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1.  Promoting physical therapists’ use of research evidence to inform clinical practice: part 2 - a mixed methods evaluation of the PEAK program 
BMC Medical Education  2014;14:126.
Background
Clinicians need innovative educational programs to enhance their capacity for using research evidence to inform clinical decision-making. This paper and its companion paper introduce the Physical therapist-driven Education for Actionable Knowledge translation (PEAK) program, an educational program designed to promote physical therapists’ integration of research evidence into clinical decision-making. This, second of two, papers reports a mixed methods feasibility study of the PEAK program among physical therapists at three university-based clinical facilities.
Methods
A convenience sample of 18 physical therapists participated in the six-month educational program. Mixed methods were used to triangulate results from pre-post quantitative data analyzed concurrently with qualitative data from semi-structured interviews and focus groups. Feasibility of the program was assessed by evaluating change in participants’ attitudes, self-efficacy, knowledge, skills, and self-reported behaviors in addition to their perceptions and reaction to the program.
Results
All 18 therapists completed the program. The group experienced statistically significant improvements in evidence based practice self-efficacy and self-reported behavior (p < 0.001). Four themes were supported by integrated quantitative and qualitative results: 1. The collaborative nature of the PEAK program was engaging and motivating; 2. PEAK participants experienced improved self-efficacy, creating a positive cycle where success reinforces engagement with research evidence; 3. Participants’ need to understand how to interpret statistics was not fully met; 4. Participants believed that the utilization of research evidence in their clinical practice would lead to better patient outcomes.
Conclusions
The PEAK program is a feasible educational program for promoting physical therapists’ use of research evidence in practice. A key ingredient seems to be guided small group work leading to a final product that guides local practice. Further investigation is recommended to assess long-term behavior change and to compare outcomes to alternative educational models.
doi:10.1186/1472-6920-14-126
PMCID: PMC4080990  PMID: 24965574
Knowledge translation; Evidence based practice; Education; Post-graduate training; Physical therapy; Mixed methods
2.  Outcomes of Irish graduate entry medical student engagement with self-directed learning of clinical skills 
BMC Medical Education  2015;15:21.
Background
Existing literature is mixed as to whether self-directed learning (SDL) delivers improvements in knowledge, skills or attitudes of medical students compared with traditional learning methods. This study aimed to determine whether there is an association between engagement in SDL and student performance in clinical examinations, the factors that influence student engagement with SDL in clinical skills, and student perceptions of SDL.
Methods
A retrospective analysis of electronic records of student bookings of SDL sessions from 2008 to 2010 was performed for students in the pre-clinical years of an Irish Graduate Entry Medical programme to assess their level of engagement with SDL. The extent to which this engagement influenced their performance in subsequent summative examinations was evaluated. A cross-sectional survey of students across the four years of the programme was also conducted to determine student perceptions of SDL and the factors that affect engagement.
Results
The level of engagement with SDL decreased over time from 95% of first years in 2008 to 49% of first years in 2010. There was no significant difference between the median exam performance for any clinical skills tested by level of engagement (none, one or more sessions) except for basic life support in first year (p =0.024). The main reason for engaging with SDL was to practice a clinical skill prior to assessment and the majority of respondents agreed that SDL sessions had improved their performance of the specific clinical skills being practised.
Conclusion
Students viewed SDL as an opportunity to practise skills prior to assessment but there were no significant differences in subsequent summative assessment by the level of engagement for most clinical skills.
doi:10.1186/s12909-015-0301-x
PMCID: PMC4336507
Clinical skills; Self-directed learning; Graduate entry medicine; Student engagement
3.  Role modelling of clinical tutors: a focus group study among medical students 
BMC Medical Education  2015;15:17.
Background
Role modelling by clinicians assists in development of medical students’ professional competencies, values and attitudes. Three core characteristics of a positive role model include 1) clinical attributes, 2) teaching skills, and 3) personal qualities. This study was designed to explore medical students’ perceptions of their bedside clinical tutors as role models during the first year of a medical program.
Methods
The study was conducted with one cohort (n = 301) of students who had completed Year 1 of the Sydney Medical Program in 2013. A total of nine focus groups (n = 59) were conducted with medical students following completion of Year 1. Data were transcribed verbatim. Thematic analysis was used to code and categorise data into themes.
Results
Students identified both positive and negative characteristics and behaviour displayed by their clinical tutors. Characteristics and behaviour that students would like to emulate as medical practitioners in the future included:
1) Clinical attributes: a good knowledge base; articulate history taking skills; the ability to explain and demonstrate skills at the appropriate level for students; and empathy, respect and genuine compassion for patients.
2) Teaching skills: development of a rapport with students; provision of time towards the growth of students academically and professionally; provision of a positive learning environment; an understanding of the student curriculum and assessment requirements; immediate and useful feedback; and provision of patient interaction.
3) Personal qualities: respectful interprofessional staff interactions; preparedness for tutorials; demonstration of a passion for teaching; and demonstration of a passion for their career choice.
Conclusion
Excellence in role modelling entails demonstration of excellent clinical care, teaching skills and personal characteristics. Our findings reinforce the important function of clinical bedside tutors as role models, which has implications for faculty development and recruitment.
doi:10.1186/s12909-015-0303-8
PMCID: PMC4335700
Role modelling; Medical students; Clinical tutors
4.  Examining the teaching roles and experiences of non-physician health care providers in family medicine education: a qualitative study 
BMC Medical Education  2015;15:15.
