCE). Med Educ 1999; 33: (1) 34 -37.

3. Gleeson F. AMEE Medical Education Guide No 9: Assessment of Clinical Competence using the Objective Structured Long Examination Record (OSLER). Med Teach 1997; 19: 17-14.

Patterns and demographics of 11 years of GMC Fitness to Practice referrals A Sturrock, K Boursicot, H Spencer, J Dacre A Sturrock, ACME, 4th floor Holborn Union Building, Archway Campus, Highgate Hill, London N19 5LW Background The General Medical Council (GMC) was established in 1858 to protect, promote and maintain the health and safety of the public. The Medical Act (1983) defined one of its functions as ‘to deal firmly and fairly with doctors whose fitness to practise is called into question’. This includes performing an appropriate investigation of any complaint received about a doctor. If the investigation needs to assess the doctors clinical performance, for the last 11 years there has been a specific assessment comprising of a peer led work based assessment and a test of competence. Since their introduction, 768 doctors have been referred for a FtP performance assessment. Summary of work We will report the pattern of overall referrals to the GMC including the effect of media coverage of the medical profession on the number of referrals received. We will then discuss the demographics of the 768 doctors that have been referred for a performance assessment in terms of age, gender and specialty in which they practice. Summary of results The number of doctors being referred to the GMC has increased from 2214 in 1996 to 5167 in 2007. However 39% of these referrals require no further investigation and 35% are investigated only if the employer expresses concern about the doctor. The referral rate appears to be influenced by the media; in particular it rises immediately after high profile reports of doctors’ professional misconduct. Of those doctors that require further investigation, only a small percentage requires a performance assessment. In the last 5 years this has averaged out as 70 doctors a year. Sixteen (16%) of these assessments involve women and the average age of doctor being assessed is 52. The majority of assessments are of general practitioners; surgeons are the second most common specialty however, the range includes physicians, anesthetists, O&G doctors, psychiatrists, pediatricians, radiologists and pathologists. Conclusions Overall referrals to the GMC have increased significantly in terms of numbers and proportion of practising doctors and this referral rate appears to be influenced by adverse coverage of the profession in the media. However, the number of doctors requiring an assessment of their performance is relatively stable at 70 per year. In the cohort of doctors that have been referred for a performance assessment certain sub groups e.g. men, appear to over represent.

Basic Science Education

Will Nursing Students surpass their Medical Peers? D M Fanning, G Chadwick D M Fanning, Conway Institute of Biomolecular and Biomedical Research, School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Ireland Aims University College Dublin (U.C.D.) has the largest and oldest University School of Nursing and Midwifery in Ireland, while also offering the largest number of training places in Medicine in Ireland. We hypothesise that modern nursing students adopt a more active approach to learning than their medical counterparts, and may surpass their medical peers. Methods Permission to survey students was attained from the Schools of Medicine and Nursing. Ethical Exemption was awarded. Learning Style Questionnaires were distributed during the first week of Semester One 2007, to first year Medical and General Nursing students. Compliance with the study was voluntary and anonymous. Completed questionnaires were analysed utilising the Statistical Package for the Social Sciences. The 2007 Central Applications Office final entry points for U.C.D Medicine and Nursing Degree courses were reviewed. Results 82.2% of 129 enrolled medical students, and 45.1% of 204 enrolled General Nursing students completed the questionnaires. The Reflector Learning Style predominates in both student cohorts. T tests reveal statistically significant differences in the prevalence of the Reflector, Theorist and Pragmatist Learning Styles, but not for the Activist Style. Medical students preferentially adopt a Reflector-Theorist-Pragmatist paradigm. 2007 U.C.D. final entry points were 570 for Medicine and 360 for Nursing. Average points were 585 for Medicine and 395 for Nursing. Conclusion The introduction of a four year BSc (Nursing) has resulted in the recruitment of high calibre, intelligent, pro-active Nursing students. However the consistent admittance of academically gifted, grounded medical students ensures their position as leaders of the multi-disciplinary clinical team.

The Science Underpinning Medical Decision Making by Junior Doctors S Bull, K Mattick S Bull, Institute of Clinical Education, Peninsula College of Medicine and Dentistry, St Luke’s Campus, Heavitree Road, Exeter It is unclear exactly ‘how’ biomedical science contributes to the medical decision making process of newly qualified doctors or ‘what’ biomedical science they apply in clinical practice. These are important questions when evaluating the transfer of biomedical science learnt within undergraduate medical education to its application in the workplace or deciding on the science content of undergraduate curricula. This paper will present the preliminary findings from a study that aims to explore the relative contribution of biomedical science knowledge to medical decision making. The study involves observing 20 foundation year 1 (F1) doctors whilst working in general medicine, general surgery or medical/surgical admissions in hospitals in the Peninsula Foundation School in South West England. The researchers observe the doctors for one hour working in clinical practice and take structured field notes to record events that involve medical decision making. Occasionally, having sought the appropriate consents, the foundation doctors are also video recorded. The doctors are then interviewed using the notes or the video recording from the observation to stimulate their recall of events. This facilitates an insight into the contribution of biomedical science to the medical decision that newly qualified doctors make. A structured approach (framework analysis) to analysing the interview data is being adopted. The findings will stimulate debate on 'what biomedical science should be covered in undergraduate medical curricula?’ We intend to hold a national meeting to debate this issue at the end of the study and are keen to hear from others researchers in this field.

Is Anatomy Different? Exploring anatomy tutors views’ on the character of anatomical knowledge, and the most effective ways to teach it K Mattick, S Regan de Bere K Mattick, Peninsula Medical School, Heavitrees Road, Exeter, EX1 2LU The study outlined in this presentation was funded by the Higher Education Authority in order to determine whether teachers think anatomy demands different approaches to teaching, learning and assessment than other topics in the undergraduate medical curriculum and, if so, why. Three previous studies emphasised the need for a survey of anatomy tutors: a semi-structured interview study exploring aspects of modern medical curricula that could present barriers to studying; an ethnographic study of student learning in anatomy sessions, in which students distinguished between ‘scientific’ and ‘soft’ approaches; and a survey of different methods of anatomy teaching in UK schools, which raised concerns about the compatibility of anatomy with problem-based learning. These studies were discussed with a small convenience sample of anatomy teachers, whose observations included the necessity to learn huge body of objective facts, an emphasis on vocabulary with few organising principles, and the suggestion that the study of anatomy is more suited to building up discrete blocks of knowledge rather than a problem-based approach, which starts with messy clinical problems. The project presented used telephone interviews with a range of anatomy tutors across the UK, to discuss the above concerns. In thirty minute interviews, researchers: a) explored how students at various UK medical schools engage with anatomy as a curricular topic, both through formal teaching and in their self-directed learning, b) recorded how anatomy tutors believe their students’ anatomical knowledge will be integrated successfully into their clinical practice as senior medical students, and their future careers as qualified doctors, and c) discussed how anatomy may or may not differ to other dimensions of medical training, in terms of its character and application. Interpretive analysis of the transcribed data was conducted using proven qualitative thematic and discursive methods. This involved two researchers to ensure the validity of the study’s findings. In our presentation, we will describe the research methodology and experience, and outline several key findings. The presenters will identify particular challenges to achieving desirable learning that anatomy tutors believe to be specific to teaching anatomy as a curricular topic, and some potential solutions. Conclusions from the study will be illustrated with quotations and reflexive notes, and the implications for broadening the horizons of medical education will be followed up in open discussion with the audience.

Learning anatomy from the living body: a modern approach to anatomical teaching D Patten, J L Donnelly, P M White, G Finn, J C McLachlan D Patten, Room C143 Holliday Building, Phase 1 Medicine, Holliday Building, Queen's Campus, University of Durham, University Boulevard, Thornaby, Stockton on Tees, TS17 6BH We have incorporated three elements of living anatomy into our traditional cadaveric anatomy course to enhance and contextualise student’s experience of learning gross anatomy. Portable ultrasound equipment (PUS) can be used to study living anatomy1,2 alongside prosections. Teaching sessions should be designed in consultation with an expert sonographer. Optimisation of the viewing conditions of the learning environment is essential. The neck and limbs of a consented volunteer can be quickly and easily scanned to consistently produce impressive, dynamic images, particularly when Doppler imaging is used. PUS imaging is relatively safe, non-invasive, introduces students to an increasingly important diagnostic tool and reinforces knowledge of cross-sectional anatomy. Recent studies3,4 report that most students are willing participants in peer physical examination (PPE) during clinical skills teaching, but that predictors of engagement are complex and student attitudes can change subsequently. In a qualitative study, our students mostly reported that PPE was a valuable learning experience. Several students reported feeling apprehensive prior to PPE and embarrassed about body image or competency levels in performing clinical skills. Large group sizes and reduced privacy/access to tutors were reported as negative impact factors on the learning experience; students reported mixed feelings about conducting PPE within friendship groups and also regarding student and staff expectations of their engagement in PPE. The PPE experience can be improved by ensuring the learning environment is sensitive to students’ needs. Body painting (BP) has been used to teach surface anatomy (SA)5,6 and can be a successful method of introducing students to PPE. BP works well when it follows traditional cadaveric anatomy teaching. Following a demonstration on a volunteer, students work in pairs, one student acting as the artist, the other as the model. Female students are usually comfortable wearing old bras/t-shirts and male students are content to be painted directly onto their bodies. Mirrors are provided to allow the model to view the work in progress. Models take an active role in reading the instructions to the artist to reinforce their learning experience and keep them focused and motivated. Once the task has been completed the students swap roles. In some sessions it may be appropriate for students to engage in PPE of the model student using the painted organs as a guide for locating structures to be auscultated or palpated. Data from evaluative feedback questionnaires reveals that students consider PUS, PPE and BP to be effective learning tools. References:

1. Tshibwabwa, E.T. and H.M. Groves, Integration of ultrasound in the education programme in anatomy. Med Educ, 2005. 39(11): p. 1148.

2. Tshibwabwa, E.T., H.M. Groves, and M.A.H. Levine, Teaching musculoskeletal ultrasound in the undergraduate medical curriculum. Med Educ, 2007. 41(5): p. 517-518.

3. O'Neill, P., et al., Medical students' willingness and reactions to learning basic skills through examining fellow students. Medical Teacher, 1998. 20(5): p. 433-437.

4. Rees, C., P. Bradley, and J.C. McLachlan, Exploring medical students' attitudes towards peer physical examination. Medical Teacher, 2004. 26(1): p. 86-88.

5. Op Den Akker, J., et al., Giving Color to a New Curriculum: Bodypaint As a Tool in Medical Education. Clinical Anatomy, 2002. 15: p. 356-362.

6. McLachlan, J.C., et al., Teaching anatomy without cadavers. Medical Education, 2004. 38: p. 418-424.

Clinical Skills

Whither Clinical Skills? R K McKinley, R B Hays R McKinley, Keele University School of Medicine, Keele, Staffordshire, ST5 9BG Background Anecdotally, many UK hospital trusts are concerned that new Foundation Year 1 doctors are unready for unsupervised practice and consider them expensive observers of care. Consequently, they are not scheduled for additional duties until the employing trusts certify them competent. This has impacts on trusts, FY1 doctors and the reputations of medical schools. The research questions are obvious. How prevalent are these concerns? Are they about some or all medical schools? Are they valid? Can they be overcome? Nevertheless Keele aims to graduate work ready doctors. We discuss the nature of this challenge and our proposal to appoint a Director of Clinical Skills charged with meeting it. Clinical skills: the educational challenge Clinical skills are a highly context specific amalgam of interpersonal, technical, cognitive and psychomotor skills. Their development, like that of any skill, requires repeated deliberate practice in the context of their eventual use. However the initial practice of clinical skills must be safe both for learners and patients and, for many skills, will require simulation to minimise harm by neophyte practitioners. Clinical skills: the management challenge The challenge is to develop and manage an integrated programme starting in the skills lab extending across many clinical areas, different teaching trusts and the community. Furthermore, progressive certification of readiness to move from ‘plastic to flesh’ to supervised practice to unsupervised practice and workplace certification of continuing competence is needed. This requires recruitment and training of trainers/assessors, negotiation of time for supervision and assessment and the collection and collation of evidence of students’ emerging competence. The Director of clinical skills We currently envision the Director of Clinical Skills as a senior clinical academic who will be part of the School’s senior management team who will have expertise in summative and formative assessment of skills, skills lab teaching and faculty development. The Director will need excellent team work, interpersonal and communication skills as well as change management skills at unit and trust level. Ideally s/he would be capable of achieving the associated research agenda. Comment We are interested in using this proposal as a basis for discussion. Do other schools share our vision of the work ready graduate? To what extent do they agree with our analysis of the challenges faced and if not, how do they differ? If others share the vision, how do they propose to achieve it?

Right-left discrimination: a cautionary tale for undergraduate medical teachers G Gormley, R Best, M Dempster G Gormley, Department of General Practice, Queen’s University Belfast, 1 Dunluce Avenue, Belfast, BT9 7HR Background Knowing the difference between your right and left side is an important skill that orientates individuals in many day-to-day tasks. When performing such right-left discriminatory tasks, individuals make demands on several higher functions, including: integration of sensory information, visuo-spatial ability and receptive/expressive language functions. However evidence would suggest that some individuals have difficultly in right-left discrimination.1 As in many professions, doctors often need to discriminate between right and left, while delivering healthcare to patients (e.g. unilateral surgery, administration of therapeutic agents and clinical procedures). The UK National Patient Safety Agency (NPSA) has highlighted this area as an important matter of patient safety. However, there have been many cited reports of wrong sided clinical tasks being carried out on patients. Between 2000-2003, 119 medico-legal cases of wrong sided surgery, were notified to the Medical Defence Union.2 The undergraduate curriculum is the first stage of medical education. In the General Medical Councils document ‘Tomorrows Doctors’ patient safety has been highlighted as a key area for undergraduate medical training.3 To date, there is a paucity of information on the degree of right-left discrimination among medical students. Furthermore there is limited information on the degree of self-awareness of right-left confusion among medical students. The aim of this study is to assess the degree of right-left discrimination among junior medical students.

Method First year undergraduate medical students, attending a clinical skills training programme (n=300) will be invited to participate in the study. Consenting students will be asked to complete an annonymised questionnaire. This questionnaire will aim to capture:

1) Basic student characteristics (Age, gender, handedness and career aspiration) 2) Techniques, if any, employed by students to help them discriminate between left and right.

The degree of students right-left discrimination, will be measured using the validated ‘Bergen Right-Left Discrimination test’.1 Analysis will explore the frequencies and variations of responses. Multiple regression analysis will be used to observe for any associations between students characteristics and their level of right-left discrimination. Results and conclusions The results of this study will aim to identify the level of right-left confusion among undergraduate medical students. Such information will help to inform medical educationalists about the prevalence of this issue and highlight its importance in the training of clinical and procedural skills to undergraduate medical students. References:

1. Ofte SH, Hugdahl K. Right-left discrimination in Male and Female, young and Old subjects. Journal of Clinical and Experimental Neuropsycholgy 2002; (24):82-92.

2. The National Patient Safety Agency and The Royal College of Surgeons of England. Patient Safety Alert 06: correct site surgery http://www.npsa.nhs.uk/site/media/documents/885_CSS%20PSA06%20FINAL.pdf

3. Tomorrow’s doctors: Recommendations on undergraduate medical education. General Medical Council, July 2002.

Evaluation of a Nephrology Outpatient Clinic designed for teaching medical students R Al-Jayyousi, A Stanley R Al-Jayyousi, Consultant Nephrologist and Honorary Senior Lecturer, Renal Unit, Leicester General Hospital, Gwendolen Road, Leicester LE5 5PW Background Teaching in an outpatient setting can be frustrating due to time pressures and thus student’s learning experience is limited. A dedicated teaching nephrology clinic was designed for students in their penultimate or final clinical year to consult with ‘new’ patients referred by GPs with supervision of a senior nephrologist. Clinic structure The clinic was held fortnightly and students were requested to ‘sign up’. Patients were allocated 75 minutes (rather than the usual 20 minutes) and had previously received information about the clinic arrangements, which also allowed an opt-out and offer of an alternative appointment in a regular clinic at a similar time. This information and a further opt-out were available to patients on arrival. On the day An initial briefing between the lead clinician and students was conducted to include a review of the referral letters, a strategy for the consult/examination, and student-led discussion of potential diagnoses and investigations. The supervising clinician attended the student’s consult with his patient, only intervening if clear errors were made or the patient became distressed. The student summarised the consult with the clinician and patient present, generating a problem list and management plan. The clinician concluded by reinforcing the key findings and agreeing a management plan with the patient. At the end of clinic, the consult and investigative results were reviewed with the student. Finally the student prepared a typed ghost clinic letter. Patients, students and clinicians were asked to complete an evaluation questionnaire. Results 29 patients, 18 students and 5 clinicians attended over 5 months with a questionnaire response of 55%, 55% and 80% respectively. Patients: 14/16 of patients found their visit useful; all commented that they would attend this clinic again and that the student did not cause distress. The free-text comments were overwhelmingly positive and the patients found the 3-way discussion very informative. Students: using a 5-point Likert scale (strongly agree to strongly disagree), all the students either agreed/strongly agreed that the clinic improved their knowledge, history taking and examination skills; all strongly agreed that the clinic improved their understanding of investigations; all strongly disagreed/disagreed that the clinic was less useful than a ‘regular clinic’. Clinicians: all stated this was a good use of time and the student-led consult did not compromise patient care. Conclusion This dedicated clinic improved patient satisfaction and student learning experiences. We propose to use this as a model for other renal undergraduate and postgraduate training.

