A Systematic Review of Ophthalmology Education in Medical Schools: The Global Decline

TOPIC

This systematic review examines geographical and temporal trends in medical school ophthalmology education in relation to course and student outcomes.

CLINICAL RELEVANCE

There is increasing evidence suggesting a decline in ophthalmology teaching in medical schools, raising concern for the adequacy of eye knowledge across the rest of the medical profession.

METHODS

Systematic review of Embase and SCOPUS, with inclusion of studies containing data on medical school ophthalmological course length, and/or one or more outcome measures on student ophthalmology knowledge, skills, self-evaluation of knowledge or skills, or student course appraisal. The systematic review was registered prospectively on PROSPERO, ID CRD42022323865. Results were aggregated with outcome sub-group analysis and description in relation to geographical and temporal trends. Descriptive statistics including nonparametric correlations were utilised to analyse data and trends.

RESULTS

Systematic review yielded 4 596 publication titles, of which 52 were included in the analysis, with data from 19 countries. Average course length ranged from 12.5-208.7 hours, with significant continental disparity between mean course length. Africa reported the longest average course length at 103.3 hours, and North America reported the shortest at 36.4 hours. On average course lengths have been declining over the last two decades, from an average overall course length of 92.9 hours in the 2000s, to 52.9 hours in the 2020s. Mean student self-evaluation of skills was 51.3%, and student self-evaluation of knowledge was 55.4%. Objective mean assessment mark of skills was 57.5%, and of knowledge was 71.7%, compared to an average pass mark of 66.7%. On average 26.4% of students felt confident in their ophthalmology knowledge, and 34.5% in their skills.

CONCLUSIONS

The majority of the evidence describes declining length of courses devoted to ophthalmology in the last 20 years, significant student dissatisfaction with courses and content, and suboptimal knowledge and confidence.

Telemedicine vs Face-to-Face for Nursing Home Residents With Acute Presentations: A Noninferiority Study

OBJECTIVES

Telemedicine and face-to-face outreach services to nursing homes (NHs) have been used to reduce hospital utilization rates for acute presentations. However, how these modalities compare against each other is unclear. This article examines if the management of acute presentations in NHs with care involving telemedicine is noninferior to care delivered face-to-face.

DESIGN

A noninferiority study was conducted on a prospective cohort. Face-to-face intervention involved on-site assessment by a geriatrician and aged care clinical nurse specialist (CNS). Telemedicine intervention involved on-site assessment by an aged care CNS with telemedicine input by a geriatrician.

SETTING AND PARTICIPANTS

A total of 438 NH residents with acute presentations from 17 NHs between November 2021 and June 2022.

METHODS

Between-group differences in proportion of residents successfully managed on-site and mean number of encounters were evaluated using bootstrapped multiple linear regression; 95% CIs were compared against predefined noninferiority margins with noninferiority P values calculated.

RESULTS

In the adjusted models, care involving telemedicine demonstrated noninferiority in the difference in proportion of residents successfully managed on-site (95% CI lower limit -6.2% to -1.4% vs -10% noninferiority margin; P < .001 for noninferiority) but not in the difference in mean number of encounters (95% CI upper limit 1.42 to 1.50 encounters vs 1 encounter noninferiority margin; P = .7 for noninferiority).

CONCLUSIONS AND IMPLICATIONS

In our model of care, care that involved telemedicine was noninferior to care delivered face-to-face in managing NH residents with acute presentations on-site. However, additional encounters may be required. Application of telemedicine ought to be tailored to fit the needs and preferences of stakeholders.

Development and validation of the student ratings in clinical teaching scale in Australia: a methodological study

PURPOSE

This study aimed to devise a valid measurement for assessing clinical students' perceptions of teaching practices.

METHODS

A new tool was developed based on a meta-analysis encompassing effective clinical teaching-learning factors. Seventy-nine items were generated using a frequency (never to always) scale. The tool was applied to the University of New South Wales year 2, 3, and 6 medical students. Exploratory and confirmatory factor analysis (exploratory factor analysis [EFA] and confirmatory factor analysis [CFA], respectively) were conducted to establish the tool’s construct validity and goodness of fit, and Cronbach’s α was used for reliability.

RESULTS

In total, 352 students (44.2%) completed the questionnaire. The EFA identified student-centered learning, problem-solving learning, self-directed learning, and visual technology (reliability, 0.77 to 0.89). CFA showed acceptable goodness of fit (chi-square P<0.01, comparative fit index=0.930 and Tucker-Lewis index=0.917, root mean square error of approximation=0.069, standardized root mean square residual=0.06).

CONCLUSION

The established tool—Student Ratings in Clinical Teaching (STRICT)—is a valid and reliable tool that demonstrates how students perceive clinical teaching efficacy. STRICT measures the frequency of teaching practices to mitigate the biases of acquiescence and social desirability. Clinical teachers may use the tool to adapt their teaching practices with more active learning activities and to utilize visual technology to facilitate clinical learning efficacy. Clinical educators may apply STRICT to assess how these teaching practices are implemented in current clinical settings.

What impacts students' satisfaction the most from Medicine Student Experience Questionnaire in Australia: a validity study

PURPOSE

This study evaluated the validity of student feedback derived from Medicine Student Experience Questionnaire (MedSEQ), as well as the predictors of students' satisfaction in the Medicine program.

METHODS

Data from MedSEQ applying to the University of New South Wales Medicine program in 2017, 2019, and 2021 were analyzed. Confirmatory factor analysis (CFA) and Cronbach's α were used to assess the construct validity and reliability of MedSEQ respectively. Hierarchical multiple linear regressions were used to identify the factors that most impact students' overall satisfaction with the program.

RESULTS

A total of 1,719 students (34.50%) responded to MedSEQ. CFA showed good fit indices (root mean square error of approximation=0.051; comparative fit index=0.939; chi-square/degrees of freedom=6.429). All factors yielded good (α>0.7) or very good (α>0.8) levels of reliability, except the "online resources" factor, which had acceptable reliability (α=0.687). A multiple linear regression model with only demographic characteristics explained 3.8% of the variance in students' overall satisfaction, whereas the model adding 8 domains from MedSEQ explained 40%, indicating that 36.2% of the variance was attributable to students' experience across the 8 domains. Three domains had the strongest impact on overall satisfaction: "being cared for," "satisfaction with teaching," and "satisfaction with assessment" (β=0.327, 0.148, 0.148, respectively; all with P<0.001).

CONCLUSION

MedSEQ has good construct validity and high reliability, reflecting students' satisfaction with the Medicine program. Key factors impacting students' satisfaction are the perception of being cared for, quality teaching irrespective of the mode of delivery and fair assessment tasks which enhance learning.

Factors predicting rural location employment intent and choice among medical students and graduates

PURPOSE

Workforce shortage is a contributing cause of health inequality in rural Australia. There is inconclusive evidence demonstrating which factors cause doctors to choose rural practice. This study's objective is to determine predictive factors for medical students' intent to work rurally and for graduates' current rural employment location choice.

METHODS

This prospective cohort study, utilized data gathered from the University of New South Wales about students and graduates who had spent one or more years in a Rural Clinical School. Participants were final year students and graduates already working in Australia. Stepwise logistic regression was used to determine predictive factors for the two outcomes.

RESULTS

Predictors for student intent to work rurally are rural background (odds ratio [OR], 7.16; 95% confidence interval [CI], 2.59-19.53), choosing to study at the Rural Clinical School (OR, 8.72; 95% CI, 1.32-57.63), and perceiving rural areas as opportunistic for career advancement (OR, 1.69; 95% CI, 1.15-2.49). Predictors for graduates currently working in a rural location are Bonded Medical Program participation (OR, 6.40; 95% CI, 1.15-35.59) and personal altruism (OR, 1.91; 95% CI, 1.02-3.57).

CONCLUSION

While intent is predicted by having a rural background, choosing to study at the Rural Clinical School and perception of rural areas as having positive career opportunities, a current rural workplace location among graduates is predicted by holding a bonded medical position and a desire to serve an under-resourced population. Maintaining the Bonded Medical Program and clear communication regarding training pathways may increase numbers of rural doctors.

Medical student selection process enhanced by improving selection algorithms and changing the focus of interviews in Australia: a descriptive study

PURPOSE

The study investigates the efficacy of new features introduced to the selection process for medical school at the University of New South Wales, Australia: (1) considering the relative ranks rather than scores of the Undergraduate Medicine and Health Sciences Admission Test and Australian Tertiary Admission Rank; (2) structured interview focusing on interpersonal interaction and concerns should the applicants become students; and (3) embracing interviewers’ diverse perspectives.

METHODS

Data from 5 cohorts of students were analyzed, comparing outcomes of the second year in the medicine program of 4 cohorts of the old selection process and 1 of the new process. The main analysis comprised multiple linear regression models for predicting academic, clinical, and professional outcomes, by section tools and demographic variables.