Background
Primary Care reform in Canada and globally has encouraged the development of interprofessional primary care initiatives. This has led to significant involvement of non-physician Health Care Providers (NPHCPs) in the teaching of medical trainees. The objective of this study was to understand the experiences, supports and challenges facing non-physician health care providers in Family Medicine education.
Methods
Four focus groups were conducted using a semi-structured interview guide with twenty one NPHCPs involved in teaching at the University of Toronto, Department of Family & Community Medicine. The focus groups were transcribed and analyzed for recurrent themes. The multi-disciplinary research team held several meetings to discuss themes.
Results
NPHCPs were highly involved in Family Medicine education, formally and informally. NPHCPs felt valued as teachers, but this often did not occur until after learners understood their educator role through increased time and exposure. NPHCPs expressed a lack of advance information of learner knowledge level and expectations, and missed opportunities to give feedback or receive teaching evaluations. Adequate preparation time, teaching space and financial compensation were important to NPHCPs, yet were often lacking. There was low awareness but high interest in faculty status and professional development opportunities.
Conclusions
Sharing learner goals and objectives and offering NPHCPs feedback and evaluation would help to formalize NPHCP roles and optimize their capacity for cross-professional teaching. Preparation time and dedicated space for teaching are also necessary. NPHCPs should be encouraged to pursue faculty appointments and to access ongoing Professional Development opportunities.
doi:10.1186/s12909-015-0283-8
PMCID: PMC4331463
5.  The mediating role of resilience in the relationship between stress and life satisfaction among Chinese medical students: a cross-sectional study 
BMC Medical Education  2015;15:16.
Background
The psychological distress of medical students has been widely acknowledged. However, few studies focused on positive well-being among medical students. The purpose of this study was to investigate related demographic factors of life satisfaction among Chinese medical students, to examine the relationship between stress and life satisfaction among this group of people, and to explore the mediating role of resilience in this relationship.
Methods
This multicenter cross-sectional study was carried out in June 2014. Self-reported questionnaires consisting of Perceived Stress Scale (PSS), Wagnild and Young Resilience Scale (RS-14), Satisfaction with Life Scale (SWLS), as well as demographic section were distributed to students at four medical colleges and universities in Liaoning province, China. A total of 2925 students (effective response rate: 83.6%) became our subjects. Hierarchical linear regression models were used to explore the mediating role of resilience.
Results
Among the demographic factors, life satisfaction was significantly different in gender (P = 0.001) and study programs (P < 0.001). Stress was negatively correlated with life satisfaction (r = −0.35, P < 0.01). After adjusting for the demographic factors, stress accounted for 12% of the variance in life satisfaction (β = −0.34, P < 0.001) while resilience explained an additional 18% of the variance (β = 0.46, P < 0.001). Resilience functioned as a partial mediator in the relationship between stress and life satisfaction among Chinese medical students.
Conclusions
Both stress and resilience played a big role in life satisfaction among Chinese medical students. Besides reducing perceived stress, the university authorities should adopt evidence-based intervention strategies to enhance their resilience in order to promote life satisfaction among the students.
doi:10.1186/s12909-015-0297-2
PMCID: PMC4332721
Stress; Life satisfaction; Resilience; Medical students
6.  Education in anesthesia: three years of online logbook implementation in an Italian school 
BMC Medical Education  2015;15:14.
Background
The progress of physicians through residency training in anesthesiology can be monitored using an online logbook. The aim of this investigation was to establish how residents record clinical activities in their computerized web-based logbooks during their first years of anesthesiology training.
Methods
For this retrospective observational trial, the ESSE 3© digital registry of the University of Modena and Reggio Emilia, Italy was used to record all anesthesia-related activities performed by three consecutive year-groups of residents (Groups A, B and C) between 2009 and 2012. The ratio of activities to sessions was chosen as a surrogate measure of compliance.
Results
A total of 41,348 actions were analyzed. The ratio of activities to sessions showed a statistically significant decline for all activities concerning the perioperative management of anesthesia, with a steady reduction from the first to the last year-group (Group A 23.7, Group B 14.1 and Group C 2.2; p = 0.003).
Conclusions
An online activities logbook is a useful tool for recording and assessing the clinical activities undertaken by each resident during residency training in anesthesiology.
doi:10.1186/s12909-015-0298-1
PMCID: PMC4331334
Online logbook; Anesthesiology; Residency; Training
7.  Can medical students identify a potentially serious acetaminophen dosing error in a simulated encounter? a case control study 
BMC Medical Education  2015;15:13.
Background
In an effort to assess medical students’ abilities to identify a medication administration error in an outpatient setting, we designed and implemented a standardized patient simulation exercise which included a medication overdose.
Methods
Fourth year medical students completed a standardized patient (SP) simulation of a parent bringing a toddler to an outpatient setting. In this case-control study, the majority of students had completed a patient safety curriculum about pediatric medication errors prior to their SP encounter. If asked about medications, the SP portraying a parent was trained to disclose that she was administering acetaminophen and to produce a package with dosing instructions on the label. The administered dose represented an overdose. Upon completion, students were asked to complete an encounter note.
Results
Three hundred forty students completed this simulation. Two hundred ninety-one students previously completed a formal patient safety curriculum while 49 had not. A total of two hundred thirty-four students (69%) ascertained that the parent had been administering acetaminophen to their child. Thirty-seven students (11%) determined that the dosage exceeded recommended dosages. There was no significant difference in the error detection rates of students who completed the patient safety curriculum and those who had not.
