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1.  Development and Validation of an Instrument for Measuring the Quality of Teamwork in Teaching Teams in Postgraduate Medical Training (TeamQ) 
PLoS ONE  2014;9(11):e112805.
Background
Teamwork between clinical teachers is a challenge in postgraduate medical training. Although there are several instruments available for measuring teamwork in health care, none of them are appropriate for teaching teams. The aim of this study is to develop an instrument (TeamQ) for measuring teamwork, to investigate its psychometric properties and to explore how clinical teachers assess their teamwork.
Method
To select the items to be included in the TeamQ questionnaire, we conducted a content validation in 2011, using a Delphi procedure in which 40 experts were invited. Next, for pilot testing the preliminary tool, 1446 clinical teachers from 116 teaching teams were requested to complete the TeamQ questionnaire. For data analyses we used statistical strategies: principal component analysis, internal consistency reliability coefficient, and the number of evaluations needed to obtain reliable estimates. Lastly, the median TeamQ scores were calculated for teams to explore the levels of teamwork.
Results
In total, 31 experts participated in the Delphi study. In total, 114 teams participated in the TeamQ pilot. The median team response was 7 evaluations per team. The principal component analysis revealed 11 factors; 8 were included. The reliability coefficients of the TeamQ scales ranged from 0.75 to 0.93. The generalizability analysis revealed that 5 to 7 evaluations were needed to obtain internal reliability coefficients of 0.70. In terms of teamwork, the clinical teachers scored residents' empowerment as the highest TeamQ scale and feedback culture as the area that would most benefit from improvement.
Conclusions
This study provides initial evidence of the validity of an instrument for measuring teamwork in teaching teams. The high response rates and the low number of evaluations needed for reliably measuring teamwork indicate that TeamQ is feasible for use by teaching teams. Future research could explore the effectiveness of feedback on teamwork in follow up measurements.
doi:10.1371/journal.pone.0112805
PMCID: PMC4231160  PMID: 25393006
2.  Comparison of expectations and beliefs about good teaching in an academic day release medical education program: a qualitative study 
BMC Medical Education  2014;14(1):211.
Background
In a professional learner-centered(ness) educational environment, communication and alignment of expectations about teaching are indispensable. Professional education of residents could benefit from an analysis and comparison of teachers’ and residents’ educational expectations and beliefs. Our purpose is to identify success factors and barriers related to aligning expectations and beliefs and building a supportive professional learner-centered educational environment.
Methods
We conducted semi-structured individual interviews with teachers and semi-structured focus groups with residents. A single interview format was used to make it possible to compare the results. Data were analysed using a qualitative software package (AtlasTi). Data analysis steps were followed by the author team, which identified four domains of good teaching: personal traits, knowledge, relationships and teaching qualities.
Results
Teachers and residents agreed about the importance of personal professional characteristics like being a role model and having an open and enthusiastic attitude. They all thought that having a specific knowledge base was essential for teaching. Approaching residents as adult learners was found to be an important element of the learner-centred environment and it was agreed that teachers should take practical experiences to a higher level. However, teachers and residents had different expectations about the practical consequences of being a role model, adult learning, coaching and openness, and the type of knowledge that was needed in the professional development program. Communication about different expectations appeared to be difficult.
Conclusions
Teachers and residents agreed on a conceptual level about expectations and beliefs regarding good teaching, but disagreed on an executive level. According to the residents, the disagreement about good teaching was not the biggest barrier to creating alignment and a supportive professional relationship; instead, it was the absence of a proper dialogue regarding issues about expectations and beliefs.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6920-14-211) contains supplementary material, which is available to authorized users.
doi:10.1186/1472-6920-14-211
PMCID: PMC4198618  PMID: 25280918
Educational expectations and beliefs; Teachers; Residents; Postgraduate day release program in medical education
3.  Investigating teaching performance in seminars; a questionnaire study with a multi-level approach 
BMC Medical Education  2014;14(1):203.
Background
Teachers play an important role in seminars as facilitators and content experts. However, contextual factors like students’ preparation, group size, group interaction, and content appear to influence their performance. Understanding the impact of these contextual factors on students’ perception of teaching performance may help to further understand seminar teaching. Besides that, it may help curriculum organisers and teachers to get more insight in how to optimise their versatile role in seminars. The aim of this study is to investigate how students’ perception of teaching performance in seminars is explained by students’ extent of preparation, seminar group size, group interaction, and content.
Methods
The Utrecht Seminar Evaluation (USEME) questionnaire was used to collect information on teaching performance and the aforementioned explanatory variables. To account for intra-student, intra-seminar, and intra-teacher correlation in the data, multilevel regression was used to analyse 988 completed questionnaires in 80 seminars with 36 different teachers.
Results
Group interaction and seminar content had large (B = 0.418) and medium (B = 0.212) positive effects on perceived teaching performance scores, whereas the effects of students’ preparation (B = -0.055) and group size (B = -0.130) were small and negative.
Conclusions
This study provides curriculum organisers and teachers indications on how to optimise variables that influence perceived teaching performance in seminars. It is suggested that teachers should search for the most appropriate combination of motivating and challenging content and facilitation method within seminars to optimise discussion opportunities between students.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6920-14-203) contains supplementary material, which is available to authorized users.
doi:10.1186/1472-6920-14-203
PMCID: PMC4190460  PMID: 25253047
Group interaction; Group size; Interactive learning; Seminar teaching performance; Student preparation
4.  An instrument for evaluating clinical teaching in Japan: content validity and cultural sensitivity 
BMC Medical Education  2014;14(1):179.