Development of a Pre-operative assessment Service as a Key Learning Opportunity for Medical Students S Cregan, J Botfield, A Walsh, A Hassell S Cregan, Keele University Medical School, City General Hospital, University Hospital of North Staffordshire, Newcastle Road, Stoke on Trent, ST4 6QG Background As surgical practice is changing the time that elective patients spend on hospital wards is reducing. This has largely been driven by the introduction of the NHS Plan 2000 which recommended that 75% of elective surgical cases should be performed as day cases1. However, even non day case surgical patients are now likely to spend less time pre-operatively in hospital, most patients arriving on the day of their surgery. Thus in many busy surgical units the “pre-operative teaching ward rounds” have all but vanished. Although shorter surgical stays may be preferred by patients and improve the efficiency of services, the risk is a major reduction in learning opportunities for medical students around patients with surgically treated conditions2,3. So is there a way that opportunities for medical students to assess pre-operative patients can be improved whilst simultaneously improving patient care too? Work done Over an 8 month period we have introduced a new care pathway for all patients undergoing elective surgery in multiple surgical specialties at a large University teaching hospital. A large proportion of patients undergoing surgery now attend a pre-op assessment service including a final “check” prior to their surgery, this is combined with a medical review by the consultant team. We have developed a pre-op assessment service as a major learning opportunity for medical students in terms of:

• The clinical assessment of patients requiring surgical treatment, including eliciting clinical signs • Demonstration of gaining patient consent for surgical procedures • Evaluating patients for anaesthetic and surgical risk – by history, examination and investigations • Performing simple practical procedures – phlebotomy, ECGs etc.

This service has improved patient care and Consultants now find their pre-op patients are not only better prepared for surgery but they are also less likely to be cancelled. In addition it has presented a raft of excellent learning opportunities for students at a variety of stages in their education. Conclusions Restructuring the pre-assessment of all surgical patients is a huge under taking in any NHS trust, however the benefits are many. Crucially both services can be re-defined and improved whilst simultaneously creating new learning opportunities for medical students within surgery.

The preservation of good clinical opportunities in hospitals is dependent on changing and adapting service infrastructure. The work done to date at this hospital has proved that with the right support services can be changed and utilised for teaching.

References

1. DOH, The NHS Plan 2000, Department of Health: London. 2. Olson, L.G., S.R. Hill, and D.A. Newby, Barriers to student access to patients in a group of teaching hospitals. The Medical Journal Of

Australia, 2005. 183(9): p. 461-463. 3. McManus, I.C., et al., The changing clinical experience of British medical students. Lancet, 1993. 341(8850): p. 941-944.

Communicating Clinical Information: the Four Point Presentation R Nair, J Morrissey, V Patel J Morrissey, Diabetes Centre, George Eliot Hospital NHS Trust, College Street, Nuneaton, Warwickshire CV10 7DJ, United Kingdom Why the idea was necessary Although medical students receive much training in how to communicate with patients, less attention is paid to communication with other health care professionals. The ability to present information coherently and succinctly is an essential clinical skill. The Four Point Presentation organises information under four headings: a general introduction, positive findings, negative findings and clinical conclusion. We evaluated the training of students in its use. What was done Fifteen third-year Warwick Medical School students participated in a workshop. They circulated through twelve stations at which they were shown clinical, radiological or laboratory data. Their verbal presentations of the data were video recorded. Instruction was then given in the Four Point Presentation and the process was repeated: the students rotated through similar stations and were again video recorded. Finally they were encouraged to assess their presentational skills and to reflect, and were given feedback. Quantitative data were obtained from pre- and post-workshop questionnaires which asked students to self-rate their confidence in presenting the various types of information. Free-text comments were encouraged. Qualitative data were also obtained from feedback and debriefing. Results and conclusions The students’ confidence in their presentational skills improved (p < 0.05). Review of the video recordings and reflection on performance proved to be a useful formative exercise. The students identified that the Four Point Presentation method: • Established priorities in communicating information. • Ensured reception of information and its significance. • Allowed cross-checking of information. • Enabled focusing on the relevant data. However, improvements were not uniform across all types of material: the largest occurred where students were familiar with it (for example, chest x-ray and fundoscopy), the smallest where they were less so (for example, spirometry and CSF analysis). Comments from students included: • “Helped me to focus on key points needed to communicate information in a short period of time.” • “In an already busy schedule of study I thought the 4 point presentation is particularly good to use.” • “Understood what examiners are trying to identify in hospital medicine.” The Four Point Presentation structures knowledge and data in a meaningful way. Students can use it effectively on the ward round and in clinical assessments. Assessing the video presentations for completeness, clarity, organisation and delivery was challenging and we are developing a more objective instrument. We intend to apply this at the beginning and end of clinical attachments to assess improvements in presentation skills.

Alphabet Strategy for Diabetes Care: An international evidence-based, patient-centred medical education approach for Long Term Conditions V Patel , J Morrissey L Varadhan, A Gopinath, J D Lee, S Shaikh, D James, P Sear, Jo Wilson, T Ritchie, R Nair, for the George Eliot Diabetes Care Team V Patel, Institute of Clinical Education, Warwick Medical School, The University of Warwick, Coventry, CV4 7AL and George Eliot Diabetes Centre, George Eliot Hospital NHS Trust, Nuneaton, UK Background Long Term Conditions are increasingly recognised as significant causes of morbidity and mortality in all countries in the world. This poses a clinical education challenge that must be met. This paper will use diabetes as an example to propose a model of healthcare education and delivery for Long Term Conditions. Effective evidence-based care can reduce all diabetes complications, including death, end-stage renal failure and blindness by 50%. Many guidelines exist but rarely apply to patients or apply multi-professionally. Aim Evaluate an innovative locally-created education strategy that encompasses patient education and effective evidence-based healthcare professional education. Method A patient-centred, evidence-based, multi-professional strategy based on seven most important aspects of diabetes care was evaluated (Advice, Blood Pressure, Cholesterol, Diabetes Care, Eyes, Feet, Guardian drugs). Results

• Healthcare professional Education programme: delivered over 100 times. Evaluations have been consistently positive. The most recent course was delivered under the auspices of the UN Development Fund in Bahrain. We have a move towards accreditation of teams in Diabetes Care.

• Practice Of Evidence-based Medicine Audit: Over 5 years BP, Cholesterol, Diabetes control, Eye and

Feet screening improved with a significant improvement in the cardiovascular risk score (31.2% to 23.7% p<0.05). Our published results are similar to those obtained in well funded intensively treated cohorts of large randomized controlled trials (UKPDS and Steno-2).

• GAIA Survey (Global Alphabet Strategy Implementation Audit) In 35 diabetes centres in 25 countries,

57.5% of 146 healthcare professionals felt they were likely to adopt the strategy. 84.5% felt it was evidence-based and 88.0% practical.

• Patient Education Programme: Knowledge in 100 patients, improvement from 61.5 % to 80.0% (p<0.01).

An “expert” patient programme has been created which involves patient studying the Alphabet Strategy materials and being accredited if the stipulated score is reached on the “quiz”.

• i-DREAM Programme: Improvement in application of evidence-base research and correct prescribing

scores (69% before, 98% afterwards (15 clinicians on 10 cases, p<0.001)).

• ASIAD Study: Implementation in an economically-deprived Indian setting. Main improvements (p<0.01): cholesterol (60% to 90%), statin use (5% to 38%), aspirin use (6% to 71%), proteinuria assessment (48% to 93%).

Conclusion The strategy delivers high quality patient education and management. Its theoretical basis is the limit on our capacity for processing information first researched by GA Miller (“the Magical Number Seven, Plus or Minus Two”). Such programmes may be applied to other chronic disease states with similar benefits.

Peer Physical Examination - A qualitative analysis of student perceived problems viewed with the lens of activity theory P Bradley, C Rees, A Wearn, A Vnuk P Bradley, John Bull Building, Peninsula Medical School, Research Way, Tamer Science Park Plymouth, PL6 8BU Introduction Peer physical examination (PPE) has been employed for many years in the formal curriculum for learning clinical skills and surface anatomy. Previous studies of students’ engagement with PPE have been largely limited to single institution, quantitative analyses with little appreciation of the issues and concerns as felt by students. In addition, previous studies have often lacked a theoretical stance in which to locate their findings. The current study explores students’ views from geographically and culturally diverse schools. Methods Using an adaptation of the Examining Fellow Students questionnaire, we captured qualitative data from first-year medical students about their attitudes towards PPE. 617 (78.7%) medical students from six schools in five countries (UK, Australia, New Zealand, Japan and Hong Kong) provided free-text comments that were later transcribed and analysed using Framework Analysis. Results This paper focuses on several related themes about the complexities of students’ relationships within the context of PPE and their concurrent anxieties about peer examination as a simulation of patient examination. Students expressed their concerns about engaging in PPE by contrasting the peer examiner-examinee relationship with the doctor-patient relationship. They explained how these two types of relationship differed in terms of their levels of interaction and the nature of the relationships. Discussion Our findings are relevant to various features of the PPE activity system, namely the subject, object, outcomes, rules and community. We discuss our results in light of Engeström’s model of activity theory examining the activity system of PPE to better understand the complex interactions at work within this learning environment; we also provide recommendations for educational practice and further research based on the five principles of activity theory.

Communication with patients: Does performance at the start of medical education predict students’ skills in the clinical years? A M Hastings, S Petersen, R K McKinley A Hastings, Leicester Medical School, University of Leicester, Leicester, LE1 9HN Aim To investigate whether students’ performance in a communication skills station in the year one OSCE predicted their abilities in the ‘History Taking’ and ‘Relationship with Patients’ domains of their clinical assessment in years 3 and 4. Introduction The consultation skills of students at the Leicester Medical School are assessed using a validated instrument at regular intervals throughout the five years of the course, with specified competences and standard grade descriptors. As they progress the pass/fail threshold rises and the complexity of the challenge increases through the sequential addition of the domains of ‘Examination’, ‘Problem Solving’ and ‘Patient Management’. The Communication Skills Station in the Year One OSCE tests their ability to elicit a history in a patient centred manner. In Years 3 and 4 students undertake a course in Clinical Methods, which is assessed by observation of their consultation skills in all five domains1,2. Methods A data set is being compiled to record students’ performance in these two summative assessments. Students starting the five year course between 2001 and 2005 have subsequently progressed and completed the Clinical Methods Course between 2003 and 2007. All students who did the Communication Skills station in the year one examination during this period and remained on the course, have completed the Clinical Methods assessment and obtained scores in each of the five domains of consultation competence. Analysis These data sets will be analysed to determine whether performance by students in the Communication Skills station predicts their scores in the ‘History taking’ and ‘Relationship with patients’ domains at the end of the Clinical Methods Course. We will explore whether scores in ‘Examination’, ‘Problem Solving’ and ‘Patient Management’ are predicted by Communication skills scores. The Communication Skills station identifies a small proportion of students with very poor performance who receive remedial teaching. The resulting performance in the Clinical Methods Course of the bottom decile of these students will be analysed and presented separately. References:

1. McKinley RK, Fraser RC, Van der Vleuten C, Hastings AM. Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the Leicester Assessment Package. Med.Educ. 2000;34(7):573-579.

2. Hastings AM, McKinley RK, Fraser RC. Strengths and weaknesses in the consultations of medical students: identification, enhancement and curricular change. Med Educ 2006;40 (5):437-443.

The “TRIALOGUE”: A new model and metaphor for understanding clinical teaching and learning and developing skills J McKimm J McKimm, Centre for Medical and Health Sciences Education (CMHSE), Faculty of Medical and Health Sciences, The University of Auckland, PO Box 92019, Auckland Many models describing clinical teaching emphasise patients as active participants3 in the learning process, indicating how learners should interact with the patient or actively observe the clinician. Such models often operate as a series of consecutive dialogues or activity sets rather than focussing on relations and interactions. “The behaviour of a complicated thing should be explained in terms of the interaction between its component parts.”1 Dawkins’ comment about evolution underpinned the ‘Trialogue’: a simple model based on interactions which helps explain the complexity of communications and activities in clinical teaching. A trialogue is“an interchange and discussion …. among three groups having different origins, philosophies, principles”2. The Trialogue conceptualises clinical teaching settings with three participants: patient, learner and clinician (as clinical teacher). Each participant brings their own agendas, histories, experiences, expectations, fears and fantasies. The Trialogue provides a model for analysing complex interactions between all three ‘players’ through the metaphor of a continually shifting dialogue. It provides clinical teachers with a framework for scaffolding learning, for facilitating learner and patient active engagement in the learning process and for ‘reflecting in action’4 to promote student learning whilst simultaneously attending to the needs of the patient. ‘Trialogue’ draws from many disciplines including leadership and game theory, psychotherapy, psychiatry, education and sociology, incorporating emotional intelligence, self reference and meta-attention. It is relational, rather than task or activity focussed, takes a social constructivist perspective and acknowledges activity theory and the communal construction of meaning through language5. It enables us to articulate the often tacit: making explicit shifts in therapeutic and learning alliance between clinical teacher, student and patient. The Trialogue draws from the ‘parallel dialogue5’ and the ‘inner consultation6’ suggesting that clinical teachers operate within two sets of parallel processes: one attending to the patient (the inner clinical consultation) and one attending to the learner (the inner teaching dialogue). Inner dialogues can become intrusive and unhelpful6. However, if clinical teachers pay conscious attention to the relationship and emerging dialogue between players in the Trialogue, unhelpful ‘noise’ from inner voices and subsequent inappropriate responses are diminished. This facilitates development of the double parallel processes the ‘expert’ clinical teacher often unconsciously utilises8. Conclusions The Trialogue is a developing model. As a metaphor it is partial, blinding us to other aspects and activities9, however, it offers us a new model for deepening understanding of clinical teaching/learning processes and for developing strategies for clinicians to become ‘expert’ clinical teachers. References:

1. Lake, FR and Ryan, G. Teaching on the run 4: Teaching with patients, MJA, Volume 181 Number 3, 2 August 2004 2. Dawkins, R. (1996). The blind watchmaker: Why the evidence of evolution reveals a universe without design. W. W. Norton 3. Source www.yourdictionary.com 4. Schon. D. (1991). The Reflective Practitioner. How Professionals Think in Action. Jossey Bass, San Francisco 5. Ref: Gergen, KJ; Hoffman, MSW and Anderson, H (1996) Is Diagnosis a Disaster?: A Constructionist Trialogue, chapter in Kaslow, F.

(Ed.) Relational Diagnosis, Wiley 6. Neighbour, R. (2004). The inner consultation, 2nd edition, Petroc Press, Newbury 7. Isaacs, W. (1999). "Dialogue and the Art of Thinking Together: A Pioneering Approach to Communicating in Business and in Life"

Bantam Doubleday Dell Publishing 8. Proctor, B. (2001). Training for supervision: Attitude, skills and intention in Cutliffe, J, Butterworth, T and Proctor, B (eds)

Fundamental themes in Clinical Supervision, Routledge, London 9. Morgan, G. (1986). Images of organisations, Sage Publications, Newbury Park, CA

Assessment of a novel objective structured video examination for the assessment of clinical competence in paediatrics E A Webb, V Nanduri, L Davis, G Muir, S J Newell S J Newell, Royal College of Paediatrics and Child Health, 5-11 Theobalds Road, London, WC1X 8SH Introduction In 2004, the Royal College of Paediatrics and Child Health (RCPCH) introduced a video station into the clinical examination. The video station aims to evaluate candidate’s competence in the assessment and management of acute conditions or signs which cannot safely or easily be tested elsewhere in the clinical examination. Cases presented include neonatal, accident and emergency, and intensive care patients. Candidates have 22 minutes to view 8-9 video clips, each with 1-2 ‘best of many’ questions. The video station is one part of a 10 station structured clinical examination in a high stakes postgraduate examination. Objective We aim to assess the ability of the video station to discriminate between candidates taking the clinical examination for Membership of the RCPCH, and to assess the degree of agreement between scores obtained in the video station and other stations in the clinical exam. Methods Data was collated on the 1518 candidates (overseas and UK) taking the clinical examination in 2007 (3 exams). Laptop computers recorded the time taken by candidates. The independent samples t-test was used to compare candidates’ performance in the video station with their overall performance. Spearmans Rho correlation coefficient was used to correlate performance in the video station with scores overall, and in individual stations. Results The pass rate for the video station was 71.3%, and 32.5% for the overall clinical examination. Mean time taken to complete the station was 19 minutes 33 seconds (range: 10-22minutes). Candidates who passed the clinical examination had significantly higher scores on the video station (t = 10.47; p = 0.001) than those who failed. 95% of those passing the overall examination passed the video station. There was a significant positive correlation between scores on the video station and overall total score (rs = .300; p = 0.001), and between the video station scores and 6 of the other 9 clinical stations (the 3 remaining stations correlate positively with video station scores although correlation was not significant). Conclusion There is good agreement between scores for the video station and the overall clinical examination. The video station discriminates well between good and poor candidates, with candidates passing the overall clinical examination achieving significantly higher marks on the video station (p=0.001). The video station adds to the validity of the MRCPCH enabling assessment of the candidate’s ability to deal with acutely unwell children, an important skill which would not otherwise be practical or safe to assess.

