medical students 2006 occupational medicine

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Occupational Medicine 2006;56:110114Published online 21 December 2005 doi:10.1093/occmed/kqj006

Medical students evaluation of a teachingsession in occupational medicine: the value ofa workplace visit

Paul Grime1, Sian Williams1 and Sandra Nicholson2

Background Undergraduate teaching in occupational medicine in UK medical schools is in decline. We devel-

oped a teaching programme for the new curriculum at our medical school, and then used student

evaluation to tailor it to students perceived learning needs.

Aims To examine medical students perception of a teaching session in occupational medicine after

changes made in the light of earlier student evaluation, and in particular their views on the inclusion

of a workplace visit.

Methods Questionnaire evaluation feedback completed immediately after teaching sessions, triangulated with

a student focus group session conducted by an external facilitator to explore what students valued

most and least and why. Comparison of student evaluations before and after changes introduced in

the light of student evaluations.

Results Students perception of the usefulness and relevance of the session significantly improved after the

changes. Students consistently identified the use of case scenarios as helpful but demonstrated

a dichotomy of opinion about the value of a workplace visit. Overall, students valued the brevity

of the session that resulted from removing the workplace visit.

Conclusions It is possible to enhance students perception of the value of a teaching session by modifying the

session in the light of student-based evaluation.

Key words Evaluation; medical students; occupational medicine; undergraduate teaching.

Introduction

Teaching of occupational medicine is in decline in UK

medical schools, and no school includes a workplace visit

as part of such teaching [1]. Yet the General Medical

Council (GMC) has stated that medical graduates must

understand the areas of sociology relevant to medicine,

including occupation, and must be aware of the signifi-

cance of health and safety issues and risk assessment in

the health care setting [2].

For the new curriculum at our medical school, we de-

veloped an undergraduate occupational medicine teach-

ing programme. This included a workplace visit. We then

used student evaluation to tailor the teaching to students

perceived learning needs. This paper describes the results

of student evaluations before and after changes that were

made in the light of student feedback.

Occupational medicine is taught as a half-day seminar

in the third of 4 weeks of primary care teaching. Other

seminars include ethics, communication and consulta-

tion skills, chronic care and clinical reasoning. In addi-

tion, students attend general practice attachments and

teaching sessions in community and hospital dermatol-

ogy. This is the only formal teaching in occupational

medicine that students receive. The session is repeated

nine times throughout the fourth academic year to differ-

ent groups of 2030 students. Most of the teaching is

delivered by one consultant/honorary senior lecturer in

occupational medicine with support from another, and

a specialist registrar in occupational medicine.

We planned and structured the session with clearly

defined and stated learning objectives. The aim of the

session is to enable students to apply the principles of

occupational medicine to their professional practice as

1Occupational Health Unit, Royal Free Hospital, Pond Street, London NW3

2QG, UK.

2Education Directorate, Barts and the London, Queen Marys School of

Medicine and Dentistry, Medical Sciences Building, Mile End Road, London

E1 4NS, UK.

Correspondence to: Paul Grime, Occupational Health Unit, Royal

Free Hospital, Pond Street, London NW3 2QG, UK. Tel: 144 20 7830 2519;

fax: 144 20 7830 2512; e-mail: [email protected]

The Author 2005. Published by Oxford University Press on behalf of the Society of Occupational Medicine.All rights reserved. For Permissions, please email: [email protected]

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doctors. The specific learning objectives for this session

are shown in Box 1.

We used a variety of teaching activities including stu-

dent participation in interactive small and large groups.

Students worked in groups of four to six to consider case

studies to illustrate basic concepts in occupational medi-

cine including the hazards of work, work-related ill-

health, taking an occupational history and the assessment

of medical fitness for work. We took groups of 812 stu-

dents to visit a workplace within the hospital: the kitchens,

the carpenters workshop or the boiler house. We asked

students to observe and identify workplace hazards and

control measures and record them on a paper grid. We

prepared multiple choice and extended matching ques-

tions, which contributed to the bank of questions used

for the student assessments. The content of our questions

reflected the material included in the teaching session.

