Автор неизвестен - Mededworld and amee 2013 conference connect - страница 23

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Take-home messages: Social and situational aspects of the learning process must be considered in the analysis of the strategies that students use to adapt to the demands of medical training. Funded by FONDECYT grant 1120534


Structured observations of teaching and learning in clinical settings

Louise Young (James Cook University, School of Medicine and Dentistry, Angus Smith Drive, Douglas, Townsville 4811, Australia)

Helen Heussler (The University of Queensland, School of Medicine, Brisbane, Australia)

Background: The need for quality clinical placements is an issue for medical schools internationally who are dealing with significantly increasing student numbers and changing demographics and illness patterns. There is a need for a cost-effective, evidence-based curriculum in clinical settings for the benefit of both teachers and learners. Structured observation measures the extent to which high cognitive teaching and learning is occurring in different clinical settings.

Summary of work: Mixed methods of structured (time sampling) and unstructured observations, focus group discussions (students and teachers) and questionnaires were used in a final year clinical rotation of a graduate entry medical program. Congruence between teaching and learning objectives and documentation of valued learning were recorded.

Summary of results: Many actions were teacher focused, involving low cognitive effort and passive learning. Learners perceived low value in working ward rounds. Teachers and learners had similar views on the value of different learning opportunities and characteristics of good clinical teaching. Constraints on learning imposed by organisational issues occurred frequently.

Conclusions: Structured observation is able to identify when and how learning and teaching occur during a clinical rotation and can identify constraints (perceived and real) to learning and teaching opportunities. In time poor teaching contexts clinical attachments should acknowledge the most valuable learning opportunities. Programs for professional development of clinical

teachers are imperative to facilitate valued higher cognitive learning opportunities. Take-home messages: It is often logistical and organisational issues that detract from learning. Structured observation is useful for providing an objective account of the type of teaching and learning occurring in medical education settings.


Less is More: Reduction of the Practical Year Logbook on an Excellence Basis Results in Higher Compliance

Petra Ganschow (University of Heidelberg, Department for General, Visceral and Transplantation Surgery, Im Neuenheimer Feld 110, Heidelberg 69120, Germany) Guni Kadmon (University of Heidelberg, Department for General, Visceral and Transplantation Surgery, Heidelberg, Germany)

Martina Damaschke (University of Heidelberg, Department for General, Visceral and Transplantation Surgery, Heidelberg, Germany)

Serin Schiessling (University of Heidelberg, Department for General, Visceral and Transplantation Surgery, Heidelberg, Germany)

Irmgard Treiber (University of Heidelberg, Department for General, Visceral and Transplantation Surgery, Heidelberg, Germany)

Martina Kadmon (University of Heidelberg, Department for General, Visceral and Transplantation Surgery, Heidelberg, Germany)

Background: In 2004 we introduced a students' logbook for the on-ward surgical period of the final undergraduate year. It contained 31 procedures that had to be observed or performed several times under supervision, recorded, and evaluated by the training surgeon. The logbooks were collected for assessment at the end of the period. In 2009 we reported that compliance had been very poor; 59% of the collected logbooks were empty or contained no records of clinical procedures and the rest contained only very partial records.

Summary of work: Informally the students explained the low compliance by lack of time or interest of doctors and preferring their own notes, which they could keep for future learning. Accordingly a new version with fewer procedures was introduced that with one exception had to be recorded and evaluated only once. After practicing and feeling secure in performing a procedure the students were to have their performance evaluated by doctors who were assigned to this duty or within the weekly practice afternoon. The collected logbooks were returned within two weeks. Summary of results: In the four surgical periods following the introduction of the shortened logbook compliance was 100% with 77%±16,7% (mean±SD) of the procedures recorded and 65%±24% of the procedures examined and approved. Conclusions: Although the desired situation has not yet been reached, the results show that adjustment of a logbook on an excellence basis to the needs of the


students and the workload of the doctors increases the students' compliance.