Background
Many instruments for evaluating clinical teaching have been developed but almost all in Western countries. None of these instruments have been validated for the Asian culture, and a literature search yielded no instruments that were developed specifically for that culture. A key element that influences content validity in developing instruments for evaluating the quality of teaching is culture. The aim of this study was to develop a culture-specific instrument with strong content validity for evaluating clinical teaching in initial medical postgraduate training in Japan.
Methods
Based on data from a literature search and an earlier study we prepared a draft evaluation instrument. To ensure a good cultural fit of the instrument with the Asian context we conducted a modified Delphi procedure among three groups of stakeholders (five education experts, twelve clinical teachers and ten residents) to establish content validity, as this factor is particularly susceptible to cultural factors.
Results
Two rounds of Delphi were conducted. Through the procedure, 52 prospective items were reworded, combined or eliminated, resulting in a 25-item instrument validated for the Japanese setting.
Conclusions
This is the first study describing the development and content validation of an instrument for evaluating clinical teaching specifically tailored to an East Asian setting. The instrument has similarities and differences compared with instruments of Western origin. Our findings suggest that designers of evaluation instruments should consider the probability that the content validity of instruments for evaluating clinical teachers can be influenced by cultural aspects.
Electronic supplementary material
The online version of this article (doi:10.1186/1472-6920-14-179) contains supplementary material, which is available to authorized users.
doi:10.1186/1472-6920-14-179
PMCID: PMC4167259  PMID: 25164309
Evaluation; Instrument; Clinical teaching; Japan; Culture; Modified Delphi method; Content validity
5.  Outcome and impact of Master of Public Health programs across six countries: education for change 
Background
The human resources for health crisis has highlighted the need for high-level public health education to add specific capacities to the workforce. Recently, it was questioned whether Master of Public Health (MPH) training prepared graduates with competencies relevant to low- and middle-income countries (LMICs). This study aims to examine the influence of the MPH programs geared towards LMICs offered in Vietnam, China, South Africa, Mexico, Sudan, and the Netherlands on graduates’ careers, application of acquired competencies, performance at the workplace, and their professional contribution to society.
Methods
A self-administered questionnaire was sent to graduates from six MPH programs. Frequency distributions of the answers were calculated, and a bivariate analysis and logistic regression of certain variables was performed.
Results
The response rate was 37.5%. Graduates reported change in leadership (69%), in technical position (69%), acquiring new responsibilities (80%), and increased remuneration (63%); they asserted that MPH programs contributed significantly to this. Graduates’ attribution of their application of 7 key competencies ‘substantially to the MPH program’ ranged from 33% to 48%. Of the 26 impact variables, graduates attributed the effect they had on their workplace substantially to the MPH program; the highest rated variable ranged from 31% to 73% and the lowest ranged from 9% to 43%. Of the 10 impact variables on society, graduates attributed the effect they had on society substantially to the MPH program; for the highest rated variable (13% to 71%); for the lowest rated variable (4% to 42%). Candidates’ attribution of their application of acquired competencies as well as their impact at the workplace varied significantly according to institution of study and educational background.
Conclusions
This study concludes that these MPH programs contribute to improving graduates’ careers and to building leadership in public health. The MPH programs contribute to graduates’ application of competencies. MPH programs contribute substantially towards impact variables on the workplace, such as development of research proposals and reporting on population health needs, and less substantially to their impact on society, such as contributing equitable access to quality services. Differences reported between MPH programs merit further study. The results can be used for curriculum reform.
doi:10.1186/1478-4491-12-40
PMCID: PMC4130699  PMID: 25099707
Evaluation; Graduate; Impact; Low- and middle-income countries; Master of Public Health; Outcome
6.  A pilot study of a practice management training module for medical residents 
BMC Medical Education  2014;14:107.
Background
In 2005 a competency based curriculum was introduced in the Dutch postgraduate medical training programs. While the manager’s role is one of the seven key competencies, there is still no formal management course in most postgraduate curricula. Based on a needs assessment we conducted, several themes were identified as important for a possible management training program. We present the results of the pilot training we performed to investigate two of these themes.
Methods
The topics “knowledge of the healthcare system” and “time management” were developed from the list of suggested management training themes. Fourteen residents participated in the training and twenty-four residents served as control. The training consisted of two sessions of four hours with a homework assignment in between. 50 True/false-questions were given as pre- and post-test to both the test and control groups to assess the level of acquired knowledge among the test group as well as the impact of the intervention. We also performed a qualitative evaluation using evaluation forms and in-depth interviews.
Results
All fourteen residents completed the training. Six residents in the control group were lost to follow up. The pre- and post-test showed improvement among the participating residents in comparison to the residents from the control group, but this improvement was not significant. The qualitative assessment showed that all residents evaluated the training positively and experienced it as a useful addition to their training in becoming a medical specialist.
