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1.  Survey and analysis of the current state of residency training in medical-school-affiliated hospitals in China 
BMC Medical Education  2014;14:111.
Background
Since the global standards for postgraduate medical education (PGME) were published in January 2003, they have gained worldwide attention. The current state of residency training programs in medical-school-affiliated hospitals throughout China was assessed in this study.
Methods
Based on the internationally recognized global standards for PGME, residents undergoing residency training at that time and the relevant residency training instructors and management personnel from 15 medical-school-affiliated hospitals throughout China were recruited and surveyed regarding the current state of residency training programs. A total of 938 questionnaire surveys were distributed between June 30, 2006 and July 30, 2006; of 892 surveys collected, 841 were valid.
Results
For six items, the total proportions of “basically meets standards” and “completely meets standards” were <70% for the basic standards. These items were identified in the fields of “training settings and educational resources”, “evaluation of training process”, and “trainees”. In all fields other than “continuous updates”, the average scores of the western regions were significantly lower than those of the eastern regions for both the basic and target standards. Specifically, the average scores for the basic standards on as many as 25 of the 38 items in the nine fields were significantly lower in the western regions. There were significant differences in the basic standards scores on 13 of the 38 items among trainees, instructors, and managers.
Conclusions
The residency training programs have achieved satisfactory outcomes in the hospitals affiliated with various medical schools in China. However, overall, the programs remain inadequate in certain areas. For the governments, organizations, and institutions responsible for PGME, such global standards for PGME are a very useful self-assessment tool and can help identify problems, promote reform, and ultimately standardize PGME.
doi:10.1186/1472-6920-14-111
PMCID: PMC4059472  PMID: 24885865
Residency training; Global standards for postgraduate medical education; Medical-school-affiliated hospitals; China
2.  Implementing the 2009 Institute of Medicine recommendations on resident physician work hours, supervision, and safety 
Long working hours and sleep deprivation have been a facet of physician training in the US since the advent of the modern residency system. However, the scientific evidence linking fatigue with deficits in human performance, accidents and errors in industries from aeronautics to medicine, nuclear power, and transportation has mounted over the last 40 years. This evidence has also spawned regulations to help ensure public safety across safety-sensitive industries, with the notable exception of medicine.
In late 2007, at the behest of the US Congress, the Institute of Medicine embarked on a year-long examination of the scientific evidence linking resident physician sleep deprivation with clinical performance deficits and medical errors. The Institute of Medicine’s report, entitled “Resident duty hours: Enhancing sleep, supervision and safety”, published in January 2009, recommended new limits on resident physician work hours and workload, increased supervision, a heightened focus on resident physician safety, training in structured handovers and quality improvement, more rigorous external oversight of work hours and other aspects of residency training, and the identification of expanded funding sources necessary to implement the recommended reforms successfully and protect the public and resident physicians themselves from preventable harm.
Given that resident physicians comprise almost a quarter of all physicians who work in hospitals, and that taxpayers, through Medicare and Medicaid, fund graduate medical education, the public has a deep investment in physician training. Patients expect to receive safe, high-quality care in the nation’s teaching hospitals. Because it is their safety that is at issue, their voices should be central in policy decisions affecting patient safety. It is likewise important to integrate the perspectives of resident physicians, policy makers, and other constituencies in designing new policies. However, since its release, discussion of the Institute of Medicine report has been largely confined to the medical education community, led by the Accreditation Council for Graduate Medical Education (ACGME).
To begin gathering these perspectives and developing a plan to implement safer work hours for resident physicians, a conference entitled “Enhancing sleep, supervision and safety: What will it take to implement the Institute of Medicine recommendations?” was held at Harvard Medical School on June 17–18, 2010. This White Paper is a product of a diverse group of 26 representative stakeholders bringing relevant new information and innovative practices to bear on a critical patient safety problem. Given that our conference included experts from across disciplines with diverse perspectives and interests, not every recommendation was endorsed by each invited conference participant. However, every recommendation made here was endorsed by the majority of the group, and many were endorsed unanimously. Conference members participated in the process, reviewed the final product, and provided input before publication. Participants provided their individual perspectives, which do not necessarily represent the formal views of any organization.
In September 2010 the ACGME issued new rules to go into effect on July 1, 2011. Unfortunately, they stop considerably short of the Institute of Medicine’s recommendations and those endorsed by this conference. In particular, the ACGME only applied the limitation of 16 hours to first-year resident physicans. Thus, it is clear that policymakers, hospital administrators, and residency program directors who wish to implement safer health care systems must go far beyond what the ACGME will require. We hope this White Paper will serve as a guide and provide encouragement for that effort.
Resident physician workload and supervision
By the end of training, a resident physician should be able to practice independently. Yet much of resident physicians’ time is dominated by tasks with little educational value. The caseload can be so great that inadequate reflective time is left for learning based on clinical experiences. In addition, supervision is often vaguely defined and discontinuous. Medical malpractice data indicate that resident physicians are frequently named in lawsuits, most often for lack of supervision. The recommendations are: The ACGME should adjust resident physicians workload requirements to optimize educational value. Resident physicians as well as faculty should be involved in work redesign that eliminates nonessential and noneducational activity from resident physician dutiesMechanisms should be developed for identifying in real time when a resident physician’s workload is excessive, and processes developed to activate additional providersTeamwork should be actively encouraged in delivery of patient care. Historically, much of medical training has focused on individual knowledge, skills, and responsibility. As health care delivery has become more complex, it will be essential to train resident and attending physicians in effective teamwork that emphasizes collective responsibility for patient care and recognizes the signs, both individual and systemic, of a schedule and working conditions that are too demanding to be safeHospitals should embrace the opportunities that resident physician training redesign offers. Hospitals should recognize and act on the potential benefits of work redesign, eg, increased efficiency, reduced costs, improved quality of care, and resident physician and attending job satisfactionAttending physicians should supervise all hospital admissions. Resident physicians should directly discuss all admissions with attending physicians. Attending physicians should be both cognizant of and have input into the care patients are to receive upon admission to the hospitalInhouse supervision should be required for all critical care services, including emergency rooms, intensive care units, and trauma services. Resident physicians should not be left unsupervised to care for critically ill patients. In settings in which the acuity is high, physicians who have completed residency should provide direct supervision for resident physicians. Supervising physicians should always be physically in the hospital for supervision of resident physicians who care for critically ill patientsThe ACGME should explicitly define “good” supervision by specialty and by year of training. Explicit requirements for intensity and level of training for supervision of specific clinical scenarios should be providedCenters for Medicare and Medicaid Services (CMS) should use graduate medical education funding to provide incentives to programs with proven, effective levels of supervision. Although this action would require federal legislation, reimbursement rules would help to ensure that hospitals pay attention to the importance of good supervision and require it from their training programs
Resident physician work hours
Although the IOM “Sleep, supervision and safety” report provides a comprehensive review and discussion of all aspects of graduate medical education training, the report’s focal point is its recommendations regarding the hours that resident physicians are currently required to work. A considerable body of scientific evidence, much of it cited by the Institute of Medicine report, describes deteriorating performance in fatigued humans, as well as specific studies on resident physician fatigue and preventable medical errors.