RESULTS

Selection interview marks from the new interview (512 applicants, 2 interviewers each) were analyzed for inter-rater reliability, which identified a high level of agreement (kappa=0.639). No such analysis was possible for the old interview since it required interviewers to reach a consensus. Multivariate linear regression models utilizing outcomes for 5 cohorts (N=905) revealed that the new selection process was much more effective in predicting academic and clinical achievement in the program (R2=9.4%–17.8% vs. R2=1.5%–8.4%).

CONCLUSION

The results suggest that the medical student selection process can be significantly enhanced by employing a non-compensatory selection algorithm; and using a structured interview focusing on interpersonal interaction and concerns should the applicants become students; as well as embracing interviewers’ diverse perspectives.

Equal Z standard-setting method to estimate the minimum number of panelists for a medical school’s objective structured clinical examination in Taiwan: a simulation study

PURPOSE

Undertaking a standard-setting exercise is a common method for setting pass/fail cut scores for high-stakes examinations. The recently introduced equal Z standard-setting method (EZ method) has been found to be a valid and effective alternative for the commonly used Angoff and Hofstee methods and their variants. The current study aims to estimate the minimum number of panelists required for obtaining acceptable and reliable cut scores using the EZ method.

METHODS

The primary data were extracted from 31 panelists who used the EZ method for setting cut scores for a 12-station of medical school’s final objective structured clinical examination (OSCE) in Taiwan. For this study, a new data set composed of 1,000 random samples of different panel sizes, ranging from 5 to 25 panelists, was established and analyzed. Analysis of variance was performed to measure the differences in the cut scores set by the sampled groups, across all sizes within each station.

RESULTS

On average, a panel of 10 experts or more yielded cut scores with confidence more than or equal to 90% and 15 experts yielded cut scores with confidence more than or equal to 95%. No significant differences in cut scores associated with panel size were identified for panels of 5 or more experts.

CONCLUSION

The EZ method was found to be valid and feasible. Less than an hour was required for 12 panelists to assess 12 OSCE stations. Calculating the cut scores required only basic statistical skills.

Screening for media use in the ED among young Australians: a cross-sectional study (Preprint)

BACKGROUND

Research on problematic internet use has largely adhered to addiction paradigms, possibly impeding the identification of specific internet behaviors related to psychopathology. This study presents a novel approach to screening for specific problematic internet behaviors by using a new measure, the emergency department media use screener (EDMUS).

OBJECTIVE

The purpose of this study was to identify patterns of internet use in young people presenting with mental health concerns to the emergency department (ED), ascertain associations with their mental health, and evaluate whether the EDMUS can be used to predict subsequent ED presentations within 3 months.

METHODS

This cross-sectional retrospective study of Australian young people (N=149, aged 11-25 years; female: n=92, 61.7%) sought to use the EDMUS, a 24-item questionnaire, to identify problematic internet behaviors, including accessing or posting prosuicidal or proeating disorder content, cyberbullying, and inappropriate digital content. Data on each person's mental health were extracted from electronic medical records to look for associations with EDMUS responses and ED re-presentation over 3 months. EDMUS items were grouped into clusters for analysis using chi-square tests, binary logistic regression, and path analyses.

RESULTS

Sharing suicidal digital content was the most common problematic internet use pattern identified by the EDMUS. However, this did not correlate with having a prior mental health diagnosis or predict readmission. Most participants had families with a concern for their internet use; however, this was less likely in participants with a diagnosis of personality disorder. Diagnoses of personality disorder or posttraumatic stress disorder were independent predictors of readmission (P=.003; P=.048).

CONCLUSIONS

Although a history of complex psychopathology increases the likelihood of subsequent ED presentations, its links to internet use-related behaviors are still unclear. The EDMUS has potential for identifying young people who are most vulnerable to problematic internet behaviors and offers the opportunity for early intervention and potential prevention of more entrenched difficulties.

Medical school grades may predict future clinical competence

BACKGROUND

In real-world medical education, there is a lack of reliable predictors of future clinical competencies. Hence, we aim to identify the factors associated with clinical competencies and construct a prediction model to identify "improvement required" trainees.

METHODS

We analyzed data from medical students who graduated from National Yang-Ming University with clerkship training and participated in the postgraduate year (PGY) interview at Taipei Veterans General Hospital. Clinical competencies were evaluated using grades of national objective structured clinical examination (OSCEs). This study used data from medical students who graduated in July 2018 as the derivation cohort (N = 50) and those who graduated in July 2020 (n = 56) for validation.

RESULTS

Medical school grades were associated with the performance of national OSCEs (Pearson r = 0.34, p = 0.017), but the grades of the structured PGY interviews were marginally associated with the national OSCE (Pearson r = 0.268, p = 0.06). A prediction model was constructed to identify "improvement required" trainees, defined: trainees with the lowest 25% of scores in the national OSCEs. According to this model, trainees with the lowest 25% medical school grades predicted a higher risk of the "improvement required" clinical performance (Q1-Q3 vs Q4 = 15% vs 60%, odds ratio = 8.5 [95% confidence interval = 1.8-39.4], p = 0.029). In the validation cohort, our prediction model could accurately classify 76.7% "improvement required" and "nonimprovement required" students.

CONCLUSION

Our study suggests that interventions for students with unsatisfactory medical school grades are warranted to improve their clinical competencies.

Faculty appointment and promotion in Taiwan's medical schools, a systematic analysis

BACKGROUND

A rigorous faculty appointment and promotion (FAP) system is vital for the success of any academic institution. However, studies examining the FAP system in Asian universities are lacking. We surveyed the FAP policies of Taiwan's medical schools and identified an overreliance on the CJA score (manuscript Category, Journal quality, and Author order). The potential shortcomings of this metric and recommendations for refinement were discussed.

METHODS

We obtained the FAP documents from all 12 medical schools in Taiwan, and analyzed their use of traditional versus non-traditional criteria for FAP according to a published methodology. The influence of the journal impact factor (JIF) on the FAP process was quantified by comparing its relative weight between papers with two extreme JIFs. To better understand the research impact and international standing of each school, we utilized the public bibliographic database to rank universities by the number of papers, and the proportions of papers within the top 10% or 50% citation.

RESULTS

Compared with other countries, Taiwan's medical schools focus more on the quantifiable quality of the research, mostly using a "CJA" score that integrates the category, JIF or ranking, and authorship of a paper, with the JIF being the most influential factor. The CJA score for an article with a JIF of 20 can be up to three times the threshold for promotion to Assistant Professor. The emphasis on JIF is based on a presumed correlation between JIF and citation counts. However, our analysis shows that Taiwan's medical schools have lower-than-average citation counts despite a competitive rank in the number of publications.

CONCLUSIONS

The JIF plays an unrivaled role in determining the outcome of FAP in Taiwan's medical schools, mostly via the CJA system. The questionable effectiveness of the current system in elevating the international standing of Taiwan's higher-education institutions calls for a re-examination of the FAP system. We recommend a reduction in the relative importance of CJA score in the FAP system, adopting more rigorous metrics such as the h-index for evaluating research quality, and supporting more research aimed at improving the FAP system.

Implementing a flipped classroom model in an evidence-based medicine curriculum for pre-clinical medical students: evaluating learning effectiveness through prospective propensity score-matched cohorts

BACKGROUND

In a flipped classroom (FC) model, blended learning is used to increase student engagement and learning by having students finish their readings at home and work on problem-solving with tutors during class time. Evidence-based medicine (EBM) integrates clinical experience and patient values with the best evidence-based research to inform clinical decisions. To implement a FC and EBM, students require sufficient information acquisition and problem-solving skills. Therefore, a FC is regarded as an excellent teaching model for tutoring EBM skills. However, the effectiveness of a FC for teaching EBM competency has not been rigorously investigated in pre-clinical educational programs. In this study, we used an innovative FC model in a pre-clinical EBM teaching program.

METHODS

FC's teaching was compared with a traditional teaching model by using an assessment framework of prospective propensity score matching, which reduced the potential difference in basic characteristics between the two groups of students on 1:1 ratio. For the outcome assessments of EBM competency, we used an analysis of covariance and multivariate linear regression analysis to investigate comparative effectiveness between the two teaching models. A total of 90 students were prospectively enrolled and assigned to the experimental or control group using 1:1 propensity matching.

RESULTS

Compared with traditional teaching methods, the FC model was associated with better learning outcomes for the EBM competency categories of Ask, Acquire, Appraise, and Apply for both written and oral tests at the end of the course (all p-values< 0.001). In particular, the "appraise" skill for the written test (6.87 ± 2.20) vs. (1.47 ± 1.74), p < 0.001), and the "apply" skill for the oral test (7.34 ± 0.80 vs. 3.97 ± 1.24, p < 0.001) had the biggest difference between the two groups.

CONCLUSIONS

After adjusting for a number of potential confunding factors, our study findings support the effectiveness of applying an FC teaching model to cultivate medical students' EBM literacy.