Conclusions
Despite a formal patient safety curriculum concerning medication errors, 89% of medical students did not identify an overdose of a commonly used over the counter medication during a standardized patient simulation. Further educational interventions are needed for students to detect medication errors. Additionally, 31% of students did not ask about the administration of over the counter medications suggesting that students may not view such medications as equally important to prescription medications. Simulation may serve as a useful tool to assess students’ competency in identifying medication administration errors.
doi:10.1186/s12909-015-0288-3
PMCID: PMC4335408
8.  The effect of an e-learning course on nursing staff’s knowledge of delirium: a before-and-after study 
BMC Medical Education  2015;15:12.
Background
Delirium is a common condition in hospitalized patients, associated with adverse outcomes such as longer hospital stay, functional decline and higher mortality, as well as higher rates of nursing home placement. Nurses often fail to recognize delirium in hospitalized patients, which might be due to a lack of knowledge of delirium diagnosis and treatment. The objective of the study was to test the effectiveness of an e-learning course on nurses’ delirium knowledge, describe nursing staff’s baseline knowledge about delirium, and describe demographic factors associated with baseline delirium knowledge and the effectiveness of the e-learning course.
Methods
A before-and-after study design, using an e-learning course on delirium. The course was introduced to all nursing staff of internal medicine and surgical wards of 17 Dutch hospitals.
Results
1,196 invitations for the e-learning course were sent to nursing staff, which included nurses, nursing students and healthcare assistants. Test scores on the final knowledge test (mean 87.4, 95% CI 86.7 to 88.2) were significantly higher than those on baseline (mean 79.3, 95% CI 78.5 to 80.1). At baseline, nursing staff had the most difficulty with questions related to the definition of delirium: what are its symptoms, course, consequences and which patients are at risk. The mean score for this category was 74.3 (95% CI 73.1 to 75.5).
Conclusions
The e-learning course significantly improved nursing staff's knowledge of delirium in all subgroups of participants and for all question categories. Contrary to other studies, the baseline knowledge assessment showed that, overall, nursing staff was relatively knowledgeable regarding delirium.
Trial registration
The Netherlands National Trial Register (NTR). Trial number: NTR 2885, 19 April 2011.
doi:10.1186/s12909-015-0289-2
PMCID: PMC4327788  PMID: 25653115
Delirium; Education; Nurses; e-learning
9.  Virtual patients - what are we talking about? A framework to classify the meanings of the term in healthcare education 
BMC Medical Education  2015;15:11.
Background
The term “virtual patients” (VPs) has been used for many years in academic publications, but its meaning varies, leading to confusion. Our aim was to investigate and categorize the use of the term “virtual patient” and then classify its use in healthcare education.
Methods
A literature review was conducted to determine all articles using the term “virtual patient” in the title or abstract. These articles were categorized into: Education, Clinical Procedures, Clinical Research and E-Health. All educational articles were further classified based on a framework published by Talbot et al. which was further developed using a deductive content analysis approach.
Results
536 articles published between 1991 and December 2013 were included in the study. From these, 330 were categorized as educational. Classifying these showed that 37% articles used VPs in the form of Interactive Patient Scenarios. VPs in form of High Fidelity Software Simulations (19%) and Virtual Standardized Patients (16%) were also frequent. Less frequent were other forms, such as VP Games.
Analyzing the literature across time shows an overall trend towards the use of Interactive Patient Scenarios as the predominant form of VPs in healthcare education.
Conclusions
The main form of educational VPs in the literature are Interactive Patient Scenarios despite rapid technical advances that would support more complex applications. The adapted classification provides a valuable model for VP developers and researchers in healthcare education to more clearly communicate the type of VP they are addressing avoiding misunderstandings.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-015-0296-3) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-015-0296-3
PMCID: PMC4318546  PMID: 25638167
Virtual patients; Healthcare education; Classification
10.  The validity and reliability of the sixth-year internal medical examination administered at the King Abdulaziz University Medical College 
BMC Medical Education  2015;15:10.
Background
Exams are essential components of medical students’ knowledge and skill assessment during their clinical years of study. The paper provides a retrospective analysis of validity evidence for the internal medicine component of the written and clinical exams administered in 2012 and 2013 at King Abdulaziz University’s Faculty of Medicine.
Methods
Students’ scores for the clinical and written exams were obtained. Four faculty members (two senior members and two junior members) were asked to rate the exam questions, including MCQs and OSCEs, for evidence of content validity using a rating scale of 1–5 for each item.
Cronbach’s alpha was used to measure the internal consistency reliability. Correlations were used to examine the associations between different forms of assessment and groups of students.
Results
A total of 824 students completed the internal medicine course and took the exam. The numbers of rated questions were 320 and 46 for the MCQ and OSCE, respectively. Significant correlations were found between the MCQ section, the OSCE section, and the continuous assessment marks, which include 20 long-case presentations during the course; participation in daily rounds, clinical sessions and tutorials; the performance of simple procedures, such as IV cannulation and ABG extraction; and the student log book.
Although the OSCE exam was reliable for the two groups that had taken the final clinical OSCE, the clinical long- and short-case exams were not reliable across the two groups that had taken the oral clinical exams. The correlation analysis showed a significant linear association between the raters with respect to evidence of content validity for both the MCQ and OSCE, r = .219 P < .001 and r = .678 P < .001, respectively, and r = .241 P < .001 and r = .368 P = .023 for the internal structure validity, respectively. Reliability measured using Cronbach’s alpha was greater for assessments administered in 2013.