A quasi-experimental trial of interprofessional education (IPE) of resuscitation skills P Bradley, S Cooper, F Duncan P Bradley, Peninsula Medical School, Research Way, Tamar Science Park, Plymouth, PL6 8BU Introduction The drive towards interprofessional education (IPE) posits it will prepare people to work together and provide better patient care. It is surprising, despite widespread support, that there is little empirical evidence to support IPE. A systematic review could not find a single randomised control trial, before-and-after or interrupted time series design that demonstrated interprofessional learning influenced clinical performance and few studies that meet standards required to make research findings generalisable. The current study uses Immediate Life Support (ILS) training as a vehicle for IPE and seeks to identify the effect of teaching in an interprofessional setting on attitudes, leadership, team work and performance skills of medical students (MS) and nursing students (NS). Methods A partial quasi-experimental approach using mixed methods methodology was adopted. Consenting 2nd year MS (n=25) and NS (n=27) undertook a 1 day ILS course in uniprofessional (UP) and interprofessional (IP) groups of 5-7 students. The Readiness for Interprofessional Learning Scale (RIPLS) was administered before, immediately after and again 3-4 months later. Observation of video recorded leadership, team work and skills performance were rated quantitatively. Five focus group interviews (MS = 12; NS = 13) were held to explore students perceptions 3-4 months after the intervention. Results The RIPLS was completed by 100%, 100% and 81% of students for the first, second and third distribution. Team work/collaboration and professional identity subscales were significantly more positive for IP students immediately after the day than at the start or 3-4 months afterwards. NS scored significantly higher for roles and responsibilities subscale at all collection points. IP groups scored significantly higher for teamwork/collaboration and professional identity at all collection points. Observational ratings for UP and IP teams showed no differences. MS had higher leadership ratings (p= .01) and led more dynamic (p= .039) and efficient teams (p= .021). Focus groups supported using ILS as a simulation of clinical reality and saw IPE having benefit for teamwork and communication and improved understanding of roles and perspectives. There were concerns regarding inappropriate role adoptions, hierarchy issues, professional identity and the timing of IPE episodes. Conclusion The study illustrates that an intervention based on common shared learning outcomes, relevant to both groups and provided in a realistic educational context can work even though students may have differing levels of previous IPE and skills training experience. Further work is required to examine other domains of learning and the timing of interventions.

Teaching Communication Skills in Mental Health: Interprofessional Learning S Abbott, J Attenborough, A Cushing, M Hanrahan, A Korszun, A Cushing, Clinical and Communication Skills Unit, Barts and The London School of Medicine and Dentistry, Queen Mary College, St Bartholomew’s Hospital, London EC1A 7BE In psychiatry and mental health nursing it is essential to be able to establish a therapeutic relationship with patients who may have disordered affect or experiencing psychotic symptoms. However, students have expressed concern that they do not have the skills needed to interact with patients who have acute mental health problems (Wolf, 2001; Lezzoni et al, 2006;). Limited teaching resources are currently available which are student-centred, interactive or which demonstrate currently accepted good practice (Singh et al, 1998; Lezzoni et al,2006). The need for inter-professional working and inter-professional education in healthcare has been highlighted (Norman and Peck, 1999; Reeves, 2001; Oandasan and Reeves 2005) but no teaching and learning resources have been identified which specifically address current inter-professional working between medical and nursing staff in acute mental health care. We have produced a DVD with accompanying workbook showing psychiatrists and mental health nurses working with actors portraying patients. The DVD has been used and evaluated with uni-professional groups of nursing and medical students. Results demonstrated increase in both medical and nursing students’ ratings of understanding specific aspects of communication, ability to empathise, knowing what to ask and how to phrase questions, lower anxiety and uncertainty and the importance of understanding the roles of the doctor and nurse and the need to work together as a team. Changes were made to the DVD following feedback and the revised version has now been evaluated in mixed groups as well as uni-professional groups. The potential additional value of learning together with this resource has been evaluated using analysis of group interaction and identification of discussion themes as well as student perception of inter-professional learning. References:

1. Iezzoni, L.I., Ramanan, R.A., Lees, S.(2006) Teaching medical students about communicating with patients with major mental illness Journal of General Internal Medicine 21(10),1112-1115

2. Norman, J. and Peck, E. (1999) Working together in adult community mental health services: An inter-professional dialogue. Journal of Mental Health 8(3) June1,217-230

3. Oandasan I, Reeves S (2005) Key elements of interprofessional education. Part 2: factors, processes and outcomes. J Interprof Care 19. Suppl 1 1:39-48

4. Reeves, S. (2001) A systematic review of the effects of inter-professional education on staff involved in the care of adults with mental health problems. Journal of Psychiatric and Mental Health Nursing 8(6), 533-542

5. Singh, S.P., Baxter, H., Standen, P., Duggan, C. (1998) Changing the attitudes of tomorrow’s doctors towards mental illness and psychiatry: a comparison of two teaching methods Journal of Medical Education 32(2), 115-120

6. Wolf, Z.R. (2001)Communicating for the first time with delusional patients Journal of the American Psychiatric Nurses’ Association Oct 7(5),155-162

Continuing Education

Working as a newly appointed Consultant: an investigation into the transition from Specialist Registrar (SpR) to Hospital Consultant J M Brown, I Ryland, N J Shaw, D Graham J M Brown, Senior Lecturer, Evidence-based Practice Research Centre (EPRC), Faculty of Health, Edge Hill University / Mersey Deanery, St Helen’s Road, Ormskirk, Lancashire L39 4QP Aims This case study explored the views of newly appointed Hospital Consultants (appointed in or after May 2006) within the Mersey Deanery, focusing on their experiences of making the transition from Specialist Registrar (SpR) to Consultant. Methods Three phases of data collection took place between May and December 2007: 7 open-ended interviews informed the design of a questionnaire containing open and closed questions which in turn informed the development of a schedule for 6 semi-structured interviews. Twenty eight (19, 67.9% male and 9, 32.1% female) Consultants (21 Physicians, 7 Surgeons) participated in the study from a potential study population of 45 (response rate = 62.2%). Findings Participants felt well prepared for their clinical practice as a Consultant but relatively unprepared for the managerial and financial aspects of their role. Formal support mechanisms were rarely established however informal support networks were generally strong. This was often due to the proactive nature of the new appointees as well as supportive colleagues. Many participants explained they had to learn how to ‘take on the role of Consultant’, for example their words, manner and attitude had an impact on their department. Fifteen (63%) participants believed they had reflected upon and questioned both their career choice and their abilities to fulfil their new role. Career choices were reported to be made during: Specialist training (7, 26.9%); SHO training (9, 34.6%); Pre-registration / Medical School or earlier (10, 38.5%). Discussion Preparation for the clinical aspects of the Consultant role is extensive but the managerial and financial aspects are not addressed during Specialist training to the same extent. The difficulty is trying to incorporate an effective and relevant way of preparing SpRs for this aspect of the job with many of the difficulties faced being Trust specific issues that generic training cannot cover. As previously reported by Brown et al transition often raises feelings of anxiety and insecurity due to the fear of not knowing fully how to adapt to a new professional role. Previous studies (e.g. McKinstry et al) have suggested that formal mentoring programmes would benefit some Consultants. However, findings suggest that these mechanisms are best developed by the individual themselves. Facilitation for this is easier if the Consultant is working in a team that is welcoming and supportive from the outset. There still seems to be a reliance, as in earlier postgraduate experiences, on the support and guidance of friends and colleagues. References

1. Brown J, Chapman T, Graham D. Becoming a new doctor: a learning or survival exercise? Med Educ 2007 41:653-660. 2. McKinstry B., Macnicol M, Elliot K., Macpherson S. (2005) The transition from learner to provider/teacher: The learning needs of new

orthopaedic consultants, BMC Medical Education, http://www.biomedcentral.com/1472-6920/5/17.

Onlining or Flatlining? The challenge of Internet CME provision J Pearson J Pearson, Education Development Officer, The Royal New Zealand College of General Practitioners, PO Box 10-440 Wellington, New Zealand 6143 Introduction Internet access assists general practitioners to undertake good quality, continuing medical education (CME). The Internet offers a wide range of topics, available on demand, and developed by experts. There are a number of evaluative studies assessing the pedagogical and instructional design effectiveness of online continuing professional education. However, the size and scope of online usage is rarely studied.1 The impetus for the present study came from two CME providers approaching the Royal New Zealand College, offering commercial access to their websites. Members were invited to join a pilot online learning group designed to view both sites and provide feedback. The minimal response to join the group prompted a survey to measure online CME usage. Following the decision to purchase access to one website for all members, ongoing enrolment figures and monthly usage records have been kept. Outcomes from an impact evaluation of the first six months will be presented. Results The initial survey attracted 55 valid responses (membership of around 3,500) for the ten-week pilot. Thirty-three respondents (60%) had previous experience of online CME with 26 (44%) accessing CME sites regularly. During the free trial, there was limited usage with 22 respondents only (40%) completing modules on one site and 14 (25%) completing modules on the other. So far this year less than 5% of the College membership has enrolled to the selected site. It may be that busy practitioners with computerised practices feel they already spend too long interacting with computers to want to do anything additional. Feedback from the earlier survey on modules completed indicated that GPs prefer short modules able to be completed between patients, whereas interactive modules requiring longer periods of time “need to be planned for”. Conclusion There is no doubt of the educational value of much of the online CME on offer. It offers a great opportunity for working GP parents as well as rural GPs to meet professional development requirements without the need to travel to traditional CME courses. The challenge is not in making it available but in developing ways in which participation by all is facilitated. References: 1 Pullen, D. L. (2005) Online continuing professional education: an evaluative case study. Journal of adult and continuing education, V 11, p. 129-141. McKendree, J. (2006) eLearning. Association for the Study of Medical Education. Edinburgh 2 Hill, R.; Malone, P.; Markham, S. (2003). Researching the size and scope of online usage in the vocational education and training sector. NCVER. Australian National Training Authority

Curriculum Planning

Evidence for the acceptability and academic success of an innovative remote and rural extended placement M Wilson, J Cleland J Cleland, Clinical Senior Lecturer, Department of General Practice and Primary Care, School of Medicine, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY

Background Time spent in remote medicine as an undergraduate is influential in career choice in Australia and Northern America but its influence is not known in smaller countries, such as the UK, where recruitment into rural medicine is also problematic. Differences in training and recruitment of medical students, and geographical differences, mean work is required to explore determinants of success of remote and rural undergraduate training locally. Methods This was a mixed methods (questionnaire, focus group, assessment data) study exploring student views and performance outcomes in 4th year medical undergraduate students (n=14), University of Aberdeen, who completed an innovative, one-year remote and rural placement. Results Fourteen students took part in the study. Questionnaire data indicated they viewed remote and rural medicine positively. This interest was maintained over the placement. Most had no definite career plans, but did have a slight preference towards general practice. Focus group data indicated four main themes relating to the decision to select the remote and rural placement: teaching reputation, to experience remote and rural medicine, a change from Aberdeen, and lifestyle factors. Assessment data indicated that student performances at the end of the year placement were consistent with their 3rd year performance on all assessments: OSCEs (p=0.79), written exams (p=0.10; p=0.49), SSM/Ethics (p=0.10) and Year mark averages (p=0.48). Conclusion A year-long remote and rural option was positively received by fourth year medical students. Assessment data indicated that the extended placement did not adversely influence academic performance in end-of-year written, essay-based and clinical exams. We do not know if the success of this extended option will translate into choosing remote and rural training posts for postgraduate training and posts post-qualification. How we attract those without an existing interest in remote and rural medicine remains to be addressed. Further longitudinal research is required to follow up students exposed to remote and rural medicine in Scotland as undergraduates, to assess the impact of this experience on career choice.

Undergraduate ethics: theory and practice in the clinical years R Knight R Knight, Department of Medical and Social Care Education, Maurice Shock Building, University of Leicester, PO Box 138, Leicester, LE1 9HN Background The place of ethics in undergraduate medical curricula continues to grow, facilitated largely by The Pond Report1, Tomorrows Doctor’s2, and the core curriculum3,4. Now attention is focussed on how this teaching can be optimally delivered. Mattick and Bligh5 identified integration and small group learning as secrets of success. The clinical years provide exposure to multiple medical ethical issues and the small group setting in which to discuss them. This integrated experience is often disjointed and in an environment of limited ethical, legal and philosophical expertise. Aim Leicester Medical School Ethics Week takes place at the end of the first year. There is limited further formal ethics teaching, yet many ethical aspects of medical practice are encountered in the clinical years. The aim of this project was to identify and make explicit ethical teaching provided within the twelve, seven-week modules of the Phase II curriculum, mapping these onto the core curriculum. Using these findings a learner-centred, facilitative, resource-light approach to structure this learning is being developed, to enable students to develop skills in identifying and analysing ethical issues relevant to their clinical placement, furthering understanding and knowledge of the relevant professional values, law, philosophy and ethical theory, in a structured and explicit way. Methods Module leaders of Phase II were asked to identify what ethical, law, professionalism and moral philosophy themes were addressed in their modules, which each focus on a different clinical field. An analysis of the module booklets was undertaken. The relevant themes addressed in each module were then mapped on to the core curriculum. Results Eleven out of twelve module leads responded to the initial e-mail questions, five following this up with a discussion. All twelve workbooks were analysed and relevant themes found in all. In the light of the findings, one of the twelve core curriculum areas was ‘assigned’ to each Phase II module as a focus for formal learning. After receiving a draft of the final document with the proposed link to a core curriculum area, module leads discussed this further with the author, feeding back additional aspects that they wished to see included, one module lead indicating a desire to use a web-based resource. Agreed worksheets on an ethics and law theme are being be piloted in eleven modules and a web-based approach is being developed for the twelfth. References:

1. Institute of Medical Ethics. The Pond report: report of a working party on the teaching of medical ethics. London: IME Publications; 1987.

2. General Medical Council. Tomorrow’s Doctors. London: GMC; 1993. 3. Consensus Group of Teachers of Medical Ethics and Law in UK Medical Schools. Teaching medical ethics and law within medical

education: a model for the UK core curriculum. J Med Ethics 1998;24:188–92. 4. Doyal L, Gillon R. Medical ethics and law as a core subject in medical education. Br Med J 1998 May 30; 316:1623–4. 5. Mattick K, Bligh J. Undergraduate ethics teaching: revisiting the Consensus Statement. Med Educ 2006; 40(4):329–32.

Eliciting students’ preferences for teaching in ophthalmology: a conjoint analysis approach

A J King, A J Foss

A J King, Department of Ophthalmology, Eye and Ear Building, Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH Aims To determine medical students' preferences for provision of ophthalmology module teaching using a conjoint analysis approach. The following aspects were examined; teaching group size, grade of teacher, number of hours of teaching and presence or absence of patients. Methods 100 students undertaking the undergraduate ophthalmology module at the University Hospital Nottingham underwent an interview based assessment during which a series of scenario options for provision of teaching in ophthalmology were presented. Students ranked the scenario options (11 of them) from most to least desirable. Percentage preferences were calculated and utility values for each of the aspects examined in the scenarios were generated. Results Group size (33.4% importance) was the most important factor followed by grade of teacher (30.7%), patients present (18.2%) and hours of teaching (17.7%). Utility scores generated within each aspect examined indicated small group size, junior doctor, patients present and the greatest number of hours of teaching offered having the highest utility values (the more positive the utility value the more desirable it is). Conclusion Medical students would ideally like to be taught by a junior doctor in a small group with patients as often as possible. Conjoint analysis is an effective technique for eliciting students’ preferences for teaching. FACTOR Factor Level Mean Utility Mean Importance Grade of Teacher Senior

Junior Allied Medical

-0.4491 0.6944 -0.2454

30.69%

Group Size 1 - 2 5 – 10 > 20

-1.3387 -2.6574 -3.9861

33.40%

Hours of Teaching 3 hours 6 hours 12 hours

0.25 0.50 0.75

17.69%

Patients present Yes No

0.7917 -1.5833

18.21%

Delivering Online Computer Aided Learning in Gastroenterology to a Large Multi-Campus Medical School: An Exploration of Student Attitudes N Khan, O Epstein N Khan, 22 Burston Drive, Park Street, St Albans, Herts, AL2 2HR Introduction The significant rise in medical student numbers over the last decade is well describedi as is the paucity of clinical teachers available to meet the subsequent increase in demandii. Computer Aided Learning (CAL) initiatives have been introduced by a number of medical schools in an attempt to bridge this gap but there is little detailed information in the public domain about how these initiatives are received by students and what place such initiatives might occupy in modern curricula. Methods A novel teaching program in gastroenterology called AnswersIn was developed and successfully pilotediii. The program was then placed on a university server and made available to third year medical students at the beginning of their ten week gastroenterology/general medical specialties module. There are four such blocks in the academic year. For the first three blocks, the module was made available only to the local campus and then, for the final block, was made available to all three campuses. At the end of each block, students were asked to complete a written questionnaire asking them to evaluate their experience of using AnswersIn online based on its own merits and in the context of other educational resources available to them. Results A total of 178 students were given access to the AnswersIn module over the study period. Completed questionnaires were collected from 143 students, giving an overall response rate of 80 percent. 85 percent of respondents said that they had used the program whilst those who did not cited a number of reasons including exam pressures and a preference for textbooks. Of those who did use the program, all respondents found that it worked on their computer and was easily navigable. Only 28 percent of respondents saw AnswersIn as a replacement for lectures and only 9 percent saw it as a replacement for small group teaching. Reasons cited included a preference for live interaction and potential loss of social cohesion between students. A common response was that AnswersIn was seen as a valuable supplement to formal teaching rather than a replacement for it. All but one student, however, expressed a desire for other subjects to be made available in this format. Conclusions The AnswersIn program was deemed to be user friendly and universally accessible to students. However, concerns were expressed about its potential to replace other more traditional forms of instruction, particularly with respect to potential loss of the social and interactive aspect of the learning process. Such concerns should be addressed whenever planning CAL initiatives. References:

1. The NHS Plan. DOH Jul 2000 2. Council of Heads of Medical Schools Survey 2001 3. Khan N. ASME Annual Scientific Meeting Presentation 2007

Qualitative evaluation of specialist oncology training – unexpected tails I J Robbé, M Button I J Robbé, School of Medicine, Cardiff University, Temple of Peace & Health, Cathays Park, Cardiff CF10 3NW Introduction Postgraduate medical training includes both service and education interests1. Training is influenced by the contemporary shifts from the traditional teaching perspectives of transmission and apprenticeship towards the perspectives of development and nurturing2 and the power of the hidden curriculum should not be underestimated3. This qualitative evaluation of a specialist registrar (SpR) oncology training programme investigated a wide range of outcomes from the perspectives of the SpRs themselves. Objectives To examine the individual SpR’s views on the culture of the training programme, learning needs assessments, opportunities beyond clinical training, and any other areas considered important by the learners. Methods Semi-structured interviews using a schedule based on Stufflebeam’s context, inputs, processes and products (CIPP) model4 and Scriven’s Goal-free model5 took place on an individual basis with each SpR. Hand written notes were taken at the interviews and there was no other form of recording. Each set of notes remained confidential to the interviewer and only transcribed, anonymised results were available to the other researcher. An open coding method was adopted to generate themes from the transcripts. Following piloting with oncology SpRs outside Wales, a quantitative survey was performed in parallel with the interviews. Results All ten invited SpRs participated. Overall themes included:

- recognising the andragogical values, principles and perspectives in the training programme despite the pressures between service demands and education needs

- assessments, appraisals and feedback on training needs were highly dependent on the individual consultant

- there were limited opportunities for the teaching of others, research and reflections in action. Unexpected outcomes from the SpRs’ perspectives included:

- the importance of mentorship by a consultant that would include individualised learning needs assessments, regular and structured feedback, timetable flexibility, support from peer SpRs

- the need for a Generic Curriculum that is sensitive to changes in NHS specialist training and NHS Trusts’ actions.

