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1.  Optimisation of simulated team training through the application of learning theories: a debate for a conceptual framework 
BMC Medical Education  2014;14:69.
Background
As a conceptual review, this paper will debate relevant learning theories to inform the development, design and delivery of an effective educational programme for simulated team training relevant to health professionals.
Discussion
Kolb’s experiential learning theory is used as the main conceptual framework to define the sequence of activities. Dewey’s theory of reflective thought and action, Jarvis modification of Kolb’s learning cycle and Schön’s reflection-on-action serve as a model to design scenarios for optimal concrete experience and debriefing for challenging participants’ beliefs and habits. Bandura’s theory of self-efficacy and newer socio-cultural learning models outline that for efficient team training, it is mandatory to introduce the social-cultural context of a team.
Summary
The ideal simulated team training programme needs a scenario for concrete experience, followed by a debriefing with a critical reflexive observation and abstract conceptualisation phase, and ending with a second scenario for active experimentation. Let them re-experiment to optimise the effect of a simulated training session. Challenge them to the edge: The scenario needs to challenge participants to generate failures and feelings of inadequacy to drive and motivate team members to critical reflect and learn. Not experience itself but the inadequacy and contradictions of habitual experience serve as basis for reflection. Facilitate critical reflection: Facilitators and group members must guide and motivate individual participants through the debriefing session, inciting and empowering learners to challenge their own beliefs and habits. To do this, learners need to feel psychological safe. Let the group talk and critical explore. Motivate with reality and context: Training with multidisciplinary team members, with different levels of expertise, acting in their usual environment (in-situ simulation) on physiological variables is mandatory to introduce cultural context and social conditions to the learning experience. Embedding in situ team training sessions into a teaching programme to enable repeated training and to assess regularly team performance is mandatory for a cultural change of sustained improvement of team performance and patient safety.
doi:10.1186/1472-6920-14-69
PMCID: PMC3975868  PMID: 24694243
Teamwork; Team training; In-situ simulation; Experiential learning theory; Socio-cultural learning theories; Conceptual framework
2.  Analysis of internet use behaviors among clinical medical students in China 
BMC Medical Education  2014;14:67.
Background
The availability of internet-based information resources is increasing and the appropriate use of such resources is an important subject for clinical medical students. The aims of this study were to investigate the behaviors of clinical medical students regarding the use of internet-based activities, to analyze the behavior and characteristics of the students’ information demands, and to discuss the behaviors and time preferences related to internet use of students with different levels of education.
Methods
Librarians obtained real-time feedback from 999 clinical medical students to record online activities. The data was recorded in a standard form and then analyzed statistically.
Results
There were significant differences in the use of the internet for learning activities among the different groups of clinical medical students (P < 0.0001). Learning accounted for 73.5% of all internet use for doctoral candidates, 47.6% of internet use for master’s candidates, 28.7% of internet use for seven-year undergraduate students, and 14.1% of use for five-year undergraduate students. There was also a significant difference in the proportions of leisure and e-commerce activities among the student groups (P < 0.0001), with five-year students displaying the highest total proportion of these activities (59.4% and 18.8%). Internet use for entertainment activities was the same for all groups of clinical medical students. Time of day of internet use was consistent across all student groups, but internet use differed by day of the week (P < 0.01). There was no difference among the time of day of internet use for learning, leisure and entertainment activities during a single day (P > 0.05), but e-commerce activities varied according to time of day (P < 0.05). Learning and e-commerce activities by clinical medical students did not vary by day of the week (P > 0.05), but the distributions of leisure and entertainment activities were different according to day of the week (P < 0.05).
Conclusions
A stronger demand for learning is associated with a higher academic level of clinical medical students. Differences exist among student groups regarding internet use behaviors and internet use during different time periods.
doi:10.1186/1472-6920-14-67
PMCID: PMC3976031  PMID: 24690437
3.  Modification of Peyton’s four-step approach for small group teaching – a descriptive study 
BMC Medical Education  2014;14:68.
Background
Skills-lab training as a methodological teaching approach is nowadays part of the training programs of almost all medical faculties. Specific ingredients have been shown to contribute to a successful learning experience in skills-labs. Although it is undoubted that the instructional approach used to introduce novel clinical technical skills to learners has a decisive impact on subsequent skills performance, as yet, little is known about differential effects of varying instructional methods. An instructional approach that is becoming increasingly prevalent in medical education is “Peyton’s Four-Step Approach”. As Peyton’s Four Step Approach was designed for a 1:1 teacher : student ratio, the aim of the present study was to develop and evaluate a modified Peyton’s Approach for small group teaching.
Methods
The modified Peyton’s Approach was applied in three skills-lab training sessions on IV catheter insertion, each with three first- or second year medical students (n = 9), delivered by three different skills-lab teachers. The presented descriptive study investigated the practicability and subjective impressions of skills-lab trainees and tutors. Skills-lab sessions were evaluated by trainees’ self-assessment, expert ratings, and qualitative analysis of semi-standardized interviews conducted with trainees and tutors.