Conclusion
Our training was evaluated positively and considered to be valuable. This study supports the need for mandatory medical management training as part of the postgraduate medical curriculum. Our training could be an example of how to teach two important themes in the broad area of medical management education.
doi:10.1186/1472-6920-14-107
PMCID: PMC4038828  PMID: 24885442
Medical residents; Management training; Competency; Postgraduate curriculum
7.  Medical Students Perceive Better Group Learning Processes when Large Classes Are Made to Seem Small 
PLoS ONE  2014;9(4):e93328.
Objective
Medical schools struggle with large classes, which might interfere with the effectiveness of learning within small groups due to students being unfamiliar to fellow students. The aim of this study was to assess the effects of making a large class seem small on the students' collaborative learning processes.
Design
A randomised controlled intervention study was undertaken to make a large class seem small, without the need to reduce the number of students enrolling in the medical programme. The class was divided into subsets: two small subsets (n = 50) as the intervention groups; a control group (n = 102) was mixed with the remaining students (the non-randomised group n∼100) to create one large subset.
Setting
The undergraduate curriculum of the Maastricht Medical School, applying the Problem-Based Learning principles. In this learning context, students learn mainly in tutorial groups, composed randomly from a large class every 6–10 weeks.
Intervention
The formal group learning activities were organised within the subsets. Students from the intervention groups met frequently within the formal groups, in contrast to the students from the large subset who hardly enrolled with the same students in formal activities.
Main Outcome Measures
Three outcome measures assessed students' group learning processes over time: learning within formally organised small groups, learning with other students in the informal context and perceptions of the intervention.
Results
Formal group learning processes were perceived more positive in the intervention groups from the second study year on, with a mean increase of β = 0.48. Informal group learning activities occurred almost exclusively within the subsets as defined by the intervention from the first week involved in the medical curriculum (E-I indexes>−0.69). Interviews tapped mainly positive effects and negligible negative side effects of the intervention.
Conclusion
Better group learning processes can be achieved in large medical schools by making large classes seem small.
doi:10.1371/journal.pone.0093328
PMCID: PMC3988014  PMID: 24736272
8.  Influence of the workplace on learning physical examination skills 
BMC Medical Education  2014;14:61.
Background
Hospital clerkships are considered crucial for acquiring competencies such as diagnostic reasoning and clinical skills. The actual learning process in the hospital remains poorly understood. This study investigates how students learn clinical skills in workplaces and factors affecting this.
Methods
Six focus group sessions with 32 students in Internal Medicine rotation (4–9 students per group; sessions 80–90 minutes). Verbatim transcripts were analysed by emerging themes and coded independently by three researchers followed by constant comparison and axial coding.
Results
Students report to learn the systematics of the physical examination, gain agility and become able to recognise pathological signs. The learning process combines working alongside others and working independently with increasing responsibility for patient care. Helpful behaviour includes making findings explicit through patient files or during observation, feedback by abnormal findings and taking initiative. Factors affecting the process negatively include lack of supervision, uncertainty about tasks and expectations, and social context such as hierarchy of learners and perceived learning environment.
Conclusion
Although individual student experiences vary greatly between different hospitals, it seems that proactivity and participation are central drivers for learning. These results can improve the quality of existing programmes and help design new ways to learn physical examination skills.
doi:10.1186/1472-6920-14-61
PMCID: PMC3976051  PMID: 24678562
9.  Effect of the Learning Climate of Residency Programs on Faculty’s Teaching Performance as Evaluated by Residents 
PLoS ONE  2014;9(1):e86512.
Background
To understand teaching performance of individual faculty, the climate in which residents’ learning takes place, the learning climate, may be important. There is emerging evidence that specific climates do predict specific outcomes. Until now, the effect of learning climate on the performance of the individual faculty who actually do the teaching was unknown.
Objectives
This study: (i) tested the hypothesis that a positive learning climate was associated with better teaching performance of individual faculty as evaluated by residents, and (ii) explored which dimensions of learning climate were associated with faculty’s teaching performance.
Methods and Materials
We conducted two cross-sectional questionnaire surveys amongst residents from 45 residency training programs and multiple specialties in 17 hospitals in the Netherlands. Residents evaluated the teaching performance of individual faculty using the robust System for Evaluating Teaching Qualities (SETQ) and evaluated the learning climate of residency programs using the Dutch Residency Educational Climate Test (D-RECT). The validated D-RECT questionnaire consisted of 11 subscales of learning climate. Main outcome measure was faculty’s overall teaching (SETQ) score. We used multivariable adjusted linear mixed models to estimate the separate associations of overall learning climate and each of its subscales with faculty’s teaching performance.
Results
In total 451 residents completed 3569 SETQ evaluations of 502 faculty. Residents also evaluated the learning climate of 45 residency programs in 17 hospitals in the Netherlands. Overall learning climate was positively associated with faculty’s teaching performance (regression coefficient 0.54, 95% confidence interval: 0.37 to 0.71; P<0.001). Three out of 11 learning climate subscales were substantially associated with better teaching performance: ‘coaching and assessment’, ‘work is adapted to residents’ competence’, and ‘formal education’.
Conclusions
Individual faculty’s teaching performance evaluations are positively affected by better learning climate of residency programs.
doi:10.1371/journal.pone.0086512
PMCID: PMC3904911  PMID: 24489734
10.  Validation of public health competencies and impact variables for low- and middle-income countries 
BMC Public Health  2014;14:55.