Conclusions This specialist oncology training produces highly skilled clinicians but there are deficits in the training notably in the development and nurturing2 of the SpRs and in creating a reflective environment3. Further work needs to be done to quantify these results locally and at other oncology centres. Consultant educators should be involved in evaluating their roles. Other stakeholders should participate particularly the Wales Deanery, the Clinical Oncology Faculty of the Royal College of Radiologists, and the GMC/PMETB. References:

1. Department of Health (2003). Modernising Medical Careers. London: HMSO. 2. Pratt, D.D. & Collins J. (1998). Five Perspectives on Teaching in Adult and Higher Education. Malabar, Florida: Krieger. 3. Cribb, A. & Bignold, S. (1999) Towards the Reflexive Medical School: the Hidden Curriculum and Medical Education Research.

Studies in Higher Education 24(2),195-209. 4. Stufflebeam, D.C. (1971) Educational Evaluation and Decision-making. Boston: Peacock Publishers Inc. 5. Scriven, M. (1991). Evaluation Thesaurus, 4th Edition. London: Sage.

Developing a national strategy for undergraduate education in psychiatry N Dogra (Chair of the Scoping Group) and Suzanne Hardy N Dogra, Greenwood Institute of Child Health, University of Leicester, Westcotes House, Westcotes Drive, Leicester, LE3 0QU The Royal College of Psychiatrists Scoping Group on undergraduate psychiatric medical education was established in response to research on the teaching and learning of psychiatry in UK medical schools 1-4. The remit of the Scoping Group was discussed and agreed over the first two meetings and is as follows: 1) Draft a core curriculum for undergraduate psychiatry 2) Identify best practice documents about financial clarity and Trust management of education 3) Best practice guides for clinical teachers (to develop support and ideas for the delivery of quality teaching)

and; 4) Develop material that would support the promotion of psychiatry to medical students. This in turn has led to a series of projects and sub-groups including:

1. The core curriculum was written by a subgroup, modified in response to comments by the wider group. The second draft was circulated for consultation with the Membership of the College and other relevant partners (e.g. General Medical Council, students). We have now received comments and will be using the Delphi technique as a way of honing down the curriculum and achieving some consensus (depending on resources available) but one that is rooted in the evidence available

2. A Higher Education Academy Subject Centre for Medicine, Dentistry and Veterinary Medicine (HEASC for MEDEV) funded project to explore student views of psychiatry

3. An Images of Psychiatry funded project to develop a website to promote psychiatry to medical students in the first instance

4. Development of a case study approach regarding financial clarity and Trust management of education 5. A questionnaire survey of the views of clinical psychiatric teachers regarding education 6. Development of website for clinical teachers in which we can include support e.g. information about

existing support such as special study skills modules 7. Developing and evaluating specific teaching clinical skills workshops for clinical teachers (in conjunction

with the HEASC for MEDEV) ,

This presentation will focus on how the group was established (including how and why broad membership was agreed; liaison with key stakeholders such as the GMC)), how the remit was agreed and delivered. We believe that psychiatry is the first discipline to have undertaken such a project and the fact that the work was commissioned by the College may help ensure that the outcomes can be more effectively utilised. We highlight the application of facilitating curriculum change through effective engagement of the practice community5, 6. We hope to facilitate an interactive discussion on our experience and exchange tips with the audience. References:

1. Karim K, Dogra N, Edwards R et al (submitted) The Teaching and Assessment of Undergraduate Psychiatry In the Medical schools of the United Kingdom and Ireland: a cross sectional survey. Medical Teacher

2. Dogra N, Edwards R, Karim K & Cavendish S. Current issues in undergraduate psychiatry education: the findings of a qualitative study. Advances in Health Sciences Education Theory and Practice, 2006, Nov 16; [Epub ahead of print]

3. Dogra N, Edwards R, Anderson J & Cavendish S (in press) Service user perspectives about their roles in undergraduate medical training about mental health. Medical Teacher

4. Dogra N, Cavendish S, Anderson J & Edwards R (submitted) Service user perspectives on the content of the undergraduate curriculum in psychiatry. Psychiatric Bulletin.

5. Wenger E. Communities of practice: Learning, meaning, and identity, Cambridge University Press, 1998 6. Wenger e, McDermott R & Snyder W. Cultivating communities of practice: A guide to managing knowledge. Harvard Business School

Press, 2002

Clinical teachers’ views on barriers to undergraduate teaching S Bonas, A Akkad, D Heney A Akkad, Women’s and Perinatal Directorate, Kensington Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW Expansion of student numbers, alongside mounting clinical and organisational pressures, has led to a substantially increased burden on Senior Clinicians delivering undergraduate clinical teaching. We set out to explore Clinicians’ experiences of these competing demands and their views on barriers to the delivery of teaching, as well as on possible solutions, in semi-structured interviews. With ethical approval, we approached 28 Consultants working in a women’s healthcare setting (obstetrics & gynaecology and GUM); 10 women and 13 men agreed to be interviewed, giving a response rate of 82%. Interviews were conducted by SB using a prompt guide. Interviews were recorded, and anonymised transcripts were generated. The transcripts were then subjected to framework analysis to identify emerging themes. We identified 12 major thematic groups of barriers and potential solutions raised by the participants, including tutors’ own views and attitudes to teaching, student related characteristics, specialty specific constraints, organisational issues involving both the Medical School and the Trust, resources, targets and pressures, staff related problems, and communication difficulties. For the purpose of the presentation we will discuss the themes of tutors’ own views and attitudes to teaching and student related barriers, as well as the solutions proposed by the participants. In conclusion, Clinical Teachers identified a range of barriers to the successful delivery of undergraduate teaching alongside clinical services. Medical schools and Teaching hospitals should be aware of these problems and formally support Clinicians to try and overcome them.

Education on the move: a survey of medical students experiences of m-learning

I Bickle, P Hamilton, G Gormley, S Bridgett, A Davey, P Stirling

I Bickle, 17 The Crescent, Wood Lane, Rotherham, South Yorkshire, S60 5UU

Background Medical education has traditionally been paper-based. In recent years there has been a rapid evolution in computer related technology and web-based educational material accompanied with further advances in the portability of media storage and player devices. Mobile or ‘m-learning’ is the use of portable devices to access educational material in non-traditional settings with flexibility and convenience. Ownership and use of such portable technology has become very popular for leisure purposes and serious potential exists for such devices to be used as a medium for accessing medical education material on the web by a global audience. Two of the most important factors in the potential utility of m-learning devices in global medical education are ownership and learning preference. If medical students do not own or intend to own a portable device then m-learning is not possible. Secondly, if students feel the available content or interface of their device is not suitable for learning, then the ability to obtain educational material on their devices will be of little use.

Method A 23 point online questionnaire was distributed to over 900 medical students at Queen’s University Belfast. This encompassed students from years 1 to 5. The questionnaire covered a range of issues related to m-learning, including: access and ownership of portable equipment, current utilisation patterns and the anticipated value of using such devices for medical education. Data was collated and entered to an SPSS database. Analysis will explore the frequencies and variations of responses. Multiple regression analysis will be used to observe any associations between respondent’s demographic characteristics, and their attitudes towards m-learning.

Conclusion/Discussion This paper is the single largest study of m-learning to date outlining the demographics and proportions of portable media device users amongst medical students and their attitudes towards this using this technology as a learning medium. The results will aid educationalists, including curriculum planners, in providing educational opportunities to maximise student participation and so performance outcome.

Professional, Ethical and Legal Awareness of Students in the Medical and Health Sciences Fields: A Cohort Study S Abdul Rahman, N Muhammad, M Ahmad Mansur, J K Candlish S Abdul Rahman, Faculty of Allied Health Sciences, International Islamic University Malaysia, Jalan Istana, Bandar Indera Mahkota, 25200 Kuantan, Pahang, Malaysia Background This study was initiated to evaluate the effectiveness of the medical and health sciences curriculum in developing the ethical and legal perceptions of undergraduate students where Islamic ethics is taught as part of the Islamization of the curriculum endeavour in the university. The differences in the attitudes of students in the two fields, if any, were also investigated to identify discrepancies in the understanding of ethical and legal issues. Summary of work Second and final year students of the Medical and Allied Health Sciences faculties were given contrived dilemmas to solve in the form of a questionnaire consisting of multiple choice questions of the ‘one best answer’ type. Questions were constructed to include common ethical and legal concerns from patient confidentiality to legal liability. A separate section (section B) explored the impact of the teachings of Islam in ethical and legal decisions. The feedback was collected at one sitting for each batch of students and later analyzed for any significance in undergraduate judgment. Summary of results What transpired from the work is represented by the examples of the feedback obtained for questions with regard to the issues below:

Preferr

ed answers are

the best

answer

option agreed upon by the investigators in this research which may be controversial even to professional experts in the area. Conclusions There seemed to be some anomaly in what we would expect students to know and what have been taught either in class or during clinical trainings and attachments indicating that some improvements to the curricula is in order. It is apparent that senior students are able to make better judgment in some ethical/legal areas as compared to their younger counterparts. Also, the Islamic orientation of the programmes in the university does play a significant role in influencing the ethical and legal opinions of these undergraduates.

Preferred Answers (%) Medical Allied Health Sciences Section/Question

No. Ethical/ Legal Issues Year 2 Year 5 Year 2 Year 4

A/1. Patient confidentiality 2.0 3.0 3.6 50.0

A/15. Handling of paediatric patients 16.3 39.7 18.9 42.1

B/2. Brain-dead patient 19.6 23.8 24.1 26.3

Swallows, Amazons and Mayan Peoples: Learning Outcomes, Curricular Objectives and the Hidden Curriculum R Talbot, M Talbot M Talbot, University of Sheffield and Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF Background Even at undergraduate level, much learning in medical education happens by chance rather than by planning. There is anecdotal evidence that this is so and we add to the narrative. Argument More than that, we argue that although modern pressures often call for each school to legislate curricular objectives and learning outcomes, the tendency is for this process to deflect attention away from the learner. Although the so-called ‘hidden curriculum’ has come in for some criticism, we discuss the downside of objective-setting. We argue that setting objectives may even be an unhelpful task when preparing young doctors for a medical practice that is, in the real world, less than frequently positivist. We illustrate our exegesis by way of a case vignette in which the excitement and experiential learning gained by an attachment in a rainforest mission hospital (where the student was ‘thrown into the deep end’) is contrasted with the boredom and relative lack of learning in a first-world, first-class, teaching hospital.

Management/Administration

Using action research to improve and administer the Child health teaching programme for Warwick Medical students T Bindal, E Peile T Bindal, 108 Metchley Lane, Harborne, Birmingham, B17 OHY

Background Demographic changes whereby children’s’ stays in hospital are shorter and more conditions are managed in the community have led to a reduction of hospital admissions and thus limited student contact with paediatric inpatients. The access for students to child patients is particularly problematic where medical student numbers have increased substantially. At Warwick University, student numbers in the clinical phase have increased by 50%, raising concerns about clinical exposure for students at existing teaching sites in the present curriculum format. Aims A Paediatric registrar was appointed as project manager to investigate how teaching of an equivalent standard to that provided in the past could be delivered for students starting in April 2006. Method Adopting the action research approach, current practice for paediatric teaching with review of current attachments in acute and community settings was explored to see if there was scope for expansion. In addition alternative options were investigated and included:

1. Changing the configuration for student placements 2. Finding additional community placements 3. Exploring the utility of student visits to ambulatory settings and child-relevant adult clinics 4. Introducing and evaluating new teaching tools

Results Changes to the teaching programme included abandoning the “hub and spoke” model so students remained at their base hospital for the entire attachment and extra student placements were negotiated. At the tertiary hospital only adult specialities provided extra clinical placements in general surgery, dermatology, and orthopaedics. Although extra community placements were identified, funding was needed to support these. Within the core programme a further day of formalised teaching in disease pathophysiology and communication was introduced. More interactive teaching tools such as problem based learning, debating and use of the Computer-assisted Learning in Paediatrics Programme (CLIPP) was piloted with positive feedback from both teachers and students. Reassuringly the teaching programme changes made no difference to the student pass rate on the end of block assessments (failure rate 4% for 2006/7 cohort compared to 4.3% for 2005/6). Conclusion With increasing medical student numbers, additional and different teaching methods are needed to those which have traditionally been used. These enhance the quality of the teaching programme, give broad exposure to paediatrics and deal with the capacity issue. Delivery of a comprehensive teaching programme can also be achieved either solely in a district general hospital or teaching hospital. However faculty in both centres need the resources and support to provide good clinical paediatric experience for students.

Multi-professional Education

Enhancing confidence in practising and teaching communication skills – impact of a Masters level module M Barnett, J Kidd M Barnett, Associate Clinical Professor in Medical Education, Medical Teaching Centre, Warwick Medical School, Gibbet Hill Road, Coventry CV4 7AL We are reporting on the background, running of and preliminary results from an innovative Masters level module aimed at multi-disciplinary health care professionals entitled: Communication skills: educational methods and effective clinical practice. The design of the module is learner-centred and experiential, involving two full-time facilitators working with a maximum of 12 participants. It runs in two 3-day blocks scheduled 1-2 months apart. The first block focuses on participants’ own communication skills: participants examine and receive feedback on consultations with simulated patients recorded pre-module, and conduct real-time simulated consultations in the course of small group work. This block also contains a day that focuses on exploration of participants’ own life experiences and attitudes, both to facilitate a more person-centred approach in their professional communication and to help them identify areas for personal development and avoiding burnout. The second block develops knowledge, skills and attitudes related to teaching communication skills in the healthcare setting. Participants consider: processes of teaching, facilitation skills, how to work with simulated patients and use of media. They complete the block by running a real-time teaching session, which is designed during the block, with participants working in teams. Each teaching session is delivered to their peers, and evaluated by feedback based on peer and facilitator observation. During the teaching sessions, all participants experience teaching, learning and evaluation/observer roles. Participants completed a 15 item questionnaire on perceived confidence in clinical and educational practice, before and six weeks after the module. They also reflected on changes in their behaviour. Results 63 participants have attended (37 female, 26 male). The majority come from three disciplines: general practitioners (14), nurse specialists in palliative care and oncology (13), and a range of hospital specialist doctors (26). Pre-module participants’ confidence is greater across personal communication skills items compared with teaching skills. Post module this pattern persists but confidence across all items increases significantly (using paired t-test). Participants also identified a number of changes to their daily practice in terms of effective communication with patients and teaching practice, which they perceive to have resulted from attending the module. Conclusions This module has an innovative design incorporating skills, self reflection and teaching practice, all within a multi-professional learning context. Results indicate that it has achieved its stated objectives to enhance confidence and skills in both personal and teaching communications skills.

