developing communication skills for pharmacist-led clinics

Really Good StuffReports of new ideas in medical education

Annual, peer-reviewed collection of reportson innovative approaches to medical education

Edited by M. Brownell AndersonAssociation of American Medical Colleges

Really Good Stuff

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1084–1110

Contents

Introduction to Really Good Stuff

M. Brownell Anderson and J. Bligh

Really Good Stuff reviewers

Asia

Teaching of forensic medicine in the undergraduate

curriculum in Sri Lanka: bridging the gap between

theory and practice

Australasia

Teaching teamwork to medical students: goals, roles

and power

Self-directed learning during community-based place-

ments

Europe

Voluntary student research groups in biochemical

education

A special study module in hospital management

Developing communication skills for pharmacist-led

clinics

Taking the skills lab onto the wards

Evaluating a teaching skills workshop for medical stu-

dents

The influence of self-deception and impression man-

agement on surgeons’ self-assessment scores

‘Whose life is it anyway?’ An innovative course on

mental health issues

The ethics of teamwork in an interprofessional under-

graduate setting

Standardised audio-visual equipment to support the

corporate identity of an integrated curriculum

Current forms of psychotherapy: teaching their history,

concept and application

A training post in women’s health care for GP registrars

North America

The resident as teacher of medical humanities

Bringing medical ethics to life: an educational pro-

gramme using standardised patients

Virtual handouts for handheld computers

BaFa BaFaTM: a cross cultural simulation experience

for medical educators and trainees

Doing it well: demonstrating general competencies for

resident education utilising the ACGME Toolbox of

Assessment Methods as a guide for implementation of an

evaluation plan

MammoEd: digital interactive breast imaging educa-

tion

Through the Patient’s Eyes

Increasing the instructional equivalency at a tri-clinical

campus: going online with an Ob-Gyn clerkship

Conquering conflict in medicine

An integrated structure–function module for first year

medical students: correlating anatomy, clinical medi-

cine and radiology

Preventive health counselling for paediatric residents

Undergraduate training to expand regional health care:

Med Experience Plus at Brock University

Who’s afraid of the pre-school child? A parent and

toddler programme for teaching pre-clerkship clinical

skills

Integrated simulation experiences to enhance clinical

education

Really Good Stuff 1085


Introduction

November 2002 is the third edition of �Really Good

Stuff� (RGS) and marks something of a turning point

for the piece. One could call it evolution or �growing

pains� but as we reviewed the comments from external

reviewers this year, and re-read the submissions, we

were faced with some difficult questions. One of the

issues is time. Since the purpose of RGS is to provide a

glimpse at a work in progress, before it has been

submitted to years of evaluation and data collection,

and to do so in a timely manner, there is little time for a

promising work to be returned to the author for

changes that might make it a terrific report. Other

issues we face are submissions on important topics that

are not really educational reports, but raise critical points

for further consideration

The submissions continue to be dominated by the

US and the UK and we hope to encourage all countries

to submit reports for review. However, a major issue

that arose repeatedly in our deliberations was the

international applicability of some of the reports.

Medical Education is truly an international journal. Its

readers hail from around the globe and face different

educational programme structures, accreditation stand-

ards, licensure requirements, and political climates. As

a result, a topic that would be of critical importance in

one country may have little or no relevance to a large

number of the journal’s readers. So, we must weigh the

benefits of publishing a piece that may have little

relevance to a majority of the readers, against the

overall importance of the topic presented. We typically

elect to publish reports that may be of more relevance

and importance to one country than others, in order to

provide as broad a perspective of really good stuff as

possible.

A significant change has occurred in a US journal,

Academic Medicine. For eight years, the feature �InProgress� was published in Academic Medicine. �InProgress� was a sister publication to �Really Good Stuff�– the format, length of reports, review process, all were

the same. The new editor of Academic Medicine has

determined that �In Progress� does not meet the needs

of the journal and has decided to discontinue publica-

tion of this feature. This change provides an opportun-

ity for Medical Education to publish �Really Good Stuff�more than once a year. We have decided to do just that

and will have a section devoted to RGS in both the

November and May issues of the journal. The call for

submissions and the process for review will remain the

same for each of the two issues.

We wish to thank the authors who submitted their

work. They are the reason for the existence of Really

Good Stuff. We especially acknowledge, with gratitude,

the role of the external reviewers. The time they spend,

and their comments and insights, contribute enor-

mously to the quality of the reports selected and to the

task of making the selections.

Our wish for you – authors and readers – is that these

reports will stimulate you to consider new approaches

to medical education and encourage you to submit

some really good stuff you are doing to be published in

a future edition of this feature.

M Brownell Anderson

Association of American Medical Colleges

Washington, DC

John BlighPeninsula Medical School,

UK

Really Good Stuff1086


International review panel

We are grateful to the following for their valuable

assistance in reviewing manuscripts for this section:

Ducksun Ahn South Korea

Heather Alexander Australia

Marshall Anderson USA

Raja Bandaranayake Bahrain

Robert Batey Australia

Margaret Bearman Australia

Gabor Biro Hungary

Kim Blake Canada

Julia Blitz South Africa

Colin Bradley Ireland

Paul Bradley UK

Pam Bradley UK

Tom Brown UK

Anthony Busutill UK

Susan Case USA

L C Chan Hong Kong

Francois Cilliers South Africa

Gillian Clack UK

Jennifer J Conn Australia

John Cookson UK

Nick Cooper UK

Eugene Custers Netherlands

Ara Darzi UK

Pierre de Villiers South Africa

Reg Dennick UK

J Dequeker Belgium

Elisabeth Dial USA

Helge Dohn Denmark

Stephanie Dowling Ireland

C Drinkwater UK

Clair du Boulay UK

Florian Eitel Germany

Paul Finucane Ireland

Andy Flett UK

Josep Fornells Spain

Pia Forsberg Sweden

Heather Fry UK

Remi Gagnayre France

Derek Gallen UK

Ronnie Glavin UK

Fergus Gleeson Ireland

Shimon Glick Israel

Jacqueline Gray UK

Steve Greene UK

Janet Hafler USA

Mats Hammar Sweden

Geoff Hammond UK

Peter Harasym Canada

Ann Hesketh UK

David Hill Australia

Ann Jervie Sefton Australia

Cindy Johnson UK

Roger Jones UK

Farhad Kamali UK

Navneet Kapur UK

Maureen Kelly Ireland

Emma Kennedy Australia

H E Khoo Singapore

Sue Klein UK

Michael Kochen Germany

Donald Langille Canada

John Lazarus UK

CJ Lazarus USA

David Leeder UK

Christina Liossi UK

Martin Lischka Austria

Patricia Lyon Australia

S M MacLeod Canada

R D MacLeod New Zealand

Bob Mash South Africa

Alan Maynard UK

Colin Melville UK

Barbara Miflin Australia

Michael Modell UK

Andrew W Murphy Ireland

Jørgen Nordenstrom Sweden

George Pachev Canada

Ashis Pathak India

Emil Petrusa USA

Katinka Prince Netherlands

M A L Pringle UK



Ian Pullen UK

Ian Purves UK

Virginia Reed USA

Scott Reeves UK

Wendy Reid UK

Jim Rennie UK

Lewis Ritchie UK

Chris Salisbury UK

Beverley Schweitzer South Africa

Judith Searle UK

Janet Seggie South Africa

John Shatzer USA

Frank Smith UK

Stephen Smith USA

Rita Sood India

Nigel Stott UK

Ray B Sutton UK

Mark Swartz USA

Peter Tutton Australia

Zephne van der Spuy South Africa

J P van Niekerk South Africa

Marta van Zanten USA

Tim van Zwanenberg UK

Susan Ward UK

Val Wass UK

Michael Watson UK

Rodney Wellard Australia

Sue Whittle UK

David Wiegman USA

Lindon Wing Australia

Thomas Wolf USA

Rob Wrate UK

Sherry Wulff USA



Reports of new ideas in medical education

Teaching of forensic medicine in the under-graduate curriculum in Sri Lanka: bridging thegap between theory and practice

Nilukshi L Abeyasinghe

Context and setting In 1995 the undergraduate

medical curriculum at the Faculty of Medicine in

Colombo underwent a change in focus, the objective of

which was to foster a student-oriented learning ap-

proach rather than a lecturer-oriented teaching ap-

proach. Accordingly, the teaching of forensic medicine

changed from 60 hours of lectures distributed over

1 year to an intensive month-long module consisting of

50 hours of medico-legal training.

Why the change was necessary According to exist-

ing law in Sri Lanka, any medical officer can be called

upon to perform medico-legal work, which includes

performing autopsies and clinical examinations of

victims of injury. This can take place as early as 2 years

after qualifying as a doctor. The only previous exposure

to such work a doctor might have had was as a fourth

year medical student. The formal lectures and the

2-week clinical attachment of the traditional method of

training were primarily teacher-oriented and based on

demonstrations of clinical work which did not provide

students with practical experience. The shortcomings

of this approach were reflected in the dissatisfaction

expressed by lawyers at the quality of medico-legal

reports submitted to court by medical officers. The new

curriculum seeks to bring as much practical experience

as possible into the training.

What was done A new module was designed to

include student-centred methods of teaching. These

included slide demonstrations of injuries, video dem-

onstrations of dissection techniques and fixed learning

modules illustrating core knowledge, case reports,

journal articles, the law and other relevant literature.

Students were given practical forensic problems to

discuss in groups. They were expected to formulate

the questions necessary to solve the problem in hand, to

seek additional information on the subject, and to

present their findings a week later. A role-play session

where students enacted the investigation of a crime

scene of a murder, the postmortem examination and the

subsequent court trial helped to focus on what facts and

opinions might be expected of them when giving both

written and oral evidence in court. Students were

evaluated by a written and multiple choice examination.

With this comprehensive background knowledge,

students underwent a 2-week practical appointment in

small groups. They took histories and examined victims

of injury in hospital wards. They completed copies of all

the relevant medico-legal documents as forensic doctors

would do. During their autopsy training, students per-

formed autopsies under supervision, observed different

autopsy techniques, and reported on natural, accidental,

suicidal and homicidal deaths using copies of the relevant

medico-legal documents. All reports were corrected and

handed back to the students. They were later evaluated

with a practical examination and a viva on their reports.

Impact The impact of these methods on the students

was tremendous. They were able to describe and record

injuries, and formulate relevant opinions in the manner

expected in court. Using similar medico-legal docu-

ments was a useful way of enabling students to gain first-

hand experience of report writing for a court situation.

How effective these changes have been will be reflected

and could be evaluated by improvements in the quality

of the medico-legal documents submitted to court.

Correspondence: Dr Nilukshi L Abeyasinghe, Senior Lecturer, De-

partment of Forensic Medicine, Faculty of Medicine, Kynsey Road,

Colombo 8, Sri Lanka

Teaching teamwork to medical students:goals, roles and power

Tim J Wilkinson

Context and setting The programme was aimed at

Year 4 medical students during a clinical attachment in

geriatric medicine.

Really Good Stuff

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1084–1110 1089

Why the idea was necessary Doctors need to be

collaborative team workers. Interprofessional education

and small group learning are responses to this need.

Some medical students find small group interactive

learning difficult. Ingrained competitive behaviours can

disrupt the learning of other group members. An attempt

to provide formal teaching on group work was not

perceived to be relevant. An attempt to promote inter-

disciplinary collaboration by having novice professionals

of one discipline learn alongside novices from another

was also unsuccessful in helping them understand each

other’s roles. We were concerned that ingrained stereo-

types might be reinforced if roles were unclear.

