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1.  Experiences of using an interactive audience response system in lectures 
Background
Lectures are good for presenting information and providing explanations, but because they lack active participation they have been neglected.
Methods
Students' experiences were evaluated after exposing them to the use of voting during lectures in their paediatrics course. Questions were delivered to the students taking paediatrics course. Thirty-six students out of the total of 40 (90%) attended the opening lecture, at which the first survey concerning previous experiences of lectures was performed. Thirty-nine students (98%) answered the second series of questions at the end of the paediatrics course.
Results
Most of the students felt that voting improved their activity during lectures, enhanced their learning, and that it was easier to make questions during lectures than earlier.
Conclusions
The students gained new, exciting insights much more often during the paediatrics course than before. We as teachers found that voting during lectures could easily overcome some of the obstacles of good lecturing.
doi:10.1186/1472-6920-3-12
PMCID: PMC317338  PMID: 14678571
2.  Factors affecting the intention of providers to deliver more effective continuing medical education to general practitioners: a pilot study 
Background
Despite the importance of continuing medical education (CME) for GPs, there has been little research into how providers decide what types of CME to deliver to GPs. This study aimed to identify factors affecting the intention of providers to provide more effective types of CME; and to design a survey instrument which can be used to test the applicability of Triandis' model of social behaviour to the provision of CME to general practitioners.
Methods
This was a cross-sectional study on a convenience sample of 11 Australian providers of CME for interviews and a random sample of 25 providers for the pilot test. Open-ended interviews structured on Triandis' theory were performed with key informants who provide CME to GPs. These were used to develop a pilot survey instrument to measure the factors affecting intention, resulting in a revised instrument for use in further research.
Results
There was a broad range of factors affecting providers' intention to deliver more effective forms of CME identified, and these were classifiable in a manner which was consistent with Triandis' model. Key factors affecting providers' intention were the attitude toward CME within organisations and the time and extra work involved.
Conclusions
We identified a range of potential factors influencing the intention of providers to provide more effective forms of CME, in all categories of Triandis model. Those interested in increasing the choice of more effective CME activities available to GPs may need to broaden the methods used in working with providers to influence them to use more effective CME techniques. The interview material and questionnaire analysis of the pilot survey support the use of Triandis model. Further research is needed to validate Triandis'model for the intention to deliver more effective forms of CME. Such research will inform future strategies aimed at increasing the amount and choice of effective CME activities available for GPs.
doi:10.1186/1472-6920-3-11
PMCID: PMC317337  PMID: 14675493
3.  Critical appraisal skills of family physicians in Ontario, Canada 
Background
Our primary objective in this study was to measure family physicians' knowledge of the key elements that go into assessing the validity and interpreting the results in three different types of studies: i) a randomized controlled trial (RCT); ii) a study evaluating a diagnostic test; and iii) a systematic review (SR). Our secondary objectives were to determine the relationship between the above skills and age, gender, and type of practice.
Methods
We obtained a random sample of 1000 family physicians in Ontario from the College of Family Physicians of Canada database. These physicians were sent a questionnaire in the mail with follow-up mailings to non-responders at 3 and 8 weeks. The questionnaire was designed to measure knowledge and understanding of the basic concepts of critical appraisal skills. Based on the responses to the questions an Evidence Based Medicine (EBM) Knowledge Score was determined for each physician.
Results
A response rate of 30.2% was achieved. The respondents were younger and more likely to be recent graduates than the population of Ontario Family Physicians as a whole. This was an expected outcome. Just over 50% of respondents were able to answer questions concerning the critical appraisal of methods and the interpretation of results of research articles satisfactorily. The average score on the 12-point EBM Knowledge Scale was 6.4. The younger physicians scored higher than the older physicians, and academic physicians scored higher than community-based physicians. Scores of male and female physicians did not differ.
Conclusions
We have shown that in a population of physicians which is younger than the general population of physicians, about 50% have reasonable knowledge regarding the critical appraisal of the methods and the interpretation of results of a research article. In general, younger physicians were more knowledgeable than were older physicians. EBM principles were felt to be important to the practice of medicine by 95% of respondents.
doi:10.1186/1472-6920-3-10
PMCID: PMC317336  PMID: 14651755
4.  What can we learn from facilitator and student perceptions of facilitation skills and roles in the first year of a problem-based learning curriculum? 
Background
The small group tutorial is a cornerstone of problem-based learning. By implication, the role of the facilitator is of pivotal importance. The present investigation canvassed perceptions of facilitators with differing levels of experience regarding their roles and duties in the tutorial.
Methods
In January 2002, one year after problem-based learning implementation at the Nelson R. Mandela School of Medicine, facilitators with the following experience were canvassed: trained and about to facilitate, facilitated once only and facilitated more than one six-week theme. Student comments regarding facilitator skills were obtained from a 2001 course survey.