Results
The model was well accepted by trainees, and was rated as easy to realize, resulting in a good flow of teaching and success in attracting trainee’s attention when observed by expert raters. Qualitative semi-standardized interviews performed with all of the trainees and tutors revealed that trainees valued repeated observation, instruction of trainees and the opportunity for independent performance, while tutors stressed that trainees were highly concentrated throughout the training and that they perceived repeated observation to be a valuable preparation for their own performance.
Conclusion
The modified Peyton’s Approach to instruct small groups of students in skills-lab training sessions has revealed to be practicable, well accepted by trainees, and easy for tutors to realize. Further research should address the realization of the model in larger skills-lab training groups.
doi:10.1186/1472-6920-14-68
PMCID: PMC3976361  PMID: 24690457
Undergraduate medical education; Clinical skills; Catheter insertion; Simulation; Instructional approach; Peyton; Small group teaching
4.  Feasibility and sustainability of an interactive team-based learning method for medical education during a severe faculty shortage in Zimbabwe 
BMC Medical Education  2014;14:63.
Background
In 2010, in the midst of the human immunodeficiency virus (HIV) epidemic in Zimbabwe, 69% of faculty positions in the Department of Medicine of the University of Zimbabwe College of Health Sciences (UZ-CHS) were vacant. To address the ongoing need to train highly skilled HIV clinicians with only a limited number of faculty, we developed and implemented a course for final-year medical students focused on HIV care using team-based learning (TBL) methods.
Methods
A competency-based HIV curriculum was developed and delivered to final-year medical students in 10 TBL sessions as part of a 12 week clinical medicine attachment. A questionnaire was administered to the students after completion of the course to assess their perception of TBL and self-perceived knowledge gained in HIV care. Two cohorts of students completed the survey in separate academic years, 2011 and 2012. Descriptive analysis of survey results was performed.
Results
Ninety-six of 120 students (80%) completed surveys. One hundred percent of respondents agreed that TBL was an effective way to learn about HIV and 66% strongly agreed. The majority of respondents agreed that TBL was more stimulating than a lecture course (94%), fostered enthusiasm for the course material (91%), and improved teamwork (96%). Students perceived improvements in knowledge gained across all of the HIV subjects covered, especially in challenging applied clinical topics, such as management of HIV antiretroviral failure (88% with at least a “large improvement”) and HIV-tuberculosis co-infection (80% with at least a “large improvement”).
Conclusions
TBL is feasible as part of medical education in an African setting. TBL is a promising way to teach challenging clinical topics in a stimulating and interactive learning environment in a low-income country setting with a high ratio of students to teachers.
doi:10.1186/1472-6920-14-63
PMCID: PMC3972960  PMID: 24678606
Team-based learning; TBL; Resource-limited; Medical education; NECTAR; MEPI; HIV
5.  Teaching musculoskeletal examination skills to UK medical students: A comparative survey of Rheumatology and Orthopaedic education practice 
BMC Medical Education  2014;14:62.
Background
Specialists in Rheumatology and Orthopaedics are frequently involved in undergraduate teaching of musculoskeletal (MSK) examination skills. Students often report that specialty-led teaching is inconsistent, confusing and bears little resemblance to the curricula. The Gait, Arms, Legs and Spine (GALS) is a MSK screening tool that provides a standardised approach to examination despite it being fraught with disapproval and low uptake. Recent studies would appear to support innovative instructional methods of engaging learners such as patient educators and interactive small group teaching.
Methods
This comparative cross-sectional survey evaluates the current state of undergraduate teaching in Rheumatology and Orthopaedics, including preferred teaching methods, attitudes towards GALS, and barriers to effective teaching. An electronic questionnaire was sent to specialist trainees and Consultants in the East and West Midlands region, representing 5 UK medical schools. Descriptive statistical data analysis was performed.
Results
There were 76 respondents representing 5 medical schools. There was a request for newer teaching methodologies to be used: multi-media computer-assisted learning (35.5%), audio-visual aids (31.6%), role-playing (19.7%), and social media (3.9%). It is evident that GALS is under-utilised with 50% of clinicians not using GALS in their teaching.
Conclusions
There is a genuine desire for clinical educators to improve their teaching ability, collaborate more with curriculum planners, and feel valued by institutions. There remains a call for implementing a standardised approach to MSK clinical teaching to supersede GALS.
doi:10.1186/1472-6920-14-62
PMCID: PMC3973615  PMID: 24678598
Musculoskeletal; Undergraduate; Education; Medical; Curriculum
6.  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
7.  The professionalism disconnect: do entering residents identify yet participate in unprofessional behaviors? 
BMC Medical Education  2014;14:60.
Background
Professionalism has been an important tenet of medical education, yet defining it is a challenge. Perceptions of professional behavior may vary by individual, medical specialty, demographic group and institution. Understanding these differences should help institutions better clarify professionalism expectations and provide standards with which to evaluate resident behavior.