What is done We use medical students’ own experiences

of group work and their desire to learn about individual

patients to stimulate them to understand both interdisci-

plinary co-operation and collaborative learning. During a

clinical attachment in geriatric medicine, students learn

about the role of another health professional by accom-

panying their patient to treatment sessions. The student

discusses the goals the experienced practitioner shares

with the patient and the techniques they use to achieve

this. Students also observe and contribute to team

meetings and family goal setting meetings.

In a separate session, we draw on the students’ own

experiences of group work, co-operative learning and

their observations of teamwork within clinical teams.

This reflection and debriefing is then followed by a

theoretical session covering the definition and setting of

goals, the importance of understanding roles, and how

power is expressed within groups. We link teamwork in

a clinical setting with group work in a learning setting

by focusing on how:

• the value of clarifying treatment goals for patients

parallels clarifying of learning goals within a group of

students;

• different disciplines have different roles and strengths

that can be used to help patients; different students

within a group also have different strengths that can

be exploited to help each other learn;

• health professionals may have little choice regarding

the clinical team into which they are placed; similarly

medical students have little choice of which student

group they are placed in;

• understanding roles, how power is expressed and the

importance of setting common goals helps enhance

cohesion within such groups.

Evaluation of results The students apply their new

understanding by documenting the input of another

health professional into the management of their

patient. This shows how the professional’s role and

strengths benefit the patient’s care. We have found

that novice practitioners are less certain of their

roles than experienced practitioners. Consequently we

have found our medical students’ learning is more

effective when gained from experienced practitioners.

We were initially concerned that the practitioners

themselves might find this exercise a burden but

they also have found it valuable. This partly relates to

the �reversal of power� that comes about through

having other health professionals teach �doctors�.An experiential learning cycle and the �carrot� of

learning about patient care have contributed to a simple

and easily transferable method of introducing the more

difficult concepts of teamwork and collaborative

learning.

Correspondence: Associate Professor T J Wilkinson, Christchurch

School of Medicine and Health Sciences, c⁄o Princess Margaret

Hospital, PO Box 800, Christchurch, New Zealand

Self-directed learning during community-based placements

Sharon Reid & Tim Usherwood

The context and the setting In the final year of the

4-year graduate-entry medical programme at the

University of Sydney, students undertake a 9-week

term in community practice. Four of these weeks are

spent on placement in an urban general practice, and 4

in a rural practice.

Why the idea or change was necessary While clin-

ical placements offer invaluable clinical exposure, the

experience gained does vary from placement to place-

ment. To complement this varied experiential curricu-

lum, a core curriculum was defined which reflects the

learning that all students are expected to achieve. One

of the strategies for ensuring coverage of the core cur-

riculum is the Self Directed Learning Problems (SDLPs).

What was done The SDLPs comprise a pack of 50

general practice case vignettes. Each vignette is

followed by four assessment questions; at least one of

these addresses a topic from the core curriculum.

Students are given the pack at the beginning of the term

and are allocated 5 of the SDLPs to work through

during each 4-week placement (i.e. each student is

allocated a total of 10 during the term). Allocations are

made so that most or all of the SDLPs have been

allocated. Students are required to prepare answers to

all four questions associated with each of their allocated



SDLPs, and are encouraged to work beyond their

allocated set. After the completion of each placement

students attend a workshop where they are randomly

allocated one of their five SDLPs to present. The

presentation is then discussed within the workshop, and

is assessed against defined criteria.

Evaluation of the results or impact The SDLPs are

intended to ensure coverage of the core curriculum

through individual work and group learning in the

workshops. Two successive terms (66 students) have

been evaluated. Of 132 student questionnaires (com-

pleted after each SDLP workshop), 110 (83%) were

returned. Respondents spent a mean of 14.4 hours in

preparation; 18 (16%) prepared more than their allo-

cated SDLPs. Journals and supervisors were the most

highly ranked information resources. Students were

more likely to have difficulty in accessing information

during their rural placement (X2 ¼ 12.2 p<0.001).

When asked about useful aspects of the SDLPs,

respondents identified: focused learning; steady ongo-

ing study; talking to supervisors; and, ‘‘that we had to

do them’’. When asked about useful aspects of the

workshops, responses included: opportunity to get

feedback; comparing notes with other students; hearing

answers from other students; and, hearing other

perspectives on clinical problems.

Negative aspects identified by students included:

time consuming; detracted from the placement experi-

ence; difficulties in accessing information during rural

placements; and, topic coverage in the workshops

sometimes superficial. Student suggestions included:

more consistent level of difficulty; and, more time for

group discussion.

Tutors also reported their experience of the

workshops. Comments included: wide range of

topics covered; more enjoyable than marking essays;

discussion around issues that students couldn’t

determine for themselves; and, more discussion time

needed.

Correspondence: Sharon Reid, 37A Booth St, Balmain NSW 2041,

Australia

Voluntary student research groups inbiochemical education

H Hakan Aydin, Handan AK Celik & Biltan Ersoz

Context and setting Medical biochemistry provides

the medical student with insight into the principles of

basic science as well as the methods of scientific research.

The acquisition of relevant factual information in

medical biochemistry and the skills gained in practicals

are useful in the continuing phases of the student’s

education and during his or her future medical career.

Rationale Having noted the interest of first phase

medical students in scientific investigation, it was deci-

ded that, despite limited theoretical knowledge, students

should be given the opportunity to join voluntary

scientific research groups. These groups, formed in the

early days of medical education, were expected to

stimulate the students’ active participation in scientific

research and to provide motivation that would facilitate

the process of learning in biochemistry and other basic

sciences as well as in medical education as a whole.

What was done A voluntary student research group

(VSRG), made up of first year medical students, was

founded in the Department of Biochemistry. Of 269

freshmen, 19 applied to join the VSRG. Meetings were

scheduled not more than once or twice per week in

consideration of the dates of the students’ examinations.

It was clearly stated that the goal was neither to reinforce

nor review former biochemical knowledge, but to involve

students in biochemical studies, offering them the

chance to discover essential biochemical facts and basic

scientific methods relevant to future research projects.

Group meetings included interactive discussion of

selected topics as follows:

• accessing information sources;

• steps in preparing a scientific essay;

• assembling scientific research and forming hypothe-

ses;

• the demonstration of basic analytical methods and

their principles, and

• some fundamental information related to the main

research topics of the department.

As interactive learning was an objective of the

project, small groups of two or three students were

formed. These groups investigated and made presen-

tations related to the activities. Following their presen-

tation, group members evaluated their own

presentation and commented on their work.

Evaluation of impact At the end of the first year, all

members of the group were noted to have progressed in

terms of their active participation and accomplishment

during the activities carried out by the group. Further-

more, self-confidence improved in all members. It was

observed that this progress had an independent positive

effect on the students’ academic achievement in first phase

medical education,particularly in relation tobiochemistry.

In the light of these outcomes, our department

considers that VSRGs formed at the beginning of the



medical education experience will lead us to discover

enthusiastic students earlier. Although lack of basic

theoretical knowledge represents an important limitation

at the beginning, motivating students to participate in

scientific activities will be advantageous to their progress

in both curricular and extra-curricular activities.

The activities of VSRGs will continue in coming

years. Trained group members will have the opportun-

ity to participate in different research projects in our

department. We hope that the process will facilitate

students’ development into inspired scientists and⁄or

well-trained doctors.

Correspondence: Dr H Hakan Aydin, Ege University School of Medi-

cine, Department of Biochemistry, Bornova, 35100 Izmir, Turkey

A special study module in hospitalmanagement

Caroline Boggis & Caroline Davidson

Context and setting Learning to manage patient care

is fundamental to undergraduate medical education.

After graduation, pre-registration house officers prac-

tise medicine within the context of managed organisa-

tions. Doctors are increasingly encouraged to

participate in unit, hospital and general practice

management, necessitating the learning of the theories

and skills underpinning management. In its document

�Tomorrow�s Doctors’, the General Medical Council

(GMC) proposes that special study modules (SSMs)

should be made available for students to study areas of

interest in depth. The GMC also suggests that these

SSMs should cover a wide range of topics.

The idea In 2001 we devised and introduced a 3-week

SSM in hospital management, open to Year 4 student

doctors in South Manchester University Hospitals NHS

Trust. The module’s format offers students learning

opportunities in three main themes, namely strategic,

operational and facilities management. The students are

incorporated into the management team, contribute to

its activities, and are expected to undertake specific

work-related projects in addition to shadowing manag-

ers in various disciplines and at different levels.

The SSM’s objectives are:

• to facilitate understanding of NHS management

structure;

• to facilitate understanding of the different types of

managers employed in an acute NHS trust and their

roles;

• to provide a means of gaining insight into the day to

day clinical management of a hospital;

• to show how managers operate through the organ-

isation’s committee structure.

Students are required to submit a final report of

2000 words for the medical programme assessment.

This is marked by the supervisor and a second

marker.

Impact Two students have taken up SSMs in hospital

management since this learning opportunity was initi-

ated. The feedback they have given through our

standard web-based evaluation of teaching has been

generally positive, with the students rating the meeting

of their objectives for the SSM at 4Æ5 on a 5-point

Likert scale. The two students also gave this SSM an

overall rating of 5, representing a maximum score. Both

these evaluation scores exceed those for all other SSM

topics. The free text comments from the individual

students indicate that the module’s impact on them has

been to increase their understanding of the frameworks

within which managers operate. The students have had

a reciprocal impact on the hospital managers, who have

commented on their �ingenuity�, �self direction�, and

�competence�. The students’ SSM reports have contribu-

ted to the working activities of the management team

and have been used in management decisions. Both

reports were graded to Honours standard, as were the

students’ attendance and working practices.

Interprofessional learning introduced at an early

stage in a programme may be the education activity

most likely to challenge the development of stereotypes.

The SSM in hospital management has the potential to

do this, in that it can challenge students’ views of

managers and management’s view of future doctors.

Managers have been enthused by this SSM and

propose to increase their intake from one to two

students for each SSM opportunity.

Correspondence: Caroline R M Boggis MBBS FRCR, Hospital Dean

for Clinical Studies, Undergraduate Medical Education, 1st Floor,

Education & Research Centre, Wythenshawe Hospital, Southmoor

Road, Wythenshawe, Manchester M23 9LT, UK

Developing communication skills for pharma-cist-led clinics

Sally Johnson, Elizabeth Hughes & Rowena White

Context and setting A training day was organised in

Cardiff by the Welsh School of Pharmacy and the

Communication Skills Unit of the Department of



General Practice, University of Wales College of

Medicine. The day aimed to develop the communica-

tion skills of experienced pharmacists involved in

pharmacist-led clinics.

The role of the pharmacist has changed radically over

the past 10 years. Increasingly, pharmacists run special-

ist clinics in areas such as anticoagulation and cardiac

rehabilitation, where they conduct one-to-one consul-

tations with patients. The benefit of good communica-

tion skills to improve consultation outcome in doctor–

patient consultations is well known, but there has been

less research on the importance of communication skills

in pharmacist–patient interactions. It is known, how-

ever, that patients are more likely to take prescribed

medication when the doctor or pharmacist has spent

time sharing information and management options. It

would seem logical, therefore, that pharmacists should

be offered training in communication skills similar to

that given to doctors. Some basic communication skills

training has now been introduced for undergraduate

pharmacists in Cardiff but this does not involve the use

of videos. There is little or no communication skills

training available for postgraduate pharmacists who are

setting up and running specialist clinics in Wales.

What was done Fourteen pharmacists from across

Wales attended a 1-day training programme using

simulated consultations. The day started with a brief

interactive session discussing core communication skills

and the challenges that pharmacists encounter in their

clinics. The group reviewed a prepared video of a role-

play of an anticoagulation clinic and explored the areas

where poor communication affected consultation out-

come.