The Trialogue: a framework for teachers to integrate complex teaching and clinical skills on the ward round

S S Davis (ABM University Health Board, Dept. of ENT, Ward 2, Singleton Hospital, Swansea SA2 8QA, United Kingdom)

J McKimm (Swansea University, College of Medicine, Swansea, United Kingdom)

Background: Leading ward rounds effectively requires integrating complex teaching, communication and clinical skills; which many senior trainee doctors find difficult. This can leave both learners and patients with unmet needs.

Summary of work: Qualitative action research methodology with insider research was used to analyse the ward round process using Engestrom's 'Activity Theory' framework. The Trialogue provided an explanatory framework for clinical teachers to conceptualise and plan teaching and clinical interactions between teacher, learner and patient. Summary of results: Senior trainees often isolate learners from patient contact, moving teaching away from the ward. Practical application of The Trialogue suggests that such trainees, when equipped with an analytical framework, engage learners more meaningfully in patient contact on the ward round, although this is dependent on the teachers' teaching and 'reflection-in-action' skills. Conclusions: The ward round is not a natural teaching environment, requiring clinical teachers to demonstrate the application of a complex integration of clinical and teaching expertise, both in planning ward rounds where learners are engaged and 'in the moment'. The Trialogue enables senior trainees to adapt to this role, but they need specific teaching skills, including that of 'Reflection-in-action', before applying the framework in practice.

Take-home messages: Leading a ward round which engages learners meaningfully needs clinical teachers to have acquired teaching skills before they are expected to assume the role: The Trialogue can help facilitate the requisite complex integration of clinical and teaching

3I Short Communications: Postgraduate

Education 1

Location: Club A, PCC


Ensuring the "trainee voice" is heard. A description of the methods used to appoint, train and articulate the representative voice of Trainees in Schools serving Secondary Care

Kevin Kelleher (KSS Deanery, Secondary Care, 7 Bermondsey Street, London SE1 2DD, United Kingdom)

Background: It is recognised in the literature that delivery of curriculum is improved when the Postgraduate doctor has an opportunity to comment on all aspects relating to the standards of curriculum delivery (GMC). It is also implicitly stated that such commentary is mandated in "The Duties of a Doctor" (GMC).

Summary of work: The Postgraduate Deanery for Kent, Surrey and Sussex (KSS) has recruited trainee representatives for all the Programmes it manages. It has also appointed a trainee representative of all representatives to engage with and communicate the most important themes emerging from this cohort of individuals. These themes are moved onto the Secondary Care group meeting of all Schools and then onto the Deanery Business plan for the following year. Summary of results: We describe the selection methods for recruiting trainee representatives. We also describe the terms of reference of the overarching Trainee Representative and their competitive appointment. The Schools run regular training for the role and we describe the syllabus for these events and summarise the assessment of the training and its subsequent modification.

Conclusions: To ensure a standardised approach to the selection, appointment and training of the trainee representative in KSS secondary Care Schools. Take-home messages: An efficient and effective trainee voice on the delivery of PGME Programmes enhances their delivery.


Knowledge, skills but not attitudes change with pain education

Helen Laycock (Imperial College, Anaesthetics, Pain Management and Intensive Care, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10

9NH, United Kingdom)

Emma Casely (Hillingdon Hospital, Anaesthetics, London, United Kingdom)

Carsten Bantel (Imperial College, Anaesthetics, Pain Management and Intensive Care, London, United Kingdom)

Background: Poor management of acute pain in hospitals (Hefand 2009) is partly a consequence of junior doctor prescribing habits. These are influenced by


learning and memory schemas, which generate values about specific therapies (Higgins 2005). Barriers to effective analgesia include value judgements, influenced by attitudes rather than cognition. (Bunnin and Yu 2004). Junior doctors lack knowledge regarding pain management, but attitudes appear to evolve with training. Aim: Evaluate the effect of a knowledge-based teaching session on confidence in pain management and value judgements on analgesic drugs. Summary of work: A knowledge based education session ("iv loading of opioids") was delivered to 18 Foundation Year 1 doctors. This included video based clinical scenarios and factual information. Pre- and post-teaching assessments used 100mm visual analogue scales (VAS) to assess confidence and ease of managing an acute pain scenario and eight value judgment word pairings (e.g. risky-safe, anxious-unconcerned) for morphine and paracetamol. VAS lengths before and after teaching for each variable were compared using paired t-tests.