Early Interprofessional Interactions: Does student age matter? E S Anderson, L N Thorpe E S Anderson, Department of Medical and Social Care Education, Maurice Shock Medical Sciences Building, University of Leicester, University Road, Leicester, LE1 9HN Background The age of students entering health and social care training varies. Graduate programmes, e.g. in medicine and social work, are attracting mature learners many of whom have held senior positions in the caring professions, while undergraduate programmes are attracting mostly late teenagers naïve about the realities of their chosen career, with only a scattering of mature learners. We share our experiences and evaluations of the first year alignment of health and social care students to a new region-wide interprofessional education (IPE) curriculum 1. Method Prior to this event all students completed a Readiness for Interprofessional Learning Scale (RIPLS) Questionnaire 2. The evaluation consisted of a pre and post course questionnaire on the learning outcomes, scored on a Likert scale; a post course questionnaire for immediate free text responses, considering content, context and timing; Focus groups run by an independent researcher with a random sample of uni professional students, up to 12, within four to ten weeks of the workshop. Results The RIPLS did not discern any difference between students. 754 (84%) students completed questionnaires, 638 (84.6%) undergraduates and 116 (15.4%) graduates. Medical (undergraduate), nursing, social work (BA), and pharmacy students increased their knowledge and appreciation of team working across all four learning outcomes (P<0.045-< P.001). Graduate medical, social work (MA), speech and language (S&LT) and clinical psychology students, made significant gains in 2 of the measures. Younger students rated aspects of the learning more positively than older. The dominant themes from focus groups for the graduate medical students, mirrored those of other older students and were, in order, i) repetition as the majority had worked in health and social care teams and felt they “had done this before”, although willing to reflect and consider new learning, ii) a desire for the learning to be more orientated towards practice, iii) acknowledgment that this was a priority for the undergraduates, and iv) a desire to be placed for IPE events with other graduates, although they did recognise that they were likely to be working in practice with younger colleagues. Conclusion The paper explores the different learning needs on IPE, of students according to their professional group and age at entry. The findings challenge educators to provide graduate medical students with a challenging and meaningful early introduction to IPE. Full copies of the accepted paper will be available for delegates 3. References:

1. Anderson ES, Knight T, (2004). The Three Strand Model of Interprofessional Education in Leicestershire, Northamptonshire and Rutland Workforce Development Confederation. CAIPE, Bulletin, Winter 2004/5; 24: 12.

2. The Readiness for Interprofessional Learning Scale (RIPLS), a validated measure to explore differences in student perceptions and attitudes towards IPE (Parsell et al 1998, 1999).

3. Anderson ES, Thorpe LN (2008). Early Interprofessional Interaction: Does Age Matter? Journal of Interprofessional Care. Accepted February 2008, in press.

Should medical students learn about patient safety with other students? A comparative study E S Anderson, L N Thorpe, S A Petersen, D Heney E S Anderson, Department of Medical and Social Care Education, Maurice Shock Medical Sciences Building, University of Leicester, University Road, Leicester, LE1 9HN Background Medical students at Leicester have been taking part in a one-day workshop on patient safety in their final clinical years. The workshop utilises a DVD resource, filmed with actors, depicting the actual patient journey of a stroke patient from GP referral into an accident and emergency unit and subsequent care by ward and theatre teams. The identified patient story came from complaint letters followed up by home interviews. A clinical team from Queen’s Hospital Burton with Leicester Medical School developed the new educational resource with funds from The National Patient Safety Agency. Learning themes include; communication; situational awareness; team working roles including leadership and empowerment within teams. Workshops within the research time period have consisted of medical students only and interprofessional student groups with medical students learning with nurses, midwives, therapy, pharmacy and operating department practitioner students. The teaching methods include small group interactive and reflective problem based learning. Method Student groups have completed self-assessed pre and post workshop questionnaires on their learning outcomes scored on a 5 point Likert scale, and detailed post-course questionnaires with scored and comment questions. Focus groups with each student group have been completed after the event. Facilitator views were obtained using post-course questionnaires for free text comments. Results The workshop has been positively evaluated by over 200 students, across all learning outcomes (P<0.005). Medical students increased their knowledge whether learning alone or in mixed student groups. On the post-course questionnaire medical students working alone gained significantly higher scores than those working in mixed groups (range 64.3%-96.4% uni; 54.3%- 80% inter). Learning interprofessionally medical students were concerned about stereotyping but appreciated the opportunity to develop good team working skills. All focus group data endorsed the benefits of the workshop for preparation on safety in healthcare delivery. The context of considering these were different, 14% of medical students only commented on the perspective of working within a safe team as compared to 38% of those who worked interprofessionally. Skills strengthened were the same for all students including; confidence to challenge others or speak out; assessing risk and hazardous situations; recognition of good leadership; listening; clarity of communication; and effective team working. Fourteen facilitators endorsed the workshop stating interprofessional groups are harder to manage.

Conclusion Learning interprofessionally is beneficial.

Learning together in practice – evaluating the impact of undergraduate, inter-professional learning using the Leicester Model of Interprofessional Education

E S Anderson, A Lennox, S A Petersen, L N Thorpe E S Anderson, Department of Medical and Social Care Education, Maurice Shock Medical Sciences Building, University of Leicester, University Road, Leicester, LE1 9HN Since 1998 joint working across two Higher Education Institutions with health and social care organisations has led to a new interprofessional education (IPE) teaching model in which medical students learn jointly with other health and social care student. The Models’ learning cycle enables them to explore patients’ needs and the constituents of effective team and collaborative working for improved patient outcomes1. Patients are central to the learning which is supported by practice teams who analyse with students care and care delivery. We report on a 10 year evaluation of the student views of the Model in the community setting where socio-economic disadvantage is high. Evaluation methods include uni professional focus groups. A semi-structured questionnaire, distributed pre and post course to access learning using a 5 point Likert Scale and a free text questionnaire on hopes, concerns and expectations. Post course students complete 23 scored questions on all aspects of the course and add comments. Results Over 3,000 students have worked on this course over the 10 years. Medical students learn alongside nursing, midwifery, pharmacy, speech and language therapy, social work, and clinical psychology students. Early focus group findings (1998-2001) identified positive learning related to the patient-centred, experiential problem-based approach, working in mixed student teams (n=4) alongside patients and their practitioners. They learnt about day-to-day team responsibilities for patients with complex care needs. “Learning about the agencies involved in health care and what they actually do. Real insight into community care and what needs to be done to help people who have problems…Getting an overall picture from everybody involved in the patients care”, extract. Pre course concerns about learning interprofessionally were common until 2005 when all schools aligned with a new trajectory of IPE, giving students earlier preparation through class-room based events. Annually there are significant learning gains for all students (P<0.001) with the exception of clinical psychology students in 2005. Post-course data identified that students learn about the training of each other’s professions and respective roles and responsibilities; valued IPE in practice; appreciated why collaboration helps tackle disadvantage and the need for effective communication within and between teams 2. Conclusion Cyclical evaluation has led to course refinement, e.g. timing within uni professional curricula, design of workbooks acceptable to interprofessional student groups and the need for adequate pre-course preparation. Listening to student voices has played a significant role in making The Model replicable and sustainable. References:

1. Lennox A, Anderson ES. The Leicester Model of Interprofessional Education. A practical guide for the implementation in health and social care. The Higher Education Academy of Medicine, Dentistry and Veterinary Medicine, Special Report 9, Newcastle.

2. Anderson ES, Lennox A. The Leicester Model of Interprofessional Education: Developing, Delivering and learning from student voices for 10 years. Journal of Interprofessional Care: In review.

Working with the patient voice: developing teaching resources for inter-professional education S Fielden, C Carney, Sue Kilminster, A Onafowokan S Kilminster, Medical Education Unit, Level 7, Worsley Building, University of Leeds, Clarendon Way, Leeds, LS2 9NL Introduction The Medical Education Unit is developing an inter-professional education strategy across all years of the MBChB undergraduate programme. We are working on evaluation strategies for undergraduate and postgraduate inter-professional education. Students in both the first and final years of the programme have been involved in small group sessions on group and team work. First year students have attended a 4 week course on group and team work; and final year students have had the opportunity to attend inter-professional education workshops at placement sites to learn about communication and team working skills with students across a range of health and social care professionals. Methods In partnership with service users, carers and health professionals we developed a series of case scenarios for use as teaching resources for two projects relating to inter-professional education. The first project involved first year medical undergraduates on working in groups and healthcare teams and included the review and development of 8 case scenarios of virtual patients with chronic conditions. The second project involved the delivery of inter-professional education workshops to final year students at placement sites across the region where service users and carers were involved in developing the case scenario, training the delivery teams and also in the delivery of workshops. Qualitative data was collected from evaluation forms and student focus groups and analysed thematically from each project. Results The case scenario format enabled students to apply knowledge to real situations and to develop their understanding about the actuality of life with a chronic illness and the treatment of service users and carers in a holistic way. In addition, the course enabled students to improve their understanding of different areas of health and social care and about the roles and responsibilities of different health professionals. Conclusions This is an innovative and effective method of learning about holistic approaches to patient care and professional roles. This is a model for good practice in developing educational partnerships with service user and carer groups. This project links to another project in the Medical Education Unit at the University of Leeds. All are concerned with developing evaluation strategies for undergraduate and postgraduate interprofessional education and training.

Developing Professional Identity: A study of the perceptions of the first year Nursing, Medical, Dental and Pharmacy students

S Morison, A O’Boyle

S Morison, School of Medicine and Dentistry, Queen’s University Belfast, Belfast, BT12 6BP

Background Working in a team has become a significant component of modern healthcare practice and pre-qualification education must prepare students for this role. Interprofessional learning is increasingly regarded as key to achieving this although there remains considerable debate about the value of it. In particular there is concern that students need to develop their own professional identity before they can learn to work with others.

Aim To use social identity theory as a vehicle to examine and compare nursing, dental, medical and pharmacy students’ perceptions of the professional identity of their discipline and to consider the implications for developments in interprofessional education.

Method Focus groups were carried out with pre-qualification students from four healthcare professions in the first semester of the first year of their course in order to gain an insight into the shared understandings, attitudes and values of becoming a healthcare professional. Focus group data were analysed using an ethnographic approach where interaction is understood as being negotiated through sequenced talk.

Results Some common themes emerged with all groups indicating that their knowledge of the identity of their discipline, and their motivation to join the profession, came from contact with professionals in healthcare settings or having a member of their family involved in healthcare. Analogies were made between the process of becoming a professional and the developmental process of moving from childhood to adulthood. Differences emerged between the professions with regard to students’ perceptions of their future professional role, of other healthcare professionals and others’ perceptions of them. In-group and out-group identities were apparent with nursing students located in the out-group of the other professions and also placing themselves in this group. The focus group process itself reinforced the group identity.

Conclusion A greater understanding of students’ perceptions of their professional identity and the processes involved in becoming a professional can help to inform developments in pre-qualification healthcare education. Pre-qualification interprofessional learning should be developed to encourage students to have an inclusive rather than an exclusive professional identity if effective team workers are to emerge.

New Technologies

The Internet in medical education: A relist review G Wong, T Greenhalgh, R Pawson G Wong, Open Learning Unit, Department of Primary Care and Population Sciences, 2nd Floor, Holborn Union Building, Archway Campus, Highgate Hill, London, N19 5LW Over the past decade, the Internet has been increasingly used to deliver medical education and the growth of research in this field has followed suit. Despite this growth in research, medical educators and researchers still have little idea as to the answer to the important and pressing questions of ‘how’, ‘why’, ‘for whom’, ‘in what circumstances’ and ‘to what extent’ does this method of delivering education work. Attempts have been made to systematically review the evidence, but epistemological and methodological shortcomings have hampered the ability of these reviews to fully answer these questions. This paper looks to answer these very questions by using a new review methodology – realist review. This methodology focuses on underlying explanatory theories and is able to account for the complex and heterogeneous nature of the studies invariably found in this field. The findings from this realist review shows that two main theories appear to be in operation. To answer the ‘how’ and ‘why’ questions, the Conversational Framework by Laurillard provides an explanation as to how learning takes place, namely through dialogue. In response to ‘for whom’, ‘in what circumstances’ and ‘to what extent’, Rogers’ theory on the diffusion of innovations provides three main attributes of an innovation which explain whether or not an Internet based course will be successful, namely, ‘relative advantage’, ‘ease of use’ and ‘compatibility’. ‘Relative advantage’ appears to be the most important component and their explanatory power is dependent on a context-specific interaction between them. Theories are available that are able to predict whether or not e-learning will be a success. These theories indicate that there is no such thing as a ‘cook-book’ of success factors for such courses. Course developers are however able to explain and predict if their course will ‘work’ if they apply these theories to their specific course and its unique educational context.

Connected, but not connecting? An interactive ‘blog’ website within a PBL curriculum D Maxton, S T Creavin Dr D Maxton, Keele University Medical School (Shropshire Campus), Royal Shrewsbury Hospital, Royal Shrewsbury Hospital Mytton Road, Shrewsbury, SY3 8XQ Background Interest is growing in how new technologies can support an undergraduate curriculum. We report on an interactive problem based learning (PBL) website based on freely available internet information sources. Methods The Keele year three undergraduate PBL curriculum has two 14 week long modules with a case each week. Internet links to ten educational journal articles relevant to the weekly case or other objectives were identified (total 280 links). Resources included: review articles, original papers, case histories, ethical discussion and communication skills. Each link included a comment or learning objective from a faculty member. Students were encouraged to add their own links to the site as a collective resource. An anonymous questionnaire was distributed towards the end of the course (response rate = 100%) and anonymous visitor statistics were collected without student knowledge. Results Access was restricted to 33 students. A total of 475 visits (4.66 visits per day) with 4660 page views were recorded, averaging 9.8 pages per visit. Access was most frequent between 16.00-20.00 hours, with a mean duration of 9.29 minutes per visit. Students claimed to spend 2-6 hours per week preparing for PBL tutorials. The site was found useful by 71% of students, and used as their first resource for PBL by 26%. While 84% had downloaded at least one article, 16% could not access the site and 33% could not post links, this may be why students contributed to the site only 20 times. Specific comments varied from “great” and “cuts down time spent preparing for PBL” to “can't access”. The majority of students (81%) preferred material that was directly relevant to the course, rather than general teaching. Conclusions This pilot study suggests that the majority of students value an interactive blog website within a PBL case based curriculum. Surprisingly a minority of students may be limited by their computer skills. Students prefer material directly linked to the relevant weekly case and do not request additional “general” articles. Approximately ten links per case appears adequate. Significant future challenges include encouraging students to find their own links and share with colleagues. More aggressive tutor interaction on-line may stimulate a greater response.

Factors influencing clinical teachers’ (dis)engagement with their own on-line learning C Morris, Judy McKimm Clare Morris, Associate Dean, Bedfordshire & Hertfordshire Postgraduate Medical School, University of Bedfordshire, Putteridge Bury Campus, Hitchin Road, Luton, LU2 8LE e-learning is fast becoming an integral part of both undergraduate and postgraduate programmes in medical and healthcare education and training.1 Recent studies have explored the challenges of using e-learning effectively2

and have examined medical teachers’ first experiences of on-line facilitation3. One might expect that those who have specific educational roles and responsibilities would seek out opportunities to engage with on-line learning – both as learners and educators. Currently, there is little research examining the e-learning (as opposed to e-teaching) experiences of medical educators. This paper presents the preliminary findings of an ongoing study, supported by funding from the MEDEV Subject Centre, exploring clinical teachers’ engagement with their own on-line learning. The participants are sixty medical/healthcare educators engaged in Masters level study in Medical Education. The programmes explicitly combines face to face study, with on-line learning in a supported Virtual Learning Environment (VLE) (an approach supported by recent research4). The VLE is used as a ‘repository’ for a range of educational resources e.g. course materials, e-learning units, web-links and ‘hot-links’ to e-journals and articles. Importantly, it includes interactive elements which foster a virtual learning community through reflective diary spaces (visible and accessible by each individual student and module tutors), discussion forums, collaborative wiki building and moderated reading groups. Students demonstrate considerable variation in the level and nature of engagement with the VLE. This study explores the factors that influence engagement and has three key components, supported by a focussed literature review around engagement with e-learning by ‘professional’, work-based learners. Firstly, an analysis of the nature, amount and types of engagement with the VLE. Secondly, focus group interviews with a purposeful sample of students who demonstrate features of ‘engagement’ or ‘disengagement’ and finally, a survey of all past and current students, to explore their experiences of on-line learning and the factors that they perceive influence their engagement or otherwise. The survey findings will be presented in this paper, and implications discussed. Conclusions Preliminary analysis highlights a range of personal, professional, practical and pedagogic factors that influence clinical teachers engagement with on-line learning. The outcomes of the larger study will inform developments at two levels. Firstly to identify ways in which we can encourage and support learners to engage with their own on-line learning. Secondly it will inform Faculty Development initiatives by identifying the knowledge, skills and attitudinally based factors that lead them to (dis) engage with on-line learning. References:

1. Ward JP, Gordon J, Field M & Lehman, HP (2001) Communication and information technology in medical education. Lancet, 357 (9258), pp792-796

2. Ellaway, R. (2006) Weaving the ‘e’s’ togther. Medical Teacher 28(7), pp 587-590. 3. Lockyer J, Sargeant J, Curran V and Fleet L. (2006) The transition from face-to-face to online CME facilitation. Medical Teacher 28(7),

pp 625-630. 4. Carbona, M., King, S., Taylor, E., Franziska, S., Snart F and Drummond J. (2008) Integration of e-learning technologies in an inter-

professional health science course. Medical Teacher 30(1), 25-33.

