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1.  Medical Students' Exposure to and Attitudes about the Pharmaceutical Industry: A Systematic Review 
PLoS Medicine  2011;8(5):e1001037.
A systematic review of published studies reveals that undergraduate medical students may experience substantial exposure to pharmaceutical marketing, and that this contact may be associated with positive attitudes about marketing.
The relationship between health professionals and the pharmaceutical industry has become a source of controversy. Physicians' attitudes towards the industry can form early in their careers, but little is known about this key stage of development.
Methods and Findings
We performed a systematic review reported according to PRISMA guidelines to determine the frequency and nature of medical students' exposure to the drug industry, as well as students' attitudes concerning pharmaceutical policy issues. We searched MEDLINE, EMBASE, Web of Science, and ERIC from the earliest available dates through May 2010, as well as bibliographies of selected studies. We sought original studies that reported quantitative or qualitative data about medical students' exposure to pharmaceutical marketing, their attitudes about marketing practices, relationships with industry, and related pharmaceutical policy issues. Studies were separated, where possible, into those that addressed preclinical versus clinical training, and were quality rated using a standard methodology. Thirty-two studies met inclusion criteria. We found that 40%–100% of medical students reported interacting with the pharmaceutical industry. A substantial proportion of students (13%–69%) were reported as believing that gifts from industry influence prescribing. Eight studies reported a correlation between frequency of contact and favorable attitudes toward industry interactions. Students were more approving of gifts to physicians or medical students than to government officials. Certain attitudes appeared to change during medical school, though a time trend was not performed; for example, clinical students (53%–71%) were more likely than preclinical students (29%–62%) to report that promotional information helps educate about new drugs.
Undergraduate medical education provides substantial contact with pharmaceutical marketing, and the extent of such contact is associated with positive attitudes about marketing and skepticism about negative implications of these interactions. These results support future research into the association between exposure and attitudes, as well as any modifiable factors that contribute to attitudinal changes during medical education.
Please see later in the article for the Editors' Summary
Editors' Summary
The complex relationship between health professionals and the pharmaceutical industry has long been a subject of discussion among physicians and policymakers. There is a growing body of evidence that suggests that physicians' interactions with pharmaceutical sales representatives may influence clinical decision making in a way that is not always in the best interests of individual patients, for example, encouraging the use of expensive treatments that have no therapeutic advantage over less costly alternatives. The pharmaceutical industry often uses physician education as a marketing tool, as in the case of Continuing Medical Education courses that are designed to drive prescribing practices.
One reason that physicians may be particularly susceptible to pharmaceutical industry marketing messages is that doctors' attitudes towards the pharmaceutical industry may form early in their careers. The socialization effect of professional schooling is strong, and plays a lasting role in shaping views and behaviors.
Why Was This Study Done?
Recently, particularly in the US, some medical schools have limited students' and faculties' contact with industry, but some have argued that these restrictions are detrimental to students' education. Given the controversy over the pharmaceutical industry's role in undergraduate medical training, consolidating current knowledge in this area may be useful for setting priorities for changes to educational practices. In this study, the researchers systematically examined studies of pharmaceutical industry interactions with medical students and whether such interactions influenced students' views on related topics.
What Did the Researchers Do and Find?
The researchers did a comprehensive literature search using appropriate search terms for all relevant quantitative and qualitative studies published before June 2010. Using strict inclusion criteria, the researchers then selected 48 articles (from 1,603 abstracts) for full review and identified 32 eligible for analysis—giving a total of approximately 9,850 medical students studying at 76 medical schools or hospitals.
Most students had some form of interaction with the pharmaceutical industry but contact increased in the clinical years, with up to 90% of all clinical students receiving some form of educational material. The highest level of exposure occurred in the US. In most studies, the majority of students in their clinical training years found it ethically permissible for medical students to accept gifts from drug manufacturers, while a smaller percentage of preclinical students reported such attitudes. Students justified their entitlement to gifts by citing financial hardship or by asserting that most other students accepted gifts. In addition, although most students believed that education from industry sources is biased, students variably reported that information obtained from industry sources was useful and a valuable part of their education.
Almost two-thirds of students reported that they were immune to bias induced by promotion, gifts, or interactions with sales representatives but also reported that fellow medical students or doctors are influenced by such encounters. Eight studies reported a relationship between exposure to the pharmaceutical industry and positive attitudes about industry interactions and marketing strategies (although not all included supportive statistical data). Finally, student opinions were split on whether physician–industry interactions should be regulated by medical schools or the government.
What Do These Findings Mean?
This analysis shows that students are frequently exposed to pharmaceutical marketing, even in the preclinical years, and that the extent of students' contact with industry is generally associated with positive attitudes about marketing and skepticism towards any negative implications of interactions with industry. Therefore, strategies to educate students about interactions with the pharmaceutical industry should directly address widely held misconceptions about the effects of marketing and other biases that can emerge from industry interactions. But education alone may be insufficient. Institutional policies, such as rules regulating industry interactions, can play an important role in shaping students' attitudes, and interventions that decrease students' contact with industry and eliminate gifts may have a positive effect on building the skills that evidence-based medical practice requires. These changes can help cultivate strong professional values and instill in students a respect for scientific principles and critical evidence review that will later inform clinical decision-making and prescribing practices.