Background
The number of Master of Public Health (MPH) programmes in low- and middle-income countries (LMICs) is increasing, but questions have been raised regarding the relevance of their outcomes and impacts on context. Although processes for validating public health competencies have taken place in recent years in many high-income countries, validation in LMICs is needed. Furthermore, impact variables of MPH programmes in the workplace and in society have not been developed.
Method
A set of public health competencies and impact variables in the workplace and in society was designed using the competencies and learning objectives of six participating institutions offering MPH programmes in or for LMICs, and the set of competencies of the Council on Linkages Between Academia and Public Health Practice as a reference. The resulting competencies and impact variables differ from those of the Council on Linkages in scope and emphasis on social determinants of health, context specificity and intersectoral competencies. A modified Delphi method was used in this study to validate the public health competencies and impact variables; experts and MPH alumni from China, Vietnam, South Africa, Sudan, Mexico and the Netherlands reviewed them and made recommendations.
Results
The competencies and variables were validated across two Delphi rounds, first with public health experts (N = 31) from the six countries, then with MPH alumni (N = 30). After the first expert round, competencies and impact variables were refined based on the quantitative results and qualitative comments. Both rounds showed high consensus, more so for the competencies than the impact variables. The response rate was 100%.
Conclusion
This is the first time that public health competencies have been validated in LMICs across continents. It is also the first time that impact variables of MPH programmes have been proposed and validated in LMICs across continents. The high degree of consensus between experts and alumni suggests that these public health competencies and impact variables can be used to design and evaluate MPH programmes, as well as for individual and team assessment and continuous professional development in LMICs.
doi:10.1186/1471-2458-14-55
PMCID: PMC3899921  PMID: 24438672
Public health competencies; Impact; Low- and middle-income countries; Master of Public Health
11.  Does community health care require different competencies from physicians and nurses? 
Background
Recently competency approach in Health Professionals’ Education (HPE) has become quite popular and for an effective competency based HPE, it is important to design the curriculum around the health care needs of the population to be served and on the expected roles of the health care providers. Unfortunately, in community settings roles of health providers tend to be described less clearly, particularly at the Primary Health Care (PHC) level where a multidisciplinary and appropriately prepared health team is generally lacking. Moreover, to tailor the education on community needs there is no substantial evidence on what specific requirements the providers must be prepared for.
Methods
This study has explored specific tasks of physicians and nurses employed to work in primary or secondary health care units in a context where there is a structural scarcity of community health care providers. In-depth Interviews of 11 physicians and 06 nurses working in community settings of Pakistan were conducted along with review of their job descriptions.
Results
At all levels of health settings, physicians’ were mostly engaged with diagnosing and prescribing medical illness of patients coming to health center and nurses depending on their employer were either providing preventive health care activities, assisting physicians or occupied in day to day management of health center. Geographical location or level of health facility did not have major effect on the roles being expected or performed, however the factors that determined the roles performed by health providers were employer expectations, preparation of health providers for providing community based care, role clarity and availability of resources including health team at health facilities.
Conclusions
Exploration of specific tasks of physicians and nurses working in community settings provide a useful framework to map competencies, and can help educators revisit the curricula and instructional designs accordingly. Furthermore, in community settings there are many synergies between the roles of physicians and nurses which could be simulated as learning activities; at the same time these two groups of health providers offer distinct sets of services, which must be harnessed to build effective, non-hierarchal, collaborative health teams.
doi:10.1186/1472-6920-14-1
PMCID: PMC3893590  PMID: 24387322
Competencies; Community settings; Undergraduate curriculum; Health care providers; Tasks & functions
12.  Competence, commitment and opportunity: an exploration of faculty views and perceptions on community- based education 
BMC Medical Education  2013;13:167.
Background
Community-Based Education (CBE) is an instructional approach designed and carried out in a community context and environment in which not only students, but also faculty and Health Professionals’ Education (HPE) institutions must be actively engaged throughout the educational experience. Despite the growing evidence of CBE being an effective approach for contemporary HPE, doubts about its successful implementation still exist. This study has explored HPE structure, policies and curriculum from the point of view of faculty members to gain understanding about the prevailing practices and to propose recommendations that nurtures and promotes CBE.
Method
A purposive sample was drawn from three major cities of Pakistan- Karachi, Rawalpindi and Islamabad. Out of twelve HPE institutions present in these cities we selected six, which provided a sound representation of medical and nursing colleges around the country. At each institution we had two Focus Group Discussions; in addition we interviewed registrars of medical and nursing councils and two CBE experts.
Results
The factors effecting implementation of CBE as perceived by study participants are categorized as: preparation of faculty members; institutional commitment and enthusiasm; curricular priorities and external milieu. Within each theme, participants recurrently described structural and curricular deficiencies, and lack of commitment and appreciation for community based teaching, service and research permeating at all levels: regulatory bodies, institutional heads and faculty members.
Conclusions
The factors highlighted by our study and many others suggest that CBE could not perpetuate effectively within HPE. To enhance the effectiveness of CBE approach in a way that mutually benefits local communities as well as HPE institutions and health professionals, it is important that reforms in HPE must be strategized in a holistic fashion i.e. restructuring and aligning its polices, curriculum and research priorities.
doi:10.1186/1472-6920-13-167
PMCID: PMC4029465  PMID: 24330679
13.  Students’ perceptions of anatomy across the undergraduate problem-based learning medical curriculum: a phenomenographical study 
BMC Medical Education  2013;13:152.