Methods
Duke University Hospital and Vidant Medical Center/East Carolina University surveyed entering PGY1 residents. Residents were queried on two issues: their perception of the professionalism of 46 specific behaviors related to training and patient care; and their own participation in those specified behaviors. The study reports data analyses for gender and institution based upon survey results in 2009 and 2010. The study received approval by the Institutional Review Boards of both institutions.
Results
76% (375) of 495 PGY1 residents surveyed in 2009 and 2010 responded. A majority of responders rated all 46 specified behaviors as unprofessional, and a majority had either observed or participated in each behavior. For all 46 behaviors, a greater percentage of women rated the behaviors as unprofessional. Men were more likely than women to have participated in behaviors. There were several significant differences in both the perceptions of specified behaviors and in self-reported observation of and/or involvement in those behaviors between institutions.
Respondents indicated the most important professionalism issues relevant to medical practice include: respect for colleagues/patients, relationships with pharmaceutical companies, balancing home/work life, and admitting mistakes. They reported that professionalism can best be assessed by peers, patients, observation of non-medical work and timeliness/detail of paperwork.
Conclusion
Defining professionalism in measurable terms is a challenge yet critical in order for it to be taught and assessed. Recognition of the differences by gender and institution should allow for tailored teaching and assessment of professionalism so that it is most meaningful. A shared understanding of what constitutes professional behavior is an important first step.
doi:10.1186/1472-6920-14-60
PMCID: PMC3974201  PMID: 24674275
8.  Effects of a blended learning approach on student outcomes in a graduate-level public health course 
BMC Medical Education  2014;14:47.
Background
Blended learning approaches, in which in-person and online course components are combined in a single course, are rapidly increasing in health sciences education. Evidence for the relative effectiveness of blended learning versus more traditional course approaches is mixed.
Method
The impact of a blended learning approach on student learning in a graduate-level public health course was examined using a quasi-experimental, non-equivalent control group design. Exam scores and course point total data from a baseline, “traditional” approach semester (n = 28) was compared to that from a semester utilizing a blended learning approach (n = 38). In addition, student evaluations of the blended learning approach were evaluated.
Results
There was a statistically significant increase in student performance under the blended learning approach (final course point total d = 0.57; a medium effect size), even after accounting for previous academic performance. Moreover, student evaluations of the blended approach were very positive and the majority of students (83%) preferred the blended learning approach.
Conclusions
Blended learning approaches may be an effective means of optimizing student learning and improving student performance in health sciences courses.
doi:10.1186/1472-6920-14-47
PMCID: PMC3975233  PMID: 24612923
Blended learning; Flipped classroom; Graduate education in public health; Online education; Student learning
9.  Motivational component profiles in university students learning histology: a comparative study between genders and different health science curricula 
BMC Medical Education  2014;14:46.
Background
The students’ motivation to learn basic sciences in health science curricula is poorly understood. The purpose of this study was to investigate the influence of different components of motivation (intrinsic motivation, self-determination, self-efficacy and extrinsic -career and grade- motivation) on learning human histology in health science curricula and their relationship with the final performance of the students in histology.
Methods
Glynn Science Motivation Questionnaire II was used to compare students’ motivation components to learn histology in 367 first-year male and female undergraduate students enrolled in medical, dentistry and pharmacy degree programs.
Results
For intrinsic motivation, career motivation and self-efficacy, the highest values corresponded to medical students, whereas dentistry students showed the highest values for self-determination and grade motivation. Genders differences were found for career motivation in medicine, self-efficacy in dentistry, and intrinsic motivation, self-determination and grade motivation in pharmacy. Career motivation and self-efficacy components correlated with final performance in histology of the students corresponding to the three curricula.
Conclusions
Our results show that the overall motivational profile for learning histology differs among medical, dentistry and pharmacy students. This finding is potentially useful to foster their learning process, because if they are metacognitively aware of their motivation they will be better equipped to self-regulate their science-learning behavior in histology. This information could be useful for instructors and education policy makers to enhance curricula not only on the cognitive component of learning but also to integrate students’ levels and types of motivation into the processes of planning, delivery and evaluation of medical education.
doi:10.1186/1472-6920-14-46
PMCID: PMC3973968  PMID: 24612878
Motivation; Components; Curriculum; Histology; Health sciences
10.  Comparing two methods of education (virtual versus traditional) on learning of Iranian dental students: a post-test only design study 
BMC Medical Education  2014;14:45.
Background
The importance of using technologies such as e-learning in different disciplines is discussed in the literature. Researchers have measured the effectiveness of e-learning in a number of fields.
Considering the lack of research on the effectiveness of online learning in dental education particularly in Iran, the advantages of these learning methods and the positive university atmosphere regarding the use of online learning. This study, therefore, aims to compare the effects of two methods of teaching (virtual versus traditional) on student learning.