Summary of results: Confidence and reported ease of management improved significantly following teaching (p<0.001). There was no statistical difference in VAS scores for each judgement word pairing, which remained unchanged after teaching for both drugs. Conclusions: A purely knowledge based educational intervention significantly improved confidence and reported ease of managing an acute pain scenario, however value judgments regarding analgesic drugs remained unchanged. Whether increased confidence leads to experiential learning, which subsequently influences value judgments long term, requires further evaluation.

Take-home messages: Effective pain management teaching that focuses on knowledge alone may be inadequate to change clinical practice.


The relation between educational innovations, attention to competencies, learning environment and preparedness for practice. A correlational study to evaluate postgraduate medical education.

Ids Dijkstra (University Medical Center Groningen, Wenckebach Institute, Hanzeplein 1, FC13, Groningen

9700 RB, Netherlands)

Jan Pols (University Medical Center Groningen, Wenckebach Institute, Groningen, Netherlands) Pine Remmelts (University Medical Center Groningen, Wenckebach Institute, Groningen, Netherlands) Eric Rietzschel (University of Groningen, Faculty of Behavioral Sciences, Groningen, Netherlands) Janke Cohen-Schotanus (University Medical Center Groningen, Center for Research and Innovation in Medical Education, Groningen, Netherlands) Paul Brand (Isala Klinieken, Princess Amalia Children's Clinic, Zwolle, Netherlands)

Background: Although the shift of Post Graduate Medical Education (PGME) towards competency based training has been embraced by many educationalists

and practitioners, the effects of this shift on preparedness for independent practice are unknown. That's why we explored how elements of competency based programmes in PGME are related to perceived preparedness for practice among new consultants. Summary of work: After developing a conceptual model of the relationships between educational innovations, attention to competencies, the learning environment, and preparedness for practice, a questionnaire was distributed among 330 new consultants from various specialties to examine these relationships, adjusting for general self-efficacy and gender. Respondents were asked to rate how well their PGME training programme prepared them for practice, the degree of implementation of educational innovations, attention to CanMEDS competencies during feedback and coaching, and answered questions on the learning environment and general self-efficacy. Multiple regression and mediation analyses were used to analyse data. Summary of results: The response rate was 43% (143/330). Controlling for self-efficacy and gender, the learning environment was the strongest predictor of preparedness for practice (B = 0.42, p < 0.001, followed by attention to competencies (B = 0.29, p < 0.01 and general self-efficacy (B= 0.23 p < 0.001. The overall model explained 53% of the variance in preparedness for practice. Attention to competencies mediated the relation between educational innovations and preparedness for practice. This mediation became stronger at higher values of the learning environment. Conclusions: Our study showed that educational innovations and attention to competencies in PGME were related to higher levels of preparedness for practice, most strongly in a supportive learning environment.

Take-home messages: The learning environment plays a key role in determining the degree to which competency based PGME programmes prepare trainees for independent practice.


Development of a Tool to Measure the Educational Environment in Outpatient Clinics

James Milburn (NHS Grampian, Dept of General Surgery, 261 Westburn Road, Aberdeen AB25 2QH, United Kingdom)

Paul Bachoo (NHS Grampian, Dept of Vascular Surgery, Aberdeen, United Kingdom)

Madawa Chandratilake (University of Dundee, Dept of Medical Education, Dundee, United Kingdom)

Background: Postgraduate training in the outpatient clinic (OPC) has gradually declined in favour of inpatient experience despite the abundant and unique learning opportunities available. There is a need to maximise the restricted training opportunities within this setting. The aim of this study was to create a new instrument to assess the educational environment of the OPC for postgraduate doctors.