Conclusion
The pattern of relationships between the MCQ and OSCE scores provides evidence of the validity of these measures for use in the evaluation of knowledge and clinical skills in internal medicine. The OSCE exam is more reliable than the short- and long-case clinical exams and requires less effort on the part of examiners and patients.
doi:10.1186/s12909-015-0295-4
PMCID: PMC4322795  PMID: 25638149
Validity; Assessment; Undergraduate medical education
11.  Digital rectal examination skills: first training experiences, the motives and attitudes of standardized patients 
Background
Physical clinical examination is a core clinical competence of medical doctors. In this regard, digital rectal examination (DRE) plays a central role in the detection of abnormalities of the anus and rectum. However, studies in undergraduate medical students as well as newly graduated doctors show that they are insufficiently prepared for performing DRE. Training units with Standardized Patients (SP) represent one method to deliver DRE skills. As yet, however, it is little known about SPs’ attitudes.
Methods
This is a qualitative study using a grounded theory approach. Interviews were conducted with 4 standardized patients about their experiences before, during and after structured SP training to deliver DRE competencies to medical students. The resulting data were subjected to thematic content analysis.
Results
Results show that SPs do not have any predominant motives for DRE program participation. They participate in the SP training sessions with relatively little prejudice and do not anticipate feeling highly vulnerable within teaching sessions with undergraduate medical students.
Conclusions
The current study examined SPs’ motives, views, expectations and experiences regarding a DRE program during their first SP training experiences. The results enabled us to derive distinct action guidelines for the recruitment, informing and briefing of SPs who are willing to participate in a DRE program.
doi:10.1186/s12909-015-0292-7
PMCID: PMC4322856  PMID: 25638247
Intimate physical examinations; Digital rectal examination; Standardized patients; Qualitative research
12.  Medical education research in GCC countries 
Background
Medical education is an essential domain to produce physicians with high standards of medical knowledge, skills and professionalism in medical practice. This study aimed to investigate the research progress and prospects of GCC countries in medical education during the period 1996–2013.
Methods
In this study, the research papers published in various global scientific journals during the period 1996–2013 were accessed. We recorded the total number of research documents having an affiliation with GCC Countries including Saudi Arabia, Bahrain, Kuwait, Qatar, United Arab Emirates and Oman. The main source for information was Institute of Scientific Information (ISI) Web of Science, Thomson Reuters.
Results
In ISI-Web of Science, Saudi Arabia contributed 40797 research papers, Kuwait 1666, United Arab Emirates 3045, Qatar 4265, Bahrain 1666 and Oman 4848 research papers. However, in Medical Education only Saudi Arabia contributed 323 (0.79%) research papers, Kuwait 52 (0.03%), United Arab Emirates 41(0.01%), Qatar 37(0.008%), Bahrain 28 (0.06%) and Oman 22 (0.45%) research papers in in ISI indexed journals. In medical education the Hirsch index (h-index) of Saudi Arabia is 14, United Arab Emirates 14, Kuwait 11, Qatar 8, Bahrain 8 and Oman 5.
Conclusion
GCC countries produced very little research in medical education during the period 1996–2013. They must improve their research outcomes in medical education to produce better physicians to enhance the standards in medical practice in the region.
doi:10.1186/s12909-015-0293-6
PMCID: PMC4330984  PMID: 25638308
GCC; Medical Education; Research papers; Indexed Journal
13.  Addressing disparities in academic medicine: what of the minority tax? 
Background
The proportion of black, Latino, and Native American faculty in U.S. academic medical centers has remained almost unchanged over the last 20 years. Some authors credit the "minority tax"—the burden of extra responsibilities placed on minority faculty in the name of diversity. This tax is in reality very complex, and a major source of inequity in academic medicine.
Discussion
The “minority tax” is better described as an Underrepresented Minority in Medicine (URMM) faculty responsibility disparity. This disparity is evident in many areas: diversity efforts, racism, isolation, mentorship, clinical responsibilities, and promotion.
Summary
The authors examine the components of the URMM responsibility disparity and use information from the medical literature and from human resources to suggest practical steps that can be taken by academic leaders and policymakers to move toward establishing faculty equity and thus increase the numbers of black, Latino, and Native American faculty in academic medicine.
doi:10.1186/s12909-015-0290-9
PMCID: PMC4331175  PMID: 25638211
Underrepresented minority; Black; Latino; Hispanic; Native american; Minority tax
14.  Clinical assessment of transthoracic echocardiography skills: a generalizability study 
Background
Transthoracic echocardiography (TTE) is a widely used cardiac imaging technique that all cardiologists should be able to perform competently. Traditionally, TTE competence has been assessed by unstructured observation or in test situations separated from daily clinical practice. An instrument for assessment of clinical TTE technical proficiency including a global rating score and a checklist score has previously shown reliability and validity in a standardised setting. As clinical test situations typically have several sources of error giving rise to variance in scores, a more thorough examination of the generalizability of the assessment instrument is needed.
Methods
Nine physicians performed a TTE scan on the same three patients. Then, two raters rated all 27 TTE scans using the TTE technical assessment instrument in a fully crossed, all random generalizability study. Estimated variance components were calculated for both the global rating and checklist scores. Finally, dependability (phi) coefficients were also calculated for both outcomes in a decision study.
Results
For global rating scores, 66.6% of score variance can be ascribed to true differences in performance. For checklist scores this was 88.8%. The difference was primarily due to physician-rater interaction. Four random cases rated by one random rater resulted in a phi value of 0.81 for global ratings and two random cases rated by one random rater showed a phi value of 0.92 for checklist scores.