Postgraduate Education

How successful is the Foundation Programme? Views of trainees, consultants and nurses in NHS Scotland F French, J Wakeling, C Rooke, K McHardy, G Bagnall F French, NHS Education for Scotland, Forest Grove House, Foresterhill Road, Aberdeen, AB25 2ZP Background The Foundation Programme was introduced across the UK in 2005, reforming the first two years of postgraduate medical training. Medical graduates now focus on developing generic skills while working in a range of specialties (6 x 4 month rotations). The Programme was designed to give Foundation Doctors broader experience which would encourage earlier and better-informed career decisions. Whilst many recognise the potential benefits of these reforms, recent research has identified some difficulties. We therefore felt it important to investigate the collective perceptions of early successes and ongoing challenges in the implementation of Foundation training in Scotland. Work done We interviewed 45 Foundation doctors (23 Foundation Year 1, 22 Foundation Year 2), 25 nurses and 23 consultants across Scotland in the summer of 2007. A semi-structured interview schedule was used with unit-based groupings of Foundation doctors, nurses and consultants to represent different geographical locations, specialties and types of hospital. Interviews were recorded, transcribed and coded using NVivo 7. Conclusions This presentation will explore the extent to which the Foundation Programme in Scotland is considered to provide a suitable transition from Medical School to specialty training. Key elements of Foundation are: § opportunities to experience different specialties § opportunities to acquire generic skills § good educational supervision § comprehensive assessment § formal teaching based on national curriculum

We will examine how far consultants, nurses and Foundation trainees perceive that these elements are being successfully delivered. In particular: Is the broad range of specialties on offer beneficial in providing appropriate training experiences/responsibility? Are some specialties less useful than others? Do trainees rotate too often? Do the mechanisms of formal feedback from Educational Supervisors and the different assessment tools seem valid and fair? Are they likely to promptly identify doctors in difficulty? Finally, we will look at implications of Foundation training for patient care and will consider recommendations for improvement made by our interviewees.

Electronic Portfolios for Surgical Trainees: Educational Emancipation or Regulatory Suppression? L Allery, J MacDonald, L Pugsley, S Brigley L Pugsley, PGMDE, Cardiff University, Heath Park, Cardiff, CF14 4YS In the wake of MMC and PMETB, a joint initiative of the Colleges of Surgeons of Great Britain and the Republic of Ireland, the Joint Committee on Higher Surgical Training and the specialty associations was launched in August 2007. It adopted a structured approach to specialty training in line with Foundation and specialty training reforms across the UK with explicit standards, assessments and staged progression for specialty trainees. Within the initiative learning, teaching and assessment are all co-ordinated online by means of a web-based system in which the trainee’s learning agreement is the lynch pin. This paper makes use of data generated from a study which adopted a qualitative design, recruiting 13 educational supervisors and 18 surgical trainees for semi structured interviews to evaluate the Intercollegiate Surgical Curriculum Project (ICSP). It focused on surgical trainees’ engagement with the ISCP learning agreement and with the web-based tools designed to support specialty training. In particular, it explored the ways in which web-based systems allow for developing and recording learning agreements, storing assessment records and portfolio entries. It raises issues regarding the introduction of such initiatives which are designed to provide an online vehicle to inform annual review. It raises questions regarding the potential for such instruments to become educationally liberating, allowing learners to provide documentary evidence of their developing professionalism through structured learning experiences defined in learning agreements and explored in reflective writing, but highlights the potential dangers for them to become restrictive, confining the quest for knowledge and skills to the acquisition of narrow competencies acknowledged in simple summative tools locked within regulatory frameworks.

Moving the goal posts and hitting the targets: reflections on researching in a change context

L Pugsley, S Brigley, L Allery, J MacDonald L Pugsley, PGMDE, Cardiff University, Neuadd, Meirionydd, Heath Park, Cardiff, CF14 4YS

Medical education has been subjected to a significant number of policy changes over recent years, the introduction of the European Working Time Directive (EWTD), the creation of PMETB, MMC and run through training for example have each had significant impact on defining the ways in which educational time and educational activities have been organised and delivered. This paper looks at the impact that experiencing such change has had on the consultant body, responsible for the delivery of education and training within a constantly shifting change agenda. It takes as an exemplar the impacts of change as experienced in the recruitment and interviewing of participants for an evaluation of a web-based system within the Intercollegiate Surgical Curriculum Project (ICSP) which aimed to provide surgical specialties with a structured approach to specialty training in line with Foundation and specialty training reforms across the UK focused upon participants’ engagement with the ISCP learning agreement and with the web-based tools designed to support specialty training and required the participation of educational supervisors and their trainees. In this paper we reflect on the change context and the implications for the research process when researchers are faced with engaging and recruiting participants for the evaluative study from a demoralised workforce experiencing change fatigue. It argues for the need to demonstrate a period of policy stasis to allow for trainers and trainees to develop a sense of ownership of the current education policy and to allow for a full evaluation of the benefits or otherwise to be accrued from the adoption of such policy initiatives.

What can attachments in public health add to training programmes in general practice? T Swanwick, J Reynolds, J Wills T Swanwick, London Deanery, Stewart House, 32 Russell Square, London, WC1B 5DN Background Recent conceptualisations of general practice have acknowledged the need to move beyond a clinical focus on the individual, and to consider the patient within a wider social context. The curriculum of the Royal College of General Practitioners (RCGP) emphasises the importance of ‘community orientation’ and there is a specific curriculum statement on health promotion and the prevention of disease. In recognition of this, the London Deanery recently developed public health attachments in ten Primary Care Trusts (PCTs) integral to a number of three-year GP speciality training programmes. This paper details the initial findings from an evaluation of these attachments. Aims The evaluation aimed to explore the perceived value of public health attachments for GP trainees. Views on the recruitment, preparation, structure and support for the attachment were sought from public health trainers and educational supervisors. Methods Phase 1 (completed in February and June 2008) included semi-structured interviews with two cohorts of trainees towards the end of their public health attachments (sample size = 20). Phase 2 included interviews with the public health trainers and local GP training scheme supervisors (sample size = approximately 20). Thematic analysis of all interviews assessed levels of satisfaction with the attachments and the perceived relevance to general practice training. Results Preliminary findings from interviews with the first cohort of GP trainees indicate that health improvement - including health promotion and tackling health inequalities - was not well addressed across the attachments, and did not emerge strongly as an area relevant to general practice. The experience of undertaking health protection activities, however, was enjoyed and considered useful. Although trainees had limited experiences of service improvement and audit, the attachments were considered useful for learning about the organisation of a PCT. The working culture and functions of a public health department were perceived as very different to clinical practice and therefore of limited benefit to GP training. Implications The evaluation of these public health attachments will help to assess their usefulness in fulfilling training competencies set out by the RCGP. It will give an indication of the future GP workforce’s understanding of the principles of public health, and how this may impact upon their future practice. The evaluation also raises wider questions about the way in which public health is perceived and taught within the medical education system as a whole.

Selection

Admission to graduate-entry medicine – validity and equity of selection tools P Garrud P Garrud, The Medical School, Derby City Hospital, Uttoxeter Road, Derby, DE22 3DT Graduate-entry medicine (GEM) is a recent development in UK. Selection criteria and processes vary widely with poor evidential support for their validity and equity and increasing debate about the best approach (Ferguson et al, 2002; Wilkinson et al, 2008; Powis, 2008). This study examined the impact of two selection tools – a structured interview and GAMSAT over five years at Nottingham GEM medical school. The predictive validity of these tools was also investigated in terms of progress and attainment over the 4-year course. Nearly 6,000 people applied for the Nottingham GEM course and circa 500 began the course over the period 2003-7. Applicants include those with a 2nd or 1st class degree in any subject and a wide variety of demography. They then progress through a sequential selection system, first taking GAMSAT (Graduate Australian Medical School Admission Test), and then, subject to a score above criterion, a 1-hr structured interview. Performance on GAMSAT was better amongst men than women, improved with age, was positively related to class of first degree and better with arts/humanities or non-biological science qualifications than health or biological science. In contrast, at structured interview, amongst the surviving candidates, women did better than men, older applicants than younger, those with 1st class degrees and qualifications in arts/humanities or in health professions better than those with science qualifications or 2nd class degrees. Both GAMSAT and interview grade were positively related to progress and attainment throughout the 4-year course; GAMSAT primarily with knowledge-based assessment performance, interview grade with both knowledge and clinical competency assessments. This study provides evidence of predictive validity for GAMSAT and a structured interview as selection tools for GEM. Use of these tools in a sequential selection process has a marked effect on the profile of successful applicants (e.g. the gender ratio) that warrants further investigation. References:

1. Ferguson E, James D & Madeley L. Factors associated with success in medical school: systematic review of the literature. BMJ 2002; 324: 952-7.

2. Powis DA Selecting medical students. Med J Aust 2008; 188: 323-4. 3. Wilkinson D, Zhang J, Byrne GJ, Luke H, Ozolins IZ, Parker MH, Peterson RF. Medical school selection criteria and the prediction of

academic performance. Med J Aust 2008; 188: 349-54.

Staff Development

Producing highly effective interprofessional educators: a post graduate level Continual Professional Development Programme E S Anderson, D Cox, L N Thorpe E S Anderson, Department of Medical and Social Care Education, Maurice Shock Medical Sciences Building, University of Leicester, University Road, Leicester, LE1 9HN Aim We present our experience and research which lead us to contend that all interprofessional (IP) educators – new or experienced – require insights, skills and motivation in both interprofessional education (IPE) itself and its pedagogical underpinnings before they can aspire to become excellent leaders in IPE. Material Pre-existing observations and teaching evaluations of IPE identified the need to develop educators to teach interprofessional groups effectively. Expertise within Health Studies was combined with that of educational developers to design an M-level course. The content was guided by best evidence IPE practice within the UK (e.g. www.caipe.org.uk) guidelines, but this was crucially married to contemporary pedagogic theory and practice. Our course design practices what we preach: we deliver learning about IPE to interprofessional groups who work and learn together sharing and developing their skills using techniques of active and grounded learning. Method We have tested our work and progress by mixed methods of educational research. These include a pre-course questionnaire to test all participants’ hopes, concerns and expectations. We then tested knowledge gain and attitudinal perceptions using quantitative and qualitative methods post course. Qualitative comments were given on a post course questionnaire and a random sample completed one-to-one interviews with the researcher. Results We report on the experiences of over 80 participants. The results emphasise the positive knowledge gain (P<0.001) and highlight the benefits including enhanced appreciation of IPE, greater understanding of relevant theory and a willingness to establish IPE in clinical areas. Conclusions Dedicated time to reflect on the breadth and depth of IPE is essential for both experienced and new IP educators. Our type of course ensures the sustainability and engagement of practice in interprofessional learning, working along with a sound theoretical base.

Beyond consultation: the role of reflection in creating institutional change – let the students teach the teachers M Kelly, S O’ Flynn, M McCarthy, I Bairre, A Scott M Kelly, Department of General Practice, Brookfield Health Sciences Complex, University College Cork, Ireland Background The importance of role models in clinical education is fundamental. Busy doctors are challenged to meet the needs of students whilst also juggling clinical commitments. Aim Engage clinical role-models in understanding their pivotal role in the shaping of young professionals by examining their teaching methods. Summary of work A series of practice based workshops were organized between clinical teachers and medical school staff at all key clinical sites (n=6). Students were invited to attend. The stated purpose of these workshops was to showcase the changes occurring in the medical undergraduate curriculum. A key component was the presentation of research findings originating from a case study of third year medical students, during their transition from the structured class-room setting to the unpredictable clinical environment. The case study had examined the role of reflection in clinical teaching and professional development. A total of 332 reflective accounts were read and analysed by qualitative content analysis1. Credibility of the analysis was validated by an independent teacher, reading the descriptions separately, and trustworthiness was tested by presenting the data to the students as the research process continued. The workshops focused on the presentation and discussion of a series of qualitative comments, which highlighted the experiences of students during this time. Themes emphasized included; learning in new ways, professional behaviour (good and bad) and the need for recognition of learning in the affective domain. Results Locating these workshops in clinical sites made them accessible to a range of staff that would traditionally be excluded. A number expressed a better understanding of the role of the medical student within the clinical setting and expressed interest in contributing to medical student teaching for the first time. Students engaged with the discussions initiated by the workshop material – this is one of the first times many of these experienced clinicians had discussed their approach to teaching with students. Positive feedback has been given to good teachers. Many clinicians were dismayed at the negative experiences encountered by students. Student involvement in educational research helps foster a partnership model between teachers and students – leading the way to delivering a ‘student-centred’ curriculum. Take home message Creating institutional change is difficult. The use of qualitative methods would appear to be more powerful than quantitative surveys in terms of impact on the behaviour of clinical teachers and such data should also inform resource allocation to support education at clinical sites Reference:

1. Pope, C., Mays, N. (Eds) (2000) Qualitative research in Health care. London: BMJ Publishing

Moving beyond teacher competence: the case for educational leadership as a core element to accredited faculty development activity J McKimm, C Morris J McKimm, Centre for Medical and Health Sciences Education (CMHSE), Faculty of Medical and Health Sciences, The University of Auckland, PO Box 92019, Auckland Recent years have seen unprecedented change in medical education and training, creating new demands on clinical teachers. In the same period, we have led the development of a new Masters in Medical Education programme, designed with the changing needs of the clinical education workforce in mind. Programme design was informed by research into similar masters’ programmes1 and consultation with local stakeholder groups. The outcome was a flexible, blended learning programme that, in keeping with similar programmes, aimed to equip individuals to be capable medical educators and researchers. Distinctively, it led to the creation of a unique ‘educational leadership’ pathway which aimed to develop the range of leadership capabilities to manage and sustain educational change and innovation in academic and clinical settings2. Central to the programme is a 30 credit module on leadership which is also part of a stand-alone PgCert in Medical Education Leadership. Reflecting current thinking on leadership in public services3,4 and the school sector5, collaborative, transformational, servant, moral/value-led and complex adaptive leadership is emphasised.6 We integrate leadership theory with strategic and project management, leading change and policy analysis. Over 4 contact days, (including a residential event), learning activities include self-development, reflective, creative thinking and visioning exercises; case studies; discussion; debate; presentations and reading groups. Summative assessment comprised individual written assignments, reflective commentaries and group presentations. Conclusions Leadership development programmes tailored to the needs of healthcare educators lead to improved leadership/management knowledge and understanding; increased confidence as educational leaders and change agents and enhanced career progression7. Our experience to date suggests that there are tangible benefits to including leadership, strategic management, policy analysis and change leadership as a core component of M level programmes. Evidence from student feedback and assessment submissions supports our belief that our students have capacity and skills to see the wider picture, scan the horizon and communicate ideas and innovations creatively and imaginatively. They can assess the broad impact and implications of curriculum change. Most importantly, they see themselves as educational leaders: some have already progressed in their careers. We would suggest that if educators are to be fully equipped as change agents and innovators, then leadership and change techniques need to be included in formal faculty development activities. We would further note a skills gap amongst faculty and staff developers in healthcare education regarding the capacity to develop and deliver educational leadership. References:

1. Pugsley, L., Brigley, S., Allery, L and MacDonald, J. Making a difference: researching masters and doctoral research programmes in medical education. Medical Education, Volume 42, Number 2, February 2008 , pp. 157-163(7)

2. StLaHR HR Plan Project. 2004. Phase II Strategic Report. Developing and sustaining a world class workforce of educators and researchers in health and social care at www.stlahr.org.uk/consultation

3. Gilbert, P. (2004). Leadership: Being effective and remaining human. Russell House Publishing, Lyme Regis 4. van Zwanenberg, Z. 2003. Modern leadership for Modern Services. Scottish Leadership Foundation: Alloa 5. Fullan, M. The change leaders, Educational Leadership May 2002, pp16-20 6. Marion, R., & Uhl-Bien, M. Leadership in complex organizations. Leadership Quarterly 12, 2001, 389-418 7. Petersen, S and McKimm, J. 2008. Long term outcomes of a leadership programme for healthcare educators. Short paper

presentation at 13th Ottawa International conference on clinical competence (OZZAWA), Melbourne, 3 – 5 March

Teaching About Specific Subjects

Attitudes of medical students to caring for patients approaching the end of life: a cross-sectional study in the University of Cambridge S Barclay, J Benson, D Wood, J Brimicombe, E Summers, T Quince S Barclay, General Practice Research Unit and Medical Education Research Group, University of Cambridge, Institute of Public Health, Robinson Way, Cambridge, CB2 2OR Background Attitudes medical students form during their training towards end of life care may influence their future care of dying patients. Aims 1) To describe the attitudes of medical students in one UK university towards end of life care 2) To compare these attitudes with those of final year US medical students Methods Cambridge medical students were given a questionnaire during the 2007/2008 academic year that included the 9 questions concerning attitudes towards end of life care from Sullivan’s 2003 US study of 1455 US Year 4 students. Results 376 responses received to date. Data collection is complete for Year 1 (182/267 68.2%) and Year 4 (104/138 75.4%). Year 6 data collection is still underway (90 responses to date): analysis of the complete dataset and final comparisons between the three year groups will be presented. Comparative data from Sullivan’s study are indicated thus [ ] when 95% Confidence Intervals indicate significant differences. Mean age was 20.6 years, 54% being female. There was no significant difference in the attitudes of students in Years 1, 4 and 6 to any of the 9 questions. a) Doctor’s roles Most agreed that doctors have a responsibility to help patients at the end of life prepare for death (92%) and to provide bereavement care after death (61% [92%]). b) Psychological issues Most agreed it is possible to tell patients the truth about terminal prognosis while maintaining hope (71% [89%]), that patients’ psychological suffering can equal physical suffering (97%), and that depression in terminal illness is treatable (63% [94%]). c) Students’ emotions 54% [19%] agreed they might feel guilty after a patient’s death while 34% dreaded dealing with family emotional distress. Caring for dying patients was seen as depressing by 28% and as more satisfying than other clinical activities by 18%. 47% considered themselves to be spiritual persons. Discussion Most Cambridge students had positive attitudes towards their future role in providing palliative care, although anxious about coping with their own emotions and those of relatives. Compared with US students they were:

- more likely to feel guilty after a patient’s death - less likely to:

see depression in the dying as treatable think it possible to tell the truth about a terminal prognosis and maintain hope think physicians have a responsibility to provide bereavement care

Possible reasons for these differences with their US counterparts and the implications for UK palliative care training are discussed.