Results
While facilitators generally agreed that the three-day training workshop provided sufficient insight into the facilitation process, they become more comfortable with increasing experience. Many facilitators experienced difficulty not providing content expertise. Again, this improved with increasing experience. Most facilitators saw students as colleagues. They agreed that they should be role models, but were less enthusiastic about being mentors. Students were critical of facilitators who were not up to date with curriculum implementation or who appeared disinterested. While facilitator responses suggest that there was considerable intrinsic motivation, this might in fact not be the case.
Conclusions
Even if they had facilitated on all six themes, facilitators could still be considered as novices. Faculty support is therefore critical for the first few years of problem-based learning, particularly for those who had facilitated once only. Since student and facilitator expectations in the small group tutorial may differ, roles and duties of facilitators must be explicit for both parties from the outset.
doi:10.1186/1472-6920-3-9
PMCID: PMC280662  PMID: 14585108
5.  Gender awareness among physicians – the effect of specialty and gender. A study of teachers at a Swedish medical school 
Background
An important goal for medical education today is professional development including gender equality and awareness of gender issues. Are medical teachers prepared for this task? We investigated gender awareness among physician teachers, expressed as their attitudes towards the role of gender in professional relationships, and how it varied with physician gender and specialty. We discuss how this might be related to the gender climate and sex segregation in different specialties.
Method
Questionnaires were sent to all 468 specialists in the clinical departments and in family medicine, who were engaged in educating medical students at a Swedish university. They were asked to rate, on visual analogue scales, the importance of physician and patient gender in consultation, of preceptor and student gender in clinical tutoring and of physician gender in other professional encounters. Differences between family physicians, surgical, and non-surgical hospital doctors, and between women and men were estimated by chi-2 tests and multivariate logistic regression analyses.
Results
The response rate was 65 %. There were differences between specialty groups in all investigated areas mainly due to disparities among men. The odds for a male family physician to assess gender important were three times higher, and for a male non-surgical doctor two times higher when compared to a male surgical doctor. Female teachers assessed gender important to a higher degree than men. Among women there were no significant differences between specialty groups.
Conclusions
There was an interaction between physician teachers' gender and specialty as to whether they identified gender as important in professional relationships. Male physicians, especially from the surgical group, assessed gender important to a significantly lower degree than female physicians. Physicians' degree of gender awareness may, as one of many factors, affect working climate and the distribution of women and men in different specialties. Therefore, to improve working climate and reduce segregation we suggest efforts to increase gender awareness among physicians, for example educational programs where continuous reflections about gender attitudes are encouraged.
doi:10.1186/1472-6920-3-8
PMCID: PMC280661  PMID: 14577837
6.  The development and implementation of a curriculum to improve clinicians' self-directed learning skills: a pilot project 
Background
Clinicians need self-directed learning skills to maintain competency. The objective of this study was to develop and implement a curriculum to teach physicians self-directed learning skills during inpatient ward rotations.
Methods
Residents and attendings from an internal medicine residency were assigned to intervention or control groups; intervention physicians completed self-directed learning curricular exercises.
Results
Among the 43 intervention physicians, 21 (49%) completed pre- and post-curriculum tests; and 10 (23%) completed the one-year test. Immediately after exposure to the curriculum, the proportion of physicians defining short- and long-term learning goals increased [short-term: 1/21 (5%) to 11/21 (52%), p = 0.001; long-term: 2/21 (10%) to 15/21 (71%), p = 0.001]. There were no significant changes post-curriculum in the quantity or quality of clinical question asking. The physicians' mean self-efficacy (on a 100-point scale) improved for their abilities to develop a plan to keep up with the medical literature (59 vs. 72, p = 0.04). The effects of the curriculum on self-reported learning behaviors was maintained from the immediate post-curriculum test to the one-year post curriculum test: [short-term learning goals: 1/21 (5%) pre-, 11/21 (52%) immediately post-, and 5/10 (50%) one-year after the curriculum (p = 0.0075 for the pre- vs one-year comparison); long-term learning goals: 2/21 (10%) pre-, 15/21 (71%) immediately post-, and 7/10 (70%) one-year (p = 0.0013 for the pre- vs one-year comparison). At one-year, half of the participants reported changed learning behaviors.
Conclusions
A four-week curriculum may improve self-directed learning skills.
doi:10.1186/1472-6920-3-7
PMCID: PMC270081  PMID: 14572314
Medical education; physician learning
7.  Diversification of U.S. medical schools via affirmative action implementation 
Background
The diversification of medical school student and faculty bodies via race-conscious affirmative action policy is a societal and legal option for the U.S. Supreme Court has recently ruled its use constitutional. This paper investigates the implications of affirmative action, particularly race-conscious compared to race-blind admissions policy; explains how alternative programs are generally impractical; and provides a brief review of the history and legality of affirmative action in the United States.