Immersive virtual reality (VR) training increases the self-efficacy of in-hospital healthcare providers and patient families regarding tracheostomy-related knowledge and care skills: A prospective pre-post study

BACKGROUND

Virtual reality (VR)-based simulation in hospital settings facilitates the acquisition of skills without compromising patient safety. Despite regular text-based training, a baseline survey of randomly selected healthcare providers revealed deficiencies in their knowledge, confidence, comfort, and care skills regarding tracheostomy. This prospective pre-post study compared the effectiveness of regular text- and VR-based intervention modules in training healthcare providers' self-efficacy in tracheostomy care skills.

METHODS

Between January 2018 and January 2020, 60 healthcare providers, including physicians, nurses, and respiratory therapists, were enrolled. For the intervention, a newly developed head-mounted display (HMD) and web VR materials were implemented in training and clinical services. Subsequently, in-hospital healthcare providers were trained using either text or head-mounted display virtual reality (HMD-VR) materials in the regular and intervention modules, respectively. For tracheostomy care skills, preceptors directly audited the performance of trainees and provided feedback.

RESULTS

At baseline, the degree of trainees' agreement with the self-efficacy-related statements, including the aspects of familiarity, confidence, and anxiety about tracheostomy-related knowledge and care skills, were not different between the control and intervention groups. At follow-up stage, compared with the regular group, a higher percentage of intervention group' trainees reported that they are "strongly agree" or "somewhat agree" that the HMD-VR simulation increases their self-efficacy, including the aspects of familiarity and confidence, and reduced their anxiety about tracheostomy-related knowledge and care skills. After implementation, a higher degree of trainees' average satisfaction with VR-based training and VR materials was observed in the intervention group than in the regular group. Most reported that VR materials enabled accurate messaging and decreased anxiety. The increasing trend of the average written test and hands-on tracheostomy care skills scores among the intervention group trainees was significant compared to those in the regular group. The benefits of HMD-VR simulations and web-VR material-based clinical services for in-hospital healthcare providers and patient families persisted until 3 to 4 weeks later.

CONCLUSION

The current study suggests that VR materials significantly enhance trainees' self-efficacy (increased familiarity, increased confidence, and reduced anxiety) and their satisfaction with the training, while motivating them to use acquired knowledge and skills in clinical practice.

Comparison of OSCE performance between 6- and 7-year medical school curricula in Taiwan

BACKGROUND

The year 2013 marks a watershed in the history of medical education in Taiwan. Following Taiwan's Taskforce of Medical School Curriculum Reform recommendations, the medical school curriculum was reduced from 7 to 6 years. This study aimed to analyze the impact of medical school curriculum reform on medical students' performance in objective structured clinical examinations (OSCEs).

METHODS

We retrospectively analyzed the OSCE records at Taipei Veterans General Hospital (Taipei VGH), one of Taiwan's largest tertiary medical centers, between November 2016 and July 2020. The eligibility criteria were medical students receiving a full one-year clinical sub-internship training at Taipei VGH and in their last year of medical school. All medical students received a mock OSCE-1 at the beginning of their sub-internship, a mock OSCE-2 after six months of training, and a national OSCE at the end of their sub-internship. The parameters for performance in OSCEs included "percentage of scores above the qualification standard" and "percentage of qualified stations."

RESULTS

Between November 2016 and July 2020, 361 undergraduates underwent clinical sub-internship training at Taipei VGH. Among them, 218 were taught under the 7-year curriculum, and 143 were instructed under the 6-year curriculum. Based on baseline-adjusted ANCOVA results, medical students under the 7-year curriculum had a higher percentage of scores above the qualification standard than those under the 6-year curriculum at the mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 33.8% [95% CI 32.0-35.7] vs. 28.2% [95% CI 25.9-30.4], p < 0.001), and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001). Moreover, medical students in the 7-year curriculum had a higher percentage of qualified stations in mock OSCE-1 (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 87.4-91.4] vs. 84.0% [95% CI 81.5-86.4], p = 0.001) and mock OSCE-2 (7-year curriculum vs. 6-year curriculum: 91.9% [95% CI 90.1-93.8] vs. 86.1% [95% CI 83.8-88.3], p = 0.001). After clinical sub-internship training, there were no differences in the percentage of scores above the qualification standard (7-year curriculum vs. 6-year curriculum: 33.5% [95% CI 32.2-34.9] vs. 34.6 [95% CI 32.9-36.3], p = 0.328) and percentage of qualified stations (7-year curriculum vs. 6-year curriculum: 89.4% [95% CI 88.1-90.7] vs. 90.2% [95% CI 88.6-91.8], p = 0.492).

CONCLUSIONS

At the beginning of the sub-internship, medical students under the 7-year curriculum had better OSCE performance than those under the 6-year curriculum. After the clinical sub-internship training in Taipei VGH, there was no difference in the national OSCE score between the 6- and 7-year curricula. Our study suggests that clinical sub-internship is crucial for the development of clinical skills and performance in the national OSCE.

Medical students' perception of an online dental trauma course in medical education

BACKGROUND

With dental trauma education not commonly offered in medicine programmes, offering an online learning course may fill the knowledge deficiency for medical students. The aim of this study is to evaluate medical students' perceptions of an online dental trauma course.

MATERIAL AND METHODS

This was a cross-sectional questionnaire study conducted among medical students at an Australian University. Exploratory factor analysis was used to identify the underlying factor structure within the items. Cronbach's alpha was employed to estimate the factors' reliability. Confirmatory factor analysis was used to assess construct validity; SPSS v22 and AMOIS v22 were used for data analyses.

RESULTS

Exploratory factor analysis identified two distinct factors: 'visual' and 'content', with excellent reliability for visual (Cronbach's alpha = 0.911) and good reliability for content (Cronbach's alpha = 0.755).

CONCLUSIONS

This research supports the findings that medical students perceived the online dental trauma course to be easily understood for self-learning this topic.

Trust and risk pitfalls in medical education: A qualitative study of clinical teachers

PURPOSE

Learning opportunities in teaching hospitals are gated by clinical teachers. One way to unpack their decision-making is to employ a 'trust and risk' model. This study aimed to uncover clinical teachers' experience of trust, risk and vulnerability as they participate in medical education.

METHODS

Hospital-based clinical teachers were interviewed about trust, risk and vulnerability in medical education. Data analysis was undertaken using a constructivist, qualitative framework.

RESULTS

Twenty demographically diverse clinical teachers participated. Trust and risk were regarded as fundamental workplace and teaching concepts. Their concerns fell into three domains of risk: clinical, teaching and personal. Being trusted unlocked clinical learning opportunities, whereas trust failure limited future participation. Feeling trusted or not affected wellbeing and self-efficacy. Trust and risk pitfalls in education included bias, asymmetry and sidelining.

CONCLUSIONS

This study adds to the literature by voicing clinical teachers' personal risks and vulnerabilities. Attention was drawn to the benefits of being perceived as trustworthy, and to the clinical, teaching and personal vulnerabilities of trust failure.If expert judgement of trustworthiness is to be legitimised as meaningful assessment, clinical teachers must be aware not only of how trust is built, but also the pitfalls of trust failure.

It's what you do, not the way you do it - online versus face-to-face small group teaching in first year medical school

BACKGROUND

Major disruptions imposed on medical education by the COVID-19 pandemic and the rapid shift to online teaching in medical programs, necessitated need for evaluation of this format. In this study we directly compared knowledge outcomes, social outcomes, and wellbeing of first year student small group teaching in either face to face (f2f) or online format.

METHODS

At the end of the first course of our medical program, students were invited to participate in an online questionnaire with 10 quantitative items and 1 qualitative item. These were analysed using Factor Analysis Pattern Matrix and linear regression to group items and assess relatedness. Qualitative responses were thematized using Qualtrics software (Qualtrics, Provo, UT, USA). Summative assessment results were compared, both between current cohorts to historical cohorts.

RESULTS

From a cohort of 298 students there was a 77% response rate. Overall, there were no differences in knowledge gains, either between groups or when compared to historical cohorts. Questionnaire items fell reliably into groups that related to either learning outcomes, social outcomes, or wellbeing. Independent T tests showed that format for teaching (online versus f2f) had an impact on social outcomes but no direct impact on learning outcomes. Linear regression revealed that the social outcomes have a direct impact on wellbeing and almost the double the impact on learning outcomes than mode of learning i.e.. F2f or online (β = .448 and β = .232 respectively).

CONCLUSION

In this study, we were able to show with statistical strength that social outcomes for students such as engaging with peers and facilitator, contributing to the group, and making friends have a direct impact on wellbeing and indirectly impact learning outcomes (such as motivation, satisfaction, integration of knowledge). In a rapidly changing educational landscape, in our opinion, it is vital that these aspects are a focus of design and delivery of medical education. The data from this study supports the notion that activity design and the expertise of the teacher in facilitating the small group activities, has greater impact than the mode of educational delivery itself on students' learning processes.