Background
To get insight in how theoretical knowledge is transformed into clinical skills, important information may arise from mapping the development of anatomical knowledge during the undergraduate medical curriculum. If we want to gain a better understanding of teaching and learning in anatomy, it may be pertinent to move beyond the question of how and consider also the what, why and when of anatomy education.
Methods
A purposive sample of 78 medical students from the 2nd, 3rd, 4th and 6th year of a PBL curriculum participated in 4 focus groups. Each group came together twice, and all meetings were recorded and transcribed verbatim. Data were analysed with template analysis using a phenomenographical approach.
Results
Five major topics emerged and are described covering the students’ perceptions on their anatomy education and anatomical knowledge: 1) motivation to study anatomy, 2) the relevance of anatomical knowledge, 3) assessment of anatomical knowledge, 4) students’ (in)security about their anatomical knowledge and 5) the use of anatomical knowledge in clinical practice.
Conclusions
Results indicated that a PBL approach in itself was not enough to ensure adequate learning of anatomy, and support the hypothesis that educational principles like time-on-task and repetition, have a stronger impact on students’ perceived and actual anatomical knowledge than the educational approach underpinning a curriculum. For example, students state that repetitive studying of the subject increases retention of knowledge to a greater extent than stricter assessment, and teaching in context enhances motivation and transfer. Innovations in teaching and assessment, like spiral curriculum, teaching in context, teaching for transfer and assessment for learning (rewarding understanding and higher order cognitive skills), are required to improve anatomy education.
doi:10.1186/1472-6920-13-152
PMCID: PMC4225514  PMID: 24252155
Anatomy; Basic sciences; Curriculum; Education; Knowledge; Learning; Problem based learning
14.  Remediation of at-risk medical students: theory in action 
BMC Medical Education  2013;13:132.
Background
Previous work has shown that a programme that draws on a blend of theories makes a positive difference to outcomes for students who fail and repeat their first semester at medical school. Exploration of student and teacher perspectives revealed that remediation of struggling medical students can be achieved through a cognitive apprenticeship within a small community of inquiry. This community needs expert teachers capable of performing a unique combination of roles (facilitator, nurturing mentor, disciplinarian, diagnostician and role model), with high levels of teaching presence and practical wisdom. Yet, despite participants’ convergent opinions on the elements of effective remediation, significant differences were found between outcomes of students working with experienced and inexperienced teachers. The current study explores the actual practice of teachers on this remediation course, aiming to exemplify elements of our theory of remediation and explore differences between teachers.
Methods
Since it is in the classroom context that the interactions that constitute the complex process of remediation emerge, this practice-based research has focused on direct observation of classroom teaching. Nineteen hours of small group sessions were recorded and transcribed. Drawing on ethnography and sociocultural discourse analysis, selected samples of talk-in-context demonstrate how the various elements of remediation play out in practice, highlighting aspects that are most effective, and identifying differences between experienced and novice teachers.
Results
Long-term student outcomes are strongly correlated to teacher experience (r, 0.81). Compared to inexperienced teachers, experienced teachers provide more challenging, disruptive facilitation, and take a dialogic stance that encourages more collaborative group dynamics. They are more expert at diagnosing cognitive errors, provide frequent metacognitive time-outs and make explicit links across the curriculum.
Conclusions
Remediation is effective in small groups where dialogue is used for collaborative knowledge construction and social regulation. This requires facilitation by experienced teachers who attend to details of both content and process, and use timely interventions to foster curiosity and the will to learn. These teachers should actively challenge students’ language use, logical inconsistencies and uncertainties, problematize their assumptions, and provide a metacognitive regulatory voice that can generate attitudinal shifts and nurture the development of independent critical thinkers.
doi:10.1186/1472-6920-13-132
PMCID: PMC3851205  PMID: 24070196
At-risk students; Remediation; Small group teaching; Classroom discourse; Facilitation skills; Teaching experience; Pedagogical context knowledge
15.  The Teacher, the Physician and the Person: Exploring Causal Connections between Teaching Performance and Role Model Types Using Directed Acyclic Graphs 
PLoS ONE  2013;8(7):e69449.
Background
In fledgling areas of research, evidence supporting causal assumptions is often scarce due to the small number of empirical studies conducted. In many studies it remains unclear what impact explicit and implicit causal assumptions have on the research findings; only the primary assumptions of the researchers are often presented. This is particularly true for research on the effect of faculty’s teaching performance on their role modeling. Therefore, there is a need for robust frameworks and methods for transparent formal presentation of the underlying causal assumptions used in assessing the causal effects of teaching performance on role modeling. This study explores the effects of different (plausible) causal assumptions on research outcomes.
Methods
This study revisits a previously published study about the influence of faculty’s teaching performance on their role modeling (as teacher-supervisor, physician and person). We drew eight directed acyclic graphs (DAGs) to visually represent different plausible causal relationships between the variables under study. These DAGs were subsequently translated into corresponding statistical models, and regression analyses were performed to estimate the associations between teaching performance and role modeling.