We published an interim evaluation of the first six of

the teaching sessions [3]. An external lecturer observed

and commented on the fourth session. We continued to

evaluate and modify the session in the light of observa-

tions. The major changes included substituting the work-

place visit with pictures of one of the workplaces formerly

visited, curtailing the session from 165 to 120 min, quick-

ening the pace of delivery, reducing the emphasis on the

classification and control of workplace hazards and in-

troducing a didactic element of teaching on occupational

asthma, occupational dermatitis and occupational can-

cers. These changes were implemented after a student

focus group following the ninth session. The fourth learn-

ing objective was altered to reflect this. More minor

changes included integrating the case studies into the

body of the teaching, rather than leaving them to the

end (after the third session) and giving the students

a handout (after the eighth session). Using the observa-

tion that some students read their newspapers during the

session, we began subsequent sessions by asking students

to find stories about work, health or both in their news-

papers to illustrate how much these issues are part of

everyday life and therefore relevant for all doctors.

Methods

We designed an evaluation questionnaire (Appendix 1,

available as Supplementary data at Occupational Medicine

Online) for students to complete immediately after the

teaching session. Students were asked to score on a four-

point scale their perception of the usefulness and rele-

vance of the session and their enjoyment of it, whether

or not they felt that each of the five learning objectives

had been fulfilled, what they had found most useful about

the session and what they would like to change. This

strategy was based on the Kirkpatrick level I evaluation,

i.e. reaction/satisfaction [4] to facilitate sequential analy-

sis and modification of the session.

To enhance the validity of the students evaluations,

the data gained from the questionnaires were triangulated

with the outcome of a student focus group to explore in

more detail what students valued most and least about

the session and why. Students attending the ninth session

were asked to stay at the end of the session to meet with

an external lecturer, who facilitated the focus group.

The MannWhitney U-test (two samples) was used to

compare the mean scores for usefulness, relevance and

enjoyment for Sessions 19 and Sessions 1018. Fischers

Exact test was used to compare the percentage of stu-

dents who felt that the specific learning objectives had

been met for Sessions 19 and Sessions 1018. The free

text comments about what students found most useful

about the session and what they would like to change

were grouped into themes and compared for frequency

for Sessions 19 and Sessions 1018.

Results

From a year group of 341 students, 205 attended Ses-

sions 19 and 173 completed questionnaires (response

rate 84%). From the next year group of 338 students,

275 attended Sessions 1018 and 214 completed ques-

tionnaires (response rate 78%). Eighteen students

attended the focus group.

Table 1 compares students mean scores for usefulness,

relevance and enjoyment for Sessions 19 and Sessions

1018, and Table 2 compares the numbers and percen-

tages of students who felt that the specific learning objec-

tives had been met for Sessions 19 and Sessions 1018.

Some students wrote more than one comment and

some did not write comments. Themes are only in-

cluded in the Tables 3 and 4 if more than one student

Box 1. Learning objectives

By the end of this session, students should be able to:

1. Know what questions to ask in order to take an

appropriate and relevant occupational history

2. Identify factors or patterns in a patients history

that may indicate a work-related contribution to

ill-health

3. Consider a work-related health dilemma and

reach a conclusion with reasons

4. List and rank the principles of workplace hazard

assessment and control. This was changed after

Session 9 to:

List three causative agents and related work ac-

tivities for occupational asthma, allergic contact

dermatitis and cancer

5. Specify what information is necessary to make

a fully informed assessment of an individuals

medical fitness for work

P. GRIME ETAL.: MEDICAL STUDENTS EVALUATION OF A TEACHING SESSION 111

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commented. Denominators are the total number of ques-

tionnaires returned, regardless of whether or not free text

comments were entered. From the 173 questionnaires

from Sessions 19, there were 120 comments on what

was most useful and 94 on something to be changed.

From the 214 questionnaires from Sessions 1018, there

were 134 comments on what was most useful and 77 on

something to be changed.