Additional Information
Please access these Web sites via the online version of this summary at
Further information about the influence of the pharmaceutical industry on doctors and medical students can be found at the American Medical Students Association PharmFree campaign and PharmFree Scorecard, Medsin-UKs PharmAware campaign, the nonprofit organization Healthy Skepticism, and the Web site of No Free Lunch.
PMCID: PMC3101205  PMID: 21629685
2.  Student attitude towards communication skills learning in a Caribbean medical school 
The Australasian Medical Journal  2013;6(9):466-475.
Medical student attitudes towards communication skills are important for curriculum planners and teachers. Xavier University School of Medicine (XUSOM) is a private medical school admitting students mainly from the United States and Canada.
Attitude of students towards communication skills has not been previously studied in the institution. Hence the present study was carried out.
The study was carried out among the first, second, third and fourth semester undergraduate medical (MD) students at XUSOM, Aruba during July 2013 using the communication skills attitude scale (CSAS). Respondents’ age, gender, nationality, occupation of parents, place of residence of family, semester of study were noted. The positive and negative attitude scale scores were calculated and compared among different subgroups of respondents (p<0.05).
Fifty-one of the seventy-three students (69.9 per cent) participated. The majority were between 20 to 25 years of age, of American nationality, from metro cities and had excellent or good self-perceived verbal and written communication skills. The mean positive attitude scale (PAS) score was 47.65 (maximum being 65) and the mean negative attitude scale (NAS) score was 31.06 (maximum 65). PAS score was significantly higher among respondents whose fathers were not in health related professions. NAS scores were significantly lower among the third and fourth semester respondents.
Students overall had a positive attitude towards communication skills but negative attitudes were also noted Based on results of the study and a review of literature we are planning to start communication skills learning in the institution right from the first semester and students will be provided opportunities for supervised practice during early clinical exposure, hospital observership and with standardised patients. The medical humanities module will be expanded and communication skills learning will continue during the clinical years with higher order skills being taught.
PMCID: PMC3794417  PMID: 24133539
Attitudes; communication skills; education; medical school; medical students
3.  Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda 
Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital.
In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening.
Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear.
Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.
PMCID: PMC1413529  PMID: 16509979
4.  Effects of participation in a cross year peer tutoring programme in clinical examination skills on volunteer tutors' skills and attitudes towards teachers and teaching 
Development of students' teaching skills is increasingly recognised as an important component of UK undergraduate medical curricula and, in consequence, there is renewed interest in the potential benefits of cross-year peer tutoring. Whilst several studies have described the use of cross-year peer tutoring in undergraduate medical courses, its use in the clinical setting is less well reported, particularly the effects of peer tutoring on volunteer tutors' views of teachers and teaching. This study explored the effects of participation in a cross-year peer tutoring programme in clinical examination skills ('OSCE tutor') on volunteer tutors' own skills and on their attitudes towards teachers and teaching.
Volunteer tutors were final year MBChB students who took part in the programme as part of a Student Selected Component (SSC). Tutees were year 3 MBChB students preparing for their end of year 'OSCE' examination. Pre and post participation questionnaires, including both Likert-type and open response questions, were used. Paired data was compared using the Wilcoxon signed-rank test. All tests were two-tailed with 5% significance level.
Tutors reflected their cohort in terms of gender but were drawn from among the more academically successful final year students. Most had previous teaching experience. They were influenced to participate in 'OSCE tutor' by a desire to improve their own teaching and associated generic skills and by contextual factors relating to the organisation or previous experience of the OSCE tutor programme. Issues relating to longer term career aspirations were less important. After the event, tutors felt that participation had enhanced their skills in various areas, including practical teaching skills, confidence in speaking to groups and communication skills; and that as a result of taking part, they were now more likely to undertake further teacher training and to make teaching a major part of their career. However, whilst a number of students reported that their views of teachers and teaching had changed as a result of participation, this did not translate into significant changes in responses to questions that explored their views of the roles and qualities required of a good clinical teacher.
Findings affirm the benefits to volunteer tutors of cross-year peer tutoring, particularly in terms of skills enhancement and reinforcement of positive attitudes towards future teaching responsibilities, and have implications for the design and organisation of such programmes.
PMCID: PMC1925072  PMID: 17598885
5.  Attitudes toward statistics in medical postgraduates: measuring, evaluating and monitoring 
BMC Medical Education  2012;12:117.
In medical training, statistics is considered a very difficult course to learn and teach. Current studies have found that students’ attitudes toward statistics can influence their learning process. Measuring, evaluating and monitoring the changes of students’ attitudes toward statistics are important. Few studies have focused on the attitudes of postgraduates, especially medical postgraduates. Our purpose was to understand current attitudes regarding statistics held by medical postgraduates and explore their effects on students’ achievement. We also wanted to explore the influencing factors and the sources of these attitudes and monitor their changes after a systematic statistics course.
A total of 539 medical postgraduates enrolled in a systematic statistics course completed the pre-form of the Survey of Attitudes Toward Statistics −28 scale, and 83 postgraduates were selected randomly from among them to complete the post-form scale after the course.
Most medical postgraduates held positive attitudes toward statistics, but they thought statistics was a very difficult subject. The attitudes mainly came from experiences in a former statistical or mathematical class. Age, level of statistical education, research experience, specialty and mathematics basis may influence postgraduate attitudes toward statistics. There were significant positive correlations between course achievement and attitudes toward statistics. In general, student attitudes showed negative changes after completing a statistics course.