Results
The different causal models were compatible with major differences in the magnitude of the relationship between faculty’s teaching performance and their role modeling. Odds ratios for the associations between teaching performance and the three role model types ranged from 31.1 to 73.6 for the teacher-supervisor role, from 3.7 to 15.5 for the physician role, and from 2.8 to 13.8 for the person role.
Conclusions
Different sets of assumptions about causal relationships in role modeling research can be visually depicted using DAGs, which are then used to guide both statistical analysis and interpretation of results. Since study conclusions can be sensitive to different causal assumptions, results should be interpreted in the light of causal assumptions made in each study.
doi:10.1371/journal.pone.0069449
PMCID: PMC3720648  PMID: 23936020
16.  Qualitative study about the ways teachers react to feedback from resident evaluations 
BMC Medical Education  2013;13:98.
Background
Currently, one of the main interventions that are widely expected to contribute to teachers’ professional development is confronting teachers with feedback from resident evaluations of their teaching performance. Receiving feedback, however, is a double edged sword. Teachers see themselves confronted with information about themselves and are, at the same time, expected to be role models in the way they respond to feedback. Knowledge about the teachers’ responses could be not only of benefit for their professional development, but also for supporting their role modeling. Therefore, research about professional development should include the way teachers respond to feedback.
Method
We designed a qualitative study with semi-structured individual conversations about feedback reports, gained from resident evaluations. Two researchers carried out a systematic analysis using qualitative research software. The analysis focused on what happened in the conversations and structured the data in three main themes: conversation process, acceptance and coping strategies.
Results
The result section describes the conversation patterns and atmosphere. Teachers accepted their results calmly, stating that, although they recognised some points of interest, they could not meet with every standard. Most used coping strategies were explaining the results from their personal beliefs about good teaching and attributing poor results to external factors and good results to themselves. However, some teachers admitted that they had poor results because of the fact that they were not “sharp enough” in their resident group, implying that they did not do their best.
Conclusions
Our study not only confirms that the effects of feedback depend first and foremost on the recipient but also enlightens the meaning and role of acceptance and being a role model. We think that the results justify the conclusion that teachers who are responsible for the day release programmes in the three departments tend to respond to the evaluation results just like human beings do and, at the time of the conversation, are initially not aware of the fact that they are role models in the way they respond to feedback.
doi:10.1186/1472-6920-13-98
PMCID: PMC3751067  PMID: 23866849
Teachers; Professional development; Feedback; Role modeling
17.  What are the benefits of early patient contact? - A comparison of three preclinical patient contact settings 
BMC Medical Education  2013;13:80.
Background
Despite increasing attention to providing preclinical medical students with early patient experiences, little is known about associated outcomes for students. The authors compared three early patient experiences at a large American medical school where all preclinical students complete preceptorships and weekly bedside clinical-skills training and about half complete clinical, community-based summer immersion experiences. The authors asked, what are the relative outcomes and important educational components for students?
Methods
Medical students completed surveys at end of second year 2009–2011. In 2009, students compared/contrasted two of three approaches; responses framed later survey questions. In 2010 and 2011, students rated all three experiences in relevant areas (e.g., developing comfort in clinical setting). Investigators performed qualitative and quantitative analyses.
Results
Students rated bedside training more highly for developing comfort with clinical settings, one-on-one clinical-skills training, feedback, active clinical experience, quality of clinical training, and learning to be part of a team. They rated community clinical immersion and preceptorships more highly for understanding the life/practice of a physician and career/specialty decisions.
Conclusions
Preclinical students received different benefits from the different experiences. Medical schools should define objectives of early clinical experiences and offer options accordingly. A combination of experiences may help students achieve clinical and team comfort, clinical skills, an understanding of physicians’ lives/practices, and broad exposure for career decisions.
doi:10.1186/1472-6920-13-80
PMCID: PMC3674974  PMID: 23731514
18.  Quality assurance in transnational higher education: a case study of the tropEd network 
BMC Medical Education  2013;13:43.
Introduction
Transnational or cross-border higher education has rapidly expanded since the 1980s. Together with that expansion issues on quality assurance came to the forefront. This article aims to identify key issues regarding quality assurance of transnational higher education and discusses the quality assurance of the tropEd Network for International Health in Higher Education in relation to these key issues.
Methods
Literature review and review of documents.
Results
From the literature the following key issues regarding transnational quality assurance were identified and explored: comparability of quality assurance frameworks, true collaboration versus erosion of national education sovereignty, accreditation agencies and transparency. The tropEd network developed a transnational quality assurance framework for the network. The network accredits modules through a rigorous process which has been accepted by major stakeholders. This process was a participatory learning process and at the same time the process worked positive for the relations between the institutions.
Discussion
The development of the quality assurance framework and the process provides a potential example for others.
doi:10.1186/1472-6920-13-43
PMCID: PMC3614883  PMID: 23537108
Quality assurance; Higher education; Cross-border; Transnational; Networks
19.  Medical residents’ perceptions of their competencies and training needs in health care management: an international comparison 
BMC Medical Education  2013;13:25.
Background
Previous research has shown that Dutch medical residents feel inadequate in certain management areas: 85% had a need for management training and reported preferences on the format of such training. Our objective was to explore if the perceived deficiencies and needs among Dutch residents were similar to those of their peers in other countries, and if a longer duration of the incorporation of the CanMEDS competency framework into curricula as well as management training had an influence on these perceptions.