The question before this conference was what work redesign and cultural changes are needed to reform work hours as recommended by the Institute of Medicine’s evidence-based report? Extensive scientific data demonstrate that shifts exceeding 12–16 hours without sleep are unsafe. Several principles should be followed in efforts to reduce consecutive hours below this level and achieve safer work schedules. The recommendations are: Limit resident physician work hours to 12–16 hour maximum shiftsA minimum of 10 hours off duty should be scheduled between shiftsResident physician input into work redesign should be actively solicitedSchedules should be designed that adhere to principles of sleep and circadian science; this includes careful consideration of the effects of multiple consecutive night shifts, and provision of adequate time off after night work, as specified in the IOM reportResident physicians should not be scheduled up to the maximum permissible limits; emergencies frequently occur that require resident physicians to stay longer than their scheduled shifts, and this should be anticipated in scheduling resident physicians’ work shiftsHospitals should anticipate the need for iterative improvement as new schedules are initiated; be prepared to learn from the initial phase-in, and change the plan as neededAs resident physician work hours are redesigned, attending physicians should also be considered; a potential consequence of resident physician work hour reduction and increased supervisory requirements may be an increase in work for attending physicians; this should be carefully monitored, and adjustments to attending physician work schedules made as needed to prevent unsafe work hours or working conditions for this group“Home call” should be brought under the overall limits of working hours; work load and hours should be monitored in each residency program to ensure that resident physicians and fellows on home call are getting sufficient sleepMedicare funding for graduate medical education in each hospital should be linked with adherence to the Institute of Medicine limits on resident physician work hours
Moonlighting by resident physicians
The Institute of Medicine report recommended including external as well as internal moonlighting in working hour limits. The recommendation is: All moonlighting work hours should be included in the ACGME working hour limits and actively monitored. Hospitals should formalize a moonlighting policy and establish systems for actively monitoring resident physician moonlighting
Safety of resident physicians
The “Sleep, supervision and safety” report also addresses fatigue-related harm done to resident physicians themselves. The report focuses on two main sources of physical injury to resident physicians impaired by fatigue, ie, needle-stick exposure to blood-borne pathogens and motor vehicle crashes. Providing safe transportation home for resident physicians is a logistical and financial challenge for hospitals. Educating physicians at all levels on the dangers of fatigue is clearly required to change driving behavior so that safe hospital-funded transport home is used effectively. Fatigue-related injury prevention (including not driving while drowsy) should be taught in medical school and during residency, and reinforced with attending physicians; hospitals and residency programs must be informed that resident physicians’ ability to judge their own level of impairment is impaired when they are sleep deprived; hence, leaving decisions about the capacity to drive to impaired resident physicians is not recommendedHospitals should provide transportation to all resident physicians who report feeling too tired to drive safely; in addition, although consecutive work should not exceed 16 hours, hospitals should provide transportation for all resident physicians who, because of unforeseen reasons or emergencies, work for longer than consecutive 24 hours; transportation under these circumstances should be automatically provided to house staff, and should not rely on self-identification or request
Training in effective handovers and quality improvement
Handover practice for resident physicians, attendings, and other health care providers has long been identified as a weak link in patient safety throughout health care settings. Policies to improve handovers of care must be tailored to fit the appropriate clinical scenario, recognizing that information overload can also be a problem. At the heart of improving handovers is the organizational effort to improve quality, an effort in which resident physicians have typically been insufficiently engaged. The recommendations are: Hospitals should train attending and resident physicians in effective handovers of careHospitals should create uniform processes for handovers that are tailored to meet each clinical setting; all handovers should be done verbally and face-to-face, but should also utilize written toolsWhen possible, hospitals should integrate hand-over tools into their electronic medical records (EMR) systems; these systems should be standardized to the extent possible across residency programs in a hospital, but may be tailored to the needs of specific programs and services; federal government should help subsidize adoption of electronic medical records by hospitals to improve signoutWhen feasible, handovers should be a team effort including nurses, patients, and familiesHospitals should include residents in their quality improvement and patient safety efforts; the ACGME should specify in their core competency requirements that resident physicians work on quality improvement projects; likewise, the Joint Commission should require that resident physicians be included in quality improvement and patient safety programs at teaching hospitals; hospital administrators and residency program directors should create opportunities for resident physicians to become involved in ongoing quality improvement projects and root cause analysis teams; feedback on successful quality improvement interventions should be shared with resident physicians and broadly disseminatedQuality improvement/patient safety concepts should be integral to the medical school curriculum; medical school deans should elevate the topics of patient safety, quality improvement, and teamwork; these concepts should be integrated throughout the medical school curriculum and reinforced throughout residency; mastery of these concepts by medical students should be tested on the United States Medical Licensing Examination (USMLE) stepsFederal government should support involvement of resident physicians in quality improvement efforts; initiatives to improve quality by including resident physicians in quality improvement projects should be financially supported by the Department of Health and Human Services
Monitoring and oversight of the ACGME
While the ACGME is a key stakeholder in residency training, external voices are essential to ensure that public interests are heard in the development and monitoring of standards. Consequently, the Institute of Medicine report recommended external oversight and monitoring through the Joint Commission and Centers for Medicare and Medicaid Services (CMS). The recommendations are: Make comprehensive fatigue management a Joint Commission National Patient Safety Goal; fatigue is a safety concern not only for resident physicians, but also for nurses, attending physicians, and other health care workers; the Joint Commission should seek to ensure that all health care workers, not just resident physicians, are working as safely as possibleFederal government, including the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality, should encourage development of comprehensive fatigue management programs which all health systems would eventually be required to implementMake ACGME compliance with working hours a “ condition of participation” for reimbursement of direct and indirect graduate medical education costs; financial incentives will greatly increase the adoption of and compliance with ACGME standards
Future financial support for implementation
The Institute of Medicine’s report estimates that $1.7 billion (in 2008 dollars) would be needed to implement its recommendations. Twenty-five percent of that amount ($376 million) will be required just to bring hospitals into compliance with the existing 2003 ACGME rules. Downstream savings to the health care system could potentially result from safer care, but these benefits typically do not accrue to hospitals and residency programs, who have been asked historically to bear the burden of residency reform costs. The recommendations are: The Institute of Medicine should convene a panel of stakeholders, including private and public funders of health care and graduate medical education, to lay down the concrete steps necessary to identify and allocate the resources needed to implement the recommendations contained in the IOM “Resident duty hours: Enhancing sleep, supervision and safety” report. Conference participants suggested several approaches to engage public and private support for this initiativeEfforts to find additional funding to implement the Institute of Medicine recommendations should focus more broadly on patient safety and health care delivery reform; policy efforts focused narrowly upon resident physician work hours are less likely to succeed than broad patient safety initiatives that include residency redesign as a key componentHospitals should view the Institute of Medicine recommendations as an opportunity to begin resident physician work redesign projects as the core of a business model that embraces safety and ultimately saves resourcesBoth the Secretary of Health and Human Services and the Director of the Centers for Medicare and Medicaid Services should take the Institute of Medicine recommendations into consideration when promulgating rules for innovation grantsThe National Health Care Workforce Commission should consider the Institute of Medicine recommendations when analyzing the nation’s physician workforce needs
Recommendations for future research
Conference participants concurred that convening the stakeholders and agreeing on a research agenda was key. Some observed that some sectors within the medical education community have been reluctant to act on the data. Several logical funders for future research were identified. But above all agencies, Centers for Medicare and Medicaid Services is the only stakeholder that funds graduate medical education upstream and will reap savings downstream if preventable medical errors are reduced as a result of reform of resident physician work hours.
doi:10.2147/NSS.S19649
PMCID: PMC3630963  PMID: 23616719
resident; hospital; working hours; safety
3.  A comparative study of postgraduate medical education in North East Thames Region. 
Postgraduate Medical Journal  1994;70(828):722-727.