Each pharmacist was then video recorded in a consul-

tation with a simulated patient (SP). The SPs were

played by trained actors. The scenarios were designed to

offer the typical challenges that pharmacists encounter

on a day-to-day basis. Each video was discussed in a small

group, allowing for feedback from peers, the facilitator

and the actor. The pharmacists took their videos home

and were encouraged to reflect on them and to consider

using video recordings of themselves and their colleagues

in future clinics as a training tool.

Evaluation Verbal feedback and written evaluation

forms showed that the pharmacists had enjoyed the day

and found it helpful. All the participants felt they would

communicate better with patients afterwards and 85%

felt that reflecting on their communication skills had

been useful. There was a strong call for further training

of this nature.

The use of simulated consultations to improve com-

munication skills is established in the undergraduate

curriculum for medical students and is increasingly used

for postgraduate doctors and specialist nurses. Extend-

ing the training to postgraduate pharmacists who run

clinics seems to be a logical step. The pilot training day

was deemed a success by both participants and organ-

isers and it is hoped that communication skills training

using simulated consultations will be available to all

postgraduate pharmacists in Wales in the near future.

Correspondence: Dr Sally Johnson, Associate Academic General Prac-

titioner, Communication Skills Unit, Department of General Practice,

University of Wales College of Medicine, Llanedeyrn Health Centre,

Cardiff CF23 9PN, UK

Taking the skills lab onto the wards

R L Kneebone, D Nestel & A Darzi

Context and setting Health care professionals must

combine technical with communication skills when

carrying out ward-based or outpatient procedures on

patients. Although indivisible in real life, these compo-

nents of safe, patient-centred practice are often taught

separately. We have developed a scenario-based

approach to training and assessment in which students

practise technical and communication skills in clinical

scenarios using tissue models connected to simulated

patients (SPs). These scenarios create a safe yet

convincing illusion of reality, allowing students to carry

out practical procedures, such as urinary catheterisation

and wound closure, while interacting with the �patient�.These scenarios currently take place in our commu-

nication skills training suite, which is equipped with

ceiling-mounted video recording equipment. Expert

tutors watch and assess each procedure from an

adjoining room; afterwards they and the �patient�provide structured feedback. Each student then reviews

his or her recorded performance at this time of

�readiness to learn�. We developed a model for assess-

ment and feedback, using a combination of checklist

and global rating scales. Our observation and interview-

based studies with 71 undergraduate medical students

and nurses have provided strong preliminary support

for the effectiveness of this concept.

Why the change was necessary Although scenario-

based teaching can provide a powerful learning experi-

ence, it takes place outside the context in which students

will eventually use their skills. Evaluation suggested that

learning would be enhanced by safe zones that use SPs

within real clinical settings. An obvious step is to arrange

scenarios within actual hospital wards, so that students

are challenged by as many real-life cues as possible.



However, our current set-up precludes this by requiring

static studio recording facilities.

What was done A move from skills lab to ward

requires inconspicuous, easily transportable equipment

that can provide high quality, easily stored digital

recordings. In addition, students must be able to review

their performance immediately after completing it,

preferably without having to change location. A port-

able consultation recording device (the Virtual Chap-

erone) has recently been developed at Imperial College,

London. A miniature video camera is fixed to a discreet

free-standing mount resembling a drip stand and sited

just beyond the bed screens. The camera records a

digital audiovisual output directly onto disc within a

small computer.

The procedure can be watched on screen in real-time

by observers and simultaneously recorded, then played

back on a dedicated laptop computer in any available

room, using headphones to avoid disturbing or being

disturbed by others. By eliminating the need for

specialized viewing facilities, the entire process is self-

contained and can take place independently of a skills

lab. Learners can review their performance again at a

later date, using any available PC.

Evaluation of results Preliminary evaluation of the

concept with medical students has shown it to be

technically feasible. A formal evaluation programme is

currently under way, using a qualitative methodology

(observation of scenario performances, group inter-

views with all participants and analysis of transcripts

using standard qualitative techniques). The study

design examines medical students on general surgery

and obstetrical rotations and covers a range of clinical

procedures.

Correspondence: R L Kneebone, Department of Surgical Oncology and

Technology, Imperial College School of Medicine, 10th Floor QEQM

Wing, St Mary’s Hospital Campus, Praed Street, London W2 1NY, UK

Evaluating a teaching skills workshop formedical students

Debra Nestel & Jane Kidd

Context and setting Alternative ways of delivering

the most labour intensive session in the first year

communication course at Imperial College were neces-

sary. Given their recent experiences of both the course

and clinical attachments, third year students were in a

unique position to support their first year colleagues in

the acquisition of patient-centred interviewing skills.

Studies on the preparation of students for work as peer

tutors are notably absent in the literature. This paper

describes the evaluation of a workshop designed to

prepare students for this role.

Why the idea was necessary As students assume the

roles of co-tutors, they should be offered at least the same

level of support provided to faculty. In addition to

knowledge of patient-centred interviewing, fundamental

to teaching communication is the ability to observe, listen

and give feedback in a positive and constructive manner.

What was done Groups of up to 10 third year

students worked with facilitators and simulated patients

in a 3-hour workshop. Students set their own learning

objectives over and above those outlined by the

facilitators. Strategies for learning included brainstorm-

ing, discussion, reflection, role-play, videotape replay,

lecture attendance and use of a manual. Students

completed written evaluations before and after the

workshop and after co-tutoring.

Evaluation of results A total of 28 students attended

the workshops. Before the workshops they recorded

feelings of curiosity, excitement and enthusiasm. Perso-

nal expectations included improving their own commu-

nication (n ¼ 13; 46%), teaching (n ¼ 6; 21%) and

facilitation skills (n ¼ 3; 11%), an opportunity to meet

other medical students (n ¼ 3; 11%) and supporting

their preparation for examinations (n ¼ 2; 7%).

Immediately after the workshop, 20 students (71%)

reported that the workshop met their personal

expectations. Students reported rates of success in

meeting the learning objectives as follows: describe

different learning styles (n ¼ 14; 50%); experience

facilitating small groups (n ¼ 21; 75%); reflect on

own strengths (n ¼ 19; 68%) and weaknesses in

facilitating (n ¼ 19; 68%); describe patient-centred

interviewing skills for opening (n ¼ 17; 61%), exploring

(n ¼ 9; 32%) and closing (n ¼ 11; 39%); practise

patient-centred interviewing skills for opening

(n ¼ 15; 54%), exploring (n ¼ 7; 25%) and closing

(n ¼ 7; 25%); giving feedback (n ¼ 20; 74%); receiving

feedback (n ¼ 18; 64%), and describing the structure of

the first year session (n ¼ 19; 68%).

Students rated the practical exercises that simulated

the sessions they would be tutoring as the most useful

activity (n ¼ 20; 71%). The opportunity to reflect on

effective teaching and learning experiences was also

valued (n ¼ 19; 70%). Eighteen students (67%) rated

the other practical exercises on feedback and conduct-

ing interviews as effective while the learning styles

�lecture� was rated as effective by nine students (32%).

Suggestions for improving the workshop were made by

21 students (75%). These included increasing its

length, having longer interviews, running a second



session, reiterating the role of students, providing more

information on how to receive feedback, providing

more background on the course, placing greater

emphasis on group dynamics and scheduling the

workshop for the weekend. After co-tutoring, students

reinforced these ideas with additional suggestions that

co-tutors be identified in the workshop and that the

workshop be scheduled closer to teaching sessions.

Although the workshop was successful, this in part

was dependent on the participants’ high levels of

motivation and baseline knowledge.

Correspondence: Dr Debra Nestel, Lecturer in Communications Skills,

Faculty of Medicine, Imperial College London, Paterson Centre,

Room 405, 20 South Wharf Road, London W2 1PD, UK

The influence of self-deceptionand impression management on surgeons’self-assessment scores

A W Evans, R M A Leeson & T R O Newton-John

Context and setting The introduction of lifelong

learning, annual appraisal and revalidation means there

is an increasing need for doctors to be able to self-

assess. However, self-assessment skills are rarely inclu-

ded in undergraduate or postgraduate curricula. In a

previous study, we found that trainees in oral and

maxillofacial surgery over-marked themselves when

assessing their surgical skills.

Why the idea was necessary Various factors have

been suggested to account for inaccuracy in self-

assessment. These include not knowing what was

expected, scoring potential rather than actual perform-

ance, self-deception or overconfidence, and impression

management (a conscious attempt to present a more

favourable self-impression). We aimed to ascertain

whether self-deception or impression management

influenced the way these trainees self-assessed.

What was done Our study tested for a correlation

between scores for self-deception (SDE) and impres-

sion management (IM), and the difference between

trainees’ and trainers’ assessment of surgical perform-

ance. Trainees removing lower third molar teeth were

assessed (by two assessors) using an objective checklist

and a global rating scale. The trainees, who had no

previous experience of self-assessment, then scored

themselves using the same scale. No feedback was given

at this stage. The differences between the scores of

trainees and trainers were correlated with a validated

questionnaire completed postoperatively. This ques-

tionnaire tests for self-deception (overconfidence) and

impression management.

Evaluation of results In a pilot study of 25 trainees,

the majority (76%) gave themselves higher scores than

the average scores given by their trainers. Analysis

of variance shows evidence of a difference between

trainers and trainees marks (checklist score P < 0Æ05;

global rating score P < 0Æ05). There was significant

correlation between the checklist and global rating

scores using Pearson’s correlation coefficient (0Æ84,

P < 0Æ001). However, there was no correlation between

either SDE or IM scores and ability to self-assess. This

may be because of the small numbers involved and a

larger study is now in progress. What was of interest

was the number of high IM scores obtained by a large

number of trainees. In this study, 20 of the 25 trainees

scored in the high to very high IM range, suggesting

pervasive attempts to �fake good�.High SDE scores, on the other hand, indicate

overconfidence in the context of poor insight. Eight

trainees had above average scores for SDE and two of

these were very high. Thus it appears that trainee

surgeons are more likely to respond in a manner that is

intentionally socially desirable than to display gross

overconfidence. Nevertheless, the data do show that the

vast majority of trainees feel pressurised to represent

themselves in the best possible light.

What is of concern is whether this pressure to

impress will affect a trainee’s judgement of when they

should seek help and advice. Regular training in self-

assessment in a supportive atmosphere should help to

reduce these pressures and enable more accurate self-

assessments to be made. We plan to introduce self-

assessment with feedback using a portfolio. The use of

self-assessment in more threatening environments (e.g.

annual appraisal) may have to be treated with caution.

Acknowledgements AW Evans is supported by The

PPP Foundation.

Correspondence: A W Evans, Department of Oral and Maxillofacial

Surgery, Eastman Dental Institute for Oral Health Care Sciences,

University College London, 256 Grays Inn Road, London WC1X

8LD, UK

‘Whose life is it anyway?’ An innovativecourse on mental health issues

Mary Seabrook & Annalee Curran

Context and setting The course is offered as a special

study module (SSM), an elective course in the new



curriculum at Guy’s, King’s & St Thomas’ School of

Medicine. It is available in Year 3 and may be taken

before, during or after the main psychiatric course

organized by the Institute of Psychiatry, London.

Why the idea was necessary It was felt that students

should recognise that �mental illness� is a contested

concept and be aware of differing perspectives on its

causes and approaches to care. Ultimately patients may

benefit from students thinking more critically about the

nature of psychiatric services and their own role, and

learning to hear patients’ voices more effectively.