Summary of work: Following an extensive literature search and interviews with key stakeholders in


education an inventory of key areas and questions was developed. Refinement of this list led to the development of a questionnaire which was first piloted on a small numbers of trainees before a larger representative study was completed using a cohort of surgical trainees based throughout the UK. Summary of results: A 78% (n=111) response rate was achieved. Analysis showed a high internal consistency for the whole questionnaire and subscales (whole questionnaire- Cronbach's alpha co-efficient 0.935). A principal component analysis was performed to identify the internal structure of the instrument and to reduce the number of items. It was observed that the items belonged to three sub-scales (Teaching, Learning and Supervision) and the number of items can be reduced to 20 without compromising the content validity of the instrument.

Conclusions: The final instrument is termed the Outpatient Educational Environment Measure (OPEEM) and is the first to specifically measure the educational environment in the OPC for postgraduate trainees. Potential future applications of the OPEEM include dispersion of the OPEEM to different medical specialties and assessment of varied cultural and geographical environments.

Take-home messages: There is need to improve postgraduate training in the Outpatient clinic. The development of a dedicated instrument will aid the assessment of the educational environment to facilitate improvements in educational quality.


Factors affecting newly qualified doctors' wellbeing and implications for educational provision

Helen Goodyear (West Midlands Workforce Deanery, Medical Education, St Chad's Court, 213 Hagley Road, Birmingham B16 9RG, United Kingdom)

Background: Two UK reports, Tooke (2008) and Collins (2010) recommended first year postgraduate training improvements despite Modernising Medical Careers restructuring, weekly working hours reduced to 48 and educational supervisors' training. Summary of work: Free association narrative interviews of nine Foundation doctors were undertaken and analysed using grounded theory. Data validity was verified by interviewing two Foundation programme directors.

Summary of results: Two main themes emerged: newly qualified doctors' wellbeing is affected by personal experience and work related factors. They start work feeling unprepared by medical school. Shift working affects personal and social life. Enjoyment and reward come from helping patients or teaching medical students. Support from health care professionals is much valued but often lacking. Conclusions: Many factors affecting first year doctors' wellbeing are well described. New factors include shift patterns, work intensity and loss of team structure. Whilst becoming familiar with their roles, newly

qualified doctors search for identity and build up resilience. Support given during this process affects how they deal with day to day challenges, difficult issues, reward from posts and personal/social life impact. Take-home messages: For first year doctors' wellbeing, provision of support should start with preparedness at medical school followed by high standard support by hospitals, senior clinicians, healthcare workers, family and friends.


Introduction of Pilot Generalist Training

Lynn Moran (Frimley Park Hospital NHS Foundation Trust, PGEC, Portsmouth Road, Frimley GU16 7UF, United Kingdom)

Background: The KSS Deanery wished to respond to the desire to train postgraduate doctors to be generalists in response to the changing health provision and economy. The Deanery joined a pilot to place 12 post- Foundation trainees in a DG Hospital, a Psychiatric hospital and a GP Training scheme over 2 years. Six months experience is to be offered in Paediatrics, General Medicine, Psychiatry and General Practice. Summary of work: The presentation will describe the work of the steering group and all the considerations to be made when introducing a new training scheme. Identifying suitable locations, training posts, liaising with four craft colleges, liaising with the General Medical Council, making provision for national recruitment, providing careers support, engaging educational psychologists to evaluate the trainees experience. Ensuring governance of the educational experience at local level by training and supporting Educational & Clinical Supervisors. Financial considerations and service provision for Trusts and GP practices supporting these trainees will also be reported on. Summary of results: This is a live piece of work over the next 3 years. Preparation for the project began in September 2012 for implementation in August 2013. Full evaluation will be in September 2015. Interim evaluation and first stage summary will be available for August 2013.