The importance of student attitudes toward statistics must be recognized in medical postgraduate training. To make sure all students have a positive learning environment, statistics teachers should measure their students’ attitudes and monitor their change of status during a course. Some necessary assistance should be offered for those students who develop negative attitudes.
PMCID: PMC3533942  PMID: 23173770
Medical postgraduate; Statistics; Survey of attitudes toward statistics
6.  A Prospective Controlled Trial of the Influence of a Geriatrics Home Visit Program on Medical Student Knowledge, Skills, and Attitudes Towards Care of the Elderly 
To determine the impact of a geriatrics home visit program for third-year medical students on attitudes, skills, and knowledge.
Using a mixed methods, prospective, controlled trial, volunteer control group students (n = 17) at two sites and intervention group students (n = 16) at two different sites within the same internal medicine clerkship were given Internet and CDROM-based geriatric self-study materials. Intervention group students identified a geriatrics patient from their clinical experience, performed one “home” visit (home, nursing home, or rehabilitation facility) to practice geriatric assessment skills, wrote a structured, reflective paper, and presented their findings in small-group teaching settings. Papers were qualitatively analyzed using the constant comparative method for themes. All students took a pre-test and post-test to measure changes in geriatrics knowledge and attitudes.
General attitudes towards caring for the elderly improved more in the intervention group than in the control group (9.8 vs 0.5%; p = 0.04, effect size 0.78). Medical student attitudes towards their home care training in medical school (21.7 vs 3.2%; p = 0.02, effect size 0.94) improved, as did attitudes towards time and reimbursement issues surrounding home visits (10.1 vs −0.2%; p = 0.02, effect size 0.89). Knowledge of geriatrics improved in both groups (13.4 vs 15.2% improvement; p = 0.73). Students described performing a mean of seven separate geriatric assessments (range 4–13) during the home visit. Themes that emerged from the qualitative analysis of the reflective papers added depth and understanding to the quantitative data and supported results concerning attitudinal change.
While all participants gained geriatrics knowledge during their internal medicine clerkship, students who performed a home visit had improved attitudes towards the elderly and described performing geriatric assessment skills. Requiring little faculty time, a geriatrics home visit program like this one may be a useful clerkship addition to foster medical students’ professional growth.
PMCID: PMC2669870  PMID: 19294472
geriatrics; home visit; medical student; education; professionalism; narrative writing
7.  Does community-based education increase students' motivation to practice community health care? - a cross sectional study 
BMC Medical Education  2011;11:19.
Community-based education has been introduced in many medical schools around the globe, but evaluation of instructional quality has remained a critical issue. Community-based education is an approach that aims to prepare students for future professional work at the community level. Instructional quality should be measured based on a program's outcomes. However, the association between learning activities and students' attitudes is unknown. The purpose of this study was to clarify what learning activities affect students' attitudes toward community health care.
From 2003 to 2009, self-administered pre- and post-questionnaire surveys were given to 693 fifth-year medical students taking a 2-week clinical clerkship. Main items measured were student attitudes, which were: "I think practicing community health care is worthwhile" ("worthwhile") and "I am confident about practicing community health care" ("confidence") using a visual analogue scale (0-100). Other items were gender, training setting, and learning activities. We analyzed the difference in attitudes before and after the clerkships by paired t test and the factors associated with a positive change in attitude by logistic regression analysis.
Six hundred forty-five students (93.1%), 494 (76.6%) male and 151(23.4%) female, completed the pre- and post-questionnaires. The VAS scores of the students' attitudes for "worthwhile" and "confidence" after the clerkship were 80.2 ± 17.4 and 57.3 ± 20.1, respectively. Both of the scores increased after the clerkship. Using multivariate logistic regression analysis, "health education" was associated with a positive change for both attitudes of "worthwhile" (adjusted RR: 1.71, 95% CI: 1.10-2.66) and "confidence" (1.56, 1.08-2.25).
Community-based education motivates students to practice community health care. In addition, their motivation is increased by the health education activity. Participating in this activity probably produces a positive effect and improves the instructional quality of the program based on its outcomes.
PMCID: PMC3114788  PMID: 21569332
8.  Offline eLearning for undergraduates in health professions: A systematic review of the impact on knowledge, skills, attitudes and satisfaction 
Journal of Global Health  2014;4(1):010405.
The world is short of 7.2 million health–care workers and this figure is growing. The shortage of teachers is even greater, which limits traditional education modes. eLearning may help overcome this training need. Offline eLearning is useful in remote and resource–limited settings with poor internet access. To inform investments in offline eLearning, we need to establish its effectiveness in terms of gaining knowledge and skills, students’ satisfaction and attitudes towards eLearning.
We conducted a systematic review of offline eLearning for students enrolled in undergraduate, health–related university degrees. We included randomised controlled trials that compared offline eLearning to traditional learning or an alternative eLearning method. We searched the major bibliographic databases in August 2013 to identify articles that focused primarily on students’ knowledge, skills, satisfaction and attitudes toward eLearning, and health economic information and adverse effects as secondary outcomes. We also searched reference lists of relevant studies. Two reviewers independently extracted data from the included studies. We synthesized the findings using a thematic summary approach.