Methods
Medical residents from Denmark, Canada and Australia were approached for participation. The questionnaire used to survey the perceptions of Dutch residents was slightly modified, translated into English and sent by email to all international participants.
Results
Response rates were; Denmark 719/2105 (34%), Canada 177/500 (35%) and Australia 194/1213 (16%) respectively. The Danish as well as the Canadian residents rated their negotiating skills poorly. In Australia the residents found their knowledge on how their specialist department was organized to be insufficient, while residents in the Netherlands rated their knowledge on how the healthcare system was organized as inadequate. In all of the countries, more than 70% of the residents reported a perceived need for management training.
Conclusions
A majority of the residents in all countries felt the need for specific training in developing their management competencies. The adoption of the CanMEDS framework alone seems to be insufficient in meeting residents’ perceived educational needs in this area.
doi:10.1186/1472-6920-13-25
PMCID: PMC3577427  PMID: 23406436
Medical residents; CanMEDS; Managers role; Assessment; International comparison
20.  Teachers’ perceptions of aspects affecting seminar learning: a qualitative study 
BMC Medical Education  2013;13:22.
Background
Many medical schools have embraced small group learning methods in their undergraduate curricula. Given increasing financial constraints on universities, active learning groups like seminars (with 25 students a group) are gaining popularity. To enhance the understanding of seminar learning and to determine how seminar learning can be optimised it is important to investigate stakeholders’ views. In this study, we qualitatively explored the views of teachers on aspects affecting seminar learning.
Methods
Twenty-four teachers with experience in facilitating seminars in a three-year bachelor curriculum participated in semi-structured focus group interviews. Three focus groups met twice with an interval of two weeks led by one moderator. Sessions were audio taped, transcribed verbatim and independently coded by two researchers using thematic analysis. An iterative process of data reduction resulted in emerging aspects that influence seminar learning.
Results
Teachers identified seven key aspects affecting seminar learning: the seminar teacher, students, preparation, group functioning, seminar goals and content, course coherence and schedule and facilities. Important components of these aspects were: the teachers’ role in developing seminars (‘ownership’), the amount and quality of preparation materials, a non-threatening learning climate, continuity of group composition, suitability of subjects for seminar teaching, the number and quality of seminar questions, and alignment of different course activities.
Conclusions
The results of this study contribute to the unravelling of the ‘the black box’ of seminar learning. Suggestions for ways to optimise active learning in seminars are made regarding curriculum development, seminar content, quality assurance and faculty development.
doi:10.1186/1472-6920-13-22
PMCID: PMC3576232  PMID: 23399475
Seminar learning; Undergraduate (veterinary) medical education; Focus groups; Faculty development
21.  A systematic review of outcome and impact of Master’s in health and health care 
BMC Medical Education  2013;13:18.
Background
The ‘human resources for health’ crisis has highlighted the need for more health (care) professionals and led to an increased interest in health professional education, including master’s degree programmes. The number of these programmes in low- and middle-income countries (LMIC) is increasing, but questions have been raised regarding their relevance, outcome and impact. We conducted a systematic review to evaluate the outcomes and impact of health-related master’s degree programmes.
Methods
We searched the databases Scopus, Pubmed, Embase, CINAHL, ERIC, Psychinfo and Cochrane (1999 - November 2011) and selected websites. All papers describing outcomes and impact of health-related Master programmes were included. Three reviewers, two for each article, extracted data independently. The articles were categorised by type of programme, country, defined outcomes and impact, study methods used and level of evidence, and classified according to outcomes: competencies used in practice, graduates’ career progression and impact on graduates’ workplaces and sector/society.
Results
Of the 33 articles included in the review, most originated from the US and the UK, and only one from a low-income country. The programmes studied were in public health (8), nursing (8), physiotherapy (5), family practice (4) and other topics (8). Outcomes were defined in less than one third of the articles, and impact was not defined at all. Outcomes and impact were measured by self-reported alumni surveys and qualitative methods. Most articles reported that competencies learned during the programme were applied in the workplace and alumni reported career progression or specific job changes. Some articles reported difficulties in using newly gained competencies in the workplace. There was limited evidence of impact on the workplace. Only two articles reported impact on the sector. Most studies described learning approaches, but very few described a mechanism to ensure outcome and impact of the programme.
Conclusions
Evidence suggests that graduates apply newly learned competencies in the field and that they progress in their career. There is a paucity of well-designed studies assessing the outcomes and impact of health-related master’s degree programmes in low- and middle-income countries. Studies of such programmes should consider the context and define outcomes and impact.
doi:10.1186/1472-6920-13-18
PMCID: PMC3620571  PMID: 23388181
Master’s degree programmes; Evaluation; Outcomes; Impact; Systematic review; Public health
22.  Teacher-made models: the answer for medical skills training in developing countries? 
BMC Medical Education  2012;12:98.
Background
The advantages of using simulators in skills training are generally recognized, but simulators are often too expensive for medical schools in developing countries. Cheaper locally-made models (or part-task trainers) could be the answer, especially when teachers are involved in design and production (teacher-made models, TM).