Methods
This post-test only design study approached 40, fifth year dental students of Shiraz University of Medical Sciences. From this group, 35 students agreed to participate. These students were randomly allocated into two groups, experimental (virtual learning) and comparison (traditional learning). To ensure similarity between groups, we compared GPAs of all participants by the Mann–Whitney U test (P > 0.05). The experimental group received a virtual learning environment courseware package specifically designed for this study, whereas the control group received the same module structured in a traditional lecture form. The virtual learning environment consisted of online and offline materials. Two identical valid, reliable post-tests that consisted of 40 multiple choice questions (MCQs) and 4 essay questions were administered immediately (15 min) after the last session and two months later to assess for knowledge retention. Data were analyzed by SPSS version 20.
Results
A comparison of the mean knowledge score of both groups showed that virtual learning was more effective than traditional learning (effect size = 0.69).
Conclusion
The newly designed virtual learning package is feasible and will result in more effective learning in comparison with lecture-based training. However further studies are needed to generalize the findings of this study.
doi:10.1186/1472-6920-14-45
PMCID: PMC3975717  PMID: 24597923
11.  Development of the clinical learning evaluation questionnaire for undergraduate clinical education: factor structure, validity, and reliability study 
BMC Medical Education  2014;14:44.
Background
Teaching and learning of clinical skills for undergraduate medical students usually takes place during the clinical clerkship. Therefore, it is of vital importance to ensure the effectiveness of the rotations within this clerkship. The aims of this study were to develop an instrument that measures the effectiveness of the clinical learning environment, to determine its factor structure, and to find first evidence for the reliability and validity of the total scale and the different factors.
Methods
The Clinical Learning Evaluation Questionnaire (CLEQ) is an instrument, consisting of 40 items, which have been developed after consideration of the results of a qualitative study that investigated the important factors influencing clinical learning, both from the perspective of students, as well as teachers. Results of relevant literature that investigated this issue were also incorporated in the CLEQ. This instrument was administered to a sample of students (N = 182) from three medical colleges in Riyadh city, the capital of Saudi Arabia. The factor structure of the CLEQ (Principal component analysis, Oblimin rotation) and reliability of the factor scales (Cronbach’s α) were determined. Hypotheses concerning the correlations between the different factors were tested to investigate their convergent and divergent validity.
Results
One hundred and nine questionnaires were returned. The factor analysis yielded six factors: F1 Cases (8 items), F2 Authenticity of clinical experience (8 items), F3 Supervision (8 items), F4 Organization of the doctor-patient encounter (4 items), F5 Motivation to learn (5 items), and F6 Self awareness (4 items). The overall internal consistency (α) of the CLEQ was 0.88, and the reliabilities (Cronbach’s α) of the six factors varied from .60 to .86. Hypotheses concerning the correlations between the different factors were partly confirmed, which supported the convergent validity of the factors, but not their divergent validity. Significant differences were found between the scores of the students of the three different schools on the factors Supervision and Organization of patient-doctor encounter.
Conclusions
The results of this study demonstrated that CLEQ is a multidimensional and reliable instrument. It can be utilized as an evaluation tool for clinical teaching activities, both by educators as well as students. Further research is needed into the validity of the CLEQ.
doi:10.1186/1472-6920-14-44
PMCID: PMC3944808  PMID: 24592913
12.  Baccalaureate nursing Students’ perspectives on learning about caring in China: a qualitative descriptive study 
BMC Medical Education  2014;14:42.
Background
The need to provide humanistic care in the contemporary healthcare system is more imperative now and the importance of cultivating caring in nursing education is urgent. Caring as the primary work of nursing has been discussed extensively, such as the meaning of caring, and teaching and learning strategies to improve nursing students’ caring ability. Yet attempts to understand students’ perspectives on learning about caring and to know their learning needs are seldom presented. The aim of this qualitative descriptive study was to explore the baccalaureate nursing students’ perspectives on learning about caring in China.
Methods
A qualitative descriptive study using focus group interviews were undertaken in two colleges in Yunnan Province, China from February 2010 to April 2010. Purposeful sampling of 20 baccalaureate nursing students were recruited. Content analysis of the transcribed data was adopted to identify the themes.
Results
Four categories with some sub-categories related to students’ perspectives on learning about caring were identified from the data: 1) Learning caring by role model; 2) conducive learning environment as the incentive to the learning about caring; 3) lack of directive substantive way of learning as the hindrance to the learning about caring; 4) lack of cultural competency as the barrier to the learning about caring.
Conclusions
Both caring and uncaring experiences can promote the learning about caring in a way of reflective practice. The formal, informal and hidden curricula play an important role in the learning about caring. Cultural awareness, sensitivity and humility are important in the process of learning to care in a multicultural area.
doi:10.1186/1472-6920-14-42
PMCID: PMC3944811  PMID: 24589087
Caring; Baccalaureate nursing students; Focus group; Nursing; Qualitative study
13.  Promoting medical competencies through international exchange programs: benefits on communication and effective doctor-patient relationships 
BMC Medical Education  2014;14:43.
Background
Universities are increasingly organizing international exchange programs to meet the requirements of growing globalisation in the field of health care. Analyses based on the programs’ fundamental theoretical background are needed to confirm the learning value for participants. This study investigated the extent of sociocultural learning in an exchange program and how sociocultural learning affects the acquisition of domain-specific competencies.