Discussion
Selection based solely on academic qualifications such as GPA and MCAT scores does not achieve racial and ethnic diversity in medical school, nor does it adequately predict success as practicing physicians. However, race-conscious preference yields greater practice in underserved and often minority populations, furthers our biomedical research progression, augments health care for minority patients, and fosters an exceptional medical school environment where students are better able to serve an increasingly multicultural society.
Summary
The implementation of race-conscious affirmative action results in diversity in medicine. Such diversity has shown increased medical practice in underserved areas, thereby providing better health care for the American people.
doi:10.1186/1472-6920-3-6
PMCID: PMC212493  PMID: 13678423
affirmative action; race-conscious; non-cognitive factors; medical admissions; diversity; consumer choice; minority patients.
8.  Development and validation of IMAQ: Integrative Medicine Attitude Questionnaire 
Background
Complementary/alternative medicine and integrative medicine (CAM/IM) are increasingly used in the U.S. We set out to develop and validate a brief questionnaire measuring health care provider and medical student attitudes regarding these approaches to healthcare.
Methods
IMAQ is a 29-item, 7-point Likert scale rated instrument, developed from focus groups consisting of faculty, fellows, visiting residents, and medical students at a university based integrative medicine program. Respondents included 111 (of 574 contacted) internal medicine physicians on an academic medical center CME list and 85 healthcare providers (mostly physicians) attending an American Holistic Medical Association Annual Conference (296 attending). Cohorts were selected for expected differences in attitudes toward CAM/IM.
Results
Factor analysis demonstrated that a 2 factor solution best explained the variance in responses (38%). Factor 1 ("openness to new ideas and paradigms") explained 26% of variance with loadings ranging from 0.79 to 0.3, with factor 2 ("value of both introspection and relationship to patient") contributing an additional 12% of the explained variance with loadings ranging from 0.69 to 0.42. Both factors demonstrated adequate reliability. Factor 1 had a Cronbach's alpha of 0.91, while factor 2 was 0.72. As expected, AHMA conference attendees scored higher (F = 120.00, p < 0.001) than the internists on the IMAQ, supporting the construct validity. Although 63% of the AHMA subjects, and only 32% of the internists were female, analysis revealed that gender did not explain the score differences (F = 2.6, p > 0.05).
Conclusions
Analysis of the IMAQ provided evidence of its reliability and validity in measuring attitudes toward CAM/IM, specifically openness to new ideas and paradigms, and the value of relationship to self and patient. Initial findings support use of the IMAQ in measuring attitudes of students and practitioners towards CAM/IM interventions as a first step in understanding willingness to use these approaches to healing. It is our desire that this preliminary instrument will continue to be refined as the field of CAM/IM matures.
doi:10.1186/1472-6920-3-5
PMCID: PMC200993  PMID: 12946276
9.  Communicating curriculum reform to students: Advice in hindsight..... 
Backgound
In view of the changing health care needs of communities, curriculum reform of traditional curricula is inevitable. In order to allay the apprehension that may accompany such change, curriculum development and implementation should be an inclusive process, with both staff and students being well informed of the planned reform. In 2001, the Nelson R. Mandela School of Medicine implemented Year 1 of a problem-based learning curriculum. During the design phase, students and staff were invited to take part in the development and were kept abreast of developments through meetings and newsletters.
Method
A survey of Years 1–5 students of the last intake into the traditional curriculum was undertaken a few months prior to the implementation of the new programme.
Results
Students were generally well informed about the impending change, having heard about it from fellow students and staff. The more senior the students, the less the perceived impact of the reform. Although most of what students had heard was correct, some, however, had misconceptions that were generally extreme views (e.g. all self-directed learning; no Anatomy) about the new programme. Others expressed valid concerns (e.g. underpreparedness of students from disadvantaged schools; overcrowding in hospitals).
Conclusions
Advice offered to institutions considering curriculum reform include using various methods to inform internal and external affected parties, ensuring that the student representative body and staff is well informed, reiterating the need for the change, confirming that the new programme meets recognised standards and that the students most affected are reassured about their future studies.
doi:10.1186/1472-6920-3-4
PMCID: PMC165431  PMID: 12783623
10.  Long-term follow up of factual knowledge after a single, randomised problem-based learning course 
Background
The long-term effect of problem-based learning (PBL) on factual knowledge is poorly investigated. We took advantage of a previous randomised comparison between PBL and traditional teaching in a 3rd year course to follow up factual knowledge of the students during their 4th and 5th year of medical school training.