What was done The SSM was developed around an

Open University course (K257: Mental Health and

Distress: Perspectives and Practice). It runs for 1 day

per week over 12 weeks, comprising 8 days on the

distance learning materials (including workbooks, a

reader, an anthology of patients’ writings and audio

tapes) and 4 days of group work (with up to 8 students)

spaced throughout the course. It is tutored by a

psychotherapist working in general practice, and a

medical educationalist. The first workshop encourages

students to engage with the material primarily as people

and secondarily as professionals. The potential emo-

tional impact on students is acknowledged, together

with the possibility that students may experience

mental health problems at the time or in the future

(several have self-disclosed during the course). The

second workshop is run by a trainer from the psychi-

atric service users’ network, who uses a variety of

experiential exercises to help students see things from

the user’s perspective. The third workshop involves two

or more mental health professionals (a counsellor and

GP, sometimes with a psychiatrist). Through the use of

case scenarios, they model an approach that seeks to see

the person inside the patient. In the fourth session,

students present to the tutors and each other on topics

relating to ethics and service provision. They are

encouraged to be innovative and to include their own

views. The course is assessed by these presentations

(30%), an essay (60%) and contribution to the group

work (10%).

Evaluation of impact To date over 40 students have

taken the course, all of whom have passed except for 2

who did not complete the course for personal reasons. All

students completed feedback forms and contributed to

evaluation discussions. The main outcomes reported

were: gaining a better understanding of users’ perspec-

tives, making students question and criticize their own

views of psychiatry and psychiatric patients, and opening

their eyes to new issues. Hearing directly from a service

user had a powerful impact on students’ attitudes,

challenging their stereotypes and preconceptions, and

making them reconsider how they should relate to

patients. Students generally enjoyed using distance

learning materials that they can study in their own time

and at their own pace. Many students perceived the

course as �antipsychiatry� and had to address the conflict

this created with their learning on the psychiatry course.

The course tutors found that some students had diffi-

culty in viewing issues from a non-medical perspective

and working with conceptually rather than factually

based material. Running the course has highlighted the

challenges of how best to stimulate attitudinal change

and incorporate patients’ perspectives.

Correspondence: Mary Seabrook, Senior Lecturer, Department of

Medical & Dental Education, Guy’s, King’s & St Thomas’ School of

Medicine, Sherman Education Centre, 4th Floor, Thomas Guy

House, Guy’s Hospital, London SE1 5RT, UK

The ethics of teamwork in an interprofessionalundergraduate setting

Philip Cotton, Pat Smith & Margaret Lait

Context and setting At Glasgow University, the

problem-based learning medical curriculum is comple-

mented in Years 1 and 2 by Vocational Studies, which

covers themes such as �working with others� and �the right

thing to do� (ethics). Ethics forms a theme in the nursing

curriculum in Years 1 and 4. Groups of final year nursing

and medical students, all of whom are on clinical

attachments, meet together for a half-day session.

Why the idea was necessary Encouragement by the

General Medical Council (GMC) and a change of

culture within the National Health Service (NHS) have

resulted in increasing recognition of the value of

interprofessional education.

It is recognised that ethics education needs to

continue throughout undergraduate medical training

and that it should place increasing focus on real life

clinical dilemmas and examples in order to prevent

deterioration in ethical reasoning among students.

Students entering different health professions have

few opportunities to work together to address the

ethical issues located around teamwork. Risk manage-

ment provides an ideal topic through which to consider

the roles of other professionals within health teams and

to develop mutual respect for expertise and recognition

of the value of supporting colleagues. This also has

relevance to continuing professional development.

What was done The Department of General Practice

and the Department of Nursing (both at the University

of Glasgow) identified �the ethics of teamwork� as a



theme for the interprofessional session. Its topic

comprised significant event analysis. On average, 24

medical students and seven nursing students partici-

pate in each session. A presentation outlines the

definition and theory of risk and significant event

analysis. Students suggest events from their own

clinical experience and two of these events are then

analysed. Students identify issues that arise from the

chosen scenario alone before �snowballing� into pairs,

fours and ultimately into groups of around eight,

generating more ideas as they go. Mixed groups of

eight students produce learning points for the health

care team and suggest changes that should be made to

current practice to minimise risk and to prevent

recurrence. The groups give feedback at a plenary

session when issues of team working are discussed.

Supporting documentation is distributed.

Evaluation of results The scenarios have included

�failure to resuscitate in general practice�, �foot ulcers

caused by inappropriate treatment�, and �a postopera-

tive patient re-admitted to a different hospital who

subsequently died as a result of poor management�.Successes and �near misses� were discussed but not

selected for analysis by the students.

The students stressed that updating training (e.g. in

life support) for clinicians and initiating training for

nonclinical members of staff was essential, as was

reducing complexity and using coding systems to

standardise locations of vital equipment. Furthermore,

low staffing levels were described as �errors waiting to

happen�, and were seen as contributing to events that

were often not the fault of individuals. Students also felt

that responsibility fell to the team as a whole.

The students completed an evaluation form after the

session. Free text comments noted that the session had

made them consider �personal prejudice� and the

�overlapping of roles�, and issues such as �how junior

doctors work with experienced senior nurses�.

Correspondence: Philip Cotton, Department of General Practice, Uni-

versity of Glasgow, 4 Lancaster Crescent, Glasgow G12 0RR, UK

Standardised audio-visual equipment to sup-port the corporate identity of an integratedcurriculum

Richard Marz

Context and setting The University of Vienna Med-

ical School is changing its curricular focus from a

discipline-based approach to one of integrated blocks

using the organ⁄systems approach complemented with

lines focusing on clinical reasoning and skills. The

institution is unique in terms of its size: entering classes

number around 1500 students while faculty members

employed by the school itself combined with additional

external personnel amount to roughly 1800 staff.

Why the change was necessary In the discipline-

based approach, not only the content but also the

delivery aspects of the curriculum were the responsi-

bility of departments whose boundaries extended to the

point where individual units had ownership of class-

rooms; a centralised approach is now in order on all

levels. One of the difficulties involved in this concerns

the fact that professors now teach in unfamiliar lecture

halls, which �belong� to different units. Sophisticated

equipment is sometimes available, but only the depart-

ment’s technical guru is able to operate it. On many

occasions, vital pieces of equipment turn out to have

been �borrowed� and are unavailable at short notice.

The new curriculum relies heavily on lecturing.

During the first year, students are split into 4 tracks

taught in parallel; small group exercises involve many

more teachers. To achieve some degree of standardisa-

tion, the use of electronic media is emphasised both for

didactic teaching and as a learning resource.

What was done Funds were made available to equip

large and small lecture rooms. A meeting of depart-

mental heads, chaired by the dean, agreed to standard-

ise the audio-visual equipment used in all teaching

venues. Funding for ongoing projects was stopped and

a committee was established to define a standard

installation.

Guiding principles emerged as follows. The user

interface and a core set of functions are identical in all

venues; thus a lecturer who has learned to use the

equipment in one room is able to operate all other set-

ups without additional training. All equipment is

installed in such a way that it cannot be easily removed.

Projectors are suspended from the ceiling and all other

equipment is securely housed in cabinets. Identical

locks give trained teachers access to the equipment in

all rooms.

The minimum hardware consists of a powerful

projector that can be used without completely darken-

ing the room, a computer with floppy disk and

CD⁄DVD-ROM drives as well as Internet access, a

video recorder for PAL and NTSC, speakers, and VGA

and RGB in-jacks for plugging in lap-tops and other

devices.

Software installed includes two browsers and the

Microsoft Office suite; updates will be made each

summer. While users can install additional software,

rebooting from a protected partition returns the system



to its original installation. A central unit is responsible

for maintenance, relieving individual departments of

this responsibility.

Evaluation of impact The 10 rooms that were

equipped in 2001 were considered such a success that

at least 10 more will be similarly equipped during 2002.

Not only are the lecture rooms functional, but they

have come to represent the institution’s public com-

mitment to its new curriculum. In line with this change

in attitude, serious discussions are underway concern-

ing changing the locks on the lecture rooms so that

rather than allowing departmental access only, each

room will be accessed with the same keys used for the

audio-visual cabinets.

Correspondence: Richard Marz, Institute of Medical Chemistry, Uni-

versity of Vienna, Wahringerstrasse 10, A-1090 Vienna, Austria

Current forms of psychotherapy: teachingtheir history, concept and application

Thomas Muller & Claudia Becker-Witt

Context and setting A problem-based curriculum was

started in 1999 at Charite University Clinic (Humboldt

University, Berlin). The curriculum, focused on pro-

blem-based learning, provides up-to-date medical

education in a 6-year programme to 63 students en-

rolling each year. Subjects related to the humanities,

e.g. history of medicine, are considered of equal value

to clinical issues and therefore are taught in obligatory

courses during Charite’s second track. Students choose

from a pool of seminary themes. Comparisons in

teaching from curricula abroad cannot be drawn, as

these often lack core curriculum units in disciplines like

the history of medicine.

Why the idea or change was necessary Many

medical doctors lack knowledge about psychotherapy,

its history, concepts and methods of therapeutic ap-

plication. Various kinds of psychotherapy, however, are

used by many patients and a large percentage of re-

sources is spent on this branch of health services. Thus,

we concluded that an interdisciplinary seminar could

create expertise among future physicians in applying

appropriate psychotherapeutic treatment, as well as

raising awareness of medical⁄cultural history.

What was done A medical historian and a colleague

with a background in social medicine offered this

seminar on the history and current state of development

of psychotherapy, its application and status in respect

to the insurance system, and its standards of education.

A 2-step introduction was offered through lectures

imparting the general history of psychotherapy in the

20th century (1), and the current conditions of the

national health system concerning psychotherapy (2).

During the semester, groups of 3–4 students had to

prepare single seminar units and were asked to intro-

duce one school of psychotherapy to the group in every

second seminar session (90 min). The student presen-

tations were followed by a seminar led by an invited

expert on this special method. The group consisted in

21 first- and second-year undergraduate students who

were assisted in using all kinds of library, Internet or

other resources. Some students interviewed practising

psychotherapists.

Impact and evaluation of the results Seminar topics

covered subjects such as behavioural therapy, art ther-

apy, breathing⁄body therapy, and family therapy. Ad-

ditional topics included psychoanalysis and Gestalt

therapy. We would like to emphasise that this collection

has been compiled arbitrarily. Discussing the history of

different forms of psychotherapy at a German medical

school enables teachers to introduce issues like the

history of medicine and health care, to focus on psy-

chotherapy during National Socialism and to discuss

post-War consequences in this field. Few other disci-

plines, whether compared to the natural sciences or the

humanities, have been as affected by National Social-

ism as psychotherapy. The seminar was evaluated by

participating students using a standardised question-

naire (HILVE), which is well established in the health

sciences⁄psychology in German-speaking countries.

The following parameters were rated above average:

organisation and chosen content of the seminar; the

relationship between theoretical problems and their use

for practical work; the general importance of issues

discussed; stimulation to reflect on issues critically. The

majority reported that this seminar generally augmen-

ted their interest in medicine.

Correspondence: Thomas Muller M.D., Institute for the History of

Medicine, Center for the Humanities and Health Sciences, Berlin,

Klingsorstr. 119, D-12203 Berlin, Germany

A training post in women’s health care for GPregistrars

Adrian Dunbar, Philip Pue & Peter Brunskill

Context and setting Training for UK general practice

has traditionally included a 6-month hospital post in

obstetrics and gynaecology. Many factors have led to



this experience becoming less appropriate for intending

general practitioners (GPs). Changing hospital practice

has increased service pressure at the expense of

educational experience. Midwife-led obstetric care has

diverted routine obstetric experience away from GP

registrars, resulting in declining confidence amongst

young principals and reluctance to provide obstetric

care.