Teaching and Learning

Learning Approaches and Learning Styles of Medical and Nursing Students – A Comparative Analysis D M Fanning, G Chadwick D M Fanning, Conway Institute of Biomolecular and Biomedical Research, School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Ireland Aims 1. To assess the learning approaches and styles of first year Medical and General Nursing students. 2. To elicit any statistically significant correlations in learning approaches +/- styles between course types and genders. Methods Permission to survey was attained from the Heads of the Schools of Medicine and Nursing. Ethical Exemption was awarded. Combined Learning Style Questionnaires and the short version of ASSIST were distributed during the first week of Semester One 2007. Data was analysed utilising the Statistical Package for the Social Sciences. Results 82.2% of 129 enrolled medical students, and 45.1% of 204 enrolled general nursing students completed the questionnaires. T-tests show medical students adopt both the Strategic and Deep Learning Approaches more frequently than nursing students; significance level < 0.01. Conversely nursing students tend towards the Superficial Style more so than their medical counterparts, significance level < 0.05. T-tests reveal the Medical cohort score higher for the Reflector, Theorist and Pragmatist Learning Styles, significance level < 0.05. Both groups have similar tendency towards the Activist Style. Scatterogram of Activist-Theorist and Pragmatist-Reflector scores reveal clustering in the Theorist-Pragmatist quadrant. Spearman's Rank method reveals a correlation between the Strategic Approach and all Learning Styles; and between the Deep Approach and Reflector, Theorist and Pragmatist Styles; significance level < 0.05. Conclusion This study of first year medical and nursing students, conducted in Ireland’s largest university, is novel in the Irish context. The consistency of the similarities between gender and course types suggests the potential benefit of multi-disciplinary trans-institutional co-operation in regard to curriculum development and examination.

Does the Strategic Learning Approach promote Inactive Doctors? D M Fanning, G Chadwick D M Fanning, Conway Institute of Biomolecular and Biomedical Research, School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Ireland Aims The role of a young doctor is challenging and multifaceted; to succeed an individual must exhibit acclaimed academic ability and adopt a practical personable approach to their chosen vocation. We aim to investigate whether the predominant Strategic Learning Approach of medical students negatively correlates with the Activist Learning Style; does strategic learning promote a sedentary approach to clinical activities? Methods Permission to survey was attained from the School of Medicine. Ethical Exemption was awarded. Combined Learning Style Questionnaires and the short version of ASSIST were distributed during the first week of Semester One 2007. Data was analysed utilising the Statistical Package for the Social Sciences. Results 106 (82.2%) of the 129 enrolled medical students completed the questionnaires. 84.4% of female and 80% of male medical students were surveyed. The predominant Learning Approach was Strategic, followed by Deep, and finally Superficial. The least common Learning Style was Activist, the most common Reflective. Non-parametric Spearman’s Rank Correlation Method shows a negative correlation between the Strategic Approach and the Activist Style, significance level <0.01. There is a positive correlation between the Strategic Approach and the Reflector/ Theorist learning Styles, significance level <0.05. Conclusion The Strategic Learning Approach negatively correlates with the Activist Learning Style; the pressure to process large volumes of information forces trainees to adopt the Strategic/Achieving Approach to ensure academic success. This approach however, positively correlates with the more academic Reflector/Theorist Styles of Learning; students choosing to review and conclude, but not preferentially choosing to actually “do” anything active.

Learning Style Theory – Reflective versus Activist Doctors D M Fanning, G Chadwick. D M Fanning, Conway Institute of Biomolecular and Biomedical Research, School of Medicine and Medical Science, University College Dublin, Belfield, Dublin 4, Ireland Aims Honey and Mumford’s Learning Style Questionnaire (L.S.Q.)1 extends David Kolb’s concepts of experience as the source for learning2, viewing learning as a circular continuous process with 4 distinct stages in the cycle, each corresponding to a distinct Learning Style - Activist/Reflector/ Theorist/Pragmatist. L.S.Q. scores preferences for these 4 constructs on 2 Cartesian axes, producing the dimensions of Activist–Theorist & Pragmatist–Reflector; we aim to investigate the relationship between the extremes of medical students Learning Style preferences. Methods Permission to survey students was attained from the School of Medicine and Medical Science, University College Dublin. Ethical Exemption was awarded. Questionnaires were distributed during the first week of Semester One 2007, to first year medical students. Compliance with the study was voluntary and anonymous. Distribution, completion and collection occurred consecutively during scheduled lecture time. Completed questionnaires were scored manually and assimilated data analysed utilising the Statistical Package for the Social Sciences. Results 82.2% of the 129 enrolled medical students completed the questionnaires. 84.4% of female and 80% of male medical students were surveyed. T tests reveal no statistically significant gender differences. The predominant style was Reflective, the least common Active. Non-parametric Spearman’s Rank Correlation Method shows a negative correlation between the Activist Learning Style and that of the Reflector and Theorist (significance levels <0.01 and <0.05 respectively). The Reflector and Theorist styles correlate positively, significance level <0.01. Conclusion Most medical students are Reflectors, signifying that they enjoy reviewing material, assimilating and analyzing data, formulating conclusions slowly; the minority group: Activists prefer to actually immerse themselves in work, being enthusiastic, energetic and flexible. To ensure a steady input of eager, able and conscientious surgical trainees, strategies to isolate and nurture the “doers” should be adopted early in clinical training. References:

1. Honey P, Mumford A. The manual of learning styles. Maidenhead, Berkshire: Peter Honey, 1992. 2. Kolb D. Experiential learning: experience as the source of learning and development Englewood. Cliffs, NJ: Prentice-Hall, 1984

An intercalated BSc degree is associated with higher marks in subsequent medical undergraduate degree examinations J A Cleland, A Milne, H K Sinclair, A J Lee J A Cleland, Department of General Practice and Primary Care, Foresterhill Health Centre, University of Aberdeen, Westburn Road, Aberdeen, AB25 2AY Objectives Evidence as to the short-term gains of intercalating, in terms of improved performance when rejoining the medical course, is conflicting, and the studies are dated. This study aimed to compare medical students on a modern MBChB programme who did an optional intercalated degree with their peers who did not intercalate; in particular, to monitor performance in subsequent undergraduate degree exams. Methods This was a retrospective, observational study of anonymised databases of student assessment outcomes at the University of Aberdeen Medical School, Scotland, UK. Data was accessed for University of Aberdeen MBChB students who graduated in the years 2003 to 2007 (n=861). The main outcome measure was marks for summative degree assessments taken after intercalating. Results Of 861 medical students, 154 (17.9%) students did an intercalated degree. After adjustment for cohort, maturity, gender and baseline (3rd year) performance, having done an IC degree was a significant predictor of attaining high (17-20) common assessment scale (CAS) marks in three of the six degree assessments occurring after the IC students rejoined the course: the 4th year written exam (p=0.005), 4th year OSCE (p=0.005) and the 5th year Medical Elective project (p=0.005). Conclusions Intercalating adds benefits in terms of improved performance in Years 4 and 5 of the MBChB. This improved performance will further contribute to higher academic ranking for Foundation Year posts. Long-term follow-up is required to identify if doing an optional intercalated degree as part of a modern medical degree is predictive of following a career in academic medicine.

Medical students with educational problems: who and how to help? R Hays, M Lawson R Hays, School of Medicine, Keele University, Keele, ST5 5BG This paper builds on the outcomes of a workshop at ASME 2007 and followed up at a workshop at the 13th Ottawa Meeting in 2008. Medical students often present to student support services with a variety of personal and educational problems. For many the problems are transient and progress through the medical course is not seriously impeded. However for a small number of students in every medical school, presenting problems represent serious underlying issues relating to motivation, maturity, learning skills, personality and poor insight. These students often consume a large proportion of student support resources and yet often have poorer outcomes. These issues were discussed at the two recent workshops attended by student support and remedial educators from several UK and several international medical schools, resulting in: 1. a consensus-based description of the profiles of students presenting with problems; and 2. a framework for assessing student problems at presentation. The profiles and the framework have been further tested during a workshop at the Ottawa Conference, and appear to be robust. These outcomes will be presented for further discussion and clarification. References: 1. Hays RB, Jolly BJ, Caldon LJM, McCrorie P, McAvoy PA, McManus IC and Rethans J-J. Is insight important? Measuring the capacity to change. Medical Education, 2002; 36: 965-71.

Is a supervised on-call session a valuable and effective learning tool for final year medical students? C Marshall, K Rothwell, R Isba, G Byrne, P O’Neill R Isba, Manchester Medical School Education Research Group, ATR4, 1st Floor ERC, University Hospital of South Manchester, Southmoor Road, Manchester, M23 9LT Final year medical students at the University of Manchester are not required to complete an on-call as part of their training. However, the first on-call as a junior doctor can be a daunting experience. This study aimed to investigate whether carrying out a supervised on-call improved confidence and knowledge levels in final year medical students, and teaching confidence in Foundation Year 1 (FY1) doctors. Fifteen final year students at the University Hospital of South Manchester were recruited and paired with 15 FY1s (medical and surgical) working in the same hospital. Students then carried the on-call bleep during their allocated on-call, prioritising jobs and constructing patient management plans under the constant supervision of the FY1. Each student and doctor completed a structured questionnaire before and after carrying out the on-call. Preliminary analysis of the questionnaires has shown that 75% of students felt more confident following the intervention, and no student experienced a decrease in confidence. Student participants all thought that the on-call was a good idea, and many felt that it should become a compulsory part of the final year. A supervised on-call has the potential to be a very valuable learning experience both for final year medical students and FY1s.

Peer Teaching “Pepped Up” A Walker, M F Peerally, J Connors, E Weston, P Stark, N Bax P Stark, University of Sheffield, Academic Unit of Medical Education, 85 Wilkinson Street, Sheffield, S10 3GJ Background & Rationale Peer teaching at undergraduate level involves senior students teaching and supporting their junior colleagues. This method of teaching has been used for teaching clinical skills1, in lectures2 and in problem-based learning3. At the University of Sheffield, first year students undertake a 3-week Intensive Clinical Experience (ICE) which aims to develop effective communication skills with patients and healthcare professionals, provide opportunities to take clinical histories and to enhance understanding of the Duties of a Doctor 4 (GMC 2006). To support these students, a new Peer Education Programme (PEP) was introduced in 2008 by 3rd-5th year medical students. Peer tutors were trained, and expected to help with history taking, basic clinical skills and to provide personal and professional support. Methods PEP was initiated by four, fourth year medical students who have an interest in medical education. Under the supervision of senior medical education academics, they designed the structure and content of PEP and produced a booklet for the ICE students containing advice on how to make the most of their placements. They organised and delivered two lectures – one to the peer tutors on their duties, and another to the first year students on what they might expect from their peer tutors. 165 volunteer students were recruited as tutors to 205 1st year medical students. Peer tutors were allocated one tutee in most cases and met with them twice a week during ICE. A week after the completion of ICE, two online evaluation questionnaires, based on a 5 point Likert scale, were made available to tutors and tutees respectively. Results 193 out of 205 tutees (94 %) and 122 out of 165 tutors (74 %) responded to the questionnaires. Both tutees and tutors evaluated PEP highly (Mean = 3.99 / 5 and 3.91 / 5 respectively), indicating the effectiveness of the project. Free text comments further highlighted the success of PEP and brought up some issues for improvement, such as the need for a more efficient pairing up system between tutees and tutors and more homogeneity in the content of tutorials. One interesting finding was the fact that students on ICE valued peer teaching more than teaching they received from their consultants. Conclusion In light of the positive evaluation results, we plan to deliver an improved version of PEP for next year’s ICE students. We are also considering ways in which to expand the programme into other year groups. References:

1. Field M et al. Peer assisted learning: a novel approach to clinical skills learning for medical students. Med Educ 2007; 41: 411-418 2. Carroll M. Can medical students teach biochemistry? Biochem Educ 1996; 24: 3-15 3. Sobral DT. Peer tutoring and student outcomes in a problem-based course. Med Educ 1994; 28: 284-9 4. Good Medical Practice (2006) General Medical Council: London: General Medical Council

Support for Breadth of Repertoire of Learning Styles

T Quince, J Benson, J Brimicombe, Z N Djuric, D Wood T Quince, Educational Research Associate, Department of Public Health and Primary Care, Institute of Public Health, University Forvie Site, Robinson Way, Cambridge, CB2 0SR

To cope with changes in heath care delivery, patients’ expectations, and professional requirements, today’s medical students may need to learn from and in a variety of experiences. Among the definitions, theoretical models and instruments found in higher education learning Kolb’s experiential learning theory is widely accepted and cited1,2 and Honey and Mumford’s Learning Styles Questionnaire (LSQ), based loosely on Kolb’s theory, is widely used3. The potential of a broad repertoire of learning style is acknowledged,3,4,6 but studies using the LSQ with medical practitioners have focused on the number of strong orientations and/or individual styles.(5,6,7) For educators the number and nature of “weaknesses” may be more important, particularly where students confront changes in learning context and teaching methods, as found in the Cambridge medical course. Using quartile scores students may be grouped according to the number individual styles (Activist, Reflector, Theorist and Pragmatist) where they record a “weak” orientation: students recording 2 or more “weakness” are classified as having a “narrow repertoire”, those recording no weaknesses as having a “broad repertoire”. In September 2007 University of Cambridge Clinical School launched a longitudinal programme of research (Data for the Improvement of Medical Education - DIME) seeking to identify factors in undergraduate medical education which enhance the quality of patient care provided by students in their medical practice. Those factors include the ability to learn flexibly and the development of empathy. Phase 1 of the programme is observational; aimed at discovering prevalence and generating hypotheses. 301 year 1 and year 4 medical students, (response rate 71%) participated in a questionnaire survey, which included the LSQ; measures of empathy and anxiety, and attitudes towards end of life care. Additional data relating to ethnicity and past and current academic performance, are being collected. Interim results:

All students: n=298 ♦ 24% “narrow”, 39% “moderate” 37% “broad” ♦ no difference in distribution between students in different years ♦ higher proportion of males than female classified as “broad” 41%; 33% not statistically significant. ♦ “Narrow” students recorded lower cognitive empathy scores. Year 4 Students: n=92 ♦ “Narrow” students recorded lower scores in knowledge based exams in years 2005 and 2006 ♦ 35% of “broad” students improved their comparative exam scores between 2005 and 2006 compared

to only 7% of “narrow” students

Additional year 4 student data: results of 2007 exams, results of forthcoming OSCEs and analysis of 2 focus group discussions conducted blind with “narrow” and “broad”, will enhance understanding of the prevalence of breadth of learning style and utility of the concept.

. References:

1. Cassidy S. Learning Styles: an overview of theories, models and measures. Educational Psychology 2004; 24:4:419-444. 2. Desmedlt E. and Valcke M. Mapping the Learning Styles “Jungle”: An overview of the literature based on citation analysis.

Educational Psychology 2004; 24:4: 445-464 3. Kolb, D. 1984 Experiential learning. Experience as a source of learning and development. London, Prentice Hall International 4. Honey P, Mumford A. The Learning Styles Questionnaire: 40-item version, Maidenhead, Berkshire, Peter Honey Publications, 2006. 5. Lesmes-Anel J, Robinson G and Moody S. Learning preferences and learning styles: a study of Wessex general practice registrars.

British Journal of General Practice 2001; 51:559-564. 6. Astin F, José Closs S, and Hughes N. The self reported learning style preferences of female Macmillan clinical nurse specialists.

Nurse Education Today 2006; 26; 475-483. 7. Fowler P. Learning styles of radiographers. Radiography 2002; 8: 3-11.

DVD clips as an adjunct to PBL sessions: do they improve outcomes? D Gore, M Ahmed, R Isba, B Woolley, G Byrne, P O’Neill R Isba, Medical Education Research Group, ATR4, 1st Floor ERC, University Hospital of South Manchester, Southmoor Road, Manchester, M23 9LT Background The curriculum at Manchester Medical School (MMS) is based around PBL stimulated by text-based cases. We investigated whether a supplementary DVD clip enhanced the generation of intended learning outcomes (ILOs) and student clinical experiences. Work done Ten-minute DVD clips specific to two existing PBL cases were produced. Each featured an expert providing a basic introduction to the topic. Thirteen PBL groups (n=113 year 3 medical students) were randomly allocated to test (n=7) or control (n=6). Test groups viewed the DVD before starting their case; control groups undertook PBL as usual. ILOs formulated by each group were recorded for comparison to the model ILOs. All students completed a diary recording their clinical experiences until closure of the PBL case one week later. Students in the test groups completed a feedback questionnaire. Conclusions ILOs were received from all PBL groups, and all test students completed feedback (n=57). Ninety percent of test students agreed or strongly agreed that the session was enjoyable, and more than half felt it was more enjoyable than other PBL sessions. Analysis of ILOs and clinical diaries is ongoing. Take home message Preliminary results show that DVD clips are an enjoyable adjunct to PBL, and further analysis will show whether or not they improve outcomes.