As a prelude to more detailed formal contracting, North East Thames Region undertook a review to examine whether the content of postgraduate medical education (PGME) varies according to the type of hospital in which junior doctors are trained. The study covered a sample of 83 trainees at different grades in four types of hospital (postgraduate, university, district general hospital involved in off-site undergraduate medical education, and district general hospital with no formal involvement in undergraduate medical education) and was designed as a qualitative comparative study. The results of the study point to a perceived lack of structure in PGME and indicate that hospital type alone does not determine a trainees' PGME experience. Moreover, different training grades have different educational needs, which will need to be addressed under more formal contracting arrangements. The Region plans to take this work forward by convening one or more consensus conferences to examine how a more structured approach to PGME could be implemented.
PMCID: PMC2397761  PMID: 7831168
4.  Is it time for integration of surgical skills simulation into the United Kingdom undergraduate medical curriculum? A perspective from King’s College London School of Medicine 
Purpose:
Changes in undergraduate medical curricula, combined with reforms in postgraduate education, have training implications for surgical skills acquisition in a climate of reduced clinical exposure. Confidence and prior experience influences the educational impact of learning. Currently there is no basic surgical skills (BSS) programme integrated into undergraduate curricula in the United Kingdom. We explored the role of a dedicated BSS programme for undergraduates in improving confidence and influencing careers in King’s College London School of Medicine, and the programme was evaluated.
Methods:
A programme was designed in-line with the established Royal College of Surgeons course. Undergraduates were taught four key skills over four weeks: knot-tying, basic-suturing, tying-at-depth and chest-drain insertion, using low-fidelity bench-top models. A Likert-style questionnaire was designed to determine educational value and influence on career choice. Qualitative data was collected.
Results:
Only 29% and 42% of students had undertaken previous practice in knot-tying and basic suturing, respectively. 96% agreed that skills exposure prior to starting surgical rotations was essential and felt a dedicated course would augment undergraduate training. There was a significant increase in confidence in the practice and knowledge of all skills taught (p<0.01), with a greater motivation to be actively involved in the surgical firm and theatres.
Conclusion:
A simple, structured BSS programme can increase the confidence and motivation of students. Early surgical skills targeting is valuable for students entering surgical, related allied, and even traditionally non-surgical specialties such as general practice. Such experience can increase the confidence of future junior doctors and trainees. We advocate the introduction of a BSS programme into United Kingdom undergraduate curricula.
doi:10.3352/jeehp.2013.10.10
PMCID: PMC3912700  PMID: 24498471
Surgical skills; Undergraduate training; Evaluation; Career choice; Confidence; United Kingdom
5.  Graduates from a traditional medical curriculum evaluate the effectiveness of their medical curriculum through interviews 
Background
In 1996 The University of Liverpool reformed its medical course from a traditional lecture-based course to an integrated PBL curriculum. A project has been underway since 2000 to evaluate this change. Part of this project has involved gathering retrospective views on the relevance of both types of undergraduate education according to graduates. This paper focuses on the views of traditional Liverpool graduates approximately 6 years after graduation.
Methods
From February 2006 to June 2006 interviews took place with 46 graduates from the last 2 cohorts to graduate from the traditional Liverpool curriculum.
Results
The graduates were generally happy with their undergraduate education although they did feel there were some flaws in their curriculum. They felt they had picked up good history and examination skills and were content with their exposure to different specialties on clinical attachments. They were also pleased with their basic science teaching as preparation for postgraduate exams, however many complained about the overload and irrelevance of many lectures in the early years of their course, particular in biochemistry. There were many different views about how they integrated this science teaching into understanding disease processes and many didn't feel it was made relevant to them at the time they learned it. Retrospectively, they felt that they hadn't been clinically well prepared for the role of working as junior doctor, particularly the practical aspects of the job nor had enough exposure to research skills. Although there was little communication skills training in their course they didn't feel they would have benefited from this training as they managed to pick up had the required skills on clinical attachments.
Conclusion
These interviews offer a historical snapshot of the views of graduates from a traditional course before many courses were reformed. There was some conflict in the interviews about the doctors enjoying their undergraduate education but then saying that they didn't feel they received good preparation for working as a junior doctor. Although the graduates were happy with their undergraduate education these interviews do highlight some of the reasons why the traditional curriculum was reformed at Liverpool.
doi:10.1186/1472-6920-9-64
PMCID: PMC2773762  PMID: 19857252
6.  Results of a psychosomatic training program in China, Vietnam and Laos: successful cross-cultural transfer of a postgraduate training program for medical doctors 
Background
With the “ASIA-LINK” program, the European Community has supported the development and implementation of a curriculum of postgraduate psychosomatic training for medical doctors in China, Vietnam and Laos. Currently, these three countries are undergoing great social, economic and cultural changes. The associated psychosocial stress has led to increases in psychological and psychosomatic problems, as well as disorders for which no adequate medical or psychological care is available, even in cities. Health care in these three countries is characterized by the coexistence of Western medicine and traditional medicine. Psychological and psychosomatic disorders and problems are insufficiently recognized and treated, and there is a need for biopsychosocially orientated medical care. Little is known about the transferability of Western-oriented psychosomatic training programs in the Southeast Asian cultural context.
Methods
The curriculum was developed and implemented in three steps: 1) an experimental phase to build a future teacher group; 2) a joint training program for future teachers and German teachers; and 3) training by Asian trainers that was supervised by German teachers. The didactic elements included live patient interviews, lectures, communication skills training and Balint groups. The training was evaluated using questionnaires for the participants and interviews of the German teachers and the future teachers.
Results
Regional training centers were formed in China (Shanghai), Vietnam (Ho Chi Minh City and Hue) and Laos (Vientiane). A total of 200 physicians completed the training, and 30 physicians acquired the status of future teacher. The acceptance of the training was high, and feelings of competence increased during the courses. The interactive training methods were greatly appreciated, with the skills training and self-experience ranked as the most important topics. Adaptations to the cultural background of the participants were necessary for the topics of “breaking bad news,” the handling of negative emotions, discontinuities in participation, the hierarchical doctor-patient relationship, culture-specific syndromes and language barriers. In addition to practical skills for daily clinical practice, the participants wanted to learn more about didactic teaching methods. Half a year after the completion of the training program, the participants stated that the program had a great impact on their daily medical practice.
Conclusions
The training in psychosomatic medicine for postgraduate medical doctors resulted in a positive response and is an important step in addressing the barriers in providing psychosomatic primary care. The transferability of western concepts should be tested locally, and adaptations should be undertaken where necessary. The revised curriculum forms the basis of training in psychosomatic medicine and psychotherapy for medical students and postgraduate doctors in China, Vietnam and Laos.
doi:10.1186/1751-0759-6-17
PMCID: PMC3546304  PMID: 22929520
Psychosomatic medicine; Curriculum; Teaching of teachers; China; Vietnam; Laos
7.  International partnerships in telehealth: healthcare, industry and education 
Project background
In 2010 an internationally renowned American healthcare organisation partnered with Irish industry and higher education in Waterford with the goal to expand their telehealth services. Combining the skills and expertise of Nurse Consultants, Nurse Educators, IT Specialists and Healthcare Executives, these collaborative partnerships led to the delivery of telehealth services to North America from an Irish base, and to the development of new European telehealth programmes and telehealth training in Ireland. The telehealth service includes the provision of telephone triage, health information and advice, disease management and hospital discharge programmes to clients in Ireland, the UK and the USA. Telehealth nursing is an evolving specialty that requires the development of competence in key areas of information and communication technologies, assessment, triage and critical thinking in clinical decision-making within an environment where distance separates the nurse from the client.
Aims and objectives
The aim of this paper is to report on the development, implementation and evaluation of the telehealth service with a focus on the telephone triage and advice service and the hospital discharge programmes. Objectives of this paper include describing this telehealth initiative with reference to the changing nature of global healthcare provision; discuss the educational strategy and accredited programme for training competent telehealth nurses; report the results of the evaluation of nurse performance in telephone triage and present the data relating to the impact of hospital discharge programmes on patient satisfaction and readmission rates.
Methods and results
The evaluation of the telehealth training programme was undertaken six months post initial training and service commencement. One hundred triage and health information calls were reviewed, against best practice standards and programme learning outcomes, during a four-month period. Quantitative and qualitative data that demonstrates evidence of learning transfer from training to practice and the development of nurse competence from advanced beginner to levels of proficiency will be presented. The hospital discharge programmes have undergone continuous monitoring and reporting since commencement. This has enabled the collection of evidence that supports this brief telephone intervention as a method of reducing hopsital re-admissions and increasing patient satisfcation. Quantitative results will be presented and analysed in relation to the impact on patient satisfaction and readmission rates for patients discharged from cardiovascular, renal and digestive disease services.
Conclusions
This project has demonstrated the effectiveness of partnerships in healthcare, industry and education in achieving the development, implementation and evaluation of international telehealth services. Initial education, training and ongoing support and development of nurses is essential for quality telehealth provision. Weekly call review, constructive feedback and reflection on practice are effective strategies for performance assurance and improvement. As a growing element of integrated healthcare, telehealth modules should be included in pre and post-registration nursing education curricula. Further collaboration between industry, healthcare and education are necessary in moving the telehealth agenda forward for the benefit of integrating services that impact positively on service users.
PMCID: PMC3571125
telephone triage; hospital discharge programmes; partnerships
8.  Trainee satisfaction before and after the Calman reforms of specialist training: questionnaire survey 
BMJ : British Medical Journal  2000;320(7238):832-836.
Objectives
To evaluate the impact of the Calman reforms of higher specialist training on trainee satisfaction.
Design
Questionnaire surveys using portable electronic survey units, two years apart.
Setting
Postgraduate, teaching, district general, and community NHS trusts in North Thames. North Thames deanery includes London north of the Thames, Essex, and Hertfordshire.
Participants
Trainees in all grades and all specialties: 3078 took part in the first survey and 3517 in the second survey.
Main outcome measures
Trainees' satisfaction with training in their current post, including educational objectives, training agreements, induction, consultant feedback, hands on experience acquired, use of log books, consultant supervision, and overall satisfaction with the post.
Results
In the second survey respondents were more likely to have discussed educational objectives with their consultant, used a log book, and had useful feedback from their consultant. They were more likely to give high ratings to induction, consultant supervision, and hands on experience acquired in the post. Each of these elements was associated with increased satisfaction with the post overall. Improvements were most noticeable at the level of specialist registrar, but changes in the same direction were also seen in more junior grades.
Conclusions
After the reforms of specialist training, trainees in all grades reported greater satisfaction with their current posts. The changes required extra training time and effort from consultants.
PMCID: PMC27320  PMID: 10731174
9.  Validation of core competencies during residency training in anaesthesiology 
Background and goal: Curriculum development for residency training is increasingly challenging in times of financial restrictions and time limitations. Several countries have adopted the CanMEDS framework for medical education as a model into their curricula of specialty training. The purpose of the present study was to validate the competency goals, as derived from CanMEDS, of the Department of Anaesthesiology and Intensive Care Medicine of the Berlin Charité University Medical Centre, by conducting a staff survey. These goals for the qualification of specialists stipulate demonstrable competencies in seven areas: expert medical action, efficient collaboration in a team, communications with patients and family, management and organisation, lifelong learning, professional behaviour, and advocacy of good health. We had previously developed a catalogue of curriculum items based on these seven core competencies. In order to evaluate the validity of this catalogue, we surveyed anaesthetists at our department in regard to their perception of the importance of each of these items. In addition to the descriptive acquisition of data, it was intended to assess the results of the survey to ascertain whether there were differences in the evaluation of these objectives by specialists and registrars.
Methods: The questionnaire with the seven adapted CanMEDS Roles included items describing each of their underlying competencies. Each anaesthetist (registrars and specialists) working at our institution in May of 2007 was asked to participate in the survey. Individual perception of relevance was rated for each item on a scale similar to the Likert system, ranging from 1 (highly relevant) to 5 (not at all relevant), from which ratings means were calculated. For determination of reliability, we calculated Cronbach’s alpha. To assess differences between subgroups, we performed analysis of variance.
Results: All seven roles were rated as relevant. Three of the seven competency goals (expert medical action, efficient collaboration in a team, and communication with patients and family) achieved especially high ratings. Only a few items differed significantly in their average rating between specialists and registrars.
Conclusions: We succeeded in validating the relevance of the adapted seven CanMEDS competencies for residency training within our institution. So far, many countries have adopted the Canadian Model, which indicates the great practicability of this competency-based model in curriculum planning. Roles with higher acceptance should be prioritised in existing curricula. It would be desirable to develop and validate a competency-based curriculum for specialty training in anaesthesiology throughout Germany by conducting a national survey to include specialists as well as registrars in curriculum development.
doi:10.3205/000146
PMCID: PMC3172723  PMID: 21921997
clinical competence; physicians; medical education; questionnaires; attitude of health personnel; curriculum
10.  Changes in medicine course curricula in Brazil encouraged by the Program for the Promotion of Medical School Curricula (PROMED) 
Background
The Program for the Promotion of Changes in Medical School Curricula (PROMED) was developed by the Brazilian Ministries of Health and Education. The objective of this program was to finance the implementation of changes to the curricula of medical schools directed towards the Brazilian national healthcare system (SUS). This paper reports research carried out together with the coordinators responsible for the PROMED of each medical school approved, in which interviews were used to evaluate whether this financial support succeeded in stimulating changes. The aim of this study was to evaluate the impact of this program three years after implementation in the universities that received funding.
Methods
The 19 course coordinators of the medical schools in which the PROMED project was implemented were interviewed using a questionnaire containing 12 questions for qualitative analysis. This paper focuses partially on the reports of the results of this qualitative analysis. Laurence Bardin's.
Results
The universities interviewed were found to have some common concerns: the decoupling of basic and professional training difficulties in achieving proximity to the network of services; insufficient funding; and the emphasis of most teachers being on teaching hospitals and specialization. These findings indicate that the direction of curriculum reform (PROMED) is toward providing a targeted training for this system.
Conclusion
The interviewees were aware that this program would trigger future changes in all aspects of healthcare and represents an ongoing challenge to the academic field. PROMED provided the momentum for change in the nature of medical training in Brazil and was seen as powerful enough to override other processes and as a basis for guidance regarding the methodology, pedagogical approach and scenarios of practical experience.
doi:10.1186/1472-6920-8-54
PMCID: PMC2633305  PMID: 19038043
11.  GP recruitment and retention: a qualitative analysis of doctors' comments about training for and working in general practice. 
BACKGROUND AND AIMS: General practice in the UK is experiencing difficulty with medical staff recruitment and retention, with reduced numbers choosing careers in general practice or entering principalships, and increases in less-than-full-time working, career breaks, early retirement and locum employment. Information is scarce about the reasons for these changes and factors that could increase recruitment and retention. The UK Medical Careers Research Group (UKMCRG) regularly surveys cohorts of UK medical graduates to determine their career choices and progression. We also invite written comments from respondents about their careers and the factors that influence them. Most respondents report high levels of job satisfaction. A noteworthy minority, however, make critical comments about general practice. Although their views may not represent those of all general practitioners (GPs), they nonetheless indicate a range of concerns that deserve to be understood. This paper reports on respondents' comments about general practice. ANALYSIS OF DOCTORS' COMMENTS: Training Greater exposure to general practice at undergraduate level could help to promote general practice careers and better inform career decisions. Postgraduate general practice training in hospital-based posts was seen as poor quality, irrelevant and run as if it were of secondary importance to service commitments. In contrast, general practice-based postgraduate training was widely praised for good formal teaching that met educational needs. The quality of vocational training was dependent upon the skills and enthusiasm of individual trainers. Recruitment problems Perceived deterrents to choosing general practice were its portrayal, by some hospital-based teachers, as a second class career compared to hospital medicine, and a perception of low morale amongst current GPs. The choice of a career in general practice was commonly made for lifestyle reasons rather than professional aspirations. Some GPs had encountered difficulties in obtaining posts in general practice suited to their needs, while others perceived discrimination. Newly qualified GPs often sought work as non-principals because they felt too inexperienced for partnership or because their domestic situation prevented them from settling in a particular area. Changes to general practice The 1990 National Health Service (NHS) reforms were largely viewed unfavourably, partly because they had led to a substantial increase in GPs' workloads that was compounded by growing public expectations, and partly because the two-tier system of fund-holding was considered unfair. Fund-holding and, more recently, GP commissioning threatened the GP's role as patient advocate by shifting the responsibility for rationing of health care from government to GPs. Some concerns were also expressed about the introduction of primary care groups (PCGs) and trusts (PCTs). Together, increased workload and the continual process of change had, for some, resulted in work-related stress, low morale, reduced job satisfaction and quality of life. These problems had been partially alleviated by the formation of GP co-operatives. Retention difficulties Loss of GPs' time from the NHS workforce occurs in four ways: reduced working hours, temporary career breaks, leaving the NHS to work elsewhere and early retirement. Child rearing and a desire to pursue interests outside medicine were cited as reasons for seeking shorter working hours or career breaks. A desire to reduce pressure of work was a common reason for seeking shorter working hours, taking career breaks, early retirement or leaving NHS general practice. Other reasons for leaving NHS general practice, temporarily or permanently, were difficulty in finding a GP post suited to individual needs and a desire to work abroad. CONCLUSIONS: A cultural change amongst medical educationalists is needed to promote general practice as a career choice that is equally attractive as hospital practice. The introduction of Pre-Registration House Officer (PRHO) placements in general practice and improved flexibility of GP vocational training schemes, together with plans to improve the quality of Senior House Officer (SHO) training in the future, are welcome developments and should address some of the concerns about poor quality GP training raised by our respondents. The reluctance of newly qualified GPs to enter principalships, and the increasing demand from experienced GPs for less-than-full-time work, indicates a need for a greater variety of contractual arrangements to reflect doctors' desires for more flexible patterns of working in general practice.
PMCID: PMC2560447  PMID: 12049026
12.  Evaluation of a novel nutrition education intervention for medical students from across England 
BMJ Open  2012;2(1):e000417.
Objectives
Problems such as hospital malnutrition (∼40% prevalence in the UK) may be managed better by improving the nutrition education of ‘tomorrow's doctors’. The Need for Nutrition Education Programme aimed to measure the effectiveness and acceptability of an educational intervention on nutrition for medical students in the clinical phase of their training.
Design
An educational needs analysis was followed by a consultative process to gain consensus on a suitable educational intervention. This was followed by two identical 2-day educational interventions with before and after analyses of Knowledge, Attitudes and Practices (KAP). The 2-day training incorporated six key learning outcomes.
Setting
Two constituent colleges of Cambridge University used to deliver the above educational interventions.
Participants
An intervention group of 100 clinical medical students from 15 medical schools across England were recruited to attend one of two identical intensive weekend workshops.
Primary and secondary outcome measures
The primary outcome measure consisted of change in KAP scores following intervention using a clinical nutrition questionnaire. Secondary outcome measures included change in KAP scores 3 months after the intervention as well as a student-led semiqualitative evaluation of the educational intervention.
Results
Statistically significant changes in KAP scores were seen immediately after the intervention, and this was sustained for 3 months. Mean differences and 95% CIs after intervention were Knowledge 0.86 (0.43 to 1.28); Attitude 1.68 (1.47 to 1.89); Practice 1.76 (1.11 to 2.40); KAP 4.28 (3.49 to 5.06). Ninety-seven per cent of the participants rated the overall intervention and its delivery as ‘very good to excellent’, reporting that they would recommend this educational intervention to colleagues.
Conclusion
Need for Nutrition Education Programme has highlighted the need for curricular innovation in the area of clinical health nutrition in medical schools. This project also demonstrates the effectiveness and acceptability of such a curriculum intervention for ‘tomorrow's doctors’. Doctors, dietitians and nutritionists worked well in an effective interdisciplinary partnership when teaching medical students, providing a good model for further work in a healthcare setting.
Article summary
Article focus
Hospital malnutrition has been a challenge for decades in the UK due to its cost and impact on patient care.
The focus was to examine whether a novel 2-day course could make a significant improvement in the understanding of clinical nutrition, among senior medical students.
Key messages
This study summarised the need for improved training in clinical nutrition among medical students in England, a need noted in other countries too.
Statistically significant changes in KAP scores were seen immediately after the intervention among the 98 students, and this was sustained for 3 months.
Ninety-seven per cent of the participants rated the overall intervention and its delivery as ‘very good to excellent’, reporting that they would recommend this educational intervention to colleagues.
Strengths and limitations of this study
The learning outcomes seemed appropriate and the teaching intervention appeared effective.
A multidisciplinary teaching team helped emphasise the roles of various team members, in dealing with nutrition-related problems in a healthcare setting.
Comparing change to a parallel student control group would have been preferable to monitoring within-group change.
doi:10.1136/bmjopen-2011-000417
PMCID: PMC3277906  PMID: 22327628
13.  Improving hospital doctors' working lives: online questionnaire survey of all grades 
Postgraduate Medical Journal  2005;81(951):49-54.
Background: In 2001, the Department of Health produced the Improving Working Lives (IWL) for Doctors document. This is the first national survey which asks hospital doctors what changes are needed to improve their working lives.
Methods: An online questionnaire was run over a period of six weeks and was open to all doctors of all grades. Doctors were asked to choose their top five factors from a list of 35 diverse choices or to provide alternatives in free text. Demographic data were also collected.
Results: 1603 hospital doctors working in the UK completed the online questionnaire. Improved secretarial or managerial support was the first IWL choice for consultants, with different aspects of clinical and non-clinical support representing their top four choices. Junior hospital doctors and staff and associate specialist grades (staff grades, associate specialists, and clinical assistants) identified improved support for education and training as their first choice, while among the female specialist registrars, it was improved support for childcare.
Greater opportunities to develop new skills was an important issue for doctors in the surgical specialties and improved access to mentoring was important for all junior doctors, staff and associate specialist grades, and doctors from black and ethnic minority groups.
Conclusions: Hospital doctors in the UK need more support to improve their working lives. The principle needs are better secretarial and managerial support for consultants; education, training, and mentoring for junior doctors and staff and associate specialist grades; and improved opportunities to develop new skills for those in surgical specialties. Support with childcare is an important issue for female specialist registrars. The Department of Health, NHS trusts, deaneries, and Royal Colleges need to endorse policies that promote a training and working environment that will improve working lives for all hospital doctors, ensuring that appropriate and continuing support is available from the time doctors enter the new foundation programmes and proposed run-through grades, to their time spent as consultants in today's NHS.
doi:10.1136/pgmj.2004.029512
PMCID: PMC1743185  PMID: 15640429
14.  The resident-as-teacher educational challenge: a needs assessment survey at the National Autonomous University of Mexico Faculty of Medicine 
BMC Medical Education  2010;10:17.
Background
The role of residents as educators is increasingly recognized, since it impacts residents, interns, medical students and other healthcare professionals. A widespread implementation of resident-as-teacher courses in developed countries' medical schools has occurred, with variable results. There is a dearth of information about this theme in developing countries. The National Autonomous University of Mexico (UNAM) Faculty of Medicine has more than 50% of the residency programs' physician population in Mexico. This report describes a needs assessment survey for a resident as teacher program at our institution.
Methods
A cross-sectional descriptive survey was developed based on a review of the available literature and discussion by an expert multidisciplinary committee. The goal was to identify the residents' attitudes, academic needs and preferred educational strategies regarding resident-as-teacher activities throughout the residency. The survey was piloted and modified accordingly. The paper anonymous survey was sent to 7,685 residents, the total population of medical residents in UNAM programs in the country.
Results
There was a 65.7% return rate (5,186 questionnaires), a broad and representative sample of the student population. The residents felt they had knowledge and were competent in medical education, but the majority felt a need to improve their knowledge and skills in this discipline. Most residents (92.5%) felt that their role as educators of medical students, interns and other residents was important/very important. They estimated that 45.5% of their learning came from other residents. Ninety percent stated that it was necessary to be trained in teaching skills. The themes identified to include in the educational intervention were mostly clinically oriented. The educational strategies in order of preference were interactive lectures with a professor, small groups with a moderator, material available in a website for self-learning, printed material for self-study and homework, and small group web-based learning.
Conclusions
There is a large unmet need to implement educational interventions to improve residents' educational skills in postgraduate educational programs in developing countries. Most perceived needs of residents are practical and clinically oriented, and they prefer traditional educational strategies. Resident as teachers educational interventions need to be designed taking into account local needs and resources.
doi:10.1186/1472-6920-10-17
PMCID: PMC2830225  PMID: 20156365
15.  Training evaluation: a case study of training Iranian health managers 
Background
The Ministry of Health and Medical Education in the Islamic Republic of Iran has undertaken a reform of its health system, in which-lower level managers are given new roles and responsibilities in a decentralized system. To support these efforts, a United Kingdom-based university was contracted by the World Health Organization to design a series of courses for health managers and trainers. This process was also intended to develop the capacity of the National Public Health Management Centre in Tabriz, Iran, to enable it to organize relevant short courses in health management on a continuing basis. A total of seven short training courses were implemented, three in the United Kingdom and four in Tabriz, with 35 participants. A detailed evaluation of the courses was undertaken to guide future development of the training programmes.
Methods
The Kirkpatrick framework for evaluation of training was used to measure participants' reactions, learning, application to the job, and to a lesser extent, organizational impact. Particular emphasis was put on application of learning to the participants' job. A structured questionnaire was administered to 23 participants, out of 35, between one and 13 months after they had attended the courses. Respondents, like the training course participants, were predominantly from provincial universities, with both health system and academic responsibilities. Interviews with key informants and ex-trainees provided supplemental information, especially on organizational impact.
Results
Participants' preferred interactive methods for learning about health planning and management. They found the course content to be relevant, but with an overemphasis on theory compared to practical, locally-specific information. In terms of application of learning to their jobs, participants found specific information and skills to be most useful, such as health systems research and group work/problem solving. The least useful areas were those that dealt with training and leadership. Participants reported little difficulty in applying learning deemed "useful", and had applied it often. In general, a learning area was used less when it was found difficult to apply, with a few exceptions, such as problem-solving. Four fifths of respondents claimed they could perform their jobs better because of new skills and more in-depth understanding of health systems, and one third had been asked to train their colleagues, indicating a potential for impact on their organization. Interviews with key informants indicated that job performance of trainees had improved.
Conclusion
The health management training programmes in Iran, and the external university involved in capacity building, benefited from following basic principles of good training practice, which incorporated needs assessment, selection of participants and definition of appropriate learning outcomes, course content and methods, along with focused evaluation. Contracts for external assistance should include specific mention of capacity building, and allow for the collaborative development of courses and of evaluation plans, in order to build capacity of local partners throughout the training cycle. This would also help to develop training content that uses material from local health management situations to demonstrate key theories and develop locally required skills. Training evaluations should as a minimum assess participants' reactions and learning for every course. Communication of evaluation results should be designed to ensure that data informs training activities, as well as the health and human resources managers who are investing in the development of their staff.
doi:10.1186/1478-4491-7-20
PMCID: PMC2654422  PMID: 19265528
16.  The national portfolio for postgraduate family medicine training in South Africa: a descriptive study of acceptability, educational impact, and usefulness for assessment 
BMC Medical Education  2013;13:101.
Background
Since 2007 a portfolio of learning has become a requirement for assessment of postgraduate family medicine training by the Colleges of Medicine of South Africa. A uniform portfolio of learning has been developed and content validity established among the eight postgraduate programmes. The aim of this study was to investigate the portfolio’s acceptability, educational impact, and perceived usefulness for assessment of competence.
Methods
Two structured questionnaires of 35 closed and open-ended questions were delivered to 53 family physician supervisors and 48 registrars who had used the portfolio. Categorical and nominal/ordinal data were analysed using simple descriptive statistics. The open-ended questions were analysed with ATLAS.ti software.
Results
Half of registrars did not find the portfolio clear, practical or feasible. Workshops on portfolio use, learning, and supervision were supported, and brief dedicated time daily for reflection and writing. Most supervisors felt the portfolio reflected an accurate picture of learning, but just over half of registrars agreed. While the portfolio helped with reflection on learning, participants were less convinced about how it helped them plan further learning. Supervisors graded most rotations, suggesting understanding the summative aspect, while only 61% of registrars reflected on rotations, suggesting the formative aspects are not yet optimally utilised. Poor feedback, the need for protected academic time, and pressure of service delivery impacting negatively on learning.
Conclusion
This first introduction of a national portfolio for postgraduate training in family medicine in South Africa faces challenges similar to those in other countries. Acceptability of the portfolio relates to a clear purpose and guide, flexible format with tools available in the workplace, and appreciating the changing educational environment from university-based to national assessments. The role of the supervisor in direct observations of the registrar and dedicated educational meetings, giving feedback and support, cannot be overemphasized.
doi:10.1186/1472-6920-13-101
PMCID: PMC3733709  PMID: 23885806
17.  Addressing Assessment in Libyan Medical Education 
Assessment is a powerful driver of student learning: it gives a message to learners about what they should be learning, what the learning organisation believes to be important, and how they should go about learning. Assessment tools allow measurement of student achievement and thereby give teachers insight into their students' learning, and enable teachers to make systematic judgements about progress and achievement. It is vital then that assessment tools drive students to learn the right things as well as measure student learning appropriately. Any attempts to reform curricula and teaching methods must consider the role of assessment in the learning process.
Libyan doctors and medical students have been calling for changes to teaching and assessment methods at undergraduate and postgraduate levels. A team from the Academic Centre for Medical Education at University College, London have been running workshops in conjunction with the Libyan Board of Medical Specialties since 2006 to discuss strategic aims of assessment in medical education in Libya for the 21st century and to deliver an assessment skills course to Libyan educators. This article outlines the course and the outcomes of preliminary discussions between academics from the UK, participants in the assessment courses and representatives from the Libyan Board of Medical Specialties. As a result of these discussions it was agreed by all that Libyan Medical School assessment methods need updating and, despite significant challenges, changes in assessment must be made as soon as possible. There is a real need for support in both addressing these changes and for practical training for assessors in contemporary assessment methods.
doi:10.4176/081020
PMCID: PMC3066704  PMID: 21483506
Education; Medical; Educational measurement; Libya
18.  Maximising harm reduction in early specialty training for general practice: validation of a safety checklist 
BMC Family Practice  2012;13:62.
Background
Making health care safer is a key policy priority worldwide. In specialty training, medical educators may unintentionally impact on patient safety e.g. through failures of supervision; providing limited feedback on performance; and letting poorly developed behaviours continue unchecked. Doctors-in-training are also known to be susceptible to medical error. Ensuring that all essential educational issues are addressed during training is problematic given the scale of the tasks to be undertaken. Human error and the reliability of local systems may increase the risk of safety-critical topics being inadequately covered. However adherence to a checklist reminder may improve the reliability of task delivery and maximise harm reduction. We aimed to prioritise the most safety-critical issues to be addressed in the first 12-weeks of specialty training in the general practice environment and validate a related checklist reminder.
Methods
We used mixed methods with different groups of GP educators (n = 127) and specialty trainees (n = 9) in two Scottish regions to prioritise, develop and validate checklist content. Generation and refinement of checklist themes and items were undertaken on an iterative basis using a range of methods including small group work in dedicated workshops; a modified-Delphi process; and telephone interviews. The relevance of potential checklist items was rated using a 4-point scale content validity index to inform final inclusion.
Results
14 themes (e.g. prescribing safely; dealing with medical emergency; implications of poor record keeping; and effective & safe communication) and 47 related items (e.g. how to safety-net face-to-face or over the telephone; knowledge of practice systems for results handling; recognition of harm in children) were judged to be essential safety-critical educational issues to be covered. The mean content validity index ratio was 0.98.
Conclusion
A checklist was developed and validated for educational supervisors to assist in the reliable delivery of safety-critical educational issues in the opening 12-week period of training, and aligned with national curriculum competencies. The tool can also be adapted for use as a self-assessment instrument by trainees to guide patient safety-related learning needs. Dissemination and implementation of the checklist and self-rating scale are proceeding on a national, voluntary basis with plans to evaluate its feasibility and educational impact.
doi:10.1186/1471-2296-13-62
PMCID: PMC3418214  PMID: 22721273
19.  Evaluation of specialists' outreach clinics in general practice in England: process and acceptability to patients, specialists, and general practitioners. 
OBJECTIVES: The wider study aimed to evaluate specialists' outreach clinics in relation to their costs, processes, and effectiveness, including patients' and professionals' attitudes. The data on processes and attitudes are presented here. DESIGN: Self administered questionnaires were drawn up for patients, their general practitioners (GPs) and specialists, and managers in the practice. Information was sought from hospital trusts. The study formed a pilot phase prior to a wider evaluation. SETTING: Nine outreach clinics in general practices in England, each with a hospital outpatient department as a control clinic were studied. SUBJECTS: The specialties included were ear, nose, and throat surgery; rheumatology; and gynaecology. The subjects were the patients who attended either the outreach clinics or hospital outpatients clinics during the study period, the outreach patients' GPs, the outreach patients' and outpatients' specialists, the managers in the practices, and the NHS trusts which employed the specialists. MAIN OUTCOME MEASURES: Process items included waiting lists, waiting times in clinics, number of follow up visits, investigations and procedures performed, treatment, health status, patients' and specialists' travelling times, and patients' and doctors' attitudes to, and satisfaction with, the clinic. RESULTS: There was no difference in the health status of patients in relation to the clinic site (ie, outreach and hospital outpatients' clinics) at baseline, and all but one of the specialists said there were no differences in casemix between their outreach and outpatients' clinics. Patients preferred, and were more satisfied with, care in specialists' outreach clinics in general practice, in comparison with outpatients' clinics. The outreach clinics were rated as more convenient than outpatients' clinics in relation to journey times; those outreach patients in work lost less time away from work than outpatients' clinic patients due to the clinic attendance. Length of time on the waiting list was significantly reduced for gynaecology patients; waiting times in clinics were lower for outreach patients than outpatients across all specialties. In addition, outreach patients were more likely to be first rather than follow up attenders; rheumatology outreach patients were more likely than hospital outpatients to receive therapy. GPs' referrals to hospital outpatients' clinics were greatly reduced by the availability of outreach clinics. Both specialists and GPs saw the main advantages of outreach clinics in relation to the greater convenience and better access to care for patients. Few of the specialists and GPs in the outreach practices held formal training and education sessions in the outreach clinic, although over half of the GPs felt that their skills/expertise had broadened as a result of the outreach clinic. CONCLUSIONS: The processes of care (waiting times, patient satisfaction, convenience to patients, follow up attendances) were better in outreach than in outpatients' clinics. However, waiting lists were only significantly reduced for gynaecology patients, despite both GPs and consultants reporting reduced waiting lists for patients as one of the main advantages of outreach. Whether these improvements merit the increased cost to the specialists (in terms of their increased travelling times and time spent away from their hospital base) and whether the development of what is, in effect, two standards of care between practices with and without outreach can be stemmed and the standard of care raised in all practices (eg, by sharing outreach clinics between GPs in an area) remain the subject of debate. As the data were based on the pilot study, the results should be viewed with some caution, although statistical power was adequate for comparisons of sites if not specialties.
PMCID: PMC1060410  PMID: 9135789
20.  Fellows as teachers: a model to enhance pediatric resident education 
Medical Education Online  2011;16:10.3402/meo.v16i0.7205.
Objective
Pressures on academic faculty to perform beyond their role as educators has stimulated interest in complementary approaches in resident medical education. While fellows are often believed to detract from resident learning and experience, we describe our preliminary investigations utilizing clinical fellows as a positive force in pediatric resident education. Our objectives were to implement a practical approach to engage fellows in resident education, evaluate the impact of a fellow-led education program on pediatric resident and fellow experience, and investigate if growth of a fellowship program detracts from resident procedural experience.
Methods
This study was conducted in a neonatal intensive care unit (NICU) where fellows designed and implemented an education program consisting of daily didactic teaching sessions before morning clinical rounds. The impact of a fellow-led education program on resident satisfaction with their NICU experience was assessed via anonymous student evaluations. The potential value of the program for participating fellows was also evaluated using an anonymous survey.
Results
The online evaluation was completed by 105 residents. Scores were markedly higher after the program was implemented in areas of teaching excellence (4.44 out of 5 versus 4.67, p<0.05) and overall resident learning (3.60 out of 5 versus 4.61, p<0.001). Fellows rated the acquisition of teaching skills and enhanced knowledge of neonatal pathophysiology as the most valuable aspects of their participation in the education program. The anonymous survey revealed that 87.5% of participating residents believed that NICU fellows were very important to their overall training and education.
Conclusions
While fellows are often believed to be a detracting factor to residency training, we found that pediatric resident attitudes toward the fellows were generally positive. In our experience, in the specialty of neonatology a fellow-led education program can positively contribute to both resident and fellow learning and satisfaction. Further investigation into the value of utilizing fellows as a positive force in resident education in other medical specialties appears warranted.
doi:10.3402/meo.v16i0.7205
PMCID: PMC3169169  PMID: 21912479
resident education; fellow teaching; pediatrics
21.  The training and professional expectations of medical students in Angola, Guinea-Bissau and Mozambique 
Background
The purpose of this paper is to describe and analyze the professional expectations of medical students during the 2007-2008 academic year at the public medical schools of Angola, Guinea-Bissau and Mozambique, and to identify their social and geographical origins, their professional expectations and difficulties relating to their education and professional future.
Methods
Data were collected through a standardised questionnaire applied to all medical students registered during the 2007-2008 academic year.
Results
Students decide to study medicine at an early age. Relatives and friends seem to have an especially important influence in encouraging, reinforcing and promoting the desire to be a doctor.
The degree of feminization of the student population differs among the different countries.
Although most medical students are from outside the capital cities, expectations of getting into medical school are already associated with migration from the periphery to the capital city, even before entering medical education.
Academic performance is poor. This seems to be related to difficulties in accessing materials, finances and insufficient high school preparation.
Medical students recognize the public sector demand but their expectations are to combine public sector practice with private work, in order to improve their earnings. Salary expectations of students vary between the three countries.
Approximately 75% want to train as hospital specialists and to follow a hospital-based career. A significant proportion is unsure about their future area of specialization, which for many students is equated with migration to study abroad.
Conclusions
Medical education is an important national investment, but the returns obtained are not as efficient as expected. Investments in high-school preparation, tutoring, and infrastructure are likely to have a significant impact on the success rate of medical schools. Special attention should be given to the socialization of students and the role model status of their teachers.
In countries with scarce medical resources, the hospital orientation of students' expectations is understandable, although it should be associated with the development of skills to coordinate hospital work with the network of peripheral facilities. Developing a local postgraduate training capacity for doctors might be an important strategy to help retain medical doctors in the home country.
doi:10.1186/1478-4491-9-9
PMCID: PMC3079608  PMID: 21473778
22.  A Model for Persistent Improvement of Medical Education as Illustrated by the Surgical Reform Curriculum HeiCuMed 
Background: Heidelberg Medical School underwent a major curricular change with the implementation of the reform curriculum HeiCuMed (Heidelberg Curriculum Medicinale) in October 2001. It is based on rotational modules with daily cycles of interactive, case-based small-group seminars, PBL tutorials and training of sensomotor and communication skills. For surgical undergraduate training an organisational structure was developed that ensures continuity of medical teachers for student groups and enables their unimpaired engagement for defined periods of time while accounting for the daily clinical routine in a large surgery department of a university hospital. It includes obligatory didactic training, standardising teaching material on the basis of learning objectives and releasing teaching doctors from clinical duties for the duration of a module.
Objective: To compare the effectiveness of the undergraduate surgical reform curriculum with that of the preceding traditional one as reflected by students' evaluations.
Method: The present work analyses student evaluations of the undergraduate surgical training between 1999 and 2008 including three cohorts (~360 students each) in the traditional curriculum and 13 cohorts (~150 students each) in the reform curriculum.
Results: The evaluation of the courses, their organisation, the teaching quality, and the subjective learning was significantly better in HeiCuMed than in the preceding traditional curriculum over the whole study period.
Conclusion: A medical curriculum based on the implementation of interactive didactical methods is more important to successful teaching and the subjective gain of knowledge than knowledge transfer by traditional classroom teaching. The organisational strategy adopted in the surgical training of HeiCuMed has been successful in enabling the maintenance of a complex modern curriculum on a continuously high level within the framework of a busy surgical environment.
doi:10.3205/zma000741
PMCID: PMC3149464  PMID: 21818239
Medical education; undergraduate surgery curriculum; evaluation
23.  Current Status and Future Prospects of Clinical Psycholog 
SUMMARY
The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective–disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional–economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions.
Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so.
Clinical psychologists’ failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today’s clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student–faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge.
A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands highquality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer highquality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health.
doi:10.1111/j.1539-6053.2009.01036.x
PMCID: PMC2943397  PMID: 20865146
24.  A cluster randomized controlled trial to evaluate the effectiveness of the clinically integrated RHL evidence -based medicine course 
Background and objectives
Evidence-based health care requires clinicians to engage with use of evidence in decision-making at the workplace. A learner-centred, problem-based course that integrates e-learning in the clinical setting has been developed for application in obstetrics and gynaecology units. The course content uses the WHO reproductive health library (RHL) as the resource for systematic reviews. This project aims to evaluate a clinically integrated teaching programme for incorporation of evidence provided through the WHO RHL. The hypothesis is that the RHL-EBM (clinically integrated e-learning) course will improve participants' knowledge, skills and attitudes, as well as institutional practice and educational environment, as compared to the use of standard postgraduate educational resources for EBM teaching that are not clinically integrated.
Methods
The study will be a multicentre, cluster randomized controlled trial, carried out in seven countries (Argentina, Brazil, Democratic Republic of Congo, India, Philippines, South Africa, Thailand), involving 50-60 obstetrics and gynaecology teaching units. The trial will be carried out on postgraduate trainees in the first two years of their training. In the intervention group, trainees will receive the RHL-EBM course. The course consists of five modules, each comprising self-directed e-learning components and clinically related activities, assignments and assessments, coordinated between the facilitator and the postgraduate trainee. The course will take about 12 weeks, with assessments taking place pre-course and 4 weeks post-course. In the control group, trainees will receive electronic, self-directed EBM-teaching materials. All data collection will be online.
The primary outcome measures are gain in EBM knowledge, change in attitudes towards EBM and competencies in EBM measured by multiple choice questions (MCQs) and a skills-assessing questionniare administered eletronically. These questions have been developed by using questions from validated questionnaires and adapting them to the current course. Secondary outcome measure will be educational environment towards EBM which will be assessed by a specifically developed questionnaire.
Expected outcomes
The trial will determine whether the RHL EBM (clinically integrated e-leraning) course will increase knowledge, skills and attitudes towards EBM and improve the educational environment as compared to standard teaching that is not clinically integrated. If effective, the RHL-EBM course can be implemented in teaching institutions worldwide in both, low-and middle income countries as well as industrialized settings. The results will have a broader impact than just EBM training because if the approach is successful then the same educational strategy can be used to target other priority clinical and methodological areas.
Trial Registration
ACTRN12609000198224
doi:10.1186/1742-4755-7-8
PMCID: PMC2880979  PMID: 20470382
25.  Train the Trainer for general practice trainer - a report of the pilot within the programme Verbundweiterbildungplus 
Background: Since 2008 the Verbundweiterbildungplus programme of the Competence Centre General Practice Baden-Wuerttemberg offers continual improvement with regards to content and structure of general practice training. The programme uses the didactical concept of the CanMEDs competencies, which were developed in Canada, as a postgraduate medical training framework. Train the trainer (TTT)-programmes are an additional important element of these contentual optimisations of postgraduate training. Within this article we describe the conception and evaluation of the first TTT-workshop within the programme Verbundweiterbildungplus.
Methods: The conception of the first TTT-workshop was influenced by results of a survey of general practitioner (GP) trainers and by experiences with teaching GP trainers involved in medical undergraduate teaching. A questionnaire was designed to get a self-assessment about organisational and didactic aspects oriented on the CanMEDs competencies of postgraduate medical training. In addition, the workshop was evaluated by the participants.
Results: The workshop lasted 12 teaching units and included the following elements: introduction into the CanMEDs competencies, feedback training, fault management, legal and organisational aspects of post graduate training. From the 29 participating trainers 76% were male and on average 57 years old. The evaluation showed a good to very good acceptance of the workshop. Initial self-rating showed the need of improving in the fields of determining learning objectives, providing formative feedback and incorporation of a trainee. Most trainers rated themselves as very good in procure CanMEDs competencies with the exclusion of the competencies “Manager“ and “Scholar“.
Conclusion: A TTT-programme is an important method to improve GP training which has not been used in Germany so far. Such a GP TTT-programme should highlight especially training in providing feedback and teaching in management aspects. Results of this article add information that can be used for developing TTT-programmes also in other specialties.
doi:10.3205/zma000813
PMCID: PMC3374139  PMID: 22737198
General Practice; Train the Trainer; Feedback Training; Management; Postgraduate Medical Training

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