Empirical analysis comparing the tele-objective structured clinical examination (teleOSCE) and the in-person assessment in Australia

PURPOSE

It aimed to compare the use of the tele objective structured clinical examination (teleOSCE) with in-person assessment in high-stakes clinical examination so as to determine the impact of the teleOSCE on the assessment undertaken. Discussion follows regarding what skills and domains can effectively be assessed in a teleOSCE.

METHODS

This study is a retrospective observational analysis. It compares the results achieved by final year medical students in their clinical examination, assessed using the teleOSCE in 2020 (n=285), with those who were examined using the traditional in-person format in 2019 (n=280). The study was undertaken at the University of New South Wales, Australia.

RESULTS

In the domain of physical examination, students in 2020 scored 0.277 points higher than those in 2019 (mean difference -0.277, P<0.001, effect size 0.332). Across all other domains, there was no significant difference in mean scores between 2019 and 2020.

CONCLUSION

The teleOSCE does not negatively impact assessment in clinical examination in all domains except physical examination. If the teleOSCE is the future of clinical skills examination, assessment of physical examination will require concomitant workplace-based assessment.

Factors Determining Medical Students' Experience in an Independent Research Year During the Medical Program

BACKGROUND

There is ongoing debate about best practice models to support active learning by encouraging medical students to conduct independent research projects. This study explored student satisfaction, experiences, and learning outcomes of a unique, mandatory research program in an Australian medical school.

METHODS

Students were invited to complete an anonymous survey ranking statements using Likert scales and completing open-ended questions. Factors predicting student satisfaction with the research year were analysed using a generalised linear regression model. A content analysis of open-ended questions was conducted.

RESULTS

The survey was completed in October 2019 by 117 of 252 students (46%). The majority (84%) reported satisfaction with the research year. Factors associated with satisfaction were research skills learnt (OR 2.782, 95% CI 1.428-5.421; p < 0.003), supervision and support (OR = 2.587, 95% CI 1.237-5.413; p < 0.012), and meaningfulness and experience (OR = 2.506, 95% CI 1.100-5.708; p < 0.029). Qualitative results confirmed support from the faculty and supervisors, perceiving their research as meaningful, and the opportunity to learn research skills were highly regarded by students.

CONCLUSIONS

This study has shown that learning outcomes for basic research skills and high satisfaction rates can be achieved in a mandatory undergraduate research programme when students have dedicated time for their research, opportunities to negotiate their own project, and good support from faculty and mentors.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-021-01340-9.

Developing a prototype dental trauma e-learning course for medical education

This article aims to demonstrate how an expert feedback process was used to identify emerging issues within a prototype extracurricular course on dental trauma and show how the feedback was addressed prior to piloting the course more widely. Dowse's Design Research Model was adapted for the design and development of a prototype dental trauma e-learning course. This paper will focus on step five, gathering expert feedback and the evaluation process. Four critical features emerged from the feedback that ought to be incorporated into the e-learning course design, namely, 1) keep resources clinically relevant; 2) keep resources simple to learn; 3) make resources easy to understand; and 4) support self-learning. The results demonstrate the value of an expert feedback process for improving a prototype designed to address a major gap in knowledge among medical doctors identified in the literature.

Virtual reality-based preprocedural education increases preparedness and satisfaction of patients about the catheter ablation of atrial fibrillation

BACKGROUND

A recent study suggested to develop and implement more interacted material for preprocedural education to decrease patients' anxiety about the atrial fibrillation (AF) ablation. This study compared the effectiveness of using either newly developed virtual reality (VR) materials (VR group) or paper-based materials (paper group) on giving AF preprocedural education.

METHODS

This study consequentially enrolled 33 AF patients preparing for ablation from November 2019 to October 2020. After enrollment, patients were randomized as either paper (n = 22) or VR (n = 11) groups.

RESULTS

In comparison with the baseline stage, at the posteducation stage, the degree of improvement in patients' self-assessed self-efficacy on AF ablation knowledge was higher among VR group patients than those in the paper group. At the posteducation stage, the patients' satisfaction to preprocedural education and used materials were higher among the VR group than that among the paper group. In addition to meet their needs and give accurate medical information, VR group patients reported that VR materials increased the effectiveness of education, increased their preparedness for AF catheter ablation, achieved paperless purposes, and willing to recommend VR materials to others. Operators subjectively reported that the periprocedure cooperation was increased both among paper and VR group patients after preprocedural education for the details of procedure. Better preparedness of VR group patients was supported by less periprocedure pain, anxiety, and impatience than those among paper group patients.

CONCLUSION

Interactive VR-based materials are superior to the paper-based materials to provide patients immerse and imagine the journey and detail knowledge of AF catheter ablation before the procedure and better prepared patients for the procedure.

Online dental trauma course for medical education

A literature review identified a knowledge deficit among medical doctors about dental trauma management. To overcome this knowledge gap, a proposal to integrate dental traumatology teaching into the medical curriculum was made to raise medical students' awareness of, and familiarity with managing dental injuries. Despite the challenges of teaching dental trauma, online courses are viewed as a practical learning approach for students to access course material during their busy university schedules. In focusing on the constructivist model, this article details the design and development of the online dental trauma course. It is an example of a learner-led, fully online course. The six steps involved in the course development were as follows: (1) structured order from preclinical to clinical topics; (2) content covering all essential information on TDI diagnosis and management; (3) illustrative materials to support engagement and motivation to complete the course; (4) feedback processes to evaluate the learning process; (5) interactions between peers, educators, and learning materials to help facilitate learning; and (6) content that encompasses mainly visual learning styles. The online dental trauma course has the potential to make important contributions to medical education.

Proposing the inclusion of dental anatomy and trauma in the general medical curriculum

Many medical doctors are not confident in managing traumatic dental injuries (TDI). This is probably due to a lack of education and training in dental trauma. The existence of inadequate TDI knowledge by doctors should provide the catalyst to establish a dental anatomy and trauma course within the medical curriculum.

Assessment methods and the validity and reliability of measurement tools in online objective structured clinical examinations: a systematic scoping review

The coronavirus disease 2019 (COVID-19) pandemic has required educators to adapt the in-person objective structured clinical examination (OSCE) to online settings in order for it to remain a critical component of the multifaceted assessment of a student’s competency. This systematic scoping review aimed to summarize the assessment methods and validity and reliability of the measurement tools used in current online OSCE (hereafter, referred to as teleOSCE) approaches. A comprehensive literature review was undertaken following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Articles were eligible if they reported any form of performance assessment, in any field of healthcare, delivered in an online format. Two reviewers independently screened the results and analyzed relevant studies. Eleven articles were included in the analysis. Pre-recorded videos were used in 3 studies, while observations by remote examiners through an online platform were used in 7 studies. Acceptability as perceived by students was reported in 2 studies. This systematic scoping review identified several insights garnered from implementing teleOSCEs, the components transferable from telemedicine, and the need for systemic research to establish the ideal teleOSCE framework. TeleOSCEs may be able to improve the accessibility and reproducibility of clinical assessments and equip students with the requisite skills to effectively practice telemedicine in the future.

The change from UMAT to UCAT for undergraduate medical school applicants: impact on selection outcomes

OBJECTIVES

To assess whether the change from the Undergraduate Medical and Health Sciences Admissions Test (UMAT; 1991-2019) to the University Clinical Aptitude Test (UCAT) for the 2020 New South Wales undergraduate medical degree intake was associated with changes in the impact of sex, socio-economic status and remoteness of residence, and professional coaching upon selection for interview.

DESIGN, SETTING, PARTICIPANTS

Cross-sectional study of applicants for the three NSW undergraduate medical programs for entry in 2019 (4114 applicants) or 2020 (4270); 703 people applied for both intakes. Applicants selected for interview were surveyed about whether they had received professional coaching for the selection test.

MAIN OUTCOME MEASURES

Scores on the three sections of the UMAT (2019 entry cohort) and the five subtests of the UCAT (2020 entry); total UMAT and UCAT scores.

RESULTS

Mean scores for UMAT 1 and 3 and for all four UCAT cognitive subtests were higher for men than women; the differences were statistically significant after adjusting for age, socio-economic status, and remoteness. The effect size for sex was 0.24 (95% CI, 0.18-0.30) for UMAT total score, 0.38 (95% CI, 0.32-0.44) for UCAT total score. For the 2020 intake, 2303 of 4270 applicants (53.9%) and 476 of 1074 interviewees (44.3%) were women. The effect size for socio-economic status was 0.47 (95% CI, 0.39-0.54) for UMAT, 0.43 (95% CI, 0.35-0.50) for UCAT total score; the effect size for remoteness was 0.54 (95% CI, 0.45-0.63) for UMAT, 0.48 (95% CI, 0.39-0.58) for UCAT total score. The impact of professional coaching on UCAT performance was not statistically significant among those accepted for interview.