Why the idea was necessary A 6-month period spent

in the surgically-based speciality of obstetrics and

gynaecology covers only a proportion of the curriculum

necessary for women’s health care in modern general

practice.

What was done In 1995 we decided to create a new

training post for GP registrars which would recognise

learning needs across the full spectrum of women’s

health care. A hospital specialist and GP teachers

devised the curriculum. We agreed the post would be

for 1 year. It would be hosted by a practice with

significant obstetric expertise. A good working rela-

tionship between the GP trainer and the consultant

obstetrician was considered essential, as was the

involvement of community midwives.

The registrar was expected to spend half their

working time in the practice and half in the women’s

health directorate at the local hospital.

In addition to surgeries and home visits, the registrar

was expected to attend ante-natal and post-natal clinics

run by the trainer and midwife and to run their own

clinics once they felt sufficiently confident to do so.

They would also participate in the practice’s �Well

Woman� clinics. Tutorials would emphasise women’s

health care. At the hospital, the registrar would

attend gynaecology and ante-natal clinics, selected

theatre sessions and perform limited ward work. They

would participate in the on-call rota and attend

departmental education sessions. Other clinics atten-

ded included family planning, gyno-urinary medicine,

infertility, menopause, colposcopy and ante-natal⁄early

pregnancy assessment; these represent opportunities

not previously available to senior house officers due to

service pressures. Each registrar’s timetable was adap-

ted according to learning needs. An important feature

of the post was the ability to follow patients from

practice to clinic, to theatre and home again.

Evaluation Evaluation was performed by question-

naire on completion of the post and again between 6

and 18 months later. To date, five registrars have

completed the post.

Significant findings fall into four categories. The first

involves organisational issues around the novelty of the

post and the need to establish new relationships with

different teams. The second involves the balance

between education and service, in that the post was

chosen because educational needs determined the

experience and heavy service commitments preventing

learning were avoided. It was clear that the post was

outstandingly successful in this respect.

The third category involves the focus of the post for

which the primary care perspective remains dominant.

Replacing two hospital posts with this year based in a

training practice provides registrars with a total of

2 years of training in the community and 1 year in

hospital, in inverse proportion to the traditional training

scheme.

Fourthly, the educational methods involved in the

year-long post enable registrars to follow a patient from

presentation through to problem resolution. This rep-

resents a powerful learning experience.

All five registrars felt enthused and confident and

expressed continuing interest in and commitment to

women’s health care. They also described their experi-

ences as pleasurable and fun as well as highly relevant

to their future in primary care.

Correspondence: Adrian Dunbar, Associate Director of Postgraduate

General Practice Education, Department of Postgraduate Medical

Education, Willow Terrace Road, University of Leeds, Leeds LS2

9JT, UK

The resident as teacher of medical humanities

Johanna Shapiro, Marni Friedman & Desiree Lie

Context and setting In 1999–2000, two faculty

members decided to offer a course on literature and

medicine to pre-clinical students at a major public

medical school in southern California. A third-year

family medicine resident suggested using her elective

time to participate as a co-instructor. The result was a

spontaneous n ¼ 1 �experiment� in utilising a resident

as teacher of medical humanities.

Why the idea was necessary Residents-as-teachers

programmes have become more common, but the

potential of residents as teachers of medical humanities

has not yet been explored. Still, teaching medical

humanities can provide residents with creative oppor-

tunities to explore issues such as the patient’s experi-

ence of illness and the doctor–patient relationship from

a unique interdisciplinary perspective.

What was done Faculty met weekly with the resi-

dent for a 6-week period of course planning. The

resident was actively involved in the development of

specific learning objectives, choosing appropriate



study materials, developing student study guides, and

designing a course evaluation instrument. The plan-

ning group defined the primary course objective to be

the enhancement of student empathy for patients

through skills of close textual analysis, emotional

connectivity with fictional characters and reflection on

narrative. Topics addressed through poetry, short

stories and drama included difficult patients, cross-

cultural issues, cancer, disability, death and dying.

The resident co-facilitated eight 90-minute sessions

with a small group of medical students (n ¼ 10)

who chose to participate in this elective. She generally

spent 30 minutes after each session reflecting with

faculty co-leaders about the teaching process.

Results Student feedback indicated that participants

found the course valuable and informative. Students

stated they would be very eager to take such a course

again (mean ¼ 5Æ0 on a 1–5 point Likert scale), and

would be likely to recommend it to other students

(mean ¼ 4Æ88). Students also reported that they

increased their empathy for patients (mean ¼ 4Æ25),

improved their ability to listen carefully (mean ¼4Æ25), and developed new ways of understanding the

doctor–patient relationship (mean ¼ 4Æ50). Student

evaluations of the instructors were high and did not

differ between faculty and resident. Students commen-

ted positively on the resident’s contributions.

Faculty members found the resident’s teaching

involvement to be of clear benefit. Her interpretation

of readings was often very different from those of

faculty members, due to her own clinical experiences �inthe trenches�. As a result of this elective, the resident

developed useful teaching skills, including small group

facilitation, a Socratic teaching method, experience in

negotiating with learners, and the ability to focus on

emotional as well as intellectual learner development.

The humanities orientation of the course also allowed

her to convey insights about patients and doctors more

fully and richly than she would have found possible as a

clinical preceptor.

Conclusion Successful implementation of a resident

elective in teaching medical humanities requires a

highly motivated, enthusiastic resident with some

understanding of and interest in the humanistic arts.

It also requires a receptive group of medical students.

Nevertheless, such a programme can be both feasible

and beneficial. We plan to continue to offer this

experience to residents in the future, and to study its

effectiveness on a broader scale.

Correspondence: Johanna Shapiro, PhD, Professor, Department of

Family Medicine, UCI Medical Center, Rte 81, Room 512, 101 City

Drive South, Orange, California 92868–3298, USA

Bringing medical ethics to life: an educationalprogramme using standardised patients

Janet Fleetwood, Dennis Novack & Bryce Templeton

Context and setting Although medical ethics is

taught in the preclinical years in virtually every medical

school, effective reinforcement in the clinical years

remains challenging. Some US schools offer didactic

programmes and ethics rounds during clinical rota-

tions; however, few schools directly observe every

student interacting with patients and provide feedback

about the student’s analysis and communication skills.

Why the idea was necessary Knowledge of clinical

ethics does not necessarily translate into thoughtful

analysis and effective communication with patients or

families about ethical dilemmas. Our goal was to

bridge the gap between classroom instruction and

bedside encounters with patients. Offering students

the opportunity to practise with standardised patients

(SPs) and providing them with feedback was a natural

solution.

What was done We designed an eight-station SP

objective structured clinical exercise (OSCE), in which

SPs present ethical dilemmas in medical practice to

students on a one-to-one basis. Funded by a Culpeper

Foundation grant, we met with several knowledgeable

faculty members interested in medical ethics to develop

cases. The cases involve issues such as confidentiality

and HIV, informed consent, medical futility, advance

care planning, physician-assisted suicide, �do not resus-

citate� orders, disclosure and cultural expectations, and

medical students’ training dilemmas.

There was a close fit between the educational goals of

the ethics cases and several already existent SP

encounters in psychiatry. The psychiatry cases include

recognising and managing depression, alcoholism,

dementia and domestic violence. Thus, during the

required Year 3 psychiatry rotation, every student

encounters four of the eight ethics cases and four cases

in psychiatry, thereby comprising an eight-station

experience.

The encounters occur in our Clinical Education and

Assessment Centre, a 10-room SP facility. After a brief

orientation, students meet with SPs alone, or in pairs or

trios with one learner and silent student observers. Each

student interacts with the SP for 10 minutes, following

instructions found on the door before entering each

room. Clinical ethics faculty members observe via

monitors or 2-way mirrors, enabling faculty to provide

specific feedback later. After students have completed

the 8 stations, they attend a 90-minute debriefing led by

a doctor and an ethicist. Faculty members place



emphasis not only on understanding of ethical concepts

and law, but also on developing communication skills

that are effective in resolving the dilemmas and

personal attitudes and biases that enhance or inhibit

effective communication.

Evaluation In its first 2 years, the programme was

offered to 207 students doing psychiatry rotations at a

single clinical site. Students completed written evalu-

ations immediately after the faculty debriefing. The

average response on a 5-point scale to the statement

�Overall this programme was a valuable educational

experience� was 4Æ3 (5 ¼ strongly agree). We therefore

expanded the programme for all Year 3 students

irrespective of clinical site. Over 1200 students have

completed the series of SP encounters, and the

programme has been exceptionally well received. In

addition, we have created a case guidebook that has

been distributed at cost to over 120 medical schools

internationally. For further evaluation, we are distribu-

ting a survey to our graduating seniors to assess the

impact of the OSCE on students’ subsequent interac-

tions with patients.

Correspondence: Janet Fleetwood, PhD, Drexel University College of

Medicine, Philadelphia, Pennsylvania, USA. E-mail:

[email protected]

Virtual handouts for handheld computers

David Topps

Context and setting Millions of pages of teaching

materials are distributed but we do not know how many

are ever used. This is particularly true in continuing

medical education (CME) activities. Using Power-

Point� for presentations increases the waste of paper

– generated handouts are typically 7–8 pages long

compared to the traditional 2-page handout. There is

evidence that dense teaching material is less effective

than skeleton frameworks designed for annotation.

Handheld computers are increasingly popular with

medical students and doctors and their communication

abilities present interesting opportunities. All dominant

handheld computer types support infrared beaming of

address cards. The presenter can create a workshop

synopsis within the notes section of an address card,

which can then be beamed to participants as a virtual

handout.

Why the idea was necessary Evidence-based medi-

cine requires us to provide more citations and web

addresses, which are complicated to transcribe if not

included in handouts. Beaming takes only seconds and

allows for rapid dissemination throughout large groups,

with exponential doubling at each step. Other advan-

tages are that it saves paper, eliminates transcription

errors for complicated references, encourages present-

ers to distil presentation highlights down to key points,

and is easy to do.

What was done While virtual handouts are simple

and practical, we have found some minor barriers to

implementation. Most presenters adopt this technique

easily but some require more support and information –

we found that placing detailed instructions, templates

and tips on our website circumvented these barriers:

www.pocketprof.org/virtual_handouts.htm. For pre-

senters who want to distribute more complex material,

hyperlinks to web-based presentations can be embed-

ded within the virtual handout. We also found freely

available software that facilitates beaming between

different device types.

Evaluation Early feedback from a convenience sam-

ple of presenters at 3 local conferences and workshops

has been positive, with 9 of 13 presenters (69%) rating

the technique as easy to use and 12 of 13 presenters

(92%) rating it as useful and worth further develop-

ment. At these presentations, 35 of 170 attendees

(21%) had a handheld computer with them. Of these,

100% participated in the virtual handout beaming

sessions. We surveyed virtual handout recipients.

Nineteen (54%) of them responded, with 79% of them

rating virtual handouts as useful. Only 46% of the

survey group reported referring to paper handouts on a

regular basis – even if we don’t increase usage, at least

we save some trees! Like many workshop surveys with

low response rates, our data is limited. However, this

technique provides us with an interesting mechanism

with which to improve this. Address card exchange

can be set up as simultaneously bi-directional. This

allows us to gather addresses from recipients for later

follow-up.

As the adoption of handheld computers increases

beyond 50% of doctors and students, we anticipate that

this technique will become more effective and more

popular. At that point, we plan to evaluate potential

cost savings by discouraging paper handouts, although

it is unlikely that they will be completely replaced.