Conclusions: Much of the evaluation will measure the decision making processes of the trainees as they progress through training and, at assessment panel at the end of year 1, make their final career decision. Take-home messages: As healthcare moves towards generalism and community care, junior doctors can be supported in career decisions to work in these fields.

3J Short Communications: Professionalism 2

Location: Club E, PCC 3J/1

An examination of a professional theme in curriculum of a medical school - a mixed methods analysis

Rulliana Agustin (University of Western Sydney, School of Medicine, Sydney, Australia)

Ian Wilson (University of Wollongong, Graduate School of Medicine, Sydney, Australia) David Mahns (University of Western Sydney, School of Medicine, Sydney, Australia)

Background: This research will add to our current understanding of curriculum of professionalism in medical education from the context of teaching, learning, and assessing. Moreover, it will help to understand how the student develops and incorporates medical professionalism as a student and after graduation as interns.

Summary of work: Twelve in-depth interviews, three focus group discussions, and questionnaires were performed. In-depth interviews were carried out involving education staff, whilst focus group discussions and questionnaires involved students and interns. The topics for the in-depth interview, focus group discussion, and questionnaires consisted of the opinion about professionalism, the satisfaction of the integration of professionalism theme into curriculum, and whether professionalism theme in the curriculum has already prepared students for an ethical-practice internship. Summary of results: Some themes have risen, e.g. the needs for the involvement of all stakeholders in integrating professionalism in the curriculum, the needs for engaging professionalism theme into a spiral structure in the curriculum, the needs for improvement in teaching and learning of professionalism theme in the curriculum, and the importance of professionalism theme in the curriculum for enabling students to perform an ethical internship.

Conclusions: There are some themes which have arisen from this research. The themes from the qualitative and quantitative data still need to be analysed further. The integration of the findings from the qualitative and quantitative data is important. Take-home messages: As an important theme in a medical school curriculum, professionalism should be evaluated continuously, especially for preparing students for ethical internship.


Which professional and unprofessional behaviours do Year 3 clinical medical students engage in?

Adam Youssef (University of Bristol at Gloucestershire Academy, Department of Undergraduate Medical


Education, Redwood Education Centre, Gloucestershire Royal Hospital, Gloucester GL1 3NN, United Kingdom) Deborah Mann (University of Bristol at Gloucestershire Academy, Department of Undergraduate Medical Education, Gloucester, United Kingdom) Joyce Muhlschlegel (University of Bristol at Gloucestershire Academy, Department of Undergraduate Medical Education, Gloucester, United Kingdom)

Peter Fletcher (University of Bristol at Gloucestershire Academy, Department of Undergraduate Medical Education, Gloucester, United Kingdom) Simon Atkinson (University of Bristol, Centre for Medical Education, Bristol, United Kingdom)

Background: Professional behaviour is an essential aspect of being a doctor. Medical students, as doctors-in-training are expected to learn and emulate the professional conduct shown by practicing doctors. This study records: 1.What unseen/unreported behaviours students display. 2. Students' insight into whether they are behaving in a professional manner. Summary of work: Year 3 clinical medical students at the University of Bristol were asked anonymously to give two examples of a time they behaved professionally and two examples of a time they behaved unprofessionally. Responses were grouped and analysed thematically. Summary of results: Many students demonstrated excellent examples of professional conduct. However, a surprising number of students engaged in behaviours which are considered unprofessional by licensing bodies such as the UK's General Medical Council. Recurring themes included dishonesty - such as lying about being ill, inappropriate behaviour outside of clinical areas, stealing medical supplies, lateness and inappropriate dress. Full results will be presented. Conclusions: This study has shown that year three students engage in unprofessional behaviours. It has also demonstrated that the students are aware that they are behaving in an unprofessional manner. It is known that professional behaviour improves through training, however these findings suggest that it should be addressed earlier in the medical school curriculum. Take-home messages: Year 3 medical students are aware of what constitutes professionalism but do not always engage in professional behaviours. It is essential to address this early in training.

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