CONCLUSIONS

Women and people from areas outside major cities or of lower socio-economic status perform less well on the UCAT than other applicants. Reviewing the test and applicant quotas may be needed to achieve selection equity.

Effect of medical students' values on their clinical decision-making

INTRODUCTION Personal and professional values of health-care practitioners influence their clinical decisions. AIM To investigate how medical students' values influence their clinical decisions. METHODS Values of 117 medical students were measured using an instrument we developed, the Healthcare Practitioner Values Scale. Factors that students consider in clinical decision-making were identified in four clinical scenarios using qualitative coding. Differences in values between students who considered given factors in decision-making and students who did not consider the same factors were analysed. Random effects models were used to investigate which differences were explained by variation in the clinical scenarios and factors considered in decision-making. RESULTS Six factors that students consider in clinical decision-making were identified and grouped into three categories: patient-centred (patient perspective, family and social circumstances); clinical (patient safety, symptoms and treatment efficacy); and situational factors (health-care practitioner self-awareness and service cost). Students who prioritised spirituality placed more emphasis on patient-centred factors, and less emphasis on clinical factors in different scenarios; students who prioritised critical thinking placed less emphasis on patient-centred factors; and students who prioritised capability, professionalism and safety values placed more emphasis on situational factors. Total proportion of variance in value differences explained by factors and clinical scenarios was 25.2% for spirituality and 56.2% for critical thinking. DISCUSSION Students who prioritise different values consider different factors in their clinical decisions. Spirituality and critical thinking values are more likely to influence students' decision-making approaches than other values. Improving students' awareness of how their own values influence their decisions can help them improve their clinical decision-making.

Standard setting made easy: validating the Equal Z-score (EZ) method for setting cut-score for clinical examinations

BACKGROUND

This study aims to assess the feasibility, reliability and validity of the panel-based Equal Z-score (EZ) method applied to objective structural clinical examination (OSCE) of Chinese medical students and undertaking a comparison with the statistical techniques-based Borderline Regression Method (BRM).

METHODS

Data received from two cohorts of 6th and 7th year medical students in Taiwan who set the mock OSCE as a formative assessment. Traditionally this medical school uses BRM to set the pass/fail cut-score. For the current study, 31 OSCE panellists volunteered to participate in the EZ method in parallel to the BRM.

RESULTS

In the conduct of this study, each panel completed this task for an OSCE exam comprising 12 stations within less than 60 min. Moreover, none of the 31 panellists, whose are busy clinicians, had indicated that the task was too difficult or too time-consuming. Although EZ method yielded higher cut-scores than the BRM it was found reliable. Intraclass correlation (ICC) measuring absolute agreement, across the three groups of panellists was .893 and .937 for the first and second rounds respectively, demonstrating high level of agreement across groups with the EZ method and the alignment between the BRM and the EZ method was visually observed. The paired t-test results identified smaller differences between the cut-scores within methods than across methods.

CONCLUSIONS

Overall this study suggests that the EZ method is a feasible, reliable and valid standard setting method. The EZ method requires relatively little resources (takes about an hour to assess a 12 station OSCE); the calculation of the cut-score is simple and requires basic statistical skills; it is highly reliable even when only 10 panellists participate in the process; and its validity is supported by comparison to BRM. This study suggests that the EZ method is a feasible, reliable and valid standard setting method.

Sustained effects of faculty leadership development modules for clinical instructors of core competences education in Taiwan: a four-year explanatory case study

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) core competencies (CC) in general medicine-based primary care are essential for junior medical trainees. In this country, a regular faculty development (FD) program aimed at training faculty in instructing (teaching and assessing) these CC had operated. However, leadership was not emphasized. In a new intervention module, the roles and associated responsibilities of clinical instructors to conduct, design, and lead CC-based education were emphasis.

AIMS

This follow-up explanatory case study compares the effectiveness of intervention module with that of the previous regular module.

METHODS

The regular group (n = 28) comprised clinical instructors who participated in the FD module during the 2013-2014 year while the intervention group (n = 28) was composed of 2015-2016 participants. Prior to the formal (hands-on) training, participants in the intervention group were asked to study the online materials of the regular module. These participants then received a 30-h hands-on training in conducting, designing, and leading skills. Finally, they prepared a 10-h reflective end-of-module presentation of their real-world practices.

RESULTS

Following the training, a higher degree improvement in participants self-reported familiarity with CC education, self-confidence in their ability to deliver CC education and sustained involve CC education were noted among the intervention FD group, compared with the regular FD group. In the intervention group, senior academicians (associate and full professor) are more substantially involved in designing and leading CC-based courses than junior academicians (lecturers and assistant professors). Among non-teaching award winners of in the intervention FD group, the follow-up degree of sustained involvement in delivering, designing and leading CC-based courses was significantly higher than that of the regular group.

CONCLUSIONS

Our study demonstrated that leadership training in the intervention FD modules substantially motivated clinical instructors to become leaders in CC education.

Selecting top candidates for medical school selection interviews- a non-compensatory approach

BACKGROUND

Medical schools apply a range of selection methods to ensure that admitted students succeed in the program. In Australia, selection tools typically include measures of academic achievement (e.g. the Australian Tertiary Admission Rank - ATAR) and aptitude tests (e.g. the Undergraduate Medicine and Health Sciences Admissions Test - UMAT). These are most commonly used to determine which applicants are invited for additional selection processes, such as interviews. However, no previous study has examined the efficacy of the first part of the selection process. In particular, are compensatory or non-compensatory approaches more effective in evaluating the outcomes of cognitive and aptitude tests, and do they affect the demographics of students selected for interview?

METHODS

This study utilised data from consecutive cohorts of mainstream domestic students who applied to enter the UNSW Medicine program between 2013 to 2018. A compensatory ranked selection model was compared with a non-compensatory ranked model. Initially, ATAR marks and UMAT scores for each applicant were ranked within each cohort. In the compensatory model, the mean of the ATAR and UMAT ranks were used to determine the outcome. In the non-compensatory model, the lowest rank of ATAR and UMAT determined the outcome for each applicant. The impact of each model on the gender and socioeconomic status of applicants selected to interview was evaluated across all cohorts.

RESULTS

The non-compensatory ranked selection model resulted in substantially higher ATAR and UMAT thresholds for invitation to interview, with no significant effect on the socioeconomic status of the selected applicants.

CONCLUSIONS

These results are important, demonstrating that it is possible to raise the academic threshold for selection to medicine without having any negative impact on applicants from low socioeconomic backgrounds. Overall, the evidence gathered in this study suggests that a non-compensatory model is preferable for selecting applicants for medical student selection interview.

Predictive validity of a tool to resolve borderline grades in OSCEs

There is inconclusive evidence suggesting which standard setting method yields the highest validity for pass/fail decisions in examinations. The Objective Borderline Method 2 (OBM2) is a decision-making tool for reclassification of borderline grades to clear pass or clear fail grades to resolve examiner uncertainty for high-stakes pass/fail decisions. This study evaluated the predictive validity of OBM2 pass/fail decisions, using consecutive years' Objective Structured Clinical Examination (OSCE) results within a medical cohort (n=271) at the University of New South Wales, Australia. OBM2 decisions in one OSCE (n=687) were compared to marks obtained in a subsequent OSCE via independent samples T-tests and analysis of variance (ANOVA). The extent of the relationship between these two variables determines the predictive validity of OBM2 decisions, given that past student grades are capable of predicting future performance. OBM2 decisions in an initial OSCE were found to have a statistically significant predictive nature for subsequent OSCE marks (p=.005). For initial decisions which reclassified to a pass grade, subsequent OSCE marks were significantly higher than for the cases where initial decisions were reclassified to a fail grade. Stronger associations were identified between related assessment domains/criteria compared to unrelated domains/criteria (Cohen's d=.469 vs Cohen's d=.388 respectively). Through demonstrating the OBM2 decisions' predictive association across exams there is support for the OBM2's predictive validity, deeming it a promising method to be used for resolving examiner uncertainty when making pass/fail decisions within OSCEs.