Poster sessions at conferences can be similarly

enhanced by improved communications between

authors and interested parties. We expect that other

uses will arise as educators become aware of the

potential of this technique.

Correspondence: Dr David Topps, UCMC Sunridge, 3465 26 Ave NE,

Calgary, Alberta T1Y 6L4, Canada



BaFa BaFaTM: a cross-cultural simulationexperience for medical educators and trainees

Bonnie B O’Connor, Randal Rockney & Anthony Alario

Context and setting We discuss presentation of an

interactive, experiential workshop for promoting skills

and attitudes supporting development of clinical

cultural competence. The workshop was presented at

the 2002 annual meeting of the Council on Medical

Student Education in Paediatrics (COMSEP) by 3

facilitators, 2 of whom were paediatricians while the

third was a medical folklorist⁄multiculturalist. This

venue provided a train-the-trainer setting for US

leaders in paediatric medical student education who

were expected to be able to reproduce the educational

experience at their home institutions.

Rationale Cultural sensitivity⁄cultural competence is

an increasingly salient topic in medical education and

practice. Although no consistently agreed definitions

have yet been formulated for these terms, there is

widespread consensus on many of their key elements,

including: self-awareness; ability to empathise with

others; willingness to try to �see through others’ eyes�when differences in values and expectations make

interactions challenging and understanding difficult to

achieve; willingness to negotiate mutually acceptable

solutions, and a capacity to act upon all of these

qualities in formulating workable action plans. Didactic

and case-based teaching sessions can deliver factual

information and help train clinicians’ problem-solving

capacities in cross-cultural situations. However, most of

the identified elements in medical cultural competence

fall into the realm of skills and attitudes – qualities best

promoted through experiential training and the heigh-

tened awareness that personal experience can provide.

For this reason, we used an experiential workshop

simulating cross-cultural interactions between two dis-

tinct cultures as a way of providing an immersion

experience leading to a more nuanced awareness and

understanding of the effects and importance of culture

in identity formation, self-expression, evaluation of self

and others, offering and recognising respect, and many

other culturally-shaped phenomena relevant to experi-

ences of and responses to health, illness and care.

What was done Designed in the mid-1970s as a

training tool for US military service personnel stationed

abroad, the cross-cultural simulation game BaFa Ba-

FaTM (Shirts, 1974; Simulation Training Systems, Inc.,

www.stsintl.com) assigns participants to membership in

one of two fictitious cultures. In separate rooms,

participants and facilitators spend 15–20 minutes learn-

ing the basic values framework and interaction rules in

their new cultures. Following this brief enculturation,

the two groups exchange successive teams of visitors

who interact in their host cultures and subsequently

attempt to describe to their co-culturists their experien-

ces with and interpretations of the �others�. When all

participants have visited one another, the exchange ends

and the groups reunite to discuss and analyse their

experiences and insights. Discussion includes descrip-

tions of each culture by members of the other; explana-

tions of each culture by cultural insiders; analysis of

feelings, evaluations, insights, language usage in

assessing self and other; and applications of lessons

learned to real life behaviour, thought patterns and

interactions.

Evaluation A total of 26 attendees participated in

BaFa BaFaTM at the 2002 COMSEP conference.

Written evaluations (n ¼ 18) were overwhelmingly

favourable, with 15 participants describing the activity

as �excellent�. Other comments noted educational

value (n ¼ 14), fun (n ¼ 5) and ready applicability to

participants’ home settings (n ¼ 3). The BaFa BaFaTM

exercise is a unique and captivating teaching tool that

can be used quite successfully in medical education.

Correspondence: Bonnie B O’Connor PhD, Associate Professor

(Research), Division of Paediatric Ambulatory Medicine, Rhode Island

Hospital, Potter Ste 200, Providence, Rhode Island 02903, USA

Doing it well: demonstrating generalcompetencies for resident education utilisingthe ACGME Toolbox of Assessment Methodsas a guide for implementation of anevaluation plan

D Kay Taylor, James Buterakos & Julie Campe

Context and setting The evaluation of a resident’s

competency to practise has never been clearly defined.

Arguably, this complex construct has long needed to be

more concrete in order to establish and enforce

standards of practice. Recently in the USA, the Accre-

ditation Council for Graduate Medical Education

(ACGME) identified 25 performance indicators in six

general competency areas and mandated that educators

establish a comprehensive assessment plan. Our com-

munity-based teaching hospital (affiliated with the

Michigan State University College of Human Medi-

cine) involves 100 residents in five sponsored pro-

grammes. Programme directors viewed the undertaking

as being extremely labour-intensive without guarantee-

ing a productive outcome. However, they gradually

recognised that select strategies might ease the process.



More importantly, a link between performance and

evaluation would be realised.

Why the change was necessary It was tempting to

embark on the easiest path. We could simply modify

our existing evaluation tools, most of which consisted of

global evaluations. However, we intended to fulfil the

mandate as effectively as possible. Hence, we chose to

incorporate the ACGME rankings of evaluation strat-

egies into our decision-making process and opted to

develop and adopt new evaluation tools.

What was done We closely examined the ACGME

Toolbox of Assessment Methods: Suggested Best Methods for

Evaluation, paying particular attention to the grid

comprising the 25 skills and 13 assessment methods.

A single tool – the portfolio – was designated an average

rating of 1 (¼ most desirable) for practice-based learn-

ing and improvement skills (analyse own practice for

needed improvements; use of evidence from scientific

studies; application of research and statistical methods;

use of information technology; facilitates learning of

others) (see www.acgme.org). Based on this designa-

tion, we identified the ideal starting point for our new

evaluation plan.

Next, we conducted a comprehensive review of

published literature on the use of portfolios in medical

education. As we hoped to gain guidance from this

process, the review was disappointing. Scant informa-

tion was available in physician-based journals, and these

works framed the portfolio as something of a diary. We

anticipated establishing the portfolio as a more formal,

structured endeavour that was broader in scope; thus,

we developed what we called a Learning Plan.

The Learning Plan enhanced existing educational

opportunities to satisfy the targeted skills better. For

example, our residents routinely attend journal clubs

where they take turns presenting and criticising articles.

By adding a simple, one-page evaluation, we measured

how well residents apply research and statistical meth-

ods. Case reports, literature reviews, research studies,

conference presentations, manuscript publications and

professional meeting presentations were also deemed

suitable portfolio items.

Impact We are embarking on a major paradigm shift in

the direction of competency-based medical education

that demands significant changes in how we conduct

skills assessments. Traditional reliance on global rating

techniques ( ¼ predominantly subjective scores of

general ability) will not produce useful evaluation data.

As we endeavoured to enhance the portfolio, we

realised that the tool represents not only a way of

demonstrating competencies but that it also serves to

enhance resident skills. Programme directors review the

status of the portfolio on a quarterly basis with their

residents. Clarification of expectations, with very con-

crete evidence of achievement, raises the bar. Although

we are still at a very early stage in the process, it would

appear that improvements in measurements translate

into improvements in performance.

Correspondence: D Kay Taylor PhD, Director of Research, Flint

Campus, Michigan State University, College of Human Medicine,

Hurley Medical Center, One Hurley Plaza, Flint, Michigan 48503,

USA

MammoEd: digital interactive breast imagingeducation

Katherine E Dee

Context and setting Exposure to a large number of

imaging cases is the mainstay of radiology education.

Internet-based teaching files have emerged as a popular

and effective learning tool for both residents and

practising radiologists.

Why the idea was necessary A paucity of digital

educational material exists for breast imaging because

mammography is the last radiological modality to

convert to digital acquisition. The new digital machines

utilise expensive high-resolution monitors and are only

now undergoing national trials. The primary aim of this

project was to provide interactive, comprehensive

teaching cases that could be easily accessed from any

computer connected to the Internet. An additional

goal was to provide a general breast imaging educa-

tional resource for radiology residents, attending

physicians, students, clinicians, technologists and

patients.

What was done The MammoEd website (http://

www.MammoEd.com) was developed using teaching

cases from daily clinical practice organised into a

computerised database. The screen-film images are

scanned using an Epson 1600 pro scanner at a resolution

of 300 dpi, and manipulated in Adobe Photoshop� 5Æ5(Adobe Systems, Inc., Seattle, Washington, USA) to

remove patient identifiers and optimise the images for

web publication. Fashioned after the oral board exam-

ination, each case begins with an �unknown� presented as

a standard screening mammogram. The student is

prompted to click on the pertinent findings or to answer

questions regarding the images. Each click renders more

images and questions, with discussion of the correct and

incorrect answers and management issues. Links are

embedded to related teaching files and references. Case

material is varied and designed to cover all aspects of



breast imaging. A separate diagnosis-labelled set is also

provided for use as a reference.

The navigation bar lists separate sections for resi-

dents, radiologists, medical students, clinicians, tech-

nologists and patients. The resident section contains

resident rotation guidelines, curriculum syllabus, and

links to online teaching files and other breast educa-

tional material. Radiologists will find links to online

continuing medical education (CME), other breast-

related information and breast meeting CME searches.

Medical students can access the medical student rota-

tion syllabus. Clinicians can access clinical guidelines

for breast diagnostic work-up. Technologists may view

breast diagnostic work-up protocols, access online

continuing education and view other information

resources. Patients will find links to helpful websites

covering all aspects of breast imaging and breast cancer.

Evaluation of impact The creation of MammoEd

teaching files has been challenging because many of

the signs of breast cancer are subtle and capturing the

imaging information for viewing on standard monitors is

difficult. The vast majority of cases in the database have

proven amenable to publication using these techniques

and further case material is added on an ongoing basis.

The teaching files have been successfully incorporated

into our residency rotations and have been actively used

for radiology oral boards study. As a result of email

requests for CME credits from practising radiologists,

these will soon be available from our CME webserver.

A preliminary survey yielded uniformly positive

feedback and formal evaluation with pre- and post-

testing of interpretive skills and a survey of participant

satisfaction will soon be underway. MammoEd is a

growing and increasingly valuable educational resource.

Correspondence: Katherine E Dee MD, University of Washington⁄Seattle Cancer Care Alliance, 825 Eastlake Ave East G2-209,

Seattle, Washington 98109–1023, USA

Through the Patient’s Eyes

Alpesh N Amin & Lloyd Rucker

Context and setting Throughout their 4 years of

medical school, students are taught the importance of

patient–doctor relationships. As a component of our

comprehensive doctoring curriculum, we developed a

new experience for graduating students called �Through

the Patient�s Eyes’.

Why the idea was necessary The goal of this

curriculum is to allow senior medical students to step

away from their role as doctors and to understand the

perspective and experience of patients.

What was done A total of 25 of 92 graduating medical

students were selected to pilot a longitudinal curricu-

lum called �Through the Patient�s Eyes’. The students

were divided into 5 groups, each of which was assigned

a particular topic, as follows: HIV, cancer, geriatrics,

dialysis and disabled patients. The faculty mentor of

each group was a specialist in the group’s particular

field. Each senior student was assigned a patient and

family unit to follow longitudinally for a period of 6–

9 months from the perspective of a �family member�.Faculty members prescreened the patients and ob-

tained verbal consent. The students met with their

patients on a routine basis, accompanying them to

medical appointments, visiting them during hospitali-

sations and attending social functions as allowed, in

much the same way a family member might. The

students met with their mentors on a routine basis and

kept diaries of their experiences.