Forty–nine studies, including 4955 students enrolled in undergraduate medical, dentistry, nursing, psychology, or physical therapy studies, met the inclusion criteria. Eleven of the 33 studies testing knowledge gains found significantly higher gains in the eLearning intervention groups compared to traditional learning, whereas 21 did not detect significant differences or found mixed results. One study did not test for differences. Eight studies detected significantly higher skill gains in the eLearning intervention groups, whilst the other 5 testing skill gains did not detect differences between groups. No study found offline eLearning as inferior. Generally no differences in attitudes or preference of eLearning over traditional learning were observed. No clear trends were found in the comparison of different modes of eLearning. Most of the studies were small and subject to several biases.
Our results suggest that offline eLearning is equivalent and possibly superior to traditional learning regarding knowledge, skills, attitudes and satisfaction. Although a robust conclusion cannot be drawn due to variable quality of the evidence, these results justify further investment into offline eLearning to address the global health care workforce shortage.
PMCID: PMC4073241  PMID: 24976964
9.  Doctor-patient interaction in Finnish primary health care as perceived by first year medical students 
In Finland, public health care is the responsibility of primary health care centres, which render a wide range of community level preventive, curative and rehabilitative medical care. Since 1990's, medical studies have involved early familiarization of medical students with general practice from the beginning of the studies, as this pre-clinical familiarisation helps medical students understand patients as human beings, recognise the importance of the doctor-patient relationship and identify practicing general practitioners (GPs) as role models for their professional development. Focused on doctor-patient relationship, we analysed the reports of 2002 first year medical students in the University of Kuopio. The students observed GPs' work during their 2-day visit to primary health care centres.
We analysed systematically the texts of 127 written reports of 2002, which represents 95.5% of the 133 first year pre-clinical medical students reports. The reports of 2003 (N = 118) and 2004 (N = 130) were used as reference material.
Majority of the students reported GPs as positive role models. Some students reported GPs' poor attitudes, which they, however, regarded as a learning opportunity. Students generally observed a great variety of responsibilities in general practice, and expressed admiration for the skills and abilities required. They appreciated the GPs' interest in patients concerns. GPs' communication styles were found to vary considerably. Students reported some factors disturbing the consultation session, such as the GP staring at the computer screen and other team members entering the room. Working with marginalized groups, the chronically and terminally ill, and dying patients was seen as an area for development in the busy Finnish primary health care centres.
During the analysis, we discovered that medical students' perceptions in this study are in line with the previous findings about the importance of role model (good or bad) in making good doctors. Therefore, medical students' pre-clinical primary health care centre visits may influence their attitudes towards primary health care work and the doctor-patient relationship. We welcome more European studies on the role of early pre-clinical general practice exposure on medical students' primary care specialty choice.
PMCID: PMC1242232  PMID: 16162300
10.  Student-Directed Learning in a Community Geriatrics Advanced Pharmacy Practice Experience 
To assess a community geriatrics advanced pharmacy practice experience (APPE) that aimed to improve students' attitudes towards older adults and provide a student-directed learning experience.
Students provided blood pressure monitoring and medication counseling to older adults living in a low-income residential facility as part of a required 6-week ambulatory care service-learning APPE. Pre-experience and post-experience essays on students' perceptions of the elderly and their intended and actual learning were retrospectively reviewed using a qualitative process to determine whether the course objectives were met.
Many students initially described older adults in factual terms or using negative descriptors. Most expressed a desire to increase their knowledge of diseases commonly occurring in and drugs commonly prescribed for the elderly or to improve specific skills. Many students initially had difficulty articulating clear and measurable learning objectives and appropriate assessment metrics, which are important components of self-directed learning. The final essays revealed many students learned more about the humanistic aspects of care than they had anticipated.
This community-based geriatrics experience improved students' attitudes towards working with older adults and provided practice in developing and assessing their personal learning objectives.
PMCID: PMC1636948  PMID: 17136175
student-directed learning; community pharmacy geriatrics; advanced pharmacy practice experience; service learning
11.  Learning Oral Presentation Skills 
Oral presentation skills are central to physician-physician communication; however, little is known about how these skills are learned. Rhetoric is a social science which studies communication in terms of context and explores the action of language on knowledge, attitudes, and values. It has not previously been applied to medical discourse. We used rhetorical principles to qualitatively study how students learn oral presentation skills and what professional values are communicated in this process.
Descriptive study.
Inpatient general medicine service in a university-affiliated public hospital.
Twelve third-year medical students during their internal medicine clerkship and 14 teachers.
One-hundred sixty hours of ethnographic observation. including 73 oral presentations on rounds. Discoursed-based interviews of 8 students and 10 teachers. Data were qualitatively analyzed to uncover recurrent patterns of communication.
Students and teachers had different perceptions of the purpose of oral presentation, and this was reflected in performance. Students described and conducted the presentation as a rule-based, data-storage activity governed by “order” and “structure.” Teachers approached the presentation as a flexible means of “communication” and a method for “constructing” the details of a case into a diagnostic or therapeutic plan. Although most teachers viewed oral presentations rhetorically (sensitive to context), most feedback that students received was implicit and acontextual, with little guidance provided for determining relevant content. This led to dysfunctional generalizations by students, sometimes resulting in worse communication skills (e.g., comment “be brief” resulted in reading faster rather than editing) and unintended value acquisition (e.g., request for less social history interpreted as social history never relevant).
Students learn oral presentation by trial and error rather than through teaching of an explicit rhetorical model. This may delay development of effective communication skills and result in acquisition of unintended professional values. Teaching and learning of oral presentation skills may be improved by emphasizing that context determines content and by making explicit the tacit rules of presentation.