Methods
3rd year medical students were initially randomized to participate in a problem-based (PBL, n = 55), or a lecture-based (LBL, n = 57) course in basic pharmacology. Summative exam results were monitored 18 months later (after finishing a lecture-based course in clinical pharmacology). Additional results of an unscheduled, formative exam were obtained 27 months after completion of the first course.
Results
Of the initial sample of 112 students, 90 participated in the second course and exam (n = 45, 45). 32 (n = 17 PBL, n = 15 LBL) could be exposed to the third, formative exam. Mean scores (± SD) were 22.4 ± 6.0, 27.4 ± 4.9 and 20.1 ± 5.0 (PBL), or 22.2 ± 6.0, 28.4 ± 5.1 and 19.0 ± 4.7 (LBL) in the first, second and third test, respectively (maximum score: 40). No significant differences were found between the two groups.
Conclusion
A small-scale exposure to PBL, applied under randomized conditions but in the context of a traditional curriculum, does not sizeably change long-term presence of factual knowledge within the same discipline.
doi:10.1186/1472-6920-3-3
PMCID: PMC154095  PMID: 12675949
11.  Randomised controlled trial of a theoretically grounded tailored intervention to diffuse evidence-based public health practice [ISRCTN23257060] 
Background
Previous studies have shown that Norwegian public health physicians do not systematically and explicitly use scientific evidence in their practice. They work in an environment that does not encourage the integration of this information in decision-making. In this study we investigate whether a theoretically grounded tailored intervention to diffuse evidence-based public health practice increases the physicians' use of research information.
Methods
148 self-selected public health physicians were randomised to an intervention group (n = 73) and a control group (n = 75). The intervention group received a multifaceted intervention while the control group received a letter declaring that they had access to library services. Baseline assessments before the intervention and post-testing immediately at the end of a 1.5-year intervention period were conducted. The intervention was theoretically based and consisted of a workshop in evidence-based public health, a newsletter, access to a specially designed information service, to relevant databases, and to an electronic discussion list. The main outcome measure was behaviour as measured by the use of research in different documents.
Results
The intervention did not demonstrate any evidence of effects on the objective behaviour outcomes. We found, however, a statistical significant difference between the two groups for both knowledge scores: Mean difference of 0.4 (95% CI: 0.2–0.6) in the score for knowledge about EBM-resources and mean difference of 0.2 (95% CI: 0.0–0.3) in the score for conceptual knowledge of importance for critical appraisal. There were no statistical significant differences in attitude-, self-efficacy-, decision-to-adopt- or job-satisfaction scales. There were no significant differences in Cochrane library searching after controlling for baseline values and characteristics.
Conclusion
Though demonstrating effect on knowledge the study failed to provide support for the hypothesis that a theory-based multifaceted intervention targeted at identified barriers will change professional behaviour.
doi:10.1186/1472-6920-3-2
PMCID: PMC153535  PMID: 12694632
12.  The role of strategy and redundancy in diagnostic reasoning 
Background
Diagnostic reasoning is a key competence of physicians. We explored the effects of knowledge, practice and additional clinical information on strategy, redundancy and accuracy of diagnosing a peripheral neurological defect in the hand based on sensory examination.
Method
Using an interactive computer simulation that includes 21 unique cases with seven sensory loss patterns and either concordant, neutral or discordant textual information, 21 3rd year medical students, 21 6th year and 21 senior neurology residents each examined 15 cases over the course of one session. An additional 23 psychology students examined 24 cases over two sessions, 12 cases per session. Subjects also took a seven-item MCQ exam of seven classical patterns presented visually.
Results
Knowledge of sensory patterns and diagnostic accuracy are highly correlated within groups (R2 = 0.64). The total amount of information gathered for incorrect diagnoses is no lower than that for correct diagnoses. Residents require significantly fewer tests than either psychology or 6th year students, who in turn require fewer than the 3rd year students (p < 0.001). The diagnostic accuracy of subjects is affected both by level of training (p < 0.001) and concordance of clinical information (p < 0.001). For discordant cases, refutation testing occurs significantly in 6th year students (p < 0.001) and residents (p < 0.01), but not in psychology or 3rd year students. Conversely, there is a stable 55% excess of confirmatory testing, independent of training or concordance.
Conclusions
Knowledge and practice are both important for diagnostic success. For complex diagnostic situations reasoning components employing redundancy seem more essential than those using strategy.
doi:10.1186/1472-6920-3-1
PMCID: PMC149359  PMID: 12542839
diagnostic reasoning; clinical decision making; medical education; cognitive psychology; entropy; experimental studies

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