Faculty consultants in the fields of Business of

Medicine, Palliative Care, Ethics, Humanities and

Spirituality were available to students. These consult-

ants each wrote a brief brochure describing their field,

how to identify issues in patients and how to call for a

consultation. Each group was required to present a

workshop to their classmates during our Year 4

advanced patient–doctor course in March, during

which they were expected to bring back their patient

and incorporate them into the workshop. The work-

shop was intended to allow students to report back their

experiences of following a patient longitudinally and to

illustrate learning issues that pertain to the patient–

doctor relationship and the experience of patients.

Evaluation of results We developed �Through the

Patient�s Eyes’ to reinforce aspects of the patient–doctor

relationship which are often lost as students progress

through their careers and adopt their professional roles.

Following a patient longitudinally as a family member

allowed the students to understand the patient’s experi-

ence of illness. We propose that students will develop a

greater empathy for patients and appreciation of their

experience. The longitudinal nature of this curriculum

helps to reinforce and, we hope, ingrain this appreciation

of the patient’s perspective, while placement at the end of

the senior year allows time for reflection and integration

of the lessons learned. Preliminary data showed that most

students ranked this experience as interesting and useful.

They also found the experience valuable for their future

careers. The primary challenge concerned the difficulties

of having senior students away from their patients for

long stretches of time. The students were asked to keep in

touch with their patients throughout these periods by



phone or email. Based on the experiences, feedback and

evaluations obtained from our pilot group, we hope to

expand this programme and make it a requirement for all

students.

Correspondence: Alpesh N Amin MD, University of California Irvine,

101 The City Drive South, Rte 1, Building 58, Room 110, Orange,

California 92868, USA

Increasing the instructional equivalency at atri-clinical campus: going online with anOb-Gyn clerkship

Julie B Walsh & Alice Goepfert

Context and setting Our obstetrics and gynaecology

(Ob-Gyn) clerkship is an 8-week programme occurring

in the third year of medical school. As with most clinical

clerkships, this clerkship requires students to learn a

vast amount of discipline-specific information and to

manage the logistics of numerous activities such as

clinical rotations, lectures, conferences and examina-

tions. Our school is comprised of three clinical

campuses located as far as 90 miles apart, thereby

increasing the complexity of the logistics. There are

multiple teaching facilities and clinics at each campus.

Why the idea was necessary Reports by the Associa-

tion of American Medical Colleges (AAMC), the Macy

Foundation and our own institution’s curriculum im-

provement guide (Curriculum 2000) have emphasised

the need to further integrate information technology into

the curriculum in an effort to increase the efficiency and

effectiveness of medical education. In addition, a recent

Liaison Committee on Medical Education (LCME)

accreditation review recommended that our tri-campus

clinical sites ensure comparable educational experiences

for students by increasing collaboration and interaction

between the sites. In response to these reports and the

LCME recommendation, and in order to provide our

students with the highest quality learning experiences,

the Ob-Gyn clerkship website was developed.

What was done The website was designed to:

1 replace the static paper-based handbook used by

students, and

2 house a common and centrally located collection of

reliable educational⁄informational resources conveni-

ently accessible to all students at the 3 campuses.

The site includes standardised goals⁄objectives,

lecture⁄clinic schedules, faculty⁄staff contact information

and an announcements page. Additionally, the site

includes links to online texts and reference material,

computer tutorials, interactive cases, instructional vid-

eos, digitised lectures, online evaluations, professional

organisations and topics related to women’s health care.

Evaluation of impact After moving to the Web-based

format, we surveyed students to determine whether

their material preference was paper-based or Web-

based. Students in the 1999⁄2000 academic year (paper-

based users) gave a response rate of 44% (n ¼ 45);

students in the 2000⁄2001 academic year (Web-based

users) gave a response rate of 45% (n ¼ 46).

The survey revealed that most students favoured

whichever format they used. A total of 73% of paper-

based users preferred the paper-based handbook, while

74% of Web-based users preferred the website. The

results suggest that both platforms promote essentially

equal student use of clerkship material, with 61% of

website users accessing clerkship material often and

54% of paper-based users accessing material often. In

an open-ended question, 26% of the Web-based users

identified ease of accessibility as the major advantage

of the website. Additionally, the website has promoted

better communication and increased collaboration

among clerkship directors at the various campuses in

order to determine and develop the contents of the

website; it also allows for easy review of the curriculum

in order to maintain comparability. This platform

also has the potential to increase instructional equiva-

lency by easily directing students at all three campuses

to the common interactive⁄supplemental educational

resources frequently being added to the website.

The website has both financial and administrative

advantages over the paper-based platform. It has de-

creased annual reproduction expenses of the handbook

used previously by $3250 and proves less demanding on

support staff by an average of 96 hours per year.

Correspondence: Julie B Walsh, Assistant Professor of Education in

Medicine, Undergraduate Medical Education, University of Alabama

at Birmingham, School of Medicine, VH L206, Box 700, 1530 3rd

Avenue South, Birmingham, Alabama 35294, USA

Conquering conflict in medicine

E A Wilson & C Kristjanson

Context and setting The Faculty of Medicine at the

University of Manitoba instituted a number of curricular

changes in 1997, which included placing increased focus

on improving communication skills. The topics ad-

dressed centred on history taking, information sharing

and interpersonal skills training. Since this time, our

attention has been drawn to the importance of doctors’



managerial roles and the need for them to possess a solid

foundation of conflict management skills.

Why the idea was necessary Conflict is an unavoid-

able and inherent part of life, especially for doctors who

are faced with changing roles, mounting workloads and

growing patient expectations. Physicians are further

predisposed to conflict by the fact that they take a

managerial role in patient care while dealing with an

increasingly interdisciplinary team of health care allies.

Despite its prevalence, most people lack a framework

with which to address conflict constructively, often

allowing it to escalate and consequently minimising

the possibility of a resolution. Our workshop provided

medical students with an opportunity to learn basic

conflict management skills. This article discusses the

effectiveness of providing conflict management training

in medical education as well as the perceived need for

its incorporation into the curriculum.

What was done A voluntary, 6-hour conflict manage-

ment workshop, conducted by a conflict resolution

trainer, was made available to first year students and

interested teaching staff. Before beginning the work-

shop, participants completed a pretest survey assessing

their conflict mediation skill levels and attitudes. The

workshop topics included �I� messages, positions and

interests, reframing and issue identification and provi-

ded opportunities to practise these and other skills.

A weekly email was sent, reminding participants to use

their new skills for 3 weeks post-workshop.

After a month, a post-test survey was sent to partici-

pants in order to reassess their attitudes towards conflict,

their approaches to dealing with conflict and the import-

ance of integrating these skills into the curriculum.

Evaluation of impact Our descriptive statistics indi-

cate:

• perceived changed behaviour: 43% of participants

increased their perceived ability to work toward

consensus building when faced with conflict;

• perceived changed attitude: 38% of participants

increased their perceived overall comfort level in

dealing with conflict;

• perceived increased competence: 52% of participants

increased their overall ability to deal with conflict as a

result of the workshop, and

• perceived need in the curriculum: 96% of partici-

pants stated that conflict management skills should

be integrated into the medical curriculum, the

majority indicating that the subject should be intro-

duced during the first year.

Although the data is based on self-reports, it is believed

that it is an individual’s attitudes and perceived ability to

deal with conflict that determine whether they approach

or avoid it and how successfully they deal with it.

This project was presented to our Curriculum

Committee, which acknowledged the importance of

such educational programming and agreed to integrate

it into our medical curriculum. We intend to introduce

the 6-hour workshop in the first year with refresher and

follow-up sessions just before clerkship, during clerk-

ship and as part of the residency core curriculum. Our

communication facilitator has agreed to take responsi-

bility for the programme.

Correspondence: C Kristjanson PhD, Department of Continuing

Medical Education, University of Manitoba, Faculty of Medicine,

S203-753 McDermot Avenue, Winnipeg, Manitoba R3E 0W3,

Canada

An integrated structure-function module forfirst year medical students: correlating anat-omy, clinical medicine and radiology

Sharon S Allen & Kenneth Roberts

Context and setting A curricular priority at our

institution is to integrate more closely the basic sciences

with clinical medicine. Knowledge of anatomy, which is

essential for doctors’ understanding of radiographic

imaging and for their clinical proficiency, provided an

ideal test case for meeting this objective. To this end, we

developed an innovative module on the upper extremity

that combines a review of surface and gross anatomy with

a practicum on clinical medicine and radiology.

Establishing meaningful linkages between scientific

principles and clinical care, particularly early in a

physician’s training, is a desirable curricular feature.

Our module emphasises the logical structure-function

model. When aware of clinically important questions,

students can optimally use cadavers to demonstrate

muscle and joint function. Students can then directly

translate their knowledge of 3-D anatomy when inter-

preting radiographic images in a clinical context. On a

wider level, we anticipate that students who are intro-

duced early and systematically to the concept of corre-

lating core scientific knowledge with actual patient care

will be more likely to develop strong, enduring appreci-

ation for another key process in medicine: the translation

of basic research findings into clinical practice.

What was done A 2-hour module was conducted

during an autumn 2001 Year 1 anatomy lab. Teams of

2 faculty members and one medical student (in the

physical diagnosis rotation) worked with groups of 12

students. Teaching materials included skeletons,



student-dissected cadavers, X-rays and colour, lamin-

ated surface anatomy cards. The module was organised

by joint (shoulder, elbow, wrist), each placed in the

context of a simple clinical case (e.g. a house painter

with progressive shoulder pain; a person with tennis

elbow; a woman experiencing numbness in her hand

from carpal tunnel syndrome while knitting). Faculty

staff demonstrated surface anatomy using skeletons,

cadavers and student volunteers. Paired students prac-

tised finding surface anatomy landmarks on each other.

Faculty demonstrated the clinical examination on a

student and cadaver (e.g. evaluation of a rotator cuff

tear versus impingement of the shoulder). Students

practised the clinical examination in pairs and were

given feedback by faculty. Radiographs were correlated

with the cadaver and the physical examination.

Evaluation Students (n ¼ 165) evaluated the mod-

ule on a 1–5 point scale where 1 ¼ excellent,

2 ¼ very good, 3 ¼ adequate, 4 ¼ fair and

5 ¼ poor. Students were positive about the module’s

value in learning surface anatomy (mean ¼ 2Æ4) and

in learning clinical principles related to the upper

extremity (mean ¼ 2Æ0). Students identified specific

strengths, exemplified in the following comments:

�clinical applications make things easy to remember

and help to relate them to the big picture� and �you

forget to think clinically when memorising anatomy, so

this brought back that focus�. Students also offered

suggestions for revising the module, including decreas-

ing the module’s length, using smaller groups and

including more X-rays. This student cohort will take a

final practical physical examination upon completing

their physical diagnosis segments. We will compare

their performance to that of a previous class which did

not experience the modified curriculum. An additional

module, on the lower extremity, will be added next

year. Future modules will be developed for the chest,

abdominal and eyes⁄ears⁄nose⁄throat examinations.

Correspondence: Sharon S Allen, MD, Department of Family Practice

and Community Health, Program in Medical Student Education,

A682 Mayo Memorial Building, 420 Delaware Street SE, MMC

#381, Minneapolis, Minnesota 55455, USA

Preventive health counselling for paediatricresidents

Meta T Lee, Chris Derauf & Richard T Kasuya

Context and setting Promoting healthy behaviour

through counselling is an important goal of paediatric

residency training. Few paediatric residency pro-

grammes, however, provide residents with formal

training in counselling. We created a new curriculum

designed to improve paediatric residents’ knowledge,

confidence and clinical skills in counselling patients on

preventive health topics.