Conclusions
Using the TTE checklist as opposed to the TTE global rating score had the effect of minimising the largest source of error variance in test scores. Two cases rated by one rater using the TTE checklist are sufficiently reliable for high stakes examinations. As global rating is less time consuming it could be considered performing four global rating assessments in addition to the checklist assessments to account for both reliability and content validity of the assessment.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-015-0294-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-015-0294-5
PMCID: PMC4334848  PMID: 25638012
Transthoracic echocardiography; Echocardiography; Assessment; Ultrasound; Generalizability study; Decision study
15.  Graduate entry and undergraduate medical students’ study approaches, stress levels and ways of coping: a five year longitudinal study 
Background
Incorporating graduate students into undergraduate medical degree programs is a commonly accepted practice. However, it has only recently been recognized that these two types of students cope with their studies in various ways. The aim was to compare the learning approaches, stress levels and ways of coping of undergraduate (UG) and graduate entry medical students (GEMP) throughout their medical course.
Methods
From 2007–2011 each of the five year cohorts of undergraduate and GEMP students completed four components of the study. The components included demographics, The Biggs’ R-SPQ-2 F questionnaire which determines students’ approaches to learning, the Perceived Stress Scale (PSS) used to rate students perceived stress during the past four weeks, and the Ways of Coping (WOC) questionnaire used to assess students’ methods of coping with everyday problems.
Results
There was a consistent difference between UG and GEMP students approaches to learning over the five years. GEMP students preferred a deep approach while the UG students preferred a superficial approach to learning. This difference became more obvious in the clinical years. There was no statistically significant difference between the groups in stress levels. There were consistent differences in the ways the two groups coped with stress.
Conclusions
There were significant differences in approaches to learning and ways of coping with stress between the UG and the GEMP students. These need to be considered when introducing curriculum change, in particular, redesigning an UG program for post graduate delivery.
doi:10.1186/s12909-015-0284-7
PMCID: PMC4310038  PMID: 25616440
16.  Characterization of medical students recall of factual knowledge using learning objects and repeated testing in a novel e-learning system 
Background
Spaced-repetition and test-enhanced learning are two methodologies that boost knowledge retention. ALERT STUDENT is a platform that allows creation and distribution of Learning Objects named flashcards, and provides insight into student judgments-of-learning through a metric called ‘recall accuracy‘. This study aims to understand how the spaced-repetition and test-enhanced learning features provided by the platform affect recall accuracy, and to characterize the effect that students, flashcards and repetitions exert on this measurement.
Methods
Three spaced laboratory sessions (s0, s1 and s2), were conducted with n=96 medical students. The intervention employed a study task, and a quiz task that consisted in mentally answering open-ended questions about each flashcard and grading recall accuracy. Students were randomized into study-quiz and quiz groups. On s0 both groups performed the quiz task. On s1 and s2, the study-quiz group performed the study task followed by the quiz task, whereas the quiz group only performed the quiz task. We measured differences in recall accuracy between groups/sessions, its variance components, and the G-coefficients for the flashcard component.
Results
At s0 there were no differences in recall accuracy between groups. The experiment group achieved a significant increase in recall accuracy that was superior to the quiz group in s1 and s2. In the study-quiz group, increases in recall accuracy were mainly due to the session, followed by flashcard factors and student factors. In the quiz group, increases in recall accuracy were mainly accounted by flashcard factors, followed by student and session factors. The flashcard G-coefficient indicated an agreement on recall accuracy of 91% in the quiz group, and of 47% in the study-quiz group.
Conclusions
Recall accuracy is an easily collectible measurement that increases the educational value of Learning Objects and open-ended questions. This metric seems to vary in a way consistent with knowledge retention, but further investigation is necessary to ascertain the nature of such relationship. Recall accuracy has educational implications to students and educators, and may contribute to deliver tailored learning experiences, assess the effectiveness of instruction, and facilitate research comparing blended-learning interventions.
Electronic supplementary material
The online version of this article (doi:10.1186/s12909-014-0275-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12909-014-0275-0
PMCID: PMC4326410  PMID: 25616353
Medical education; Memory retention; Computer-assisted instruction; E-learning; Tailored-learning; Spaced repetition; Test-enhanced learning; Judgment of learning; Curriculum evaluation; Blended-learning
17.  Cross-comparison of MRCGP & MRCP(UK) in a database linkage study of 2,284 candidates taking both examinations: assessment of validity and differential performance by ethnicity 
Background
MRCGP and MRCP(UK) are the main entry qualifications for UK doctors entering general [family] practice or hospital [internal] medicine. The performance of MRCP(UK) candidates who subsequently take MRCGP allows validation of each assessment.
In the UK, underperformance of ethnic minority doctors taking MRCGP has had a high political profile, with a Judicial Review in the High Court in April 2014 for alleged racial discrimination. Although the legal challenge was dismissed, substantial performance differences between white and BME (Black and Minority Ethnic) doctors undoubtedly exist. Understanding ethnic differences can be helped by comparing the performance of doctors who take both MRCGP and MRCP(UK).
Methods
We identified 2,284 candidates who had taken one or more parts of both assessments, MRCP(UK) typically being taken 3.7 years before MRCGP. We analyzed performance on knowledge-based MCQs (MRCP(UK) Parts 1 and 2 and MRCGP Applied Knowledge Test (AKT)) and clinical examinations (MRCGP Clinical Skills Assessment (CSA) and MRCP(UK) Practical Assessment of Clinical Skills (PACES)).
Results
Correlations between MRCGP and MRCP(UK) were high, disattenuated correlations for MRCGP AKT with MRCP(UK) Parts 1 and 2 being 0.748 and 0.698, and for CSA and PACES being 0.636.