Methods
Sociocultural learning theories were applied to study the learning effect for German medical students from the LMU Munich, Munich, Germany, of participation in the medical exchange program with Jimma University, Jimma, Ethiopia. First, we performed a qualitative study consisting of interviews with five of the first program participants. The results were used to develop a questionnaire for the subsequent, quantitative study, in which 29 program participants and 23 matched controls performed self-assessments of competencies as defined in the Tuning Project for Health Professionals. The two interrelated studies were combined to answer three different research questions.
Results
The participants rated their competence significantly higher than the control group in the fields of doctor-patient relationships and communication in a medical context. Participant responses in the two interrelated studies supported the link between the findings and the suggested theoretical background.
Conclusion
Overall, we found that the exchange program affected the areas of doctor-patient relationships and effective communication in a medical context. Vygotsky’s sociocultural learning theory contributed to explaining the learning mechanisms of the exchange program.
doi:10.1186/1472-6920-14-43
PMCID: PMC3945959  PMID: 24589133
Medical education; Sociocultural learning; Vygotsky; International cooperation; Internationalization on universities; Outcomes of exchange programs; Global health education
14.  Continuous Professional Competence (CPC) for Irish paramedics and advanced paramedics: a national study 
BMC Medical Education  2014;14:41.
Background
Internationally, continuing professional competence (CPC) is an increasingly important issue for all health professionals. With the imminent introduction of a CPC framework for paramedics and advanced paramedics (APs) in Ireland, this paper aims to identify factors that will inform the implementation of this CPC framework by seeking stakeholder input into the development of a CPC model for use by the regulatory body. Our secondary objective is to determine the attitudes of registrants towards CPC and what they consider as optimal educational outcomes and activities, for the purposes of CPC.
Methods
All paramedics and APs registered in Ireland (n = 1816) were invited by email to complete an anonymous on-line survey. The study instrument was designed based on CPD questionnaires used by other healthcare professions. Quantitative and qualitative analyses were performed.
Results
The overall response rate was 43% (n = 789), with 82% of APs and 38% of paramedics participating. Eighty-nine per cent agreed that registration was of personal importance; 74% agreed that evidence of CPC should be maintained and 39% believed that persistent failure to meet CPC requirements should mandate denial of registration. From a pre-determined list of activities, respondents indicated practical training scenarios (94%), cardiac re-certification (92%), e-learning supplemented by related practice (90%) and training with simulation manikins (88%) were most relevant, while e-learning alone (36%), project work (27%) and reading journal articles (24%) were least relevant.
Conclusions
Irish Paramedics and APs are supportive of CPC linked with their professional development and registration. Blended learning, involving evidence of patient contact, team-based learning and practical skills are preferred CPC activities.
doi:10.1186/1472-6920-14-41
PMCID: PMC3943403  PMID: 24580830
Paramedics; Advanced paramedics; Continuous professional development; CPD; Continuous professional competence
15.  A review of the integration of traditional, complementary and alternative medicine into the curriculum of South African medical schools 
BMC Medical Education  2014;14:40.
Background
Traditional, complementary and alternative (TCAM) medicine is consumed by a large majority of the South African population. In the context of increasing overall demand for healthcare this paper investigates the extent to which South African medical schools have incorporated TCAM into their curriculum because of the increased legislative and policy interest in formally incorporating TCAM into the health care system since democracy in 1994.
Methods
Heads of School from seven South African medical schools were surveyed telephonically.
Results
One school was teaching both Traditional African Medicine (TM) and CAM, five were teaching either TM or CAM and another was not teaching any aspect of TCAM.
Conclusions
In conclusion, there is a paucity of curricula which incorporate TCAM. Medical schools have not responded to government policies or the contextual realities by incorporating TCAM into the curriculum for their students. South African medical schools need to review their curricula to increase their students’ knowledge of TCAM given the demands of the population and the legislative realities.
doi:10.1186/1472-6920-14-40
PMCID: PMC3939811  PMID: 24575843
Traditional; Complementary and alternative medicine; Medical schools; South Africa
16.  Medical students’ experiences learning intimate physical examination skills: a qualitative study 
BMC Medical Education  2014;14:39.
Background
Intimate physical examination skills are essential skills for any medical graduate to have mastered to an appropriate level for the safety of his or her future patients. Medical schools are entrusted with the complex task of teaching and assessing these skills for their students. The objectives of this study were to explore a range of medical students’ experiences of learning intimate physical examination skills and to explore their perceptions of factors which impede or promote the learning of these skills.
Methods
Individual semi-structured interviews (N = 16) were conducted with medical students in years two to five from the University of Newcastle, as part of a larger research project investigating how medical students develop their attitudes to gender and health. This was a self-selected sample of the entire cohort who were all invited to participate. A thematic analysis of the transcribed data was performed.
Results
Students reported differing levels of discomfort with their learning experiences in the area of intimate physical examination and differing beliefs about the helpfulness of these experiences. The factors associated with levels of discomfort and the helpfulness of the experience for learning were: satisfaction with teaching techniques, dealing with an uncomfortable situation and perceived individual characteristics in both the patients and the students. The examination causing the greatest reported discomfort was the female pelvic examination by male students.