Effect of age on the severity of chronic lithium poisoning

Objectives: Severe lithium toxicity is commonly observed in older people. We aimed to determine the extent to which age is associated with increased severity of chronic lithium poisoning and of which a range of possible factors might explain the associations.Method: We did a retrospective review of patients aged ≥15 years old with serum lithium concentrations ≥1.3 mmol/L from three hospitals. Clinical details, treatment and outcomes were recorded. eGFR, creatinine and lithium clearance were calculated. The severity of lithium toxicity was graded into five categories (Amdisen score). ANOVA was used to quantify the association between age and severity. Spearman correlation coefficient was used to explore relationships between age and different factors expected to alter severity. Ordinal regression analysis was used to determine the interdependence of age and these factors and age on severity of lithium toxicity.Results: From 2008-2018, there were 242 patients with a median age of 56.5 years (IQR: 41-69). There were 156 females (64%). There was a statistically significant association between Amdisen severity scores and age (p = .0004). The median calculated eGFR was 65 mL/min/1.73 m² (IQR: 41-91) with a corresponding estimated lithium clearance of 18 mL/min (IQR: 13.8-22.8). There was no correlation of age with initial serum lithium concentration (p = .76). There was a strong correlation between age and estimated lithium clearance (r = -0.72, 95% CI: -0.78 to -0.66, p < .001), lithium daily dose (r = -0.65, 95% CI: -0.72 to -0.57, p < .0001) and lithium concentration/dose (r = 0.62, 95% CI: 0.53-0.69, p < .0001). There was a weak correlation between age and infection (r = 0.18, 95% CI: 0.04-0.31, p = .009) and drug interactions (r = 0.25, 95% CI: 0.11-0.37, p = .0003). Ordinal regression indicated the independent predictors for severity of lithium toxicity were lithium concentration (p < .0001) and lithium clearance (p = .03) adjusted for age and dose.Conclusions: Despite lower lithium doses, older patients had more severe toxicity. Increased severity of lithium toxicity in the elderly is largely explainable by decreased lithium clearance from multiple factors such as age-related decline in renal function, drug interactions and infection.

A proposal to introduce dental trauma into medical education: An insight

THE PROBLEM

This proposal aims to tackle the common poor management of traumatic dental injury (TDI) by medical doctors and subsequent poor healthcare outcomes for patients. The literature reports that most medical doctors, in either private practice or hospital emergency departments, lack the knowledge, skills, and confidence needed to adequately assess and manage victims of TDI. This is due to little or no clinical dentistry and dental trauma education being included in their medical studies.

THE GAP IN THE LITERATURE

From a review of the literature, there is a clear lack of learning provision for medical students on the topic of dental anatomy and trauma. In addition, there appears to be no formal university theoretical and clinical training during medical school.

THE PRACTICAL IMPLICATIONS

The introduction of dental trauma into the medical curriculum will provide students with a better understanding of the importance of early management for better patient outcomes. Medical doctors competent in managing emergency dental trauma procedures will be able to provide a higher standard of care that could prevent potentially lifelong negative repercussions for the patient.

Effect of virtual reality training to decreases rates of needle stick/sharp injuries in new-coming medical and nursing interns in Taiwan

PURPOSE

Senior nursing and medical interns' lack of familiarity and confidence with respect to practicing universal precaution for the prevention of occupational needle stick (NSI)/sharp (SI) injuries may harm themselves. Trainees' self-reported NSI/SI rate was known to be especially high during the first two months of internship in Taiwan. This prospective cohort study aimed to know the effect of new developed (virtual reality (VR) game, which uses the Gangne's learning model to improved universal precaution for NSI/SI prevention and decrease the rates of needle stick/sharp injuries in new-coming medical and nursing interns in Taiwan. .

METHODS

From 2017 to 2019, the VR system was developed and applied in training of 59 new-coming nursing and 50 medical interns. Occupational NSI/SI prevention was sought to be achieved through a game of right and wrong choices for safe or unsafe universal precaution behaviors.

RESULTS

In comparison with medical interns, a higher proportion of nursing interns have had the past experiences of deep occupational NSI/SI. Before VR training, the familiarity and confidence for NSI/SI prevention were higher among nursing interns than medical interns. Trainees with past experiences of deep NSI/SI exhibited better performance on the accuracy rate and time need for complete 20 decisions than those without past experiences in VR practice. The performances of all trainees were improved after VR training. A high proportion of trainees reported that the VR-based training significantly decreased their anxiety about NSI/SI prevention.

CONCLUSION

This self-developed VR game system using Gangne's flow improved universal precaution for NSI/SI prevention and reduced the NSI/SI rates in the first two months of nursing and medical internship.

Struggling with strugglers: using data from selection tools for early identification of medical students at risk of failure

BACKGROUND

Struggling medical students is an under-researched in medical education. It is known, however, that early identification is important for effective remediation. The aim of the study was to determine the predictive effect of medical school admission tools regarding whether a student will struggle academically.

METHODS

Data comprise 700 students from the University of New South Wales undergraduate medical program. The main outcome of interest was whether these students struggled during this 6-year program; they were classified to be struggling they failed any end-of-phase examination but still graduated from the program. Discriminate Function Analysis (DFA) assessed whether their pre-admission academic achievement, Undergraduate Medicine Admission Test (UMAT) and interview scores had predictive effect regarding likelihood to struggle.

RESULTS

A lower pre-admission academic achievement in the form of Australian Tertiary Admission Rank (ATAR) or Grade Point Average (GPA) were found to be the best positive predictors of whether a student was likely to struggle. Lower UMAT and poorer interview scores were found to have a comparatively much smaller predictive effect.

CONCLUSION

Although medical admission tests are widely used, medical school rarely use these data for educational purposes. The results of this study suggest admission test data can predict who among the admitted students is likely to struggle in the program. Educationally, this information is invaluable. These results indicate that pre-admission academic achievement can be used to predict which students are likely to struggle in an Australian undergraduate medicine program. Further research into predicting other types of struggling students as well as remediation methods are necessary.

Quantitative analysis of arterial supply to the developing brain in tetrapod vertebrates

Understanding the metabolic cost of building developing tetrapod brains is critically important to explaining the more than 10-fold differences in encephalization of adult tetrapods that have emerged during evolution. The exact metabolic costs of developing the variety of tetrapod brains are impossible to determine, but one can compare cerebral artery caliber (internal radius raised to the fourth power-r⁴ ) across developing tetrapod vertebrate groups as a proxy of cerebral arterial flow, the delivery of nutrients during embryogenesis and early postnatal development, and hence the metabolic costs of brain development. In this study, r⁴ of aortic outflow and cerebral inflow arteries, as well as aortic wall thickness as a proxy of arterial pressure, were measured and compared between developing representatives of all four tetrapod classes (mammals, birds, reptiles, and amphibians). We found a clear endotherm/ectotherm dichotomy in aortic outflow and cerebral inflow between developing mammals and birds on the one hand, and developing reptiles and amphibians on the other. We did not find strong evidence for functionally significant differences in cerebral arterial caliber between groups at the order level (i.e., within birds, reptiles or amphibians). In particular, we did not find evidence in favor of increased blood supply to the brain for more behaviorally complex and encephalized avian species.

Quantitative Analysis of the Timing of Development of the Cerebellum and Precerebellar Nuclei in Monotremes, Metatherians, Rodents, and Humans

We have used a quantitative statistical approach to compare the pace of development in the cerebellum and precerebellar systems relative to body size in monotremes and metatherians with that in eutherians (rodents and humans). Embryos, fetuses, and early postnatal mammals were scored on whether key structural events had been reached in the development of the cerebellum itself (CC-corpus cerebelli; 10 milestones), or the pontine and inferior olivary precerebellar nuclear groups (PC; 4 milestones). We found that many early cerebellar and precerebellar milestones (e.g., formation of Purkinje cell layer and deep cerebellar nuclei) were reached at a smaller absolute body length in both metatherians and eutherians together, compared to monotremes. Some later milestones (e.g., formation of the external granular layer and primary fissuration) were reached at a smaller body length in metatherians than eutherians. When the analysis was performed with proportional body length expressed as a natural log-transformed ratio of length at birth, milestones were reached at a much smaller proportional body length in rodents and humans than in the metatherians or monotremes. The findings are consistent with the slower pace of metabolic activity and embryonic development in monotremes. They also indicate slightly advanced maturation of some early features of the cerebellum in some metatherians (i.e., early cerebellar development in dasyurids relative to body size), but do not support the notion of an accelerated development of the cerebellum to cope with the demands of early birth. Anat Rec, 2019. © 2019 American Association for Anatomy Anat Rec, 303:1998-2013, 2020. © 2019 American Association for Anatomy.

Insights into student assessment outcomes in rural clinical campuses

BACKGROUND

There is an ongoing debate about the impact of studying medicine in rural vs. metropolitan campuses on student assessment outcomes. The UNSW Medicine Rural Clinical School has five main campuses; Albury-Wodonga, Coffs Harbour, Griffith, Port Macquarie and Wagga Wagga. Historical data of student assessment outcomes at these campuses raised concerns regarding potential biases in assessment undertaken, as well as the availability and quality of learning resources. The current study aims to identify the extent to which the location of examination (rural versus metropolitan) has an impact on student marks in OSCEs.

METHODS

Assessment data was employed for this study from 275 medical students who sat their final examinations in Years 3 and 6 of the undergraduate Medicine program at UNSW in 2018. The data consists of matched student assessment results from the Year 3 (Y3) MCQ examination and OSCE, and from the Year 6 (Y6) MCQ, OSCE and management viva examinations. The analysis used Univariate Analysis of Variance and linear regression models to identify the impact of site of learning and site of examination on assessment outcomes.

RESULTS

The results demonstrate that neither site of learning nor site of examination had any significant impact on OSCE or Management Viva assessment outcomes while potential confounders are controlled.