In the focus group, two main aspects of the session

were discussed frequently: the case histories and the

workplace visit. No negative comments were made con-

cerning the case histories. Students said that they found

the case histories useful because they were well structured

and led them through the learning points in a logical

order but still giving them opportunity to work things

out. Students also thought that an appropriate amount

of time was spent on this area.

Students who liked the workplace visit said they found

it interesting, enjoyed seeing a part of the hospital they

would not normally visit and also considered that they

would retain what they had learnt from the activity

longer. Students who disliked the visit did not perceive

its relevance and stated that they could have learnt about

the occupational hazards by a more didactic teaching

method. These students did not like the practical nature

of the visit; they found it patronizing.

Overall students valued the session, considered that it

was well planned and covered what they thought was

needed for their examination preparation. They com-

mented that it was an interactive session and interesting.

However, students felt that the session could be made

shorter by leaving out the workplace visit and covering

the learning objectives by a more didactic approach.

Table 3. What students found most useful about the teaching

Sessions

19

Sessions

1018

Case scenarios 36 (21%) 58 (27%)

Workplace visit 35 (20%) Not applicable

Taking an occupational history 22 (13%) 15 (7%)

Learning about work-related

ill-health

13 (7%) 11 (5%)

Learning about the assessment

of fitness for work

10 (6%) 9 (4%)

Style of teaching 8 (5%) 18 (8%)

Learning about risk assessment 7 (4%) 3 (1.5%)

Group work/discussion 7 (4%) 5 (2%)

Structure of teaching 5 (3%) 2 (1%)

Learning about the role of

occupational physicians

4 (2%) 0 (0%)

Everything/commendation 3 (2%) 13 (6%)

Short duration 2 (1%) 22 (10%)

Handouts 0 (0%) 12 (6%)

Learning about human

immunodeficiency virus in

relation to health care work

0 (0%) 9 (4%)

Pictures/slides 0 (0%) 6 (3%)

No break 0 (0%) 2 (1%)

Table 4. What students said they would most like to be changed

about the teaching

Sessions

19

Sessions 1018

Too long/too slow 25 (14%) 23 (11%)

Workplace visit 13 (7%) Not applicable

Would like a handout 11 (6%) Not applicable

Nothing 10 (6%) 6 (3%)

Style of teaching 8 (5%) 9 (4%)

Case studies 6 (3%) 4 (2%)

Small-group work 5 (3%) 0 (0%)

Its just common sense 4 (2%) 0 (0%)

Longer visit 2 (1%) Not applicable

More on fitness for work 2 (1%) 0 (0%)

More on taking an occupational

history

2 (1%) 0 (0%)

More on work-related ill-health 2 (1%) 2 (1%)

More didactic/factual teaching

rather than principles

2 (1%) 0 (0%)

Would like a break 0 (0%) 9 (4%)

More about occupational medicine

as a specialty

0 (0%) 6 (3%)

More about legal aspects 0 (0%) 4 (2%)

Include sample examination questions 0 (0%) 4 (2%)

More cases 0 (0%) 3 (1.5%)

More pictures 0 (0%) 3 (1.5%)

More on needle-stick injury 0 (0%) 2 (1%)

More about benefits 0 (0%) 2 (1%)

Table 2. Numbers and percentages of students who felt the spe-

cific learning objectives had been met and P value for differencebetween the groups

Sessions 19

(n 5 173)Sessions 1018

(n 5 214)P

Objective 1 170 (98.3%) 213 (99.5%) 0.329

Objective 2 167 (96.5%) 213 (99.5%) 0.048

Objective 3 156 (90.2%) 211 (98.6%) 0.010

Objective 4 154 (89.1%) 211 (98.6%) a

Objective 5 151 (87.3%) 200 (93.4%) 0.052

aComparison not made as Objective 4 was changed after Session 9.

Table 1. Mean scores for perceived usefulness, relevance and en-

joyment, and P value for difference in means between the groups(score 1 5 disagree, 4 5 agree)

Sessions 19

(n 5 173)Sessions 1018

(n 5 214)P

Found session useful 2.73 3.13 ,0.001Found session relevant 2.82 3.17 ,0.001Enjoyed session 2.68 2.82 0.095

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Discussion

Students perception of the usefulness and relevance of

the teaching session improved significantly following the

introduction of changes made in the light of earlier stu-

dent evaluations, but there was no statistically significant

change in their reported enjoyment of it. Most students

felt that the specific learning objectives had been met, and

the proportion of those that did, increased with time.