Conclusions
Student discomfort with the experience of learning intimate physical examination skills may be common and has ongoing repercussions for students and patients. Recommendations are made of ways to modify teaching technique to more closely match students’ perceived needs.
doi:10.1186/1472-6920-14-39
PMCID: PMC3943277  PMID: 24575827
Medical student; Intimate physical examination; Learning experiences; Teaching techniques
17.  An analysis of reported motivational orientation in students undertaking doctoral studies in the biomedical sciences 
BMC Medical Education  2014;14:38.
Background
As the source of a sizeable percentage of research output and the future arbiters of science policy, practice and direction, doctoral (Ph.D.) students represent a key demographic in the biomedical research community. Despite this, doctoral learning in the biomedical sciences has, to date, received little research attention.
Methods
In the present study we aimed to qualitatively describe the motivational orientations present in semi-structured interview transcripts from a cohort of seventeen biomedical Ph.D. students drawn from two research intensive Australian Group of Eight universities.
Results
Applying elements of self-determination theory, external and introjected control loci (both strongly associated with alienation, disengagement and poor learning outcomes) were identified as common motivational determinants in this cohort.
Conclusions
The importance of these findings to doctoral learning is discussed in light of previous research undertaken in higher education settings in the United States and the European Union. With motivation accepted as a malleable, context-sensitive factor, these data provide for both a better understanding of doctoral learning and highlight a potential avenue for future research aimed at improving outcomes and promoting meaningful learning processes in the biomedical doctorate.
doi:10.1186/1472-6920-14-38
PMCID: PMC3974041  PMID: 24571918
Ph.D.; Biomedical; Self-determination theory; Motivation; Doctorate; Control
18.  A real-time locating system observes physician time-motion patterns during walk-rounds: a pilot study 
BMC Medical Education  2014;14:37.
Background
Walk-rounds, a common component of medical education, usually consist of a combination of teaching outside the patient room as well as in the presence of the patient, known as bedside teaching. The proportion of time dedicated to bedside teaching has been declining despite research demonstrating its benefits. Increasing complexities of patient care and perceived impediments to workflow are cited as reasons for this declining use. Research using real-time locating systems (RTLS) has been purported to improve workflow through monitoring of patients and equipment. We used RTLS technology to observe and track patterns of movement of attending physicians during a mandatory once-weekly medical teaching team patient care rounding session endorsed as a walk-rounds format.
Methods
During a project to assess the efficacy of RTLS technology to track equipment and patients in a clinical setting, we conducted a small-scale pilot study to observe attending physician walk-round patterns during a mandatory once-weekly team rounding session. A consecutive sample of attending physicians on the unit was targeted, eight agreed to participate. Data collected using the RTLS were pictorially represented as linked points overlaying a floor plan of the unit to represent each physician’s motion through time. Visual analysis of time-motion was independently performed by two researchers and disagreement resolved through consensus. Rounding events were described as a sequence of approximate proportions of time engaged within or outside patient rooms.
Results
The patient care rounds varied in duration from 60 to 425 minutes. Median duration of rounds within patient rooms was approximately 33% of total time (range approximately 20-50%). Three general time-motion rounding patterns were observed: a first pattern that predominantly involved rounding in ward hallways and little time in patient rooms; a second pattern that predominantly involved time in a ward conference room; and a third balanced pattern characterized by equal proportions of time in patient rooms and in ward hallways.
Conclusions
Observation using RTLS technology identified distinct time-motion rounding patterns that hint at differing rounding styles across physicians. Future studies using this technology could examine how the division of time during walk-rounds impacts outcomes such as patient satisfaction, learner satisfaction, and physician workflow.
doi:10.1186/1472-6920-14-37
PMCID: PMC3974061  PMID: 24568589
Physicians; Real-time locating system; Teaching rounds; Patients’ rooms; Movement; Workflow
19.  Use of a virtual world computer environment for international distance education: lessons from a pilot project using Second Life 
BMC Medical Education  2014;14:36.
Virtual worlds (VWs), in which participants navigate as avatars through three-dimensional, computer-generated, realistic-looking environments, are emerging as important new technologies for distance health education. However, there is relatively little documented experience using VWs for international healthcare training. The Geneva Foundation for Medical Education and Research (GFMER) conducted a VW training for healthcare professionals enrolled in a GFMER training course. This paper describes the development, delivery, and results of a pilot project undertaken to explore the potential of VWs as an environment for distance healthcare education for an international audience that has generally limited access to conventionally delivered education.
doi:10.1186/1472-6920-14-36
PMCID: PMC3936854  PMID: 24555833
Medical education; Continuing medical education; Computer-assisted instruction; Computer aided instruction; Distance education; Computer simulation
20.  Undergraduate medical textbooks do not provide adequate information on intravenous fluid therapy: a systematic survey and suggestions for improvement 
BMC Medical Education  2014;14:35.