Methods
We evaluated the effectiveness of a TM in training and assessing intravenous injection skills in comparison to an available commercial model (CM) in a randomized, blind, pretest-posttest study with 144 undergraduate nursing students. All students were assessed on both the TM and the CM in the pre-test and post-test. After the post-test the students were also assessed while performing the skill on real patients.
Results
Differences in the mean scores pre- and post-test were marked in all groups. Training with TM or CM improved student scores substantially but there was no significant difference in mean scores whether students had practiced on TM or CM. Students who practiced on TM performed better on communication with the patient than did students who practiced on CM. Decreasing the ratio of students per TM model helped to increase practice opportunities but did not improve student’s mean scores. The result of the assessment on both the TM and the CM had a low correlation with the results of the assessment on real persons.
Conclusions
The TM appears to be an effective alternative to CM for training students on basic IV skills, as students showed similar increases in performance scores after training on models that cost considerably less than commercially available models. These models could be produced using locally available materials in most countries, including those with limited resources to invest in medical education and skills laboratories.
doi:10.1186/1472-6920-12-98
PMCID: PMC3533861  PMID: 23082941
Clinical skills laboratory; Teacher made models; Commercial models; Vietnam
23.  Does reflection have an effect upon case-solving abilities of undergraduate medical students? 
BMC Medical Education  2012;12:75.
Background
Reflection on professional experience is increasingly accepted as a critical attribute for health care practice; however, evidence that it has a positive impact on performance remains scarce. This study investigated whether, after allowing for the effects of knowledge and consultation skills, reflection had an independent effect on students’ ability to solve problem cases.
Methods
Data was collected from 362 undergraduate medical students at Ghent University solving video cases and reflected on the experience of doing so. For knowledge and consultation skills results on a progress test and a course teaching consultation skills were used respectively. Stepwise multiple linear regression analysis was used to test the relationship between the quality of case-solving (dependent variable) and reflection skills, knowledge, and consultation skills (dependent variables).
Results
Only students with data on all variables available (n = 270) were included for analysis. The model was significant (Anova F(3,269) = 11.00, p < 0.001, adjusted R square 0.10) with all variables significantly contributing.
Conclusion
Medical students’ reflection had a small but significant effect on case-solving, which supports reflection as an attribute for performance. These findings suggest that it would be worthwhile testing the effect of reflection skills training on clinical competence.
doi:10.1186/1472-6920-12-75
PMCID: PMC3492041  PMID: 22889271
24.  Preclinical students’ experiences in early clerkships after skills training partly offered in primary health care centers: a qualitative study from Indonesia 
BMC Medical Education  2012;12:35.
Background
Students may encounter difficulties when they have to apply clinical skills trained in their pre-clinical studies in clerkships. Early clinical exposure in the pre-clinical phase has been recommended to reduce these transition problems. The aim of this study is to explore differences in students' experiences during the first clerkships between students exclusively trained in a skills laboratory and peers for whom part of their skills training was substituted by early clinical experiences (ECE).
Methods
Thirty pre-clinical students trained clinical skills exclusively in a skills laboratory; 30 peers received part of their skills training in PHC centers. Within half a year after commencing their clerkships all 60 students shared their experiences in focus group discussions (FGDs). Verbatim transcripts of FGDs were analyzed using Atlas-Ti software.
Results
Clerkship students who had participated in ECE in PHC centers felt better prepared to perform their clinical skills during the first clerkships than peers who had only practiced in a skills laboratory. ECE in PHC centers impacted positively in particular on students’ confidence, clinical reasoning, and interpersonal communication.
Conclusion
In the Indonesian setting ECE in PHC centers reduce difficulties commonly encountered by medical students in the first clerkships.
doi:10.1186/1472-6920-12-35
PMCID: PMC3527268  PMID: 22640419
Clinical skills training; Early clinical experiences; Clerkships
25.  Using video-cases to assess student reflection: Development and validation of an instrument 
BMC Medical Education  2012;12:22.
Background
Reflection is a meta-cognitive process, characterized by: 1. Awareness of self and the situation; 2. Critical analysis and understanding of both self and the situation; 3. Development of new perspectives to inform future actions. Assessors can only access reflections indirectly through learners’ verbal and/or written expressions. Being privy to the situation that triggered reflection could place reflective materials into context. Video-cases make that possible and, coupled with a scoring rubric, offer a reliable way of assessing reflection.
Methods
Fourth and fifth year undergraduate medical students were shown two interactive video-cases and asked to reflect on this experience, guided by six standard questions. The quality of students’ reflections were scored using a specially developed Student Assessment of Reflection Scoring rubric (StARS®). Reflection scores were analyzed concerning interrater reliability and ability to discriminate between students. Further, the intra-rater reliability and case specificity were estimated by means of a generalizability study with rating and case scenario as facets.
Results
Reflection scores of 270 students ranged widely and interrater reliability was acceptable (Krippendorff’s alpha = 0.88). The generalizability study suggested 3 or 4 cases were needed to obtain reliable ratings from 4th year students and ≥ 6 cases from 5th year students.
Conclusion
Use of StARS® to assess student reflections triggered by standardized video-cases had acceptable discriminative ability and reliability. We offer this practical method for assessing reflection summatively, and providing formative feedback in training situations.
doi:10.1186/1472-6920-12-22
PMCID: PMC3426495  PMID: 22520632

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