CONCLUSION

It is suggested that some of the supposed disadvantages inherent at rural campuses are effectively mitigated by perceived advantages; more intensive interaction with patients, the general and medical communities at those sites, as well as effective e-learning resources and moderation of assessment grades.

Dreyfus scale-based feedback increases the medical student's satisfaction with the complex cluster part of the interviewing and physical examination course and skills' readiness in Taiwan

PURPOSE

Different from the basic core part of the clinical interviewing and physical examination (PE) skills course in basic, head-to-toe, and thorax systems, learners need structural feedback for the development of the complex skills in cluster part including abdominal, neuromuscular and musculoskeletal systems. It aimed to evaluate the effects of replacing Dreyfus scale, which having elements of continuous professional development, with Likert scale in the feedback in cluster part of training in Taiwan.

METHODS

Instructors and final-year medical students of class 2015-2016 comprised the regular cohort, whereas those of class 2017-2018 formed the intervention cohort. In the intervention cohort, Dreyfus scale-based feedback rather than Likert scale based feedback was used in the cluster part of the course in National Yang-Ming university, Taiwan.

RESULTS

Among the regular cohort, poor pre-trained standardized patients (SPs) rated class climate, low grouped students satisfaction with the instructors and course, and low grouped student self-assessed readiness were noted in the cluster part than those in the core part. In comparison with regular cohort, greater improvement of post-cluster part end-of-course group objective structured clinical examination (GOSCE) scores was noted in intervention cohort. In other word, the implementation of Dreyfus scale-based feedback in the cluster part improved the deficit in this part of the course among the intervention cohort.

CONCLUSION

The implementation of Dreyfus scale-based feedback helped instructors to create a good class climate in the cluster parts of clinical interviewing plus PE skills course in our study. Simultaneously, this new intervention achieved the goal of medical students competency in interviewing, PE and self-directed learning (SDL) skills.

A meta-analysis for comparing effective teaching in clinical education

Aim: Many factors affect learning outcomes, however studies comparing the effectiveness of different clinical teaching methods are limited. We utilize the list of influences on educational achievement compiled by John Hattie to inform a meta-analysis of learning effect sizes (ESs) associated with teaching-learning factors (TLFs) in clinical education. Methods: A literature search was conducted in PubMed to identify articles examining clinically relevant TLFs. Selection criteria were applied to identify learner-focused studies, with subsequent categorization by study design (pretest-posttest or controlled group). The Cohen's ES (d) for each TLF was extracted and a pooled ES determined. Results: From 3454 studies, 132 suitable articles enabled analysis of 16 TLFs' ESs. In general, ESs derived from pretest-posttest data were larger than those from controlled group designs, probably due to learner maturation effect. The TLFs of mastery learning, small group learning and goal settings possessed the largest ESs (d ≥ 0.8), while worked examples, play programs, questioning, concept mapping, meta-cognitive strategies, visual-perception programs and teaching strategies demonstrated ESs between 0.4 and 0.8. Conclusions: This is the first study to provide a rigorous and comprehensive overview of the effectiveness of TLFs in clinical education. We discuss the practical traits shared by effective TLFs which may assist teaching design.

Engaging trainees by actively giving feedback will increase their receptiveness to peer' feedback and motivate behavior-changes in holistic care: a pilot study

This article was migrated. The article was not marked as recommended. Background: Continuous trainings of holistic-care behaviors, including teamwork and communication, are important for health professionals to ensure holistic care. In holistic-care simulation training, receiving feedback is a regular step to help trainees assess and rethink their practice. Initial acceptance of feedback by trained health professionals will motivate them in changing behaviors. So, it is importance to increase the trainee's initial receptiveness of in-training feedback. Objective: This study aims to evaluate whether engaging trainees by actively giving feedback will increase their receptiveness to peer' feedback and motivate behavior changes in holistic care. Methods: Health professionals without previous holistic-care training were enrolled, and randomly divided into feedback-giver groups including A (bi-directional feedback recipients and givers group) and C (unidirectional feedback givers group) groups, and non-feedback givers group B (regular feedback recipients group). In addition to immediate satisfaction and receptiveness to in-training peer-feedback, the percentages of health professionals who are willing to make immediate and continuous motivated type of behavior-change were compared between groups. Results: Higher satisfaction score and higher percentage of motivated type behavior changes were noted in feedback-giving-groups (A and C) than those in non-feedback-giving group (B). The feedback training's effectiveness was confirmed by high preceptor approval of trainee's feedback skills and trainees' good receptivity to their peers' feedback. Self- and mentor-assessments revealed that initial positive receptiveness (determined by high positivity and usefulness scores) to peer's feedback is associated with more motivated-type behavior changes in their clinical practice. Conclusion: Current study suggested that feedback-giving training is a feasible strategy to increase receptiveness of participants to peer's feedback and activate participants' motivation to make the immediate and continuous behavior-type changes on giving holistic-care behavior-specific peer-feedback.

Pilot simulation-based research for evaluation, training and assessment of holistic nursing at four intensive care unit sites

This article was migrated. The article was marked as recommended. Background: Holistic nursing of intensive care unit (ICU) patients encompasses diverse challenges requiring regular in situ evaluation, training and assessment. Simulation has been adopted as a research and training tool in medicine; however, evidence for its use in enhancing holistic care at multi-sites is limited. Objective: This study aims to conduct a simulation-based research (SBR) at four ICU for standardized training of holistic nursing. Methods: There are stages of evaluating, training+in-training assessment and post-course assessment in this SBR. Specifically, the curriculum-mapped scenarios were developed according to the deficiency of each site after evaluating stage. At the training stage, the first simulation by team was defined as preparation step and the in-training assessment was undertaken at the second simulation. Results: From January 2017 to October 2018, sixty-four ICU nurses (16 teams, 4 teams in each site) at RCU, PICU, NICU and GYN ICU, attend 8 similar courses (2 courses at each site) over 20 months. In comparison with baseline performance, in-training assessments revealed the significant improvement of attendee's skills of holistic nursing. Attendees commented that simulation was a valuable training modality to enhance skills of holistic care including history taking, physical examination, communication and teamwork that are rarely taught among ICU nurses. Post-course workplace assessment by senior nurses revealed the high frequency of clinical application of holistic nursing by attendees. Additionally, post-course self assessment revealed a high attendee's confidence of holistic approaching in ICU. Conclusion: This pilot SBR demonstrated the feasibility of a standardized holistic care simulation program across four ICUs. In situ simulation and post-course workplace assessment affords situational learning without compromising patient safety and is an exciting and novel training of holistic nursing for ICU that could be integrated into regular intervention.

Applicants to medical school: if at first they don't succeed, who tries again and are they successful?

This study compared the profile of those who, after initial failure to be selected, choose to reapply to study medicine with those who did not reapply. It also evaluates the chance of a successful outcome for re-applicants. In 2013, 4007 applicants to undergraduate medical schools in the largest state in Australia were unsuccessful. Those who chose to reapply (n = 665) were compared to those who did not reapply (n = 3342). Results showed that the odds of re-applying to medicine were 55% less for those from rural areas, and 39% more for those from academically-selective schools. Those who had higher cognitive ability and high school academic performance scores in 2013 were also more likely to re-apply. Socioeconomic status was not related to re-application choice. Re-applicants' showed significant improvements in selection test scores and had a 34% greater probability of selection than first-time applicants who were also interviewed in the same selection round. The findings of this study indicate that re-testing and re-application improves one's chance of selection into an undergraduate medical degree, but may further reduce the diversity of medical student cohorts in terms of rural background and educational background.

Retest effects in medical selection interviews

CONTEXT

Repetition of a cognitive ability test is known to increase scores, but almost no research has examined whether similar improvement occurs with repetition of interviews. Retest effects can change the rank order of candidates and reduce the test's criterion validity. Because interviews are widely used to select medical students and postgraduate trainees, and because applicants apply to multiple programmes and often reapply if unsuccessful, the potential for retest effects needs to be understood.

OBJECTIVES

This study was designed to identify if retest improvements occur when candidates undertake multiple interviews and, if so, whether the effect is attributable to general interview experience or specific experience and whether repeat testing affects criterion validity.

METHODS

We compared interview scores of applicants who were interviewed for one or more of three independent undergraduate medical programmes in two consecutive years and those who were interviewed in both years for the same programme. Correlations between initial and repeat interview scores and a written test of social understanding were compared.

RESULTS

General experience (being interviewed by multiple programmes) did not produce improvement in subsequent interview performance. There was no evidence of method effect (having prior experience of the multiple mini-interview process). Specific experience (being interviewed by the same programme across 2 years) resulted in a significant improvement in scores for which regression to the mean did not fully account. Criterion validity did not appear to be affected.

CONCLUSIONS

Unsuccessful candidates for medical school who reapply and are re-interviewed on a subsequent occasion at the same institution are likely to increase their scores. The results of this study suggest the increase is probably not attributable to improved ability.