PMCID: PMC1495213  PMID: 11359549
medical education; professional competence; communication; feedback; language; socialization; social sciences
12.  Clinical teachers as humanistic caregivers and educators: perceptions of senior clerks and second-year residents 
BACKGROUND: The acquisition and nurturing of humanistic skills and attitudes constitute an important aim of medical education. In order to assess how conducive the physician-learning environment is to the acquisition of these skills, the authors determined the extent to which clinical teachers are perceived by their trainees as humanistic with patients and students, and they explored whether undergraduate and graduate students share the same perceptions. METHODS: A mail survey was conducted in 1994/95 of all senior clerks and second-year residents at Laval University, University of Montreal and University of Sherbrooke medical schools. Of 774 trainees, 259 senior clerks and 238 second-year residents returned the questionnaire, for an overall response rate of 64%. Students' perceptions of their teachers were measured on a 6-point Likert scale applied to statements about teachers' attitudes toward the patient (5 items) and toward the student (5 items). RESULTS: On average, only 46% of the senior clerks agreed that their teachers displayed the humanistic characteristics of interest. They were especially critical of their teachers' apparent lack of sensitivity, with as many as 3 out of 4 declaring that their teachers seemed to be unconcerned about how patients adapt psychologically to their illnesses (75% of clerks) and that their teachers did not try to understand students' difficulties (78%) or to support students who have difficulties (77%). Compared with the clerks, the second-year residents were significantly less critical, those with negative perceptions varying from 27% to 58%, 40% on average. Except for this difference, their pattern of responses from one item to another was similar. INTERPRETATION: This study suggests the existence of a substantial gap between what medical trainees are expected to learn and what they actually experience over the course of their training. Because such a gap could represent a significant barrier to the acquisition of important skills, more and urgent research is needed to understand better the factors influencing students' perceptions.
PMCID: PMC1232732  PMID: 9805021
13.  Early practical experience and the social responsiveness of clinical education: systematic review 
BMJ : British Medical Journal  2005;331(7513):387-391.
Objectives To find how early experience in clinical and community settings (“early experience”) affects medical education, and identify strengths and limitations of the available evidence.
Design A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001.
Data sources Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration.
Selection of studies All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication.
Results Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations.
Conclusion Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.
PMCID: PMC1184253  PMID: 16096306
14.  Medical students’ experiences learning intimate physical examination skills: a qualitative study 
BMC Medical Education  2014;14:39.
Intimate physical examination skills are essential skills for any medical graduate to have mastered to an appropriate level for the safety of his or her future patients. Medical schools are entrusted with the complex task of teaching and assessing these skills for their students. The objectives of this study were to explore a range of medical students’ experiences of learning intimate physical examination skills and to explore their perceptions of factors which impede or promote the learning of these skills.
Individual semi-structured interviews (N = 16) were conducted with medical students in years two to five from the University of Newcastle, as part of a larger research project investigating how medical students develop their attitudes to gender and health. This was a self-selected sample of the entire cohort who were all invited to participate. A thematic analysis of the transcribed data was performed.
Students reported differing levels of discomfort with their learning experiences in the area of intimate physical examination and differing beliefs about the helpfulness of these experiences. The factors associated with levels of discomfort and the helpfulness of the experience for learning were: satisfaction with teaching techniques, dealing with an uncomfortable situation and perceived individual characteristics in both the patients and the students. The examination causing the greatest reported discomfort was the female pelvic examination by male students.
Student discomfort with the experience of learning intimate physical examination skills may be common and has ongoing repercussions for students and patients. Recommendations are made of ways to modify teaching technique to more closely match students’ perceived needs.
PMCID: PMC3943277  PMID: 24575827
Medical student; Intimate physical examination; Learning experiences; Teaching techniques
15.  Attitude of medical students towards general practice and general practitioners. 
BACKGROUND: The stimuli for this work came from the need to identify and understand the origin of students' attitudes towards general practice in the context of undergraduate curriculum reform and concerns about recruitment. AIM: To evaluate attitudes of medical students towards general practice as a specialty and general practitioners (GPs) as doctors and explore factors influencing students' attitudes and intended career choice. DESIGN OF STUDY: Cross-sectional survey. SETTING: Final-year students at two London medical schools. METHOD: Questionnaires were distributed to 984 students and the results analysed using SPSS analysis. RESULTS: The mean response rate was 72% (700/984). Medical students had a positive attitude towards general practice as a specialty (mean Likert score = 3.90/5, 95% confidence interval [CI] = 3.86 to 3.94) and towards GPs as doctors (mean Likert score = 3.62/5, 95% CI = 3.59 to 3.66). They rated personal experience of GPs as the most important factor influencing their attitude. Students' attitudes towards general practice and GPs were more positive (P<0.001) in the fifth year. First-year students perceived the media to have a more important role in influencing their attitude than those in the fifth year(P<0.001). General practice was the only career option to significantly increase in popularity between the first and final year(P < 0.001). CONCLUSIONS: Medical students end their undergraduate years with a more positive attitude towards general practice than has been reported elsewhere recently. This may be partially explained by the greater contact with GPs and suggests that efforts by medical schools to ensure a more balanced, community-based curriculum promotes positive attitudes to general practice. The influence of the media on the first years of medical school requiresfurther investigation.