BME candidates performed less well on all five assessments (P < .001). Correlations disaggregated by ethnicity were complex, MRCGP AKT showing similar correlations with Part1/Part2/PACES in White and BME candidates, but CSA showing stronger correlations with Part1/Part2/PACES in BME candidates than in White candidates.
CSA changed its scoring method during the study; multiple regression showed the newer CSA was better predicted by PACES than the previous CSA.
Conclusions
High correlations between MRCGP and MRCP(UK) support the validity of each, suggesting they assess knowledge cognate to both assessments.
Detailed analyses by candidate ethnicity show that although White candidates out-perform BME candidates, the differences are largely mirrored across the two examinations. Whilst the reason for the differential performance is unclear, the similarity of the effects in independent knowledge and clinical examinations suggests the differences are unlikely to result from specific features of either assessment and most likely represent true differences in ability.
doi:10.1186/s12909-014-0281-2
PMCID: PMC4302509  PMID: 25592199
MRCGP; MRCP(UK); Applied knowledge test; Clinical skills assessment; PACES; Correlation; Ethnicity; Black and minority ethnic
18.  Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability 
Background
Particularly when undertaken on a large scale, implementing innovation in higher education poses many challenges. Sustaining the innovation requires early adoption of a coherent implementation strategy. Using an example from clinical education, this article describes a process used to implement a large-scale innovation with the intent of achieving sustainability.
Desire to improve the effectiveness of undergraduate medical education has led to growing support for a longitudinal integrated clerkship (LIC) model. This involves a move away from the traditional clerkship of ‘block rotations’ with frequent changes in disciplines, to a focus upon clerkships with longer duration and opportunity for students to build sustained relationships with supervisors, mentors, colleagues and patients. A growing number of medical schools have adopted the LIC model for a small percentage of their students. At a time when increasing medical school numbers and class sizes are leading to competition for clinical supervisors it is however a daunting challenge to provide a longitudinal clerkship for an entire medical school class. This challenge is presented to illustrate the strategy used to implement sustainable large scale innovation.
What was done
A strategy to implement and build a sustainable longitudinal integrated community-based clerkship experience for all students was derived from a framework arising from Roberto and Levesque’s research in business. The framework’s four core processes: chartering, learning, mobilising and realigning, provided guidance in preparing and rolling out the ‘whole of class’ innovation.
Discussion
Roberto and Levesque’s framework proved useful for identifying the foundations of the implementation strategy, with special emphasis on the relationship building required to implement such an ambitious initiative. Although this was innovation in a new School it required change within the school, wider university and health community. Challenges encountered included some resistance to moving away from traditional hospital-centred education, initial student concern, resource limitations, workforce shortage and potential burnout of the innovators.
Summary
Large-scale innovations in medical education may productively draw upon research from other disciplines for guidance on how to lay the foundations for successfully achieving sustainability.
doi:10.1186/s12909-014-0282-1
PMCID: PMC4310178  PMID: 25592295
Medical education; Large scale change; Longitudinal integrated clerkships; Community-based
19.  Reliability of the Interprofessional Collaborator Assessment Rubric (ICAR) in Multi Source Feedback (MSF) with post-graduate medical residents 
BMC Medical Education  2014;14:1049.
Background
Increased attention on collaboration and teamwork competency development in medical education has raised the need for valid and reliable approaches to the assessment of collaboration competencies in post-graduate medical education. The purpose of this study was to evaluate the reliability of a modified Interprofessional Collaborator Assessment Rubric (ICAR) in a multi-source feedback (MSF) process for assessing post-graduate medical residents’ collaborator competencies.
Methods
Post-graduate medical residents (n = 16) received ICAR assessments from three different rater groups (physicians, nurses and allied health professionals) over a four-week rotation. Internal consistency, inter-rater reliability, inter-group differences and relationship between rater characteristics and ICAR scores were analyzed using Cronbach’s alpha, one-way and two-way repeated measures ANOVA, and logistic regression.
Results
Missing data decreased from 13.1% using daily assessments to 8.8% utilizing an MSF process, p = .032. High internal consistency measures were demonstrated for overall ICAR scores (α = .981) and individual assessment domains within the ICAR (α = .881 to .963). There were no significant differences between scores of physician, nurse, and allied health raters on collaborator competencies (F2,5 = 1.225, p = .297, η2 = .016). Rater gender was the only significant factor influencing scores with female raters scoring residents significantly lower than male raters (6.12 v. 6.82; F1,5 = 7.184, p = .008, η 2 = .045).
Conclusion
The study findings suggest that the use of the modified ICAR in a MSF assessment process could be a feasible and reliable assessment approach to providing formative feedback to post-graduate medical residents on collaborator competencies.
doi:10.1186/s12909-014-0279-9
PMCID: PMC4318203  PMID: 25551678
Interprofessional relations; Assessment; Multi-Source Feedback (MSF); Medical education
20.  Medical residents reflect on their prejudices toward poverty: a photovoice training project 
BMC Medical Education  2014;14:1050.
Background
Clinicians face challenges in delivering care to socioeconomically disadvantaged patients. While both the public and academic sectors recognize the importance of addressing social inequities in healthcare, there is room for improvement in the training of family physicians, who report being ill-equipped to provide care that is responsive to the living conditions of these patients. This study explored: (i) residents’ perceptions and experience in relation to providing care for socioeconomically disadvantaged patients, and (ii) how participating in a photovoice study helped them uncover and examine some of their prejudices and assumptions about poverty.