Factors Affecting Adherence to Topical Glaucoma Therapy: A Quantitative and Qualitative Pilot Study Analysis in Sydney, Australia

PURPOSE

To assess which factors in the lives and disease of patients with glaucoma affect their adherence to topical glaucoma therapy and the quantitative significance of this effect. To assess qualitatively the most influential barriers to adherence from the perspective of the patient.

DESIGN

Multicenter, prospective, cross-sectional pilot study.

PARTICIPANTS

A total of 145 patients, attending outpatient metropolitan glaucoma clinics in Sydney, Australia, who were prescribed topical glaucoma medications.

METHODS

A structured interview-based questionnaire was conducted with 145 individuals using glaucoma eye drops that had been prescribed at least 2 weeks previously. The questionnaire involved 2 novel questions on adherence, 29 questions on factors identified or postulated in the literature as affecting adherence for quantitative analysis, and 1 open-response question on patient-identified causes of nonadherence for qualitative analysis. This questionnaire represents the broadest coverage of factors hypothesized to affect adherence in a single study in the glaucoma medication adherence literature to date.

MAIN OUTCOME MEASURES

Adherence rate, risk factors for poor adherence, and patient-identified barriers to adherence.

RESULTS

In response to the question "How many days have you missed a drop in the last 2 weeks," 69.7% of patients reported total adherence. Four factors were significantly related to an increased likelihood of reporting having missed drops in the last 2 weeks. These were difficulty applying drops (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.02-5.44; P < 0.05), a past or current diagnosis of depression (OR, 3.61; 95% CI, 1.53-8.52; P < 0.01), patient self-rating of own memory ≤ 7 of 10 (OR, 3.15; 95% CI, 1.36-7.30; P < 0.01), and self-reported motivation score ≤ 6 of 10 (OR, 10.94; 95% CI, 3.00-39.81; P < 0.01). Patient understanding of glaucoma, ethnicity, and socioeconomic status were among the 25 factors found not to have a statistically significant correlation with adherence.

CONCLUSIONS

There is a significant proportion of patients taking their topical glaucoma medications less often than prescribed. Adherence to topical glaucoma therapies is negatively correlated to several factors: difficulty applying drops, a past or current diagnosis of depression, poor self-rating of own memory, and poor self-rating of own motivation. These may prove useful in designing interventions to improve adherence in these patients.

Comparison of effect between simulated patient clinical skill training and student role play on objective structured clinical examination performance outcomes for medical students in Australia

PURPOSE

Optimal methods for communication skills training (CST) is an active area for research but the effect on communication performance in objective structured clinical examinations (OSCE) has not been so closely studied. Student role play (RP) for CST is common whilst volunteer simulated patient (SP) CST is cost-effective and provides authentic interactions. We assessed whether our volunteer SP CST improved OSCE performance compared to our previous RP strategy.

METHODS

We performed a retrospective, quasi-experimental study of two second year medical student cohorts' OSCE data in Australia. The 2014 cohort received RP-only CST (N=182) while the 2016 cohort received SP-only CST (N=148). T-test and ANOVA were used to compare the total scores for three assessment domains: generic communication, clinical communication and physical examination/procedural skills.

RESULTS

Baseline characteristics for groups (scores for Australian Tertiary Admission Rank (ATAR), Undergraduate Medicine and Health Sciences Admission Test (UMAT) and medicine program interview) showed no significantt difference between groups. For each domain, the SP-only CST group demonstrated superior outcomes in the OSCE and the difference between cohorts was significant (P < 0.01). Volunteer SP CST was superior to student RP CST when considering OSCE performance outcome., which was found across generic and clinical communication skills, and physical examination/procedural skills.

CONCLUSION

Better performance of the SP cohort in physical examination/procedural skills might be explained by the requirement for patient compliance and cooperation, facilitated by good generic communication skills. We recommend a volunteer SP Program as an effective and efficient way to improve CST for junior medical students.

Expert-led and artificial intelligence (AI) system-assisted tutoring course increase confidence of Chinese medical interns on suturing and ligature skills: prospective pilot study

PURPOSE

Lack of confidence in suturing/ligature skills due to insufficient practices and assessments was common among novice Chinese medical interns. This study aims to improve the skill acquisition of medical interns with new interventional program.

METHODS

In addition to regular clinical training, additional expert-led or expert-led plus artificial intelligent (AI) system tutoring courses were implemented during the first 2 week of surgical block in our hospital. Interns can voluntarily join the regular (no additional tutoring), expert-led tutoring or expert-led+AI tutoring groups freely. In regular group, interns (n=25) did not join additional tutoring. The expert-led group received 3-hour expert-led tutoring and in-training formative assessment after twice practices. After similar expert-led course as expert-led group, the expert-led+AI group (n=23) practice and assess their skills on the AI system. Through the comparison with the internal standard, the system automatically recorded and evaluated every intern's suturing/ligature skills. Among expert-led+AI group, the performance and confidence were compared between interns whose doing one, two and three times of AI practices.

RESULTS

The end-of-surgical block OSCE' performance and self-assessed confidence for the suturing/ligature skills were highest in expert-led+AI group. In comparison with expert-led group, with similar performance in in-training assessment, expert-led+AI group have higher degree of improvement in their performance in end-of surgical block OSCE. Especially, in expert-led+AI group, the best performance and highest post-OSCE confidence were noted among trice AI practicing group.

CONCLUSION

This pilot study demonstrated the promising effects of incorporation of additional expert-led plus AI system-assisted tutoring course into regular surgical curriculum.

Definition of professionalism and tools for assessing professionalism in pharmacy practice: a systemic review

PURPOSE

In contemporary pharmacy, the role of pharmacists has become more multifaceted as they now handle a wider range of tasks and take more responsibility for care provision for patients than 20 years ago. Such an evolution in the pharmacist's responsibilities is accompanied by the need for pharmacists to display high-quality patient-centred care and counselling, and to demonstrate professionalism, which now needs to be taught and assessed are part of pharmacy education and practice. This workaimed at identifying definition of professionalism in pharmacy practice and critically evaluatingpublished instruments for assessing professionalism in pharmacy practice.

METHODS

We searched the medical literature listed in Scopus, Medline, andPsycINFOdatabasesfrom 1 January 2000 to 31 December 2018. All papers meeting our selection criteria, were reviewed and summarised into a clear review of professionalism requirements in pharmacy practice. Details of the instruments measuring professionalism were reviewed in detail.

RESULTS

There is no accepted simple definition of professionalism, although we identified several theoretical and policy frameworks required for professional pharmaceutical practice. We identified 4 instruments (Behavioural Professionalism Assessment Instrument (BPAI), Lerkiatbundit's Instrument, Pharmacy Professionalism Instrument (PPI) and Professionalism Assessment Tool (PAT) that build on these frameworks and measure professional practice in pharmacy students. These were found to be reliable and valid but had only been used and tested in student populations.

CONCLUSION

Given the increasing role of community pharmacisits there is a need for assessment of professionalism in practice. Professionalism is a complex concept that is challenging to measure because it has no standardised definition and existing literature related to the topic is limited. Current instruments available focus on measuring the development of the elements of professionalism among pharmacy students rather than pharmacists.

Borderline grades in high stakes clinical examinations: resolving examiner uncertainty

BACKGROUND

Objective Structured Clinical Exams are used to increase reliability and validity, yet they only achieve a modest level of reliability. This low reliability is due in part to examiner variance which is greater than the variance of students. This variance often represents indecisiveness at the cut score with apparent confusion over terms such as "borderline pass". It is amplified by a well reported failure to fail.

METHODS

A borderline grade (meaning performance is neither a clear pass nor a clear fail) was introduced in a high stakes undergraduate medical clinical skills exam to replace a borderline pass grade (which was historically resolved as 50%) in a 4 point scale (distinction, pass, borderline, fail). Each Borderline grade was then resolved into a Pass or Fail grade by a formula referencing the difficulty of the station and the performance in the same domain by the student in other stations. Raw pass or fail grades were unaltered. Mean scores and 95%CI were calculated per station and per domain for the unmodified and the modified scores/grades (results are presented on error bars). To estimate the defensibility of these modifications, similar analysis took place for the P and the F grades which resulted from the modification of the B grades.

RESULTS

Of 14,634 observations 4.69% were Borderline. Application of the formula did not impact the mean scores in each domain but the failure rate for the exam increased from 0.7 to 4.1%. Examiners and students expressed satisfaction with the Borderline grade, resolution formula and outcomes. Mean scores (by stations and by domains respectively) of students whose B grades were modified to P were significantly higher than their counterparts whose B grades were modified to F.

CONCLUSIONS

This study provides a feasible and defensible resolution to situations where the examinee's performance is neither a clear pass nor a clear fail, demonstrating the application of the resolution of borderline formula in a high stakes exam. It does not create a new performance standard but utilises real data to make judgements about these small number of candidates. This is perceived as a fair approach to Pass/Fail decisions.