PMCID: PMC1314290  PMID: 12014532
16.  Attitudes and perceptions of medical students about family medicine in Spain: protocol for a cross-sectional survey 
BMJ Open  2011;1(2):e000231.
Despite the fact that family medicine (FM) has become established as a specialty in the past 25 years, this has not been reflected in the inclusion of the specialty in the majority of medical schools in Spain. Almost 40% of the students will work in primary care but, in spite of this, most universities do not have an assessed placement as such. There are only specific practice periods in health centres or some student-selected components with little weight in the overall curricula.
To evaluate the attitudes and perceptions of medical students about FM in the health system and their perception about the need for specific training in FM at the undergraduate level. To explore change over time of these attitudes and perceptions and to examine potential predictive factors for change. Finally, we will review what teaching activity in FM is offered across the Spanish schools of medicine.
Descriptive cross-sectional survey. Each one of the different analyses will consist of two surveys: one for all the students in the first, third and fifth year of medical school in all the Spanish schools of medicine asking about their knowledge, perceptions and attitudes in relation to primary care and FM. There will be an additional survey for the coordinating faculty of the study in each university about the educational activities related to FM that are carried out in their centres. The repetition of the study every 2 years will allow for an analysis of the evolution of the cohort of students until they receive their degree and the potential predictive factors.
This study will provide useful information for strategic planning decisions, content and educational methodology in medical schools in Spain and elsewhere. It will also help to evaluate the influence of the ongoing changes in FM, locally and at the European level, on the attitudes and perceptions of the students towards FM in Spain.
Article summary
Article focus
There is a need to explore further the reasons for which students choose a specific specialty for training and future practice. This protocol outlines the design of a cross-sectional survey to evaluate attitudes and perceptions of medical students about family medicine.
The project will assess the potential impact of medical school teaching on the final profiles of students, both in perceptions and expectations and in the choice of specialty.
Key messages
This is a protocol of a multicentre survey that will take place in Spanish medical schools. The study includes a survey for students and one for the coordinators of family medicine in each centre.
The repetition of the student survey every 2 years will allow for an analysis of the evolution of student cohorts until the end of their studies.
The results of this study will provide valuable information for curriculum development related to family medicine in the different schools of medicine and will help to prioritise those activities that are likely to be most effective for promoting this specialty.
Strengths and limitations of this study
The research team for this study includes coordinating faculty from 22 of the 27 universities throughout Spain. The study will be repeated every 2 years and will explore change over time of the issues addressed.
The principal limitations of this study are related to its design, of observational nature. The results observed will serve as hypotheses generating and cannot be regarded as definitive. Finally, the fact that the survey will be anonymous will impede the evaluation, at an individual level, of change over time.
PMCID: PMC3278481  PMID: 22189348
17.  'It gives you an understanding you can't get from any book.' The relationship between medical students' and doctors' personal illness experiences and their performance: a qualitative and quantitative study 
Anecdotes abound about doctors' personal illness experiences and the effect they have on their empathy and care of patients. We formally investigated the relationship between doctors' and medical students' personal illness experiences, their examination results, preparedness for clinical practice, learning and professional attitudes and behaviour towards patients.
Newly-qualified UK doctors in 2005 (n = 2062/4784), and two cohorts of students at one London medical school (n = 640/749) participated in the quantitative arm of the study. 37 Consultants, 1 Specialist Registrar, 2 Clinical Skills Tutors and 25 newly-qualified doctors participated in the qualitative arm. Newly-qualified doctors and medical students reported their personal illness experiences in a questionnaire. Doctors' experiences were correlated with self-reported preparedness for their new clinical jobs. Students' experiences were correlated with their examination results, and self-reported anxiety and depression. Interviews with clinical teachers, newly-qualified doctors and senior doctors qualitatively investigated how personal illness experiences affect learning, professional attitudes, and behaviour.
85.5% of newly-qualified doctors and 54.4% of medical students reported personal illness experiences. Newly-qualified doctors who had been ill felt less prepared for starting work (p < 0.001), but those who had only experienced illness in a relative or friend felt more prepared (p = 0.02). Clinical medical students who had been ill were more anxious (p = 0.01) and had lower examination scores (p = 0.006). Doctors felt their personal illness experiences helped them empathise and communicate with patients. Medical students with more life experience were perceived as more mature, empathetic, and better learners; but illness at medical school was recognised to impede learning.
The majority of the medical students and newly qualified doctors we studied reported personal illness experiences, and these experiences were associated with lower undergraduate examination results, higher anxiety, and lower preparedness. However reflection on such experiences may have improved professional attitudes such as empathy and compassion for patients. Future research is warranted in this area.
PMCID: PMC2211477  PMID: 18053231
18.  Impact of Participation in a Community-Based Intimate Partner Violence Prevention Program on Medical Students: A Multi-Center Study 
Journal of General Internal Medicine  2008;23(7):1043-1047.
Physicians are generally poorly trained to recognize, treat or refer adolescents at risk for intimate partner violence (IPV). Participation in community programs may improve medical students’ knowledge, skills, and attitudes about IPV prevention.
To determine whether the experience of serving as educators in a community-based adolescent IPV prevention program improves medical students’ knowledge, skills, and attitudes toward victims of IPV, beyond that of didactic training.
One hundred and seventeen students attending 4 medical schools.
Students were randomly assigned to didactic training in adolescent IPV prevention with or without participation as educators in a community-based adolescent IPV prevention program. Students assigned to didactic training alone served as community educators after the study was completed.