“In six months time… the patient will be happier because I have the title doctor”: medical student and junior doctor reflection on pelvic examination skill learning A Carson-Stevens, I J Robbé, A N Fiander A Carson-Stevens, Department of Obstetrics and Gynaecology, Cardiff University, School of Medicine, University Hospital of Wales, Health Park, Cardiff, CF14 4XN Introduction The General Medical Council stipulate that a medical school graduate must competently perform a full physical examination. Practical experience and adequate patient contact is fundamental to the acquisition of sound professionalism and practical wisdom. Insufficient numbers of consenting patients has long thrown up difficulties for students to obtain a sufficient experience of obstetric and gynaecological examinations. This is a difficult challenge for medical educators. Aims and Objectives To improve the undergraduate teaching of pelvic examination by identifying and working to resolve the positive and negative issues perceived and experienced by students during the teaching and practice of pelvic examination. To explore ways other healthcare professionals can positively contribute to medical student learning. Method We conducted a focus group study with three groups of final year Cardiff medical students (n=17) and separately two groups of first year junior doctors (n=7). We chose to study the student experience within obstetrics and gynaecology because of the rich opportunities to learn how medical students encounter new professional skills and opportunities to interact with new healthcare professionals such as midwives. Sessions were transcribed, coded, and themes were determined by content analysis. Results Limited knowledge and practical experience were the largest barriers for feeling competent. Some males were content with performing few pelvic examinations and agreed the skill was redundant unless future jobs or careers involved Obstetrics and Gynaecology. Incidents where midwives had refused medical student participation without reason, or instances where medical consultants would fail to introduce the student until it was time to perform the PE, were discussed. Students felt their ill-defined role as a ‘medical student’ underpinned many of these issues. Encouragingly, a number of students and junior doctors took a more positive outlook from their experiences and current skill base. They agreed by consensus that their undergraduate training provided the foundations to refer cases to someone more senior or specialist as foundation doctors or, later in their careers, in general practice or hospital medicine. Discussion With pragmatic solutions, we shall discuss where and when medical students perceive common and speciality specific barriers to their learning. Ways in which medical educators can support the important contribution made by healthcare professionals to medical student education shall be discussed. Conclusion Medical educators must recognise and work to ensure the identity and role of medical students is fully understood by the patients and healthcare professionals contributing to their education.

Systematic review of the role of intercalated BScs in medical education M Jones, S Singh M Jones, Research Department of Primary Care & Population Health, University College London Medical School, 2nd Floor, Holborn Union Building, Archway Campus, Highgate Hill, London, N19 5LW Background and need for the project Intercalated BSc courses are (usually) optional extensions to UG medicine courses done by approx 1/3 of UK students. Such courses are also reported in Canada and Australia. There appears to be no agreed generic objectives for such courses, but by custom courses appear to explore an area of medicine in more depth, and usually involve research within the discipline. They are associated with deeper strategic learning styles. Aim to review systematically published literature on the outcomes of students undertaking a BSc with the following outcomes: performance in final exams, impact on career choice and impact on professional skills and values. Methods A systematic review was undertaken to explore the outcome of BScs in medical education. Literature was searched using standard methods. We searched Medline/NLM, PsychLit, EMBASE and ERIC for papers that report student outcomes beyond the course outcome itself including performance in finals, subsequent careers, professional skills and values. Results We identified 7 papers that report student outcomes of which 6 show some improvement in student outcomes (finals performance, subsequent career progression). In terms of undergraduate performance two studies report outcomes ranging from no effect to an Odds Ratios (OR) of 4.4 (in favour of BSc students). No other data was retrieved on professional skills and values. For academic progression ORs are reported from 2.3 to 22, with one study reporting a difference of 0 to 42% in favour of BSc students. “Soft” literature such as editorials and opinion pieces support the role of iBScs in undergraduate medical education. Discussion BScs may be associated with improved student performance (in one out of 2 studies), but other measures (such as publication, academic careers) may be markers of academic success, that do not indicate necessarily that these courses produce “better doctors”. Methodologically, it is also very difficult to disentangle the selection bias effects of the academically most able medical students being offered the option to do these courses and the effect of an extra year of study / maturity. Beyond what is quantifiable, an important element of these courses seems to be helping individuals to develop intellectually. Smith quotes “that was the year I that I learnt to think and to question and to find out things for myself” and Rushforth says “many find (the iBSc) the most stimulating and rewarding year of their undergraduate studies”.

Learner centred programme evaluation T Dornan, C Boggis, J Graham, N Lown, A Scherpbier, H Boshuizen, A Muijtjens T Dornan, Hope Hospital, Stott Lane, Salford, Manchester, M6 8HD Background Few would disagree that programmes should be evaluated but they might disagree how. Use of the term ‘evaluation’ to mean summative assessment suggests assessment is synonymous with programme evaluation. Yet ten Cate argued that students compensate for poor teaching by ‘learning to the test’ and, in our research, previous assessment performance accounted for most of the variance in subsequent performance while placement quality accounted for little of it. Aim Validate a novel learner centred measure of workplace learning. Methods The study was oriented towards situated learning theory as instantiated by the Manchester Maastricht Experience Based Learning Model and had a post hoc design. 450 students attached to four different hospitals for Year 3 of a learner centred undergraduate programme were asked to complete the second generation version of a previously reported web evaluation questionnaire at the middle and end of one academic year. They numerically rated and gave textual descriptions of the conditions, processes, and outcomes of experience based learning in both hospital and community. Results There were 758 of a possible 900 responses (84%) to 47 numerical items. Bartlett’s test and the KMO index confirmed suitability of the data for factor analysis, which used both oblique and varimax rotation. Because each respondent appeared twice in the dataset, the analysis was repeated using data from just one time point and findings were similar. Seven factors accounted for 68% of the variance: Hospital Firm Quality; Community Placement Quality; Base Hospital Quality; Portfolio Learning; IT Learning Support; Real Patient Learning; and State of Mind. The questionnaire was sensitive to differences in Placement Quality within hospitals (p<0.001 by ANOVA) but showed no difference in aggregate Placement Quality between hospitals. However, it was sensitive to differences in the quality of Base Hospitals and Portfolio Learning within them (p<0.001 for both), but found no difference between them in Real Patient Learning (p=0.94) or students’ State of Mind (p=0.18). Qualitative analysis of textual responses to the State of Mind items showed how learners constructed their personal identities in response to Real Patient Learning. Conclusions An eclectic, learner centred approach to programme evaluation was feasible, had construct validity, and was sensitive to important differences. Our findings show how mixed methodology can explore learning processes in breadth and depth. Future research will explore how key performance indicators derived from such data coupled with students’ textual accounts can be used formatively to improve learning across a whole programme.

“I think, therefore I am…” … I think! Medical students’ changing personal epistemology in a problem-based curriculum G Maudsley G Maudsley, Division of Public Health, Whelan Building, Quadrangle, The University of Liverpool, Liverpool, L69 3GB It should be desirable for medical students to practise thinking relativistically about knowledge. Using greater cognitive flexibility and critical analysis in their medical career might improve their satisfaction, self-efficacy, and professionalism. Furthermore, the literature tends not to relate cognitive development (personal epistemology) to the experience of problem-based learning (PBL). Aim To explore potential changes in medical students’ personal epistemology, and its relationship to their notions of ‘ideal tutoring’ in a problem-based curriculum. Participants/Setting 5-year Liverpool problem-based curriculum (during 2006/07). The 2006 entrants (at mid-Year 1 and end-Year 1), and the 2002 entrants (at mid-Year 5) Design & outcome measures Using both cross-sectional and longitudinal design, and a ‘mixed methods’ approach to a postal questionnaire, items explored:

§ personal epistemology position (on Perry’s Scheme: Moore’s 65-item Learning Environment Preferences) in all three surveys, giving longitudinal data from Year 1 and comparison data from Year 5

§ notions of the ideal PBL tutor (24 items, 5-point Likert scale) mid-Year 1

Mid-Year 1 and mid-Year 5 gave open answers about:

§ how their knowledge-base was developing

Results From about 142 and 149, and 116 returns, respectively, findings include:

§ the potential change in cognitive development between the three time-points in the curriculum, e.g. a suggestion of significant regression (‘retreat’ to safer positions) by mid-Year 5

§ the predominance of ‘early multiplicity’, whereby learning might focus on ‘finding the right answer’ (rather than ‘judging the better answer to a question, given its context’)

§ how such data relate to students’ expectations of ‘ideal tutors’ and the knowledge-base

Comment Notwithstanding caveats about various potential biases in the data, students regressing in their cognitive development during medical school might cause concern, particularly if such change were substantial, sustained, and attributable mostly to curriculum implementation issues. How learning experiences are framed in the more senior curriculum could be crucial. A problem-based curriculum should provide a progression of cognitive challenges, and integrate these in the increasingly work-based nature of learning, in clinical placements. Furthermore, how such a measure of personal epistemology relates to the students’ expectations of ideal PBL tutoring might inform academic support for those who feel dissatisfied with this approach to the knowledge-base.

Pot Pourri

Who’s got the power – the SP or the student? A linguistic analysis of conversational dominance in communication skills assessments A de la Croix A de la Croix, Interactive Studies Unit, Dept of Primary Care and General Practice University of Birmingham, Learning centre, Room 117, Edgbaston, B15 2TT, UK Background The relationship between language and power is a very strong one; language can reveal power relations and the social context of speech. This means conversations can be analysed in terms of power distribution between participants, in which the dominant participant can limit the linguistic freedom of the other participant(s). Some work on power has been undertaken in the area of medical communication. In this area the doctor is traditionally perceived as having more power in the doctor-patient consultation; s/he knows more and controls the conversation1. Research focus At the University of Birmingham, simulated patients are used in training and assessment of communication skills. This project aims to investigate aspects of the use of simulation in medical education and assessment, focusing on power relations between SP and student. There is reason to believe that the simulated patient - rather than the medical student - is the powerful participant2, as the SP has more knowledge, experience and is part of the assessing institution. Conversely, the medical student is likely to be nervous and has limited knowledge and experience at this stage. Could this power reversal lead to a change in the structure of the conversation? No research has been done in this area to date. Methodology 100 videotaped consultations between third year medical students and simulated patients have been transcribed and are being analysed using a range of linguistic techniques from the fields of discourse analysis and conversational analysis, to reveal power relations between the two participants. For this paper, the following markers of power were looked at:

• Floor (who talks more, who interrupts) • Flow (who asks questions & initiates new topics) • Fringes (who opens & closes the consultation)

Central concepts and findings The results of a pilot study indicate that the simulated patient is indeed the participant in control. This leads to questions on the nature of role-play as an assessment tool. Is the simulated patient meant to behave exactly like a patient? Should we train SPs to be less powerful? Do we expect medical students to develop control over the conversation? If so, when do we require students to have developed conversational dominance? Should we think of alternative tools when assessing communication skills? What is the message - the ‘hidden curriculum’3 - students take away about communication skills assessments if the SPs are the ones leading the simulated consultations? References:

1. Ten Have P. Talk and Institution: A Reconsideration of the "Asymmetry" of Doctor-Patient Interaction. In: Boden D, Zimmerman DH,

editors. Talk & Social Structure; Studies in Ethnomethodology and Conversation Analysis.Oxford: Polity Press; 1991. p. 138-63. 2. Hanna M, Fins JJ. Power and Communication; Why Simulation Training Ought to Be Complemented by Experiential and Humanist

Learning. Academic Medicine 2006 Mar;81(3):265-70. 3. Medical Education in the Millennium. Oxford: Oxford University Press; 1998.

The Experiences of UK, EU, Non-UK and Non-EU Medical Graduates Making the Transition to the UK Workplace C Kergon, J Illing, G Morrow, B Burford, A Bedi C Kergon, NHS North East Education, 10-12 Framlington Place, Newcastle upon Tyne, NE2 4AB Introduction The UK depends highly on doctors who have not graduated from a UK medical school. In 2004 45% of doctors working in the NHS qualified from a non-UK medical school and 15% an EU medical school. Aims To compare the experiences of UK, EU and non-EU doctors making the transition to the UK workplace and explore whether factors can be identified which contribute to success or failure in this transition. Methods A qualitative study involving UK, EU and non-EU trainee doctors starting work in the UK. Trainees were interviewed prior to starting work and followed up at the end of their first placement. Perceptions of educational supervisors and clinicians working with them were also obtained at the end of the first placement (November 2007). Findings 65 overseas and 65 UK doctors have been interviewed. The UK doctors and most of the EU doctors have gone straight into F1 (intern) whereas most non-EU doctors have spent several years out of practice. Preliminary analysis reveals that overseas doctors benefit from clinical attachments to gain understanding of the NHS, however these are difficult to obtain. Overseas doctors need to adapt to a new style of practice. Communication with patients is different as are the roles and responsibilities of members of the clinical team. Learning portfolios were also highlighted as a new area. Conclusion Conclusions will help to identify factors that have helped or hindered transition into the UK workforce.

The Prehospital Care Programme – the Medical Student’s story Miss Emma Lightbody, Flat 3, Cable House, Lloyd Street, London, WC1X 9QT Correspondence to: emma.lightbody@doctors.org.uk The Prehospital Care Programme (PCP) is an innovative piece of curriculum at Barts & The London, Queen Mary’s School of Medicine. It is a multi-agency programme involving the London Ambulance Service (LAS), London’s Helicopter Emergency Medical Service (HEMS) and the Medical School. The PCP has developed from my ambitions as an individual Medical Student into a progressive, experiential learning opportunity for many other Students in the future. This essay is an account of how an initial interest (when supported and facilitated by an exceptional team) has resulted in the rapid development of a unique opportunity for Medical Students providing an unrivalled experience in Prehospital Care for undergraduates. Prehospital care is an emerging specialty; nationally it has a massive variation in both service provision and the nature of the incidents attended. In rural areas Prehospital Care includes mountain rescue and accidents associated with outdoor pursuits, contrasted with the falls from a height and stabbings found in inner cities. It is this variation that provides the attraction for many of the doctors in the UK who make themselves available in their own time to respond to such incidents. My fascination with Prehospital Care led me to initiate contact with both the London Ambulance Service and London’s Helicopter Emergency Medical Service whilst in my second year at Barts and The London. During the last eighteen months I have not only gained hundreds of hours of on-the-road Prehospital Care experience, but have contributed to the enhancement of inter-agency relations by involving them in Medical Student education. My ongoing work into the development of the Prehospital Care Programme has been supported by a large number of services and individuals. My key mentors are Dr Anne Weaver (Emergency Medicine & Prehospital Care Consultant & Lead Clinician for London HEMS), Dr Danë Goodsman (Senior Lecturer in Medical Education, Barts & The London Queen Mary’s School of Medicine. Interprofessional Education Lead, Queen Mary’s University and City University) and Mr Craig Cassidy (London Ambulance Service Paramedic). My initial ideas for the development of the Prehospital Care Programme were presented to all of these individuals in September 2007, and subsequently we formed a development team of four. The development team has regular meetings, and we are in constant communication with each other. The Prehospital Care Programme team presented at the London HEMS Clinical Governance Day in January 2008, and have been invited to present at the British Association of Immediate Care (BASICS) annual conference in September 2008. In addition to this a short piece regarding the PCP appeared in the London Ambulance Service News, and an article will appear in the Prehospital Care UK magazine.

Two Years’ Experience of a Large-Scale, Peer-Led Education Programme in Leicester Medical School A J Batchelder, P M Hickey, C Johnson, L-Y Lin, C M C Rodrigues A J Batchelder, Department of Medical and Social Care Education, Maurice Shock Medical Sciences Building, University of Leicester, PO Box 138, Leicester, LE1 9HN Introduction In 1997 the Medical Workforce Standing Advisory Committee published a report recommending that medical student numbers should be substantially increased.iv Subsequently, the Department of Health announced the biggest expansion in the number of medical school places for 30 years, with further growth planned for the future.v By contrast, there has been a gradual decline in the numbers of clinical lecturers in the UK; between 2000 and 2003, a fall of 36% was reported, with a further decline of 17% from 594 in 2003 to 494 in 2004.vi,vii Consequently, medical educators are increasingly exploring alternative methods for delivering curricula, including the use of multimedia tools and the development of self-directed components. Students may themselves offer an additional underexploited solution to the imbalance between educational demands and resource availability; senior students may be a valuable resource to support the education of their junior counterparts. In addition, the curricular outcomes, as defined in ‘Tomorrow’s doctors’, include the requirement for students to “develop the skills, attitudes and practices of a competent teacher”.viii In their review of careers in academic medicine in 2005, the UK Clinical Research Collaboration and Modernising Medical Careers sub-committee made several recommendations to medical schools, including that “special study modules and student-selected components should offer opportunities for students to work with clinical educators, as well as researchers”.ix In addition, the review also recommends that “greater opportunities should be made available for some students to explore both the theory and practice of education through intercalated degrees” in order to increase numbers in academic medicine. Peer-led education, also termed peer tutoring, has been defined as “an approach in which one [student] instructs another [student] in material on which the first is an expert and the second is a novice”.x An extensive body of literature exists to support the role of such methods in primary and secondary education, with benefits described for tutor and tutee. Existing medical education literature reports the effectiveness of peer-assisted learning programmes, usually in the context of student-selected components, which are co-ordinated by medical schools and delivered by students. However, to date, the published literature is devoid of descriptions of initiatives designed, developed and delivered entirely by medical undergraduates. Here we describe our experience of a peer-led education programme in Leicester Medical School, novel in terms of its format and size.