Background
Inappropriate prescribing of intravenous (IV) fluid, particularly 0.9% sodium chloride, causes post-operative complications. Fluid prescription is often left to junior medical staff and is frequently poorly managed. One reason for poor intravenous fluid prescribing practices could be inadequate coverage of this topic in the textbooks that are used.
Methods
We formulated a comprehensive set of topics, related to important common clinical situations involving IV fluid therapy, (routine fluid replacement, fluid loss, fluids overload) to assess the adequacy of textbooks in common use. We assessed 29 medical textbooks widely available to students in the UK, scoring the presence of information provided by each book on each of the topics. The scores indicated how fully the topics were considered: not at all, partly, and adequately. No attempt was made to judge the quality of the information, because there is no consensus on these topics.
Results
The maximum score that a book could achieve was 52. Three of the topics we chose were not considered by any of the books. Discounting these topics as “too esoteric”, the maximum possible score became 46. One textbook gained a score of 45, but the general score was poor (median 11, quartiles 4, 21). In particular, coverage of routine postoperative management was inadequate.
Conclusions
Textbooks for undergraduates cover the topic of intravenous therapy badly, which may partly explain the poor knowledge and performance of junior doctors in this important field. Systematic revision of current textbooks might improve knowledge and practice by junior doctors. Careful definition of the remit and content of textbooks should be applied more widely to ensure quality and “fitness for purpose”, and avoid omission of vital knowledge.
doi:10.1186/1472-6920-14-35
PMCID: PMC3933276  PMID: 24555812
Fluid Therapy; Textbooks; Teaching; Medical graduates
21.  Substance misuse teaching in undergraduate medical education 
BMC Medical Education  2014;14:34.
Background
Over 12,000 hospital admissions in the UK result from substance misuse, therefore issues surrounding this need to be addressed early on in a doctor’s training to facilitate their interaction with this client group. Currently, undergraduate medical education includes teaching substance misuse issues, yet how this is formally integrated into the curriculum remains unclear.
Methods
Semi-structured interviews with 17 key members of staff responsible for the whole or part of the undergraduate medical curriculum were conducted to identify the methods used to teach substance misuse. Using a previously devised toolkit, 19 curriculum co-ordinators then mapped the actual teaching sessions that addressed substance misuse learning objectives.
Results
Substance misuse teaching was delivered primarily in psychiatry modules but learning objectives were also found in other areas such as primary care placements and problem-based learning. On average, 53 teaching sessions per medical school focused on bio-psycho-social models of addiction whereas only 23 sessions per medical school focused on professionalism, fitness to practice and students’ own health in relation to substance misuse. Many sessions addressed specific learning objectives relating to the clinical features of substance dependence whereas few focused on iatrogenic addiction.
Conclusions
Substance misuse teaching is now inter-disciplinary and the frequent focus on clinical, psychological and social effects of substance misuse emphasises the bio-psycho-social approach underlying clinical practice. Some areas however are not frequently taught in the formal curriculum and these need to be addressed in future changes to medical education.
doi:10.1186/1472-6920-14-34
PMCID: PMC3932109  PMID: 24533849
22.  Multiple tutorial-based assessments: a generalizability study 
BMC Medical Education  2014;14:30.
Background
Tutorial-based assessment commonly used in problem-based learning (PBL) is thought to provide information about students which is different from that gathered with traditional assessment strategies such as multiple-choice questions or short-answer questions. Although multiple-observations within units in an undergraduate medical education curriculum foster more reliable scores, that evaluation design is not always practically feasible. Thus, this study investigated the overall reliability of a tutorial-based program of assessment, namely the Tutotest-Lite.
Methods
More specifically, scores from multiple units were used to profile clinical domains for the first two years of a system-based PBL curriculum.
Results
G-Study analysis revealed an acceptable level of generalizability, with g-coefficients of 0.84 and 0.83 for Years 1 and 2, respectively. Interestingly, D-Studies suggested that as few as five observations over one year would yield sufficiently reliable scores.
Conclusions
Overall, the results from this study support the use of the Tutotest-Lite to judge clinical domains over different PBL units.
doi:10.1186/1472-6920-14-30
PMCID: PMC3925793  PMID: 24528493
Assessment; G-study; Tutorial-based assessment; Programs of assessment
23.  Validating e-learning in continuing pharmacy education: user acceptance and knowledge change 
BMC Medical Education  2014;14:33.
Background
Continuing pharmacy education is becoming mandatory in most countries in order to keep the professional license valid. Increasing number of pharmacists are now using e-learning as part of their continuing education. Consequently, the increasing popularity of this method of education calls for standardization and validation practices. The conducted research explored validation aspects of e-learning in terms of knowledge increase and user acceptance.
Methods
Two e-courses were conducted as e-based continuing pharmacy education for graduated pharmacists. Knowledge increase and user acceptance were the two outcome measured. The change of knowledge in the first e-course was measured by a pre- and post-test and results analysed by the Wilcoxon signed–rank test. The acceptance of e-learning in the second e-course was investigated by a questionnaire and the results analysed using descriptive statistics.