Methods
We conducted a participatory photovoice study. Participants were four family medicine residents, two medical supervisors, and two researchers. Residents attended six photovoice meetings at which they discussed photos they had taken. In collaboration with the researchers, the participants defined the research questions, took photos, and participated in data analysis and results dissemination. Meetings were recorded and transcribed for analysis, which consisted of coding, peer debriefing, thematic analysis, and interpretation.
Results
The medical residents uncovered and examined their own prejudices and misconceptions about poverty. They reported feeling unprepared to provide care to socioeconomically disadvantaged patients. Supported by medical supervisors and researchers, the residents underwent a three-phase reflexive process of: (1) engaging reflexively, (2) break(ing) through, and (3) taking action. The results indicated that medical residents subsequently felt encouraged to adopt a care approach that helped them overcome the social distance between themselves and their socioeconomically disadvantaged patients.
Conclusions
This study highlights the importance of providing medical training on issues related to poverty and increasing awareness about social inequalities in medical education to counteract prejudices toward socioeconomically disadvantaged patients. Future studies should examine which elective courses and training could provide suitable tools to clinicians to improve their competence in delivering care to socioeconomically disadvantaged patients.
doi:10.1186/s12909-014-0274-1
PMCID: PMC4323214  PMID: 25551370
Healthcare disparities; Poverty; Participatory action research; Photovoice; Residents; Education; Healthcare professionals; Medicine
21.  Continuing medical education revisited: theoretical assumptions and practical implications: a qualitative study 
BMC Medical Education  2014;14:1051.
Background
Recent research has evidenced that although investment in Continuing Medical Education (CME), both in terms of participation as well as financial resources allocated to it, has been steadily increasing to catch up with accelerating advances in health information and technology, effectiveness of CME is reported to be rather limited. Poor and disproportional returns can be attributed to failure of CME courses to address and stimulate an adult audience.
Methods
The present study initially drew on research findings and adult learning theories, providing the basis for comprehending adult learning, while entailing practical implications on fostering effectiveness in the design and delivery of CME. On a second level, a qualitative study was conducted with the aim to elucidate parameters accounting for effectiveness in educational interventions. Qualitative data was retrieved through 12 in-depth interviews, conducted with a random sample of participants in the 26th European Workshop of Advanced Plastic Surgery (EWAPS). The data underwent a three level qualitative analysis, following the “grounded theory” methodology, comprising ‘open coding’, ‘axial coding’ and ‘selective coding’.
Results
Findings from the EWAPS study come in line with relevant literature, entailing significant implications for the necessity to apply a more effective and efficient paradigm in the design and delivery of educational interventions, advocating for implementing learner-centered schemata in CME and benefiting from a model that draws on the learning environment and social aspects of learning.
Conclusions
What emerged as a pivotal parameter in designing educational interventions is to focus on small group educational events which could provide a supportive friendly context, enhance motivation through learner-centered approaches and allow interaction, experimentation and critical reflection. It should be outlined however that further research is required as the present study is limited in scope, having dealt with a limited sample.
doi:10.1186/s12909-014-0278-x
PMCID: PMC4324803  PMID: 25551589
Continuing medical education; Adult learning; Learner-centered approach; Group interaction; Plastic surgery; Qualitative research
22.  Evaluating the Guideline Enhancement Tool (GET): an innovative clinical training tool to enhance the use of hypertension guidelines in general practice 
BMC Medical Education  2014;14:1046.
Background
This project aims to evaluate the effectiveness of an innovative educational intervention in enhancing clinical decision making related to the management of hypertension in general practice. The relatively low level of uptake of clinical practice guidelines by clinicians is widely recognised as a problem that impacts on clinical outcomes. This project addresses this problem with a focus on hypertension guidelines. Hypertension is the most frequently managed problem in general practice but evidence suggests that management of Hypertension in general practice is sub-optimal.
Methods/design
This study will explore the effectiveness of an educational intervention named the ‘Guideline Enhancement Tool (GET)’. The intervention is designed to guide clinicians through a systematic process of considering key decision points related to the management of hypertension and provides a mechanism for clinicians to engage with the hypertension clinical guidelines.
The intervention will be administered within the Australian General Practice Training program, via one of the regional training providers. Two cohorts of trainees will participate as the intervention and delayed intervention groups.
This process is expected to improve clinicians’ engagement with the hypertension guidelines in particular, and enhance their clinical reasoning abilities in general. The effectiveness of the intervention in improving clinical reasoning will be evaluated using the ‘Script Concordance Test’.
Discussion
The study design presented in this protocol aims to achieve two major outcomes. Firstly, the trial and evaluation of the educational intervention can lead to the development of a validated clinical education strategy that can be used in GP training to enhance the decision-making processes related to the management of hypertension. This has the potential to be adapted to other clinical conditions and training programs and can benefit clinicians in their clinical decision-making. Secondly, the study explores features that influence the effective use of clinical practice guidelines. The study thus addresses a significant problem in clinical education.
doi:10.1186/s12909-014-0273-2
PMCID: PMC4318171  PMID: 25547621
Clinical decision making; Clinical reasoning; Clinical practice guidelines; Guideline Enhancement Tool (GET); General practice training; Clinical education; Hypertension
23.  Bridging the gap - planning Lifestyle Medicine fellowship curricula: A cross sectional study 
BMC Medical Education  2014;14:1045.
Background
The emerging field, Lifestyle Medicine (LM), is the evidence-based practice of assisting individuals and families to adopt and sustain behaviors that can improve health. While competencies for LM education have been defined, and undergraduate curricula have been published, there are no published reports that address graduate level fellowship in LM. This paper describes the process of planning a LM fellowship curriculum at a major, academic teaching institution.