Why the idea was necessary The US Surgeon

General’s �Healthy People 2010� initiative describes

the need for more physicians to provide routine

preventive health counselling to their patients. Topics

targeted in this initiative include smoking cessation,

physical activity, nutrition and injury prevention. A

doctor’s decision to promote healthy behaviour in these

areas is based on many variables. Lack of training has

been described in the literature as one reason doctors

fail to counsel.

In most outpatient clinic teaching settings, residents

learn how to counsel patients primarily through obser-

vation of faculty–patient interactions. Residents learn

about preventive care by discussing patients seen

during clinic with their supervising faculty members.

However, in a busy clinic setting, learning by this

method can be variable and inconsistent. Formal

training in counselling may provide an alternative

method of instruction that could better prepare pro-

gramme graduates to promote healthy behaviour in

their patients.

What was done We developed a new preventive

health counselling curriculum, consisting of 8

30-minute sessions given prior to the residents’

weekly continuity clinics. One faculty member led a

group of one to 3 residents throughout the

course. Prior to implementation, faculty were trained

to teach the curriculum and to lead small group

discussions. Counselling skills were taught based on

the transtheoretical model of behavioural change and

the �5 As� of counselling. Residents applied these

skills during case simulation exercises and received

direct feedback from group members. In addition,

residents observed video demonstrations of effective

counselling and shared self-assessments of their own

counselling performance.

Evaluation of results To date, 29 residents have

completed the course and a pre- and postcourse

multiple-choice examination and attitudinal survey to

measure knowledge and confidence level. Unidentified

standardised patients evaluated resident counselling

skills before and after the intervention. These stan-

dardized patients portrayed clinic patients presenting to

residents for routine health maintenance visits.

Residents felt that the course stimulated their learn-

ing and improved their knowledge of preventive health,

their counselling skills and their general approach to



providing anticipatory guidance to patients. Faculty felt

that training sessions increased their knowledge,

improved their teaching and better prepared them for

teaching the priority topics highlighted in �Healthy

People 2010�.Residents, faculty and standardised patients identi-

fied issues that should be addressed in future imple-

mentations of this curriculum. Residents and faculty

felt discussion of certain topics was limited by time

constraints. Standardised patients, while providing

insightful feedback to residents, required significant

time and effort for training and scheduling.

Formal analysis of pre- and post-test data from

multiple choice examinations, confidence surveys and

standardised patient assessments will assist us in further

evaluating learner outcomes. We plan to improve this

curriculum based on quantitative analysis and the

feedback described above. Follow-up studies will help

to determine whether improved residency training in

this area will result in long-term improvement in

counselling performance.

Acknowledgements This module was supported by

the Hawaii Paediatric Research and Education Fund,

the Hawaii Community Foundation and the Hawaii

Dyson Initiative.

Correspondence: Meta Tjan Lee MD, University of Hawaii John A

Burns School of Medicine, Department of Paediatrics, 1319 Punahou

Street, Honolulu, Hawaii 96826, USA

Undergraduate training to expand regionalhealth care: Med Experience Plus at BrockUniversity

Daniel J Malleck

Context and setting Brock University, in St. Catha-

rines, Ontario, is an institution of approximately 10 000

students. Med Experience Plus at Brock is a 4-year,

extracurricular, experiential learning programme de-

signed for students seeking admission to health profes-

sional schools.

Why the idea was necessary Brock is located in the

Niagara Region, which is designated as under-serviced

by the provincial government. Med Plus provides

students with exposure to their field of interest in order

to allow them to make informed choices about their

health care career. It facilitates skills development and

provides experience to help students succeed in their

health profession education. It also helps students to

forge supportive networks in the community and

encourages them to return to Niagara upon completion

of their graduate education.

What was done Representatives of Brock University,

the two main hospital systems, the regional public

health department, regional social service agencies, and

faculty at McMaster University and the University of

Toronto medical schools participated in early curricu-

lum development. As the programme expanded, mem-

bers of other health programmes joined the Med Plus

Advisory Board.

Each �level� of programming (spanning one two-

semester school year) exposes students to different

aspects of health care and skills development. Students

in Level I explore general health care in the region.

They meet family doctors, physiotherapists, chiroprac-

tors, occupational therapists, speech-language patholo-

gists, pharmacists, dentists and optometrists. Skills

workshops cover team and leadership skills, computer

training, stress management and presentation skills.

Level II students are exposed to more specialized

aspects of health care including pathology, immuno-

logy, psychiatry, surgery, ophthalmology and other

health care personnel including naturopathic doctors,

epidemiologists, midwives and nurse practitioners.

Their workshops are more sophisticated and include

specialized education on cancer, diabetes, addiction

care and dementia.

Students in Levels III and IV explore medicine in the

region in a more intricate manner. Their activities

include service learning projects, health issues forums

and problem-based learning components. Students also

visit health care and education sites in larger centres.

Skills workshops for these levels include graduate

school application sessions, mock interviews and work-

shops that build on skills developed in earlier levels of

the programme.

In all levels, students have access to health profession

career advice, job shadowing, a resource library and

student mentors.

Evaluation Students evaluate their experiences

annually. They assess the speakers, workshops and

programme in general. These evaluations are compiled

into statistics that are used to guide the curriculum of

future years. It will take longer to evaluate the

programme’s broader goals. As many of the students

who entered Med Plus in its pilot year (1999–2000)

are currently in their final year of university, applica-

tions to graduate programmes will be high in 2002,

and proportional admissions results will suggest the

programme’s initial effect. Whether or not the stu-

dents return to Niagara upon completion of their

degrees will not be established for at least another

4 years.



Correspondence: Dan Malleck, Brock University, Brock University, 500

Glenridge Avenue, St. Catharines, Ontario L2S 3A1, Canada

Who’s afraid of the pre-school child? A parentand toddler programme for teaching pre-clerkship clinical skills

Kim Blake & Renee Skelley

Context and setting Parent and toddler simulated

scenarios (PTSSs) were introduced to the final pre-

clerkship year (Medical 2) at Dalhousie University to

complement students’ early experiences of history-

taking and examination of paediatric patients. Medical

students in small groups interviewed parents who had

been programmed with a simulated scenario (e.g. �my

child had meningitis 6 months ago and is being seen for

a general check-up and developmental assessment�). All

students undertook two PTSSs, as well as 3 ward-based

and one neonatal session.

Why the idea was necessary It is becoming more

difficult to teach paediatric clinical skills on ward-based

patients because of short-stay admissions and because

admitted patients are often too sick for teaching. The

pre-school child is one of the most challenging of

paediatric patients and most students lack experience

and confidence in dealing with them. This programme

was designed to give students hands-on experience of

examining a well toddler with an appropriate story to

enhance history-taking.

Description The PTSSs were mandatory and

replaced two ward-based clinical skills teaching sessions

for each group of three to five students. The PTSS used

the same format as the ward session, with a history

being taken from the parent and a physical examination

of the child, followed by discussion with the faculty

preceptor. The only difference between the PTSS and a

ward-based session was that in PTSS sessions the

parent gave feedback to the student with particular

reference to their approach to the child in question.

Evaluation of impact All students achieved greater

exposure to pre-school children than they would have

in the 2 years prior to the introduction of this pro-

gramme. Students completed more components of the

physical examination than they did with traditional

ward-based teaching. This was assessed by a checklist

of examination items used with ward-based, age-

matched toddlers and compared to the PTSS pro-

gramme. Students reported that they enjoyed the

sessions and that physical examination of toddlers was

not as difficult as they had perceived.

Comments on the ward-based sessions were more

negative, with students finding preschoolers less

co-operative and teaching often interrupted by thera-

peutic interventions the children needed. They also

commented on family fatigue and cancelled sessions.

It is, therefore, possible to successfully supplement

the clinical skills teaching of medical students with

PTSSs and so increase the students’ contact time for

examination of pre-schoolers. Clinical skills in other

areas such as geriatrics and psychiatry could be taught

in this way to supplement the dwindling numbers of

actual patients available for teaching.

Correspondence: Dr Kim Blake, Associate Professor Medicine (Pedia-

trics), Director of Undergraduate Pediatric Education, Joint Ap-

pointment with Division of Medical Education, Dalhousie, IWK

Health Centre, 5850⁄5980 University Avenue, PO Box 3070, Halifax,

NS, B3J 3G9, Canada. Tel.: 001 902 470 6499; Fax: 001 902 470

7216; E-mail: [email protected]

Integrated simulation experiences to enhanceclinical education

Ruth Greenberg, Gary Loyd & Gina Wesley

Context and setting The changing health care

environment, adult learning theory and an emphasis

on assessment and accountability have focused atten-

tion on teaching and testing clinical knowledge,

attitudes and skills. This emphasis has produced new

tools for evaluating how students interact with patients.

Standardised patients and, in some cases, computer-

driven human patient simulators are now being used to

teach and assess students’ clinical abilities.

Why the idea was necessary Both standardised

patients (SPs) and computer-driven patient simulators

(PSs) have benefits and drawbacks. Standardised

patients are �live� but cannot take medications. Com-

puter-driven PSs are extremely reliable but not as �real�as SPs; they are extremely flexible but do not convey

humanness. At the University of Louisville School of

Medicine, we are combining SPs and human PSs to

produce a new model for teaching and assessing clinical

skills; this model emphasises the benefits of each model

and minimises the limitations. Our goal is to create

richer, more realistic clinical training and assessment

experiences for our students.

What was done The Alumni Center for Medical

Education houses the Patient Simulation Center (four

human patient simulation suites and four classrooms)

and the Standardised Patient Clinic (eight examination

rooms, control room and conference room). Thus, the



physical layout of the facility supports an integrated

clinical education model. Our model integrates PSs and

SPs and involves three phases: development, imple-

mentation and assessment.

The encounter is designed by a team consisting of

representatives of the PS and SP programmes and at

least one content expert (clinician from the course⁄clerkship that will house the encounter). For example, a

general surgeon might work with the other team

members to develop an encounter for the surgery

clerkship that consists of the following activities:

1 the student meets a patient (SP) about to have an

appendectomy;

2 the student follows the patient (PS) to the operating

room and participates in anaesthetising the patient

throughout the procedure;

3 the student returns to the waiting room to discuss the

surgery with the patient’s spouse (SP), and finally

4 the student examines the patient (SP) 2 weeks later

when she presents with a fever.

Once the SPs are trained and tested for reliability and

the PSs are programmed, the encounter is ready for

implementation. Implementation involves scheduling

students, SPs and the SP Clinic and Patient Simulation

Center. Assessment involves evaluating students’ clin-

ical skills and communication skills using videotaping

and checklists and evaluating the effectiveness of the

integrated PS⁄SP experience using a survey adminis-

tered to students.

Discussion The integrated patient simulation⁄standardised patient encounter has two important

advantages over the stand-alone patient simulation or

standardised patient encounter. Firstly, the integrated

encounter simulates following a patient over time with

minimal sacrifice of realism. Simulated, realistic envi-

ronments (home, doctor’s office, operating room,

emergency room and examination room) can be

created on campus. Secondly, the integrated encounter

synthesises the realism of the standardised patient with

the computerised capabilities of the simulated patient

(symptom representation, drug dosing, treatment). We

are currently completing our first integrated PS⁄SP

encounter. We are encouraged by the positive response

of faculty and students: faculty members are more open

to exploring new clinical teaching and testing methods;

students are more engaged in their education. We are

also developing integrated encounters in the primary

care and surgery clerkships and the clinical practice

sciences course; we are assessing both the teaching and

testing value of this model.

Correspondence: Ruth Greenberg PhD, Director for Health Sciences

Center Academic Programs, University of Louisville School of Me-

dicine, Louisville, Kentucky 40292, USA



developing communication skills for pharmacist-led clinics

Documents