Knowledge, self-assessment of skills and attitudes about intimate partner violence and future plans to pursue outreach work.
The baseline mean knowledge score of 10.25 improved to 21.64 after didactic training (p ≤ .001). Medical students in the “didactic plus outreach” group demonstrated higher levels of confidence in their ability to address issues of intimate partner violence, (mean = 41.91) than did students in the “didactic only” group (mean = 38.94) after controlling for initial levels of confidence (p ≤ .002).
Experience as educators in a community-based program to prevent adolescent IPV improved medical students’ confidence and attitudes in recognizing and taking action in situations of adolescent IPV, whereas participation in didactic training alone significantly improved students’ knowledge.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-008-0624-y) contains supplementary material, which is available to authorized users.
PMCID: PMC2517914  PMID: 18612741
adolescent; community-based intervention; intimate partner violence; medical students
19.  Evidence based practice in postgraduate healthcare education: A systematic review 
Training in Evidence-Based Practice (EBP) has been widely implemented throughout medical school and residency curricula. The aim of this study is to systematically review studies that assessed the effectiveness of EBP teaching to improve knowledge, skills, attitudes and behavior of postgraduate healthcare workers, and to describe instruments available to evaluate EBP teaching.
The design is a systematic review of randomized, non-randomized, and before-after studies. The data sources were MEDLINE, Cochrane Library, EMBASE, CINAHL and ERIC between 1966 and 2006. Main outcomes were knowledge, skills, attitudes and behavior towards EBP. Standardized effect sizes (E-S) were calculated. The E-S was categorized as small (E-S < 0.2), small to moderate (E-S between 0.2 and 0.5), moderate to large (E-S between 0.51 and 0.79), large (E-S > 0.79). Reliability and validity of instruments for evaluating education were assessed. Studies excluded were those that were not original, performed in medical students, focused on prescribing practices, specific health problems, theoretical reviews of different components of EBP, continuing medical education, and testing the effectiveness of implementing guidelines.
Twenty-four studies met our inclusion criteria. There were 15 outcomes within the 10 studies for which E-S could be calculated. The E-S ranged from 0.27 (95%CI: -0.05 to 0.59) to 1.32 (95%CI: 1.11 to 1.53). Studies assessing skills, behavior and/or attitudes had a "small to moderate" E-S. Only 1 of the 2 studies assessing knowledge had E-S of 0.57 (95 CI: 0.32 to 0.82) and 2 of the 4 studies that assessed total test score outcomes had "large" E-S. There were 22 instruments used, but only 10 had 2 or more types of validity or reliability evidence.
Small improvements in knowledge, skills, attitudes or behavior are noted when measured alone. A large improvement in skills and knowledge in EBP is noted when measured together in a total test score. Very few studies used validated measures tests.
PMCID: PMC1995214  PMID: 17655743
20.  The Impact of Small Group Case-based Learning on Traditional Pharmacology Teaching 
This study aimed to measure medical students’ perceptions of incorporating small group case-based learning (CBL) in traditional pharmacology lectures.
Data were collected from third-year students (N = 68; 57% males, 43% females) at Al Quds University Medical School, Palestine. The students were offered a CBL-incorporated Pharmacology-2 course after they had been taught Pharmacology-1 in the traditional format during the preceding semester. Student attitudes towards the restructured course were examined by a self-administered structured questionnaire.
The majority of students thought that CBL was an effective learning tool for them (82%) and that it improved their learning skills (83%), independent learning skills (74%), analytical skills (70%), and their level of preparation for exams (75%). Most students reported that team discussions addressed lecture objectives (84%). Regarding cases discussed, most responders said that the cases were appropriate to the lecture topics (96%) and that the time allocated for case discussion was sufficient (86%). A large proportion of students thought that CBL improved their communication and collaborative skills (68% and 80%, respectively) and ability to work within a team (79%).
Pharmacology-2 course restructuring led to a significant improvement of self-reported student satisfaction, motivation, and engagement.
PMCID: PMC3616776  PMID: 23573391
Small group learning; Case-based learning; Pharmacology
21.  From board to bedside – training the communication competences of medical students with role plays 
BMC Medical Education  2014;14:135.
Role plays and standardized patients are often used in medical education and have proven to be effective tools for enhancing the communication skills of medical students. Most course concepts need additional time and teaching staff, and there are only a few studies about role plays in the preclinical segment.
We developed a highly consolidated concept for the curricular course of 2nd-year medical students, including ten role plays about five subjects: anamnesis, shared decision making, prevention, breaking bad news, and so-called “difficult interactions”. Before the course, all students were asked about their expectations and attitudes toward the course. After the course, all students rated the course, their individual learning progress, whether their expectations had been fulfilled, and re-evaluated their attitudes. Questionnaires were self-report measures and had a quantitative and a short qualitative section and were analyzed with descriptive statistics. Group differences (sex, age, role played) were evaluated with t tests at a Bonferonni-corrected significance level of p = .03 and the non-parametric U-tests.
Implementing this practical course concept is possible without incurring additional costs. This paper not only shows how that can be done but also provides 5 examples of role scripts for different training subjects. The course concept was highly appreciated by the students. More than 75% felt that they had learned important communication techniques and would be better able to handle difficult situations. Playing the doctor’s role was felt to be more useful than playing the patient’s role. Women admitted a higher degree of shyness in the beginning and gave higher ratings to their learning progress than men. Students’ most frequent wish in the qualitative analysis was to be able to play the doctor’s role at least once. The students’ answers showed a differentiated pattern, thus suggesting that the influence of social desirability was minimal.
Practical skills can be taught successfully in the preclinical stage of medical education even without an increase in resources. The course concept described in this article provides an effective means by which to do so.
PMCID: PMC4096752  PMID: 24996804
Teaching Materials; Teaching; Problem-based Learning; Education; Students, Medical; Students, Health Occupations; Schools, Medical; Academic Medical Centers; Psychology, Medical
22.  Attitudes of medical students towards general practice: Effects of gender, a general practice clerkship and a modern curriculum 
Aims: Planning a career in general practice depends on positive attitudes towards primary care. The aim of this study was to compare attitudes of medical students of a Modern Curriculum at Hannover Medical School with those of the Traditional Curriculum before (pre) and after (post) a three-week clerkship in general practice. In parallel, we aimed to analyse several other variables such as age and gender, which could influence the attitudes.
Methods: Prospective survey of n=287 5th-year students. Attitudes (dependent variable, Likert-scale items) as well as socio-demographic characteristics (age, gender, rural/urban background), school leaving examination grades, former qualifications, experiences in general practice and career plans were requested. Attitudes were analysed separately according to these characteristics (e.g. career plans: general practitioner (GP)/specialist), curriculum type and pre/post the clerkship in general practice. Bi- and multivariate statistical analysis was used including a factor analysis for grouping of the attitude items.
Results: Most and remarkable differences of attitudes were seen after analysis according to gender. Women appreciated general practice more than men including a greater interest in chronic diseases, communication and psychosocial aspects. The clerkship (a total of n=165 students of the “post” survey could be matched) contributed to positive attitudes of students of both gender, whereas the different curricula did not show such effects.
Conclusions: Affective learning goals such as a positive attitude towards general practice have depended more on characteristics of students (gender) and effects of a clerkship in general practice than on the curriculum type (modern, traditional) so far. For the development of outcomes in medical education research as well as for the evolution of the Modern Curriculum such attitudes and other affective learning goals should be considered more frequently.
PMCID: PMC3140385  PMID: 21818231
medical education research; general practice; curriculum; attitudes; questionnaire
23.  Medical Education and Information and Communication Technology 
Information and communication technology (ICT) has brought many changes in medical education and practice in the last couple of decades. Teaching and learning medicine particularly has gone under profound changes due to computer technologies, and medical schools around the world have invested heavily either in new computer technologies or in the process of adapting to this technological revolution. In order to catch up with the rest of the world, developing countries need to research their options in adapting to new computer technologies.
Materials and Methods:
This descriptive survey study was designed to assess medical students’ computer and Internet skills and their attitude toward ICT.
Research findings showed that the mean score of self-perceived computer knowledge for male students in general was greater than for female students. Also, students who had participated in various prior computer workshops, had access to computer, Internet, and e-mail, and frequently checked their e-mail had higher mean of self-perceived knowledge and skill score. Finally, students with positive attitude toward ICT scored their computer knowledge higher than those who had no opinion.
The results have confirmed that the medical schools, particularly in developing countries, need to bring fundamental changes such as curriculum modification in order to integrate ICT into medical education, creating essential infrastructure for ICT use in medical education and practice, and structured computer training for faculty and students.
PMCID: PMC3577362  PMID: 23555106
Basic biomedical sciences; clinical clerkship; computer knowledge and computer skills; information and communication technology; internship; medical education (MD program)
24.  An innovative quality improvement curriculum for third-year medical students 
Medical Education Online  2012;17:10.3402/meo.v17i0.18391.
Competence in quality improvement (QI) is a priority for medical students. We describe a self-directed QI skills curriculum for medical students in a 1-year longitudinal integrated third-year clerkship: an ideal context to learn and practice QI.
Two groups of four students identified a quality gap, described existing efforts to address the gap, made quantifying measures, and proposed a QI intervention. The program was assessed with knowledge and attitude surveys and a validated tool for rating trainee QI proposals. Reaction to the curriculum was assessed by survey and focus group.
Knowledge of QI concepts did not improve (mean knowledge score±SD): pre: 5.9±1.5 vs. post: 6.6±1.3, p=0.20. There were significant improvements in attitudes (mean topic attitude score±SD) toward the value of QI (pre: 9.9±1.8 vs. post: 12.6±1.9, p=0.03) and confidence in QI skills (pre: 13.4±2.8 vs. post: 16.1±3.0, p=0.05). Proposals lacked sufficient analysis of interventions and evaluation plans. Reaction was mixed, including appreciation for the experience and frustration with finding appropriate mentorship.
Clinical-year students were able to conduct a self-directed QI project. Lack of improvement in QI knowledge suggests that self-directed learning in this domain may be insufficient without targeted didactics. Higher order skills such as developing measurement plans would benefit from explicit instruction and mentorship. Lessons from this experience will allow educators to better target QI curricula to medical students in the clinical years.
PMCID: PMC3355381  PMID: 22611330
quality improvement education; undergraduate medical education; experiential learning; self-directed learning
25.  Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET 
Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.
We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.
Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.
In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.
The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).
PMCID: PMC3714007  PMID: 23835586
medical education; patient simulation; algorithms; students; community networks; problem-based learning; serious games; survey

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