Results
Results showed that knowledge increased significantly (p < 0.001) by 16 pp after participation in the first e-course. Among the participants who responded to the survey in the second course, 92% stated that e-courses were effective and 91% stated that they enjoyed the course.
Conclusions
The study shows that e-learning is a viable medium of conducting continuing pharmacy education; e-learning is effective in increasing knowledge and highly accepted by pharmacists from various working environments such as community and hospital pharmacies, faculties of pharmacy or wholesales.
doi:10.1186/1472-6920-14-33
PMCID: PMC3927623  PMID: 24528547
E-learning; Continuing pharmacy education; Lifelong learning; Just-in-time learning
24.  The effect of paramedic training on pre-hospital trauma care (EPPTC-study): a study protocol for a prospective semi-qualitative observational trial 
BMC Medical Education  2014;14:32.
Background
Accidents are the leading cause of death in adults prior to middle age. The care of severely injured patients is an interdisciplinary challenge. Limited evidence is available concerning pre-hospital trauma care training programs and the advantage of such programs for trauma patients. The effect on trauma care procedures or on the safety of emergency crews on the scene is limited; however, there is a high level of experience and expert opinion.
Methods
I – Video-recorded case studies are the basis of an assessment tool and checklist being developed to verify the results of programs to train participants in the care of seriously injured patients, also known as “objective structured clinical examination” (OSCE). The timing, completeness and quality of the individual measures are assessed using appropriate scales. The evaluation of team communication and interaction will be analyzed with qualitative methods and quantified and verified by existing instruments (e.g. the Clinical Team Scale). The developed assessment tool is validated by several experts in the fields of trauma care, trauma research and medical education. II a) In a German emergency medical service, the subjective assessment of paramedics of their pre-hospital care of trauma patients is evaluated at three time points, namely before, immediately after and one year after training. b) The effect of a standardized course concept on the quality of documentation in actual field operations is determined based on three items relevant to patient safety before and after the course. c) The assessment tool will be used to assess the effect of a standardized course concept on procedures and team communication in pre-hospital trauma care using scenario-based case studies.
Discussion
This study explores the effect of training on paramedics. After successful study completion, further multicenter studies are conceivable, which would evaluate emergency-physician staffed teams. The influence on the patients and prehospital measures should be assessed based on a retrospective analysis of the emergency room data.
Trials registration
German Clinical Trials Register, ID DRKS00004713.
doi:10.1186/1472-6920-14-32
PMCID: PMC3930288  PMID: 24528532
Paramedic; Pre-hospital; Trauma; Training; PHTLS; Medical education
25.  Predicting academic outcomes in an Australian graduate entry medical programme 
BMC Medical Education  2014;14:31.
Background
Predictive validity studies for selection criteria into graduate entry courses in Australia have been inconsistent in their outcomes. One of the reasons for this inconsistency may have been failure to have adequately considered background disciplines of the graduates as well as other potential confounding socio-demographic variables that may influence academic performance.
Methods
Graduate entrants into the MBBS at The University of Western Australia between 2005 and 2012 were studied (N = 421). They undertook a 6-month bridging course, before joining the undergraduate-entry students for Years 3 through 6 of the medical course. Students were selected using their undergraduate Grade Point Average (GPA), Graduate Australian Medical School Admissions Test scores (GAMSAT) and a score from a standardised interview. Students could apply from any background discipline and could also be selected through an alternative rural entry pathway again utilising these 3 entry scores. Entry scores, together with age, gender, discipline background, rural entry status and a socioeconomic indicator were entered into linear regression models to determine the relative influence of each predictor on subsequent academic performance in the course.
Results
Background discipline, age, gender and selection through the rural pathway were variously related to each of the 3 entry criteria. Their subsequent inclusion in linear regression models identified GPA at entry, being from a health/allied health background and total GAMSAT score as consistent independent predictors of stronger academic performance as measured by the weighted average mark for the core units completed throughout the course. The Interview score only weakly predicted performance later in the course and mainly in clinically-based units. The association of total GAMSAT score with academic performance was predominantly dictated by the score in GAMSAT Section 3 (Reasoning in the biological and physical sciences) with Section 1 (Reasoning in the humanities and social sciences) and Section 2 (Written communication) also contributing either later or early in the course respectively. Being from a more disadvantaged socioeconomic background predicted weaker academic performance early in the course. Being an older student at entry or from a humanities background also predicted weaker academic performance.
Conclusions
This study confirms that both GPA at entry and the GAMSAT score together predict outcomes not only in the early stages of a graduate-entry medical programme but throughout the course. It also indicates that a comprehensive evaluation of the predictive validity of GAMSAT scores, interview scores and undergraduate academic performance as valid selection processes for graduate entry into medical school needs to simultaneously consider the potential confounding influence of graduate discipline background and other socio-demographic factors on both the initial selection parameters themselves as well as subsequent academic performance.
doi:10.1186/1472-6920-14-31
PMCID: PMC3931285  PMID: 24528509

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