Methods
In September 2012 Harvard Medical School Department of Physical Medicine and Rehabilitation approved a “Research Fellowship in Lifestyle Medicine”. A Likert scale questionnaire was created and disseminated to forty LM stakeholders worldwide, which measured perceived relative importance of six domains and eight educational experiences to include in a one-year LM fellowship. Statistical procedures included analysis of variance and the Wilcoxon signed-rank test.
Results
Thirty-five stakeholders (87.5%) completed the survey. All domains except smoking cessation were graded at 4 or 5 by at least 85% of the respondents. After excluding smoking cessation, nutrition, physical activity, behavioral change techniques, stress resiliency, and personal health behaviors were rated as equally important components of a LM fellowship curriculum (average M = 4.69, SD = 0.15, p = 0.12). All educational experiences, with the exception of completing certification programs, research experience and fund raising, were graded at 4 or 5 by at least 82% of the responders. The remaining educational experiences, i.e. clinical practice, teaching physicians and medical students, teaching other health care providers, developing lifestyle interventions and developing health promotion programs were ranked as equally important in a LM fellowship program (average M = 4.23, SD = 0.11, p = 0.07).
Conclusions
Lifestyle fellowship curricula components were defined based on LM stakeholders’ input. These domains and educational experiences represent the range of competencies previously noted as important in the practice of LM. As the foundation of an inaugural physician fellowship, they inform the educational objectives and future evaluation of this fellowship.
doi:10.1186/s12909-014-0271-4
PMCID: PMC4318224  PMID: 25551283
Lifestyle medicine; Curriculum; Fellowship; Medical education
24.  Identifying and enhancing risk thresholds in the detection of elder financial abuse: a signal detection analysis of professionals’ decision making 
BMC Medical Education  2014;14:1044.
Background
Financial abuse of elders is an under acknowledged problem and professionals’ judgements contribute to both the prevalence of abuse and the ability to prevent and intervene. In the absence of a definitive “gold standard” for the judgement, it is desirable to try and bring novice professionals’ judgemental risk thresholds to the level of competent professionals as quickly and effectively as possible. This study aimed to test if a training intervention was able to bring novices’ risk thresholds for financial abuse in line with expert opinion.
Methods
A signal detection analysis, within a randomised controlled trial of an educational intervention, was undertaken to examine the effect on the ability of novices to efficiently detect financial abuse. Novices (n = 154) and experts (n = 33) judged “certainty of risk” across 43 scenarios; whether a scenario constituted a case of financial abuse or not was a function of expert opinion.
Novices (n = 154) were randomised to receive either an on-line educational intervention to improve financial abuse detection (n = 78) or a control group (no on-line educational intervention, n = 76). Both groups examined 28 scenarios of abuse (11 “signal” scenarios of risk and 17 “noise” scenarios of no risk). After the intervention group had received the on-line training, both groups then examined 15 further scenarios (5 “signal” and 10 “noise” scenarios).
Results
Experts were more certain than the novices, pre (Mean 70.61 vs. 58.04) and post intervention (Mean 70.84 vs. 63.04); and more consistent. The intervention group (mean 64.64) were more certain of abuse post-intervention than the control group (mean 61.41, p = 0.02). Signal detection analysis of sensitivity (A´) and bias (C) revealed that this was due to the intervention shifting the novices’ tendency towards saying “at risk” (C post intervention -.34) and away from their pre intervention levels of bias (C-.12). Receiver operating curves revealed more efficient judgments in the intervention group.
Conclusion
An educational intervention can improve judgements of financial abuse amongst novice professionals.
doi:10.1186/s12909-014-0268-z
PMCID: PMC4322548  PMID: 25547513
Professional decision making; Elder financial abuse; Signal detection theory; ROC curve
25.  Who would students ask for help in academic cheating? Cross-sectional study of medical students in Croatia 
BMC Medical Education  2014;14:1048.
Background
Academic cheating does not happen as an isolated action of an individual but is most often a collaborative practice. As there are few studies that looked at who are collaborators in cheating, we investigated medical students’ readiness to engage others in academic dishonest behaviours.
Methods
In a cross-sectional survey study in Zagreb, Croatia, 592 medical students from the first, 3rd and 6th (final) study year anonymously answered a survey of readiness to ask family, friends, colleagues or strangers for help in 4 different forms of academic cheating or for 2 personal material favours. Stepwise multiple linear regression models (MLR) were used to evaluate potential factors influencing propensity for engaging others in these two types of behaviour.
Results
Many students would ask another person for help in academic cheating, from 88.8% to 26.9% depending on a cheating behaviour. Students would most often ask a family member or friend for help in academic cheating. The same “helpers” were identified for non-academic related behaviour – asking for personal material favours. More respondents, however, would include three or four persons for asking help in academic cheating than for routine material favours. Score on material favours survey was the strongest positive predictor of readiness for asking help in academic cheating (stepwise MLR model; beta = 0.308, P < 0.0001) followed by extrinsic motivation (compensation) and male gender, whereas intrinsic motivation, year of study and grade point average were weak negative predictors.
Conclusions
Our study indicates that medical students are willing to engage more than one person in either close or distant relationships in academic cheating. In order to develop effective preventive measures to deter cheating at medical academic institutions, factors surrounding students’ preference towards academic cheating rather than routine favours should be further investigated.
doi:10.1186/s12909-014-0277-y
PMCID: PMC4322647  PMID: 25547735

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