Conscientious, competent and caring: producing the junior doctor of the future

This article is based on the Association for the Study of Medical Education Gold Medal Plenary for 2022, given by the first author. It outlines different ways in which medical training can be approached, based on his career and his work with colleagues. Among the attributes that it would be desirable to promote in future doctors are conscientiousness, competence and care for patients as individuals. This article explores each of these in separate sections. The first demonstrates that the trait of conscientiousness can be observed in first and second year medical students by their compliance in routine low level tasks such as attendance and submission of required work on time. A 'conscientiousness index' calculated on this basis is a statistically significant predictor of later events such as performance in exams, the prescribing safety assessment, and the UK situational judgement test in subsequent years, and also in postgraduate assessments such as Royal college exams and the annual reviews of competence progression. The second proposes that competence in tasks undertaken by junior doctors is better achieved by teaching on medical imaging, clinical skills and living anatomy than by cadaveric dissection. The final section argues that the incorporation of arts and humanities teaching into medical education is likely to lead to better understanding of the patient perspective in later practice.

Teaching, research or balanced? An exploration of the experiences of biomedical scientists working in UK medical schools

Driven by demand for high standards in university education, efforts have been made in the UK to address the perceived imbalance between teaching and research. However, teaching is still perceived by many as having less credibility and is attributed less importance. The purpose of our research was to explore how distinct types of academic job profiles (‘research’ or ‘education’ focused, or ‘balanced’) impact on biomedical scientists' perceptions of the lecturer role. Specifically, we investigated the experiences of biomedical scientists in ‘post‐1990’ medical schools, which are known for their commitment to excellence in both research and education. We conducted 22 face‐to‐face, semi‐structured interviews with biomedical scientists in five schools. Focusing on experiences of work, the interviews covered: ‘motivations’, ‘role expectations’, ‘teaching’, ‘research’ and ‘career’. The recorded qualitative data were transcribed and then analysed thematically. Our results, offering an insight into the working lives of biomedical scientists in medical education, suggest that in settings with a dual emphasis on education and research, individuals on ‘balanced’ contracts can experience a strong pull between research and teaching. In addition to posing significant challenges with respect to workload management, this can impact profoundly on professional identity. In contrast to the balanced role, ‘research’ or ‘education’ focused roles appear to have clearer requirements, leading to higher employee satisfaction. We conclude that to assist the educational mission of Higher Education, attention should be paid to balanced contracts, to (a) ensure employee support, (b) mitigate against negative perceptions of teaching, and ultimately, (c) guard against staff attrition.

An inexpensive retrospective standard setting method based on item facilities

BACKGROUND

Standard setting is one of the most challenging aspects of assessment in high-stakes healthcare settings. The Angoff methodology is widely used, but poses a number of challenges, including conceptualisation of the just-passing candidate, and the time-cost of implementing the method. Cohen methodologies are inexpensive and rapid but rely on the performance of an individual candidate. A new method of standard setting, based on the entire cohort and every item, would be valuable.

METHODS

We identified Borderline candidates by reviewing their performance across all assessments in an academic year. We plotted the item scores of the Borderline candidates in comparison with Facility for the whole cohort and fitted curves to the resulting distribution.

RESULTS

It is observed that for any given Item, an equation of the form y ≈ C. e^Fx where y is the Facility of Borderline candidates on that Item, x is the observed Item Facility of the whole cohort, and C and F are constants, predicts the probable Facility for Borderline candidates over the test, in other words, the cut score for Borderline candidates. We describe ways of estimating C and F in any given circumstance, and suggest typical values arising from this particular study: that C = 12.3 and F = 0.021.

CONCLUSIONS

C and F are relatively stable, and that the equation y = 12.3. e^0.021x can rapidly be applied to the item Facility for every item. The average value represents the cut score for the assessment as a whole. This represents a novel retrospective method based on test takers. Compared to the Cohen method which draws on one score and one candidate, this method draws on all items and candidates in a test. We propose that it can be used to standard set a whole test, or a particular item where the predicted Angoff score is very different from the observed Facility.

'10% of your medical students will cause 90% of your problems': a prospective correlational study

OBJECTIVES

Our aim was to explore the relationship between medical student Conscientiousness Index scores and indicators of later clinical performance held in the UK Medical Education Database (UKMED). Objectives were to determine whether conscientiousness in first-year and second-year medical students predicts later performance in medical school and in early practice. Policy implications would permit targeted remediation where necessary or aid in selection.

DESIGN

A prospective correlational study.

SETTING

A single UK medical school and early years of practice, 2005-2018.

PARTICIPANTS

The data were obtained from the UKMED on 858 students. Full outcome data was available for variable numbers of participants, as described in the text.

MAIN OUTCOME MEASURES

Scores on the UK Foundation Programme Office's Situational Judgement Test (SJT) and Educational Performance Measure (EPM), the Prescribing Safety Assessment (PSA) and Annual Review of Competency Progression (ARCP) outcomes.

RESULTS

Linear regression analysis shows Conscientiousness Index scores significantly correlate with pregraduate and postgraduate performance variables: SJT scores (R=0.373, R²=0.139, B=0.066, p<0.001, n=539); PSA scores (R=0.249, R²=0.062, B=0.343, p<0.001, n=462); EPM decile scores for the first (lowest) decile are significantly lower than the remaining 90% (p=0.003, n=539), as are PSA scores (p<0.001, n=463), and ARCP year 2 scores (p=0.019, n=517). The OR that students in the first decile fail to achieve the optimum ARCP outcome is 1.6126 (CI: 1.1400 to 2.2809, p=0.0069, n=618).

CONCLUSIONS

Conscientiousness Index scores in years 1 and 2 of medical school have predictive value for later performance in knowledge, skills and clinical practice. This trait could be used either for selection or for targeted remediation to avoid potential problems in the future.

Evaluating the complementary roles of an SJT and academic assessment for entry into clinical practice

Although there is extensive evidence confirming the predictive validity of situational judgement tests (SJTs) in medical education, there remains a shortage of evidence for their predictive validity for performance of postgraduate trainees in their first role in clinical practice. Moreover, to date few researchers have empirically examined the complementary roles of academic and non-academic selection methods in predicting in-role performance. This is an important area of enquiry as despite it being common practice to use both types of methods within a selection system, there is currently no evidence that this approach translates into increased predictive validity of the selection system as a whole, over that achieved by the use of a single selection method. In this preliminary study, the majority of the range of scores achieved by successful applicants to the UK Foundation Programme provided a unique opportunity to address both of these areas of enquiry. Sampling targeted high (>80th percentile) and low (<20th percentile) scorers on the SJT. Supervisors rated 391 trainees' in-role performance, and incidence of remedial action was collected. SJT and academic performance scores correlated with supervisor ratings (r = .31 and .28, respectively). The relationship was stronger between the SJT and in-role performance for the low scoring group (r = .33, high scoring group r = .11), and between academic performance and in-role performance for the high scoring group (r = .29, low scoring group r = .11). Trainees with low SJT scores were almost five times more likely to receive remedial action. Results indicate that an SJT for entry into trainee physicians' first role in clinical practice has good predictive validity of supervisor-rated performance and incidence of remedial action. In addition, an SJT and a measure of academic performance appeared to be complementary to each other. These initial findings suggest that SJTs may be more predictive at the lower end of a scoring distribution, and academic attainment more predictive at the higher end.

Predicting fitness to practise events in international medical graduates who registered as UK doctors via the Professional and Linguistic Assessments Board (PLAB) system: a national cohort study

BACKGROUND

International medical graduates working in the UK are more likely to be censured in relation to fitness to practise compared to home graduates. Performance on the General Medical Council's (GMC's) Professional and Linguistic Assessments Board (PLAB) tests and English fluency have previously been shown to predict later educational performance in this group of doctors. It is unknown whether the PLAB system is also a valid predictor of unprofessional behaviour and malpractice. The findings would have implications for regulatory policy.

METHODS

This was an observational study linking data relating to fitness to practise events (referral or censure), PLAB performance, demographic variables and English language competence, as evaluated via the International English Language Test System (IELTS). Data from 27,330 international medical graduates registered with the GMC were analysed, including 210 doctors who had been sanctioned in relation to at least one fitness to practise issue. The main outcome was risk of eventual censure (including a warning).

RESULTS

The significant univariable educational predictors of eventual censure (versus no censures or referrals) were lower PLAB part 1 (hazard ratio [HR], 0.99; 95% confidence interval, 0.98 to 1.00) and part 2 scores (HR, 0.94; 0.91 to 0.97) at first sitting, multiple attempts at both parts of the PLAB, lower IELTS reading (HR, 0.79; 0.65 to 0.94) and listening scores (HR, 0.76; 0.62 to 0.93) and higher IELTS speaking scores (HR, 1.28; 1.04 to 1.57). Multiple resits at either part of the PLAB and higher IELTS speaking score (HR, 1.49; 1.20 to 1.84) were also independent predictors of censure. We estimated that the proposed limit of four attempts at both parts of the PLAB would reduce the risk in this entire group by only approximately two censures per 5 years in this group of doctors.

CONCLUSIONS

Making the PLAB, or any replacement assessment, more stringent and raising the required standards of English reading and listening may result in fewer fitness to practice events in international medical graduates. However, the number of PLAB resits permitted would have to be further capped to meaningfully impact the risk of sanctions in this group of doctors.

Predictive validity of the UKCAT for medical school undergraduate performance: a national prospective cohort study

BACKGROUND

The UK Clinical Aptitude Test (UKCAT) has been shown to have a modest but statistically significant ability to predict aspects of academic performance throughout medical school. Previously, this ability has been shown to be incremental to conventional measures of educational performance for the first year of medical school. This study evaluates whether this predictive ability extends throughout the whole of undergraduate medical study and explores the potential impact of using the test as a selection screening tool.

METHODS

This was an observational prospective study, linking UKCAT scores, prior educational attainment and sociodemographic variables with subsequent academic outcomes during the 5 years of UK medical undergraduate training. The participants were 6812 entrants to UK medical schools in 2007-8 using the UKCAT. The main outcome was academic performance at each year of medical school. A receiver operating characteristic (ROC) curve analysis was also conducted, treating the UKCAT as a screening test for a negative academic outcome (failing at least 1 year at first attempt).

RESULTS

All four of the UKCAT scale scores significantly predicted performance in theory- and skills-based exams. After adjustment for prior educational achievement, the UKCAT scale scores remained significantly predictive for most years. Findings from the ROC analysis suggested that, if used as a sole screening test, with the mean applicant UKCAT score as the cut-off, the test could be used to reject candidates at high risk of failing at least 1 year at first attempt. However, the 'number needed to reject' value would be high (at 1.18), with roughly one candidate who would have been likely to pass all years at first sitting being rejected for every higher risk candidate potentially declined entry on this basis.

CONCLUSIONS

The UKCAT scores demonstrate a statistically significant but modest degree of incremental predictive validity throughout undergraduate training. Whilst the UKCAT could be considered a fairly crude screening tool for future academic performance, it may offer added value when used in conjunction with other selection measures. Future work should focus on the optimum role of such tests within the selection process and the prediction of post-graduate performance.

Predictive validity of the UKCAT for medical school undergraduate performance: a national prospective cohort study

BACKGROUND

The UK Clinical Aptitude Test (UKCAT) has been shown to have a modest but statistically significant ability to predict aspects of academic performance throughout medical school. Previously, this ability has been shown to be incremental to conventional measures of educational performance for the first year of medical school. This study evaluates whether this predictive ability extends throughout the whole of undergraduate medical study and explores the potential impact of using the test as a selection screening tool.

METHODS

This was an observational prospective study, linking UKCAT scores, prior educational attainment and sociodemographic variables with subsequent academic outcomes during the 5 years of UK medical undergraduate training. The participants were 6812 entrants to UK medical schools in 2007-8 using the UKCAT. The main outcome was academic performance at each year of medical school. A receiver operating characteristic (ROC) curve analysis was also conducted, treating the UKCAT as a screening test for a negative academic outcome (failing at least 1 year at first attempt).

RESULTS

All four of the UKCAT scale scores significantly predicted performance in theory- and skills-based exams. After adjustment for prior educational achievement, the UKCAT scale scores remained significantly predictive for most years. Findings from the ROC analysis suggested that, if used as a sole screening test, with the mean applicant UKCAT score as the cut-off, the test could be used to reject candidates at high risk of failing at least 1 year at first attempt. However, the 'number needed to reject' value would be high (at 1.18), with roughly one candidate who would have been likely to pass all years at first sitting being rejected for every higher risk candidate potentially declined entry on this basis.

CONCLUSIONS

The UKCAT scores demonstrate a statistically significant but modest degree of incremental predictive validity throughout undergraduate training. Whilst the UKCAT could be considered a fairly crude screening tool for future academic performance, it may offer added value when used in conjunction with other selection measures. Future work should focus on the optimum role of such tests within the selection process and the prediction of post-graduate performance.

Clinical vignettes improve performance in anatomy practical assessment

Although medical curricula now adopt an integrated teaching approach, this is not adequately reflected in assessment of anatomy knowledge and skills. In this study, we aimed to explore the impact of the addition of clinical vignette to item stems on students' performance in anatomy practical examinations. In this study, 129 undergraduate medical students of Durham University took part in a 30-item anatomy practical test consisting of those with and without clinical stem, in a crossover design. Classical test theory was used to analyze item difficulty, discrimination index, point biserial, and reliability. Student performance on items with clinical stem and the percentage of students who correctly answered each item was significantly improved by the addition of a clinical stem in the Year 2 cohort. Also, items with a clinical stem showed much better discrimination index than non-clinical items in the Year 2 cohort. In contrast, there was no significant difference in item performance, student performance and discrimination index between items with a clinical and non-clinical stem in Year 1 cohort. Over 65% of test items in both year groups were of good quality with point biserial exceeding 0.2. However, Year 1 test reliability for non-clinical items was better than clinical items. The results raise question as to what level to apply this method of assessment in undergraduate education. Although interpreted on the basis of a relatively small item sample, the findings support the need for improving anatomy practical examinations in line with overriding curricula changes.

Annual Review of Competence Progression (ARCP) performance of doctors who passed Professional and Linguistic Assessments Board (PLAB) tests compared with UK medical graduates: national data linkage study

OBJECTIVE

To determine whether use of the Professional and Linguistic Assessments Board (PLAB) examination system used to grant registration for international medical graduates results in equivalent postgraduate medical performance, as evaluated at Annual Review of Competence Progression (ARCP), between UK based doctors who qualified overseas and those who obtained their primary medical qualification from UK universities.

DESIGN

Observational study linking ARCP outcome data from the UK deaneries with PLAB test performance and demographic data held by the UK General Medical Council (GMC).

SETTING

Doctors in postgraduate training for a medical specialty or general practice in the UK and doctors obtaining GMC registration via the PLAB system.

PARTICIPANTS

53,436 UK based trainee doctors with at least one competency related ARCP outcome reported during the study period, of whom 42,017 were UK medical graduates and 11,419 were international medical graduates who were registered following a pass from the PLAB route.

MAIN OUTCOME MEASURE

Probability of obtaining a poorer versus a more satisfactory category of outcome at ARCP following successful registration as a doctor in the UK.

RESULTS

International medical graduates were more likely to obtain a less satisfactory outcome at ARCP compared with UK graduates. This finding persisted even after adjustment for the potential influence of sex, age, years of UK based practice, and ethnicity and exclusion of outcomes associated with postgraduate examination failure (odds ratio 1.63, 95% confidence interval 1.30 to 2.06). However, international medical graduates who scored in the highest twelfth at part 1 of the PLAB (at least 32 points above the pass mark) had ARCP outcomes that did not differ significantly from those of UK graduates.

CONCLUSIONS

These findings suggest that the PLAB test used for registration of international medical graduates is not generally equivalent to the requirements for UK graduates. The differences in postgraduate performance, as captured at ARCP, following the two routes to registration might be levelled out by raising the standards of English language competency required as well as the pass marks for the two parts of the PLAB test. An alternative might be to introduce a different testing system.

Comparison of the sensitivity of the UKCAT and A Levels to sociodemographic characteristics: a national study

BACKGROUND

The UK Clinical Aptitude Test (UKCAT) was introduced to facilitate widening participation in medical and dental education in the UK by providing universities with a continuous variable to aid selection; one that might be less sensitive to the sociodemographic background of candidates compared to traditional measures of educational attainment. Initial research suggested that males, candidates from more advantaged socioeconomic backgrounds and those who attended independent or grammar schools performed better on the test. The introduction of the A* grade at A level permits more detailed analysis of the relationship between UKCAT scores, secondary educational attainment and sociodemographic variables. Thus, our aim was to further assess whether the UKCAT is likely to add incremental value over A level (predicted or actual) attainment in the selection process.

METHODS

Data relating to UKCAT and A level performance from 8,180 candidates applying to medicine in 2009 who had complete information relating to six key sociodemographic variables were analysed. A series of regression analyses were conducted in order to evaluate the ability of sociodemographic status to predict performance on two outcome measures: A level 'best of three' tariff score; and the UKCAT scores.

RESULTS

In this sample A level attainment was independently and positively predicted by four sociodemographic variables (independent/grammar schooling, White ethnicity, age and professional social class background). These variables also independently and positively predicted UKCAT scores. There was a suggestion that UKCAT scores were less sensitive to educational background compared to A level attainment. In contrast to A level attainment, UKCAT score was independently and positively predicted by having English as a first language and male sex.

CONCLUSIONS

Our findings are consistent with a previous report; most of the sociodemographic factors that predict A level attainment also predict UKCAT performance. However, compared to A levels, males and those speaking English as a first language perform better on UKCAT. Our findings suggest that UKCAT scores may be more influenced by sex and less sensitive to school type compared to A levels. These factors must be considered by institutions utilising the UKCAT as a component of the medical and dental school selection process.

A systematic literature review of undergraduate clinical placements in underserved areas

CONTEXT

The delivery of undergraduate clinical education in underserved areas is increasing in various contexts across the world in response to local workforce needs. A collective understanding of the impact of these placements is lacking. Previous reviews have often taken a positivist approach by only looking at outcome measures. This review addresses the question: What are the strengths and weaknesses for medical students and supervisors of community placements in underserved areas?

METHODS

A systematic literature review was carried out by database searching, citation searching, pearl growing, reference list checking and use of own literature. The databases included MEDLINE, EMBASE, PsycINFO, Web of Science and ERIC. The search terms used were combinations and variations of four key concepts exploring general practitioner (GP) primary care, medical students, placements and location characteristics. The papers were analysed using a textual narrative synthesis.

FINDINGS

The initial search identified 4923 results. After the removal of duplicates and the screening of titles and abstracts, 185 met the inclusion criteria. These full articles were obtained and assessed for their relevance to the research question; 54 were then included in the final review. Four main categories were identified: student performance, student perceptions, career pathways and supervisor experiences.

CONCLUSIONS

This review reflects the emergent qualitative data as well as the quantitative data used to assess initiatives. Underserved area placements have produced many beneficial implications for students, supervisors and the community. There is a growing amount of evidence regarding rural, underserved areas, but little in relation to inner city, deprived areas, and none in the UK.

Do students learn to be more conscientious at medical school?

BACKGROUND

Professionalism in medical students is not only difficult to define but difficult to teach and measure. As negative behaviour in medical students is associated with post-graduate disciplinary action it would be useful to have a model whereby unprofessional behaviour at the undergraduate level can easily be identified to permit appropriate intervention. We have previously developed a scalar measure of conscientiousness, the Conscientiousness Index (CI), which positