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1.  Development of a 'toolkit' to identify medical students at risk of failure to thrive on the course: an exploratory retrospective case study 
BMC Medical Education  2011;11:95.
Background
An earlier study at Nottingham suggested that 10-15% of the medical student intake was likely to fail completely or have substantial problems on the course. This is a problem for the students, the Faculty, and society as a whole. If struggling students could be identified early in the course and additional pastoral resources offered, some of this wastage might be avoided. An exploratory case study was conducted to determine whether there were common indicators in the early years, over and above academic failure, that might aid the identification of students potentially at risk.
Methods
The study group was drawn from five successive cohorts. Students who had experienced difficulties were identified in any of four ways: from Minutes of the Academic Progress Committee; by scanning examination lists at key stages (end of the first two years, and finals at the end of the clinical course); from lists of students flagged to the Postgraduate Deanery as in need of extra monitoring or support; and from progress files of those who had left the course prematurely. Relevant data were extracted from each student's course progress file into a customised database.
Results
1188 students were admitted over the five years. 162 (14%) were identified for the study, 75 of whom had failed to complete the course by October 2010. In the 87 who did graduate, a combination of markers in Years 1 and 2 identified over half of those who would subsequently have the most severe problems throughout the course. This 'toolkit' comprised failure of 3 or more examinations per year, an overall average of <50%, health or social difficulties, failure to complete Hepatitis B vaccination on time, and remarks noted about poor attitude or behaviour.
Conclusions
A simple toolkit of academic and non-academic markers could be used routinely to help identify potential strugglers at an early stage, enabling additional support and guidance to be given to these students.
doi:10.1186/1472-6920-11-95
PMCID: PMC3229499  PMID: 22098629
2.  Profiling strugglers in a graduate-entry medicine course at Nottingham: a retrospective case study 
BMC Medical Education  2012;12:124.
Background
10-15% of students struggle at some point in their medicine course. Risk factors include weaker academic qualifications, male gender, mental illness, UK ethnic minority status, and poor study skills. Recent research on an undergraduate medicine course provided a toolkit to aid early identification of students likely to struggle, who can be targeted by established support and study interventions. The present study sought to extend this work by investigating the number and characteristics of strugglers on a graduate-entry medicine (GEM) programme.
Methods
A retrospective study of four GEM entry cohorts (2003–6) was carried out. All students who had demonstrated unsatisfactory progress or left prematurely were included. Any information about academic, administrative, personal, or social difficulties, were extracted from their course progress files into a customised database and examined.
Results
362 students were admitted to the course, and 53 (14.6%) were identified for the study, of whom 15 (4.1%) did not complete the course. Students in the study group differed from the others in having a higher proportion of 2ii first degrees, and scoring less well on GAMSAT, an aptitude test used for admission. Within the study group, it proved possible to categorise students into the same groups previously reported (struggler throughout, pre-clinical struggler, clinical struggler, health-related struggler, borderline struggler) and to identify the majority using a number of flags for early difficulties. These flags included: missed attendance, unsatisfactory attitude or behaviour, health problems, social/family problems, failure to complete immunity status checks, and attendance at academic progress committee.
Conclusions
Problems encountered in a graduate-entry medicine course were comparable to those reported in a corresponding undergraduate programme. A toolkit of academic and non-academic flags of difficulty can be used for early identification of many who will struggle, and could be used to target appropriate support and interventions.
doi:10.1186/1472-6920-12-124
PMCID: PMC3567936  PMID: 23249471
Graduate-entry medicine struggler identification flags UK
3.  Medical School Attrition-Beyond the Statistics A Ten Year Retrospective Study 
BMC Medical Education  2013;13:13.
Background
Medical school attrition is important - securing a place in medical school is difficult and a high attrition rate can affect the academic reputation of a medical school and staff morale. More important, however, are the personal consequences of dropout for the student. The aims of our study were to examine factors associated with attrition over a ten-year period (2001–2011) and to study the personal effects of dropout on individual students.
Methods
The study included quantitative analysis of completed cohorts and qualitative analysis of ten-year data. Data were collected from individual student files, examination and admission records, exit interviews and staff interviews. Statistical analysis was carried out on five successive completed cohorts. Qualitative data from student files was transcribed and independently analysed by three authors. Data was coded and categorized and key themes were identified.
Results
Overall attrition rate was 5.7% (45/779) in 6 completed cohorts when students who transferred to other medical courses were excluded. Students from Kuwait and United Arab Emirates had the highest dropout rate (RR = 5.70, 95% Confidence Intervals 2.65 to 12.27;p < 0.0001) compared to Irish and EU students combined. North American students had a higher dropout rate than Irish and EU students; RR = 2.68 (1.09 to 6.58;p = 0.027) but this was not significant when transfers were excluded (RR = 1.32(0.38, 4.62);p = 0.75). Male students were more likely to dropout than females (RR 1.70, .93 to 3.11) but this was not significant (p = 0.079).
Absenteeism was documented in 30% of students, academic difficulty in 55.7%, social isolation in 20%, and psychological morbidity in 40% (higher than other studies). Qualitative analysis revealed recurrent themes of isolation, failure, and despair. Student Welfare services were only accessed by one-third of dropout students.
Conclusions
While dropout is often multifactorial, certain red flag signals may alert us to risk of dropout including non-EU origin, academic struggling, absenteeism, social isolation, depression and leave of absence. Psychological morbidity amongst dropout students is high and Student Welfare services should be actively promoted. Absenteeism should prompt early intervention. Behind every dropout statistic lies a personal story. All medical schools have a duty of care to support students who leave the medical programme.
doi:10.1186/1472-6920-13-13
PMCID: PMC3565981  PMID: 23363547
Medical school attrition; Dropout; Exit interviews; Student welfare services; Academic difficulty; Absenteeism
4.  Predicting academic outcomes in an Australian graduate entry medical programme 
BMC Medical Education  2014;14:31.
Background
Predictive validity studies for selection criteria into graduate entry courses in Australia have been inconsistent in their outcomes. One of the reasons for this inconsistency may have been failure to have adequately considered background disciplines of the graduates as well as other potential confounding socio-demographic variables that may influence academic performance.
Methods
Graduate entrants into the MBBS at The University of Western Australia between 2005 and 2012 were studied (N = 421). They undertook a 6-month bridging course, before joining the undergraduate-entry students for Years 3 through 6 of the medical course. Students were selected using their undergraduate Grade Point Average (GPA), Graduate Australian Medical School Admissions Test scores (GAMSAT) and a score from a standardised interview. Students could apply from any background discipline and could also be selected through an alternative rural entry pathway again utilising these 3 entry scores. Entry scores, together with age, gender, discipline background, rural entry status and a socioeconomic indicator were entered into linear regression models to determine the relative influence of each predictor on subsequent academic performance in the course.
Results
Background discipline, age, gender and selection through the rural pathway were variously related to each of the 3 entry criteria. Their subsequent inclusion in linear regression models identified GPA at entry, being from a health/allied health background and total GAMSAT score as consistent independent predictors of stronger academic performance as measured by the weighted average mark for the core units completed throughout the course. The Interview score only weakly predicted performance later in the course and mainly in clinically-based units. The association of total GAMSAT score with academic performance was predominantly dictated by the score in GAMSAT Section 3 (Reasoning in the biological and physical sciences) with Section 1 (Reasoning in the humanities and social sciences) and Section 2 (Written communication) also contributing either later or early in the course respectively. Being from a more disadvantaged socioeconomic background predicted weaker academic performance early in the course. Being an older student at entry or from a humanities background also predicted weaker academic performance.
Conclusions
This study confirms that both GPA at entry and the GAMSAT score together predict outcomes not only in the early stages of a graduate-entry medical programme but throughout the course. It also indicates that a comprehensive evaluation of the predictive validity of GAMSAT scores, interview scores and undergraduate academic performance as valid selection processes for graduate entry into medical school needs to simultaneously consider the potential confounding influence of graduate discipline background and other socio-demographic factors on both the initial selection parameters themselves as well as subsequent academic performance.
doi:10.1186/1472-6920-14-31
PMCID: PMC3931285  PMID: 24528509
5.  Attrition Rates Between Residents in Obstetrics and Gynecology and Other Clinical Specialties, 2000–2009 
Background
As resident attrition disrupts educational and workload balance and reduces the number of graduating physicians to care for patients, an ongoing goal of graduate medical education programs is to retain residents.
Objective
We compared annual rates of resident attrition in obstetrics and gynecology (Ob-Gyn) with other clinical specialties of similar or larger size during a recent 10-year period, and explored the reasons for resident attrition.
Methods
In this observational study, we analyzed annual data from the American Medical Association Graduate Medical Education Census between academic years 2000 and 2009 for residents who entered Ob-Gyn and other core clinical specialties. Our primary outcome was the trend in averaged annual attrition rates.
Results
The average annual attrition was 196 ± 12 (SD) residents, representing 4.2% ± 0.5% of all Ob-Gyn residents. Rates of attrition were consistently higher among men (5.3%) and international medical school graduates (7.6%). The annual rate of attrition was similar to that for other clinical specialties (mean: 4.0%; range: from 1.5% in emergency medicine to 7.9% in psychiatry). The attrition rates for Ob-Gyn residents were relatively stable for the 10-year period (range: 3.6% in 2008 to 5.1% in 2006). Common reasons for attrition were transition to another specialty (30.0%), withdrawal/dismissal (28.2%), transfer to another Ob-Gyn program (25.4%), and leave of absence (2.2%). These proportions remained fairly constant during this 10-year period.
Conclusions
The average annual attrition rate of residents in Ob-Gyn was 4.2%, comparable to most other core clinical specialties.
doi:10.4300/JGME-D-12-00141.1
PMCID: PMC3693692  PMID: 24404271
6.  Predictors of Attrition and Academic Success of Medical Students: A 30-Year Retrospective Study 
PLoS ONE  2012;7(6):e39144.
Aim
To determine attrition and predictors of academic success among medical students at University of Split, Croatia.
Methods
We analysed academic records of 2054 students enrolled during 1979–2008 period.
Results
We found that 26% (533/2054) of enrolled students did not graduate. The most common reasons for attrition were ‘personal’ (36.4%), transfer to another medical school (35.6%), and dismissal due to unsatisfactory academic record (21.2%). Grade point average (GPA) and study duration of attrition students were significantly associated with parental education. There were 1126 graduates, 395 men and 731 women. Their average graduation GPA was 3.67±0.53 and study duration 7.6±2.44 years. During 5-year curriculum only 6.4% (42/654) of students graduated in time, and 55% (240/472) of students graduated in time after curriculum was extended to 6 years. Variables predicting whether a student will graduate or not were high school grades, entrance exam score and year of enrollment. Significant predictors of graduation grades were high school grades and entrance exam score. Entrance exam score predicted length of studying.
Conclusion
Preadmission academic qualifications and year of enrollment predict academic success in medical school. More attention should be devoted to high attrition.
doi:10.1371/journal.pone.0039144
PMCID: PMC3377595  PMID: 22737228
7.  Can the 12-item general health questionnaire be used to identify medical students who might ‘struggle’ on the medical course? A prospective study on two cohorts 
BMC Medical Education  2013;13:48.
Background
Students who fail to thrive on the Nottingham undergraduate medical course frequently suffer from anxiety, depression or other mental health problems. These difficulties may be the cause, or the result of, academic struggling. Early detection of vulnerable students might direct pastoral care and remedial support to where it is needed. We investigated the use of the short-form General Health Questionnaire (GHQ-12) as a possible screening tool.
Methods
Two consecutive cohorts (2006 and 2007) were invited to complete the GHQ-12. The questionnaire was administered online, during the second semester (after semester 1 exams) for the 2006 cohort and during the first semester for the 2007 cohort. All data were held securely and confidentially. At the end of the course, GHQ scores were examined in relation to course progress.
Results
251 students entered the course in 2006 and 254 in 2007; 164 (65%) and 160 (63%), respectively, completed the GHQ-12. In both cohorts, the study and non-study groups were very similar in terms of pre-admission socio-demographic characteristics and overall course marks. In the 2006 study group, the GHQ Likert score obtained part-way through the first year was negatively correlated with exam marks during Years 1 and 2, but the average exam mark in semester 1 was the sole independent predictor of marks in semester 2 and Year 2. No correlations were found for the 2007 study group but the GHQ score was a weak positive predictor of marks in semester 2, with semester 1 average exam mark again being the strongest predictor. A post-hoc moderated-mediation analysis suggested that significant negative associations of GHQ scores with semester 1 and 2 exams applied only to those who completed the GHQ after their semester 1 exams. Students who were identified as GHQ ‘cases’ in the 2006 group were statistically less likely to complete the course on time (OR = 4.74, p 0.002). There was a non-significant trend in the same direction in the 2007 group.
Conclusions
Results from two cohorts provide insufficient evidence to recommend the routine use of the GHQ-12 as a screening tool. The timing of administration could have a critical influence on the results, and the theoretical and practical implications of this finding are discussed. Low marks in semester 1 examinations seem be the best single indicator of students at risk for subsequent poor performance.
doi:10.1186/1472-6920-13-48
PMCID: PMC3616988  PMID: 23548161
8.  Some Observations on Attrition of Students from Canadian Medical Schools 
Students who entered their freshman year for the first time in 1958 and in 1959, from all medical schools in Canada, and those entering the four Western schools in 1960 were studied from the time they matriculated until they either graduated or withdrew from medical school. The rate of attrition is about 15% of matriculants each year, with the lowest rate at the University of Western Ontario (1.7%) and the highest at the University of Ottawa (33.6%) over the time period studied. Attrition was classified as academic and non-academic. Significantly higher rates were found in the case of non-academic attrition for women and in the case of academic attrition for Commonwealth students. Significantly higher rates for both types of attrition were found for older students and students who had attended undergraduate colleges different from their medical school colleges. It would appear from available statistics that the factors which combine to produce attrition are the intellectual and personality characteristics of the student, school promotional policies and evaluation methods.
PMCID: PMC1936080  PMID: 6019678
9.  Impact of extended course duration and stricter study organization on attrition and academic performance of medical students 
Croatian Medical Journal  2013;54(2):192-197.
Aim
To assess whether extended medical school duration, block/modular structure of subjects, not allowing students to transfer exams into the higher course year, and curriculum implementation in line with the Bologna Accord are associated with lower attrition and better academic outcomes of medical students.
Methods
We retrospectively investigated curricula at the University of Split School of Medicine and academic outcomes of 2301 medical students during a 33-year period (1979-2011). The following data were obtained: grade point average (GPA) at the end of the studies, duration of studies, graduation on time, and whether the student graduated or not.
Results
After extension of medical curriculum from 5 to 6 years, students had significantly better grades (3.35 vs 3.68; P < 0.001), shorter study duration (7.0 vs 6.0 years; P < 0.001), and more students graduated on time (6.5% vs 57%; P < 0.001). Changes in the 6-year curriculum, such as stricter study regulations and adoption of Bologna Accord, were associated with better indicators of students’ academic success. The lowest attrition and the highest grades during the studied period were observed after the implementation of the Bologna Accord in 2005.
Conclusion
Introduction of a longer medical curriculum, block/modular subject structure, stricter regulations of exam transfer, and curriculum in line with the Bologna Accord may contribute to better academic outcomes and lower attrition of medical students.
doi:10.3325/cmj.2013.54.192
PMCID: PMC3641877  PMID: 23630147
10.  Frequency and Predictors of Courses Repetition, Probation, and Delayed Graduation in Kashan Faculty of Nursing and Midwifery 
Nursing and Midwifery Studies  2013;2(4):89-96.
Background:
Course failing and delayed graduation are important concerns in educational systems. The reasons of these educational failures need to be clarified.
Objectives:
This study was designed to determine the academic failure rate and its predictors in Nursing and Midwifery Students in Kashan University of Medical Sciences.
Materials and Methods:
In this cross-sectional study, the records of all the students graduated in Nursing and Midwifery faculty during 18 years (1986 - 2003) were evaluated (1174 graduates). The demographic variables and the educational situation were recorded. The frequency of course repetition, probation, and delayed graduation were determined and the data were analyzed using the chi-square and logistic regression tests.
Results:
The frequency of course repetition, probation, and delayed graduation was reported to be 19.25%, 3.9% and 19.85%, respectively. Gaining Low grade in high school, transferring from other universities, having special quota, and transferring temporarily to other universities were mentioned as the risk factors of academic failure. The major had a significant relationship with academic failure. Day time students had more course failure and night time students stayed longer in the university.
Conclusions:
The individual characteristics, educational background and admission criteria had showed relation with academic failure. Vulnerable students should be identified and educational supports should be provided for these students.
PMCID: PMC4228902  PMID: 25414885
Educational Measurement; Educational Status; Student Dropouts; Education, Medical
11.  Coherent Learning: Creating High-level Performance and Cultural Empathy From Student to Expert 
Global Advances in Health and Medicine  2014;3(Suppl 1):BPA17.
Background:
Schools of nursing are charged with graduating nursing students who reflect the race and ethnicity of the communities they will serve. A college of nursing in Oklahoma received a grant to do just that for the Native American community in Oklahoma. In 1998, 19 Native American students were admitted to the school; only 12 graduated 2 years later. The rate of attrition for Native American nursing students averaged 57% between 1997 and 2001. The overall attrition rate was approximately 9%.
Methods:
HeartMath trainers were identified and prepared in 2002 and implemented the program in the nursing college in 2003. The program was voluntary for the first year, then became part of new student orientation the next year. Trainings were offered monthly for students and faculty and were available to every student. Laboratory computers were equipped with the Freeze Frame program, and students could practice during school hours. Several faculty also did one-to-one training and practice with students in their offices at student request. Many faculty members did a short HearthMath session that any student could participate in before each test.
Results:
Although only Native American students are reported here, students from all ethnicities and races reported benefits. Following implementation of HeartMath in 2003, the average attrition rate for Native American nursing students between 2003 and 2008 was 37%. During this time, requirements for admission and graduation became more stringent and required increased testing. By 2006, the overall attrition rate for the school was 3% or less. The students reported increased confidence in their test-taking abilities and fewer physical health issues with regular practice of the HeartMath process. Based on test results for all students, it was determined that practicing HeartMath increased test scores by an average of 17 points, thus highly motivating students to practice.
Conclusion:
Native American nursing students using the HeartMath stress-reducing processes demonstrated improved test-taking and perceived physical health and higher graduation rates than those who did not use HeartMath. Use of HeartMath while in school decreased the overall attrition rate by approximately 40% for Native American students over the reported timeframe.
doi:10.7453/gahmj.2014.BPA17
PMCID: PMC3923294
Nursing educatioin; biofeedback; stress reduction; HeartMath
12.  Examination performance of graduate entry medical students compared with mainstream students 
Summary
Objectives
To assess whether medical students on graduate entry/fast- track programmes perform as well as students on standard courses.
Design
Retrospective cohort study.
Setting
University of Birmingham Medical School.
Participants
Medical students on graduate entry/fast-track course and standard (5-year) course (‘mainstream’).
Main outcome measures
Examination marks from all assessments taken simultaneously by graduate entry course (GEC) and mainstream course students once the cohorts have combined: i.e. for the final three years of the programme. Honours awards for 2007 and 2008 graduates.
Results
In total 19,263 examination results were analysed from 1547 students. Of these 161 were GEC students and 1386 were mainstream medical students. On average mainstream students, male students, overseas students and students of South Asian ethnicity obtained lower examination marks than graduate entry students, female students, home or EU students and students of non-South Asian ethnicity, respectively. Graduate entry students were significantly more likely to achieve honours degrees than mainstream students.
Conclusion
On average the academic performance of Graduate Entry medical students at the University of Birmingham is better than mainstream medical students.
doi:10.1258/jrsm.2009.090121
PMCID: PMC2755335  PMID: 19797600
13.  The UK clinical aptitude test and clinical course performance at Nottingham: a prospective cohort study 
BMC Medical Education  2013;13:32.
Background
The UK Clinical Aptitude Test (UKCAT) was introduced in 2006 as an additional tool for the selection of medical students. It tests mental ability in four distinct domains (Verbal Reasoning, Quantitative Reasoning, Abstract Reasoning, and Decision Analysis), and the results are available to students and admission panels in advance of the selection process. Our first study showed little evidence of any predictive validity for performance in the first two years of the Nottingham undergraduate course.
The study objective was to determine whether the UKCAT scores had any predictive value for the later parts of the course, largely delivered via clinical placements.
Methods
Students entering the course in 2007 and who had taken the UKCAT were asked for permission to use their anonymised data in research. The UKCAT scores were incorporated into a database with routine pre-admission socio-demographics and subsequent course performance data. Correlation analysis was followed by hierarchical multivariate linear regression.
Results
The original study group comprised 204/254 (80%) of the full entry cohort. With attrition over the five years of the course this fell to 185 (73%) by Year 5. The Verbal Reasoning score and the UKCAT Total score both demonstrated some univariate correlations with clinical knowledge marks, and slightly less with clinical skills. No parts of the UKCAT proved to be an independent predictor of clinical course marks, whereas prior attainment was a highly significant predictor (p <0.001).
Conclusions
This study of one cohort of Nottingham medical students showed that UKCAT scores at admission did not independently predict subsequent performance on the course. Whilst the test adds another dimension to the selection process, its fairness and validity in selecting promising students remains unproven, and requires wider investigation and debate by other schools.
doi:10.1186/1472-6920-13-32
PMCID: PMC3621812  PMID: 23442227
14.  Retention and Attrition Among African Americans in the STAR*D Study: What Causes Research Volunteers to Stay or Stray? 
Depression and anxiety  2013;30(11):10.1002/da.22134.
Background
High attrition rates among African-Americans (AA) volunteers are a persistent problem that makes clinical trials less representative and complicates estimation of treatment outcomes. Many studies contrast AA with other ethnic/racial groups, but few compare the AA volunteers who remain in treatment with those who leave. Here, in addition to comparing patterns of attrition between African Americans and whites, we identify predictors of overall and early attrition among African Americans.
Method
Sample comprised non-Hispanic African-American (n=673) and white (n=2,549) participants in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Chi-square tests were used to examine racial group differences in reasons for exit. Multivariate logistic regression was used to examine predictors of overall attrition, early attrition (by Level 2) and top reasons cited for attrition among African Americans.
Results
For both African-American and white dropouts, non-compliance reasons for attrition were most commonly cited during the earlier phases of the study while reasons related to efficacy and medication side effects were cited later in the study. Satisfaction with treatment strongly predicted overall attrition among African Americans independent of socioeconomic, clinical, medical or psychosocial factors. Early attrition among African American dropouts was associated with less psychiatric comorbidity, and higher perceived physical functioning but greater severity of clinician-rated depression.
Conclusions
The decision to drop out is a dynamic process that changes over the course of a clinical trial. Strategies aimed at retaining African Americans in such trials should emphasize engagement with treatment and patient satisfaction immediately following enrollment and after treatment initiation.
doi:10.1002/da.22134
PMCID: PMC3818393  PMID: 23723044
Research Volunteers; Ethnic Groups; Blacks; Depression; Disparities; Treatment
15.  Medical students who decompress during the M-1 year outperform those who fail and repeat it: A study of M-1 students at the University of Illinois College of Medicine at Urbana-Champaign 1988–2000 
Background
All medical schools must counsel poor-performing students, address their problems and assist them in developing into competent physicians. The objective of this study was to determine whether students with academic deficiencies in their M-1 year graduate more often, spend less time to complete the curriculum, and need fewer attempts at passing USMLE Step 1 and Step 2 by entering the Decompressed Program prior to failure of the M-1 year than those students who fail the M-1 year and then repeat it.
Method
The authors reviewed the performance of M-1 students in the Decompressed Program and compared their outcomes to M-1 students who failed and fully repeated the M-1 year. To compare the groups upon admission, t-Tests comparing the Cognitive Index of students and MCAT scores from both groups were performed. Performance of the two groups after matriculation was also analyzed.
Results
Decompressed students were 2.1 times more likely to graduate. Decompressed students were 2.5 times more likely to pass USMLE Step 1 on the first attempt than the repeat students. In addition, 46% of those in the decompressed group completed the program in five years compared to 18% of the repeat group.
Conclusion
Medical students who decompress their M-1 year prior to M-1 year failure outperform those who fail their first year and then repeat it. These findings indicate the need for careful monitoring of M-1 student performance and early intervention and counseling of struggling students.
doi:10.1186/1472-6920-5-18
PMCID: PMC1166556  PMID: 15943876
16.  The Edinburgh intercalated honours BSc in pathology: evaluation of selection methods, undergraduate performance, and postgraduate career. 
In a study of 60 students who entered the intercalated honours BSc course in pathology at the University of Edinburgh over 10 years the conventional criteria of academic excellence and motivation were shown to be appropriate for the selection of honours students. When compared with classmates who did not take the intercalated year but who had shown similar high academic ability in the preclinical course the students who had taken the honours BSc did better in the remainder of the undergraduate curriculum. Of 42 honours students, 18 (43%) entered academic careers, particularly in pathology and medicine, but there was no observed tendency for students without honours BSc to do so. Although it is impossible to establish a causal relation between taking the honours course and subsequent academic distinction, the results suggest that the intercalated honours BSc in pathology serves a useful function in introducing able students into academic careers. The findings justify the financial support made available to such students during their intercalated year by the Medical Research Council and the Scottish Education Department.
PMCID: PMC1340712  PMID: 3087558
17.  Five-year survey of medical student attrition in a medical school in Nigeria: a pilot study 
Background
Student attrition represents a waste of career opportunity and, at times, results in a holistic loss of sense of self-worth for the students involved. The aim of this study was to evaluate the nature, causes, and impact of medical student attrition in Nigeria.
Method
A pilot analysis was undertaken using the records of students who failed at medical school as a result of inability to pass the second MBBS examination at Ebonyi State University, Abakaliki, Nigeria, between 2002 and 2007. Some of these students were interviewed using a structured questionnaire.
Results
Data analysis showed that 58 (7.8%) of the students admitted into preclinical class withdrew from their study. Thirty-six (62.1%) were males and the rest were females. Thirteen of those withdrawn were interviewed, and 53.8% of them believed they had poor academic ability, while 15.4% attributed their withdrawal to family pressure. No record of guidance or counseling session programs was noted for these students either at the point of withdrawal from the faculty and on the choice of a new career path.
Conclusion
As a result of the high attrition rate due to low academic ability, efforts should be made to check students for evidence of this at the point of admission to medicine training. Also, more accommodating teaching programs should be encouraged in faculties to accommodate students with such challenges. Good guidance and counseling programs should be encouraged to handle these inevitable cases of attrition when they occur, to avoid the demoralizing low self-esteem that plagues these individuals for the rest of their lives.
doi:10.2147/AMEP.S13395
PMCID: PMC3643137  PMID: 23745063
medical students; attrition; medical education; Nigeria
18.  Is Heavy Drinking Really Associated With Attrition From College? The Alcohol–Attrition Paradox 
Student attrition at colleges across the United States poses a significant problem for students and families, higher educational institutions, and the nation's workforce competing in the global economy. Heavy drinking is a highly plausible contributor to the problem. However, there is little evidence that it is a reliable predictor of attrition. Notably, few studies take into account indicators of collegiate engagement that are associated with both heavy drinking and persistence in college. Event-history analysis was used to estimate the effect of heavy drinking on attrition among 3,290 undergraduates at a large midwestern university during a 4-year period, and student attendance at a number of college events was included as covariates. Results showed that heavy drinking did not predict attrition bivariately or after controlling for precollege predictors of academic success. However, after controlling for event attendance (an important indicator of collegiate engagement), heavy drinking was found to predict attrition. These findings underscore the importance of the college context in showing that heavy drinking does in fact predict attrition and in considering future intervention efforts to decrease attrition and also heavy drinking.
doi:10.1037/0893-164X.22.3.450
PMCID: PMC2673793  PMID: 18778140
college attrition; heavy drinking; suppression; event-history
19.  Factors Related to Attrition from VA Healthcare Use: Findings from the National Survey of Women Veterans 
Journal of General Internal Medicine  2013;28(Suppl 2):510-516.
ABSTRACT
BACKGROUND
While prior research characterizes women Veterans’ barriers to accessing and using Veterans Health Administration (VA) care, there has been little attention to women who access VA and use services, but then discontinue use. Recent data suggest that among women Veterans, there is a 30 % attrition rate within 3 years of initial VA use.
OBJECTIVES
To compare individual characteristics and perceptions about VA care between women Veteran VA attriters (those who discontinue use) and non-attriters (those who continue use), and to compare recent versus remote attriters.
DESIGN
Cross-sectional, population-based 2008–2009 national telephone survey.
PARTICIPANTS
Six hundred twenty-six attriters and 2,065 non-attriters who responded to the National Survey of Women Veterans.
MAIN MEASURES
Population weighted demographic, military and health characteristics; perceptions about VA healthcare; length of time since last VA use; among attriters, reasons for no longer using VA care.
KEY RESULTS
Fifty-four percent of the weighted VA ever user population reported that they no longer use VA. Forty-five percent of attrition was within the past ten years. Attriters had better overall health (p = 0.007), higher income (p < 0.001), and were more likely to have health insurance (p < 0.001) compared with non-attriters. Attriters had less positive perceptions of VA than non-attriters, with attriters having lower ratings of VA quality and of gender-specific features of VA care (p < 0.001). Women Veterans who discontinued VA use since 2001 did not differ from those with more remote VA use on most measures of VA perceptions. Overall, among attriters, distance to VA sites of care and having alternate insurance coverage were the most common reasons for discontinuing VA use.
CONCLUSIONS
We found high VA attrition despite recent advances in VA care for women Veterans. Women’s attrition from VA could reduce the critical mass of women Veterans in VA and affect current system-wide efforts to provide high-quality care for women Veterans. An understanding of reasons for attrition can inform organizational efforts to re-engage women who have attrited, to retain current users, and potentially to attract new VA patients.
doi:10.1007/s11606-013-2347-y
PMCID: PMC3695263  PMID: 23807058
Veterans; women’s health; access to care; attrition
20.  Rational pharmacotherapy training for fourth-year medical students 
Objectives:
In this study we aimed to evaluate the impact of Rational Pharmacotherapy (RPT) course program, reinforced by video footages, on the rational pharmacotherapy skills of the students.
Materials and Methods:
RPT course program has been conducted in Dokuz Eylul University School of Medicine since 2008/9. The course has been organised in accordance with World Health Organisation (WHO) Good Prescribing Guide. The aim of the course was to improve the problem solving skills (methodology for selection of the (p)ersonel-drug, prescription writing and informing patient about his illness and drugs) and communication skills of students. The impact of the course has been measured by pre/post-test design by an objective structured clinical examination (OSCE). In academic year 2010/11, to further improve OSCE score of the students we added doctor-patient communication video footages to the RPT course programme. During training, the students were asked to evaluate the doctor-patient communication and prescription on two video footages using a checklist followed by group discussions.
Results:
Total post-test OSCE score was significantly higher for 2010/11 academic year students (n = 147) than it was for 2009/10 year students (n = 131). The 2010/11 academic year students performed significantly better than the 2009/10 academic year students on four steps of OSCE. These steps were “defining the patient's problem”, “specifying the therapeutic objective”, “specifying the non-pharmacological treatment” and “choosing a (drug) treatment, taking all relevant patient characteristics into account”.
Conclusions:
The present study demonstrated that the implementation of video footages and group discussions to WHO/Good Prescribing Method improved the fourth-year medical students’ performance in rational pharmacotherapy skills.
doi:10.4103/0253-7613.106426
PMCID: PMC3608292  PMID: 23543821
Education; medical students; rational prescribing skills; rational pharmacotherapy; video footages
21.  Weight, socio-demographics, and health behaviour related correlates of academic performance in first year university students 
Nutrition Journal  2013;12:162.
Background
This study aimed to examine differences in socio-demographics and health behaviour between Belgian first year university students who attended all final course exams and those who did not. Secondly, this study aimed to identify weight and health behaviour related correlates of academic performance in those students who attended all course exams.
Methods
Anthropometrics of 101 first year university students were measured at both the beginning of the first (T1) and second (T2) semester of the academic year. An on-line health behaviour questionnaire was filled out at T2. As a measure of academic performance student end-of-year Grade Point Averages (GPA) were obtained from the university’s registration office. Independent samples t-tests and chi 2 -tests were executed to compare students who attended all course exams during the first year of university and students who did not carry through. Uni- and multivariate linear regression analyses were conducted to identify correlates of academic performance in students who attended all course exams during the first year of university.
Results
Students who did not attend all course exams were predominantly male, showed higher increases in waist circumference during the first semester and consumed more French fries than those who attended all final course exams. Being male, lower secondary school grades, increases in weight, Body Mass Index and waist circumference over the first semester, more gaming on weekdays, being on a diet, eating at the student restaurant more frequently, higher soda and French fries consumption, and higher frequency of alcohol use predicted lower GPA’s in first year university students. When controlled for each other, being on a diet and higher frequency of alcohol use remained significant in the multivariate regression model, with frequency of alcohol use being the strongest correlate of GPA.
Conclusions
This study, conducted in Belgian first year university students, showed that academic performance is associated with a wide range of weight and health related behaviours. Future studies should investigate whether interventions aiming at promoting healthy behaviours among students could also have a positive impact on academic performance.
doi:10.1186/1475-2891-12-162
PMCID: PMC3878497  PMID: 24344995
Weight; Health behaviour; Correlates; Academic performance; First year university students
22.  Emotional intelligence and perceived stress in healthcare students: a multi-institutional, multi-professional survey 
Background
Emotional intelligence (EI) is increasingly discussed as having a potential role in medicine, nursing, and other healthcare disciplines, both for personal mental health and professional practice. Stress has been identified as being high for students in healthcare courses. This study investigated whether EI and stress differed among students in four health professions (dental, nursing, graduate mental health workers, medical) and whether there was evidence that EI might serve as a buffer for stress.
Method
The Schutte Emotional Intelligence and the Perceived Stress scale instruments were administered to four groups of healthcare students in their first year of study in both the autumn and summer terms of the 2005-6 academic year. The groups were undergraduate dental, nursing and medical students, and postgraduate mental health workers.
Results
No significant differences were found between males and females nor among professional groups for the EI measure. Dental students reported significantly higher stress than medical students. EI was found to be only moderately stable in test-retest scores. Some evidence was found for EI as a possible factor in mediating stress. Students in different health profession courses did not show significant differences in Emotional Intelligence.
Conclusion
While stress and EI showed a moderate relationship, results of this study do not allow the direction of relationship to be determined. The limitations and further research questions raised in this study are discussed along with the need for refinement of the EI construct and measures, particularly if Emotional Intelligence were to be considered as a possible selection criterion, as has been suggested by some authors.
doi:10.1186/1472-6920-9-61
PMCID: PMC2753627  PMID: 19761603
23.  Introduction to Evidence-Based Medicine: a student-selected component at the Faculty of Medicine, King Abdulaziz University 
Background
Evidence-based medicine (EBM) involves approaching a clinical problem using a four-step method: (1) formulate a clear clinical question from a patient’s problem, (2) search the literature for relevant clinical articles, (3) evaluate (critically appraise) the evidence for its validity and usefulness, (4) implement useful findings into clinical practice. EBM has now been incorporated as an integral part of the medical curriculum in many faculties of medicine around the world. The Faculty of Medicine, King Abdulaziz University, started its process of curriculum reform and introduction of the new curriculum 4 years ago. One of the most characteristic aspects of this curriculum is the introduction of special study modules and electives as a student-selected component in the fourth year of study; the Introduction to Evidence-Based Medicine course was included as one of these special study modules. The purpose of this article is to evaluate the EBM skills of medical students after completing the course and their perceptions of the faculty member delivering the course and organization of the course.
Materials and methods
The EBM course was held for the first time as a special study module for fourth-year medical students in the first semester of the academic year 2009–2010. Fifteen students were enrolled in this course. At the end of the course, students anonymously evaluated aspects of the course regarding their EBM skills and course organization using a five- point Likert scale in response to an online course evaluation questionnaire. In addition, students’ achievement was evaluated with regard to the skills and competencies taught in the course.
Results
Medical students generally gave high scores to all aspects of the EBM course, including course organization, course delivery, methods of assessment, and overall. Scores were also high for students’ self-evaluation of skill level and EBM experience. The results of a faculty member’s evaluation of the students’ achievement showed an average total percentage (92.2%) for all EBM steps.
Conclusion
The EBM course at the Faculty of Medicine, King Abdulaziz University, is useful for familiarizing medical students with the basic principles of EBM and to help them in answering routine questions of clinical interest in a systematic way. In light of the results obtained from implementing this course with a small number of students, and as a student-selected component, the author believes integrating EBM longitudinally throughout the curriculum would be beneficial for King Abdulaziz University medical students. It would provide a foundation of knowledge, offer easy access to resources, promote point-of-care and team learning, help students to develop applicable skills for lifelong learning, and help the faculty to achieve its goals of becoming more student-centered and encouraging students to employ more self-directed learning strategies.
doi:10.2147/AMEP.S25276
PMCID: PMC3661260  PMID: 23745093
student-selected component; evidence-based medicine; learning; curriculum
24.  Risk factors at medical school for subsequent professional misconduct: multicentre retrospective case-control study 
Objective To determine whether there are risk factors in a doctor’s time at medical school that are associated with subsequent professional misconduct.
Design Matched case-control study.
Setting Records from medical schools and the General Medical Council (GMC).
Participants 59 doctors who had graduated from any one of eight medical schools in the United Kingdom in 1958-97 and had a proved finding of serious professional misconduct in GMC proceedings in 1999-2004 (cases); 236 controls (four for each case) were selected by systematic sampling from matching graduation cohorts. Case-control status was revealed by the GMC after completion of data entry.
Main outcome measure Odds ratios for being a “case,” with multivariable conditional logistic regression of potential risk factors including pre-admission characteristics and progress during the course. These data were obtained from anonymised copies of the students’ progress files held by their original medical schools.
Results Univariate conditional logistic regression analysis found that cases were more likely to be men, to be of lower estimated social class, and to have had academic difficulties during their medical course, especially in the early years. Multivariable analysis showed that male sex (odds ratio 9.80, 95% confidence interval 2.43 to 39.44, P=0.001), lower social class (4.28, 1.52 to 12.09, P=0.006), and failure of early or preclinical examinations (5.47, 2.17 to 13.79, P<0.001) were independently associated with being a case.
Conclusions This small study suggests that male sex, a lower socioeconomic background, and early academic difficulties at medical school could be risk factors for subsequent professional misconduct. The findings are preliminary and should be interpreted with caution. Most doctors with risk factors will not come before the GMC’s disciplinary panels.
doi:10.1136/bmj.c2040
PMCID: PMC3191727  PMID: 20423965
25.  Forging a new legacy of trust in research with Alaska Native college students using CBPR 
International Journal of Circumpolar Health  2012;71:10.3402/ijch.v71i0.18475.
Objectives
Disparities in the rates of matriculation and graduation are of concern to Alaska Native (AN) students and the universities committed to their academic success. Efforts to reduce attrition require a keen understanding of the factors that impact quality of life (QOL) at college. Yet, a long-standing legacy of mistrust towards research poses challenges to conducting inquiry among AN students. We introduced a partnership between the University of Alaska Fairbank's Rural Student Services (RSS) and the Center for Alaska Native Health Research (CANHR) within which we conducted the “What makes life good?” study aimed towards developing a QOL measure for AN students. Equally important was building a legacy of research trust among AN partners.
Study design
We describe Phase I of a 2-phase study that employed a sequential mixed methods approach. Discussed are facilitators, challenges and lessons learned while striving to adhere to the principles of community-based participatory research (CBPR).
Methods
Phase I included formative focus groups and QOL measurement development. The research involved the interplay among activities that were co-developed with the goal of enhancing trust and research capacity. Emphasis was placed on ensuring that data collection and analyses were student driven.
Conclusions
All partners resided at the same university. However, trust and collaboration could not be assumed. Working within a collaborative framework, our partnership achieved the aim of developing a culturally informed QOL measure, while also creating an empowering experience for all partners who became co-investigators in a process that might normally be regarded with mistrust.
doi:10.3402/ijch.v71i0.18475
PMCID: PMC3459272  PMID: 23019564
Community-based participatory research (CBPR); Alaska Native; quality of life; college students

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