Students consistently valued the use of case scenarios to

illustrate principles of occupational medicine. Others

have also reported the value of case scenarios in delivering

education in occupational medicine, in translating the

principles learnt from teaching into clinical practice

[5,6]. Students reported different learning styles, and

there was a dichotomy of opinion about the value of the

workplace visit. The absence of workplace visits from un-

dergraduate teaching in occupational medicine has been

highlighted as an indication of the decline in commitment

to the subject [1], but in this study students preferred the

teaching session to be shorter, which was made possible

by removing the workplace visit. Workplace visits appear

to have been successfully incorporated into undergradu-

ate teaching elsewhere, although not formally evaluated

[7]. Practical difficulties may preclude the widespread

use of workplace visits in UK medical schools [8].

The content of our teaching programme reflected

what we perceived as important for aspiring doctors to

know. Others may have different priorities although pub-

lished reports of other undergraduate teaching pro-

grammes indicate similar content but various teaching

methods [7,9,10]. The delivery of the teaching session

may have improved with time as the lecturers became

more familiar with the content and structure of the ses-

sion. This was not accounted for in the analysis. There

are many variables in a Kirkpatrick level I evaluation

(reaction) and the extent to which students perceptions

can be used to evaluate teaching is probably limited. Some

students favour didactic, factual teaching, others prefer

interactional group discussion. Some perceive principles

and concepts as just common sense. The GMC states

that medical graduates must be able to identify their own

learning needs, and that the quality of teaching must be

monitored through a number of different systems, includ-

ing student feedback and review of teaching by peers [2].

The GMC also states that factual information in the un-

dergraduate curriculum should be kept to the essential

minimum that students need at this stage of medical

education [2].

Students may struggle to see the relevance of subjects

like occupational medicine in the undergraduate curric-

ulum, and it can therefore be challenging to convince

them of its value. Unless subjects are included formally

in the curriculum and tested in examinations, students

may not view them seriously [11]. If medical schools

and medical students can be persuaded of the value of

occupational medicine as an undergraduate subject, it

may be possible to reverse the observed decline in the

teaching of occupational medicine in UK medical

schools. Most work-related health problems are likely to

be managed by non-occupational physicians [11]. In

the light of current political emphasis on issues such as

sickness absence (productivity), access to work, benefits

and pensions, it is important that all doctors have an un-

derstanding of the potential for work and health to in-

teract [12,13]. Occupational medicine teaching should

be delivered by specialists in occupational medicine, but

does not need to be sophisticated, specialized or time-

consuming [11].

This study looked only at students perceptions of

teaching (Kirkpatrick level I evaluation), and the effect

of implementing changes they suggested. We did not ex-

amine other outcomes, such as learning (knowledge, skills

and attitudesKirkpatrick level II), behaviour (transfer

of knowledge and skillsKirkpatrick level III) and results

(organizational impact of teachingKirkpatrick level IV)

[4], and did not compare students perception of occu-

pational medicine with their perception of other topics.

It would be interesting to observe the effect of undergrad-

uate occupational medicine teaching on career choices.

Further research could examine the consistency between

medical schools in the delivery of occupational medicine

teaching and perhaps evaluate this teaching session in

different settings, for example in other medical schools.

This could lead to the sharing of teaching and learning

resources, thereby enhancing the quality and accessibility

of undergraduate education in occupational medicine

generally.

Conflicts of interest

None declared.

References

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Recommendations on Undergraduate Medical Education.

London: General Medical Council, 2002.

3. Grime P, Williams S, Nicholson S. A new undergraduate

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4. Kirkpatrick DL. Evaluation. In: Craig RL, ed. Training and

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5. Koh D, Chia KS, Jeyaratnam J, Chia SE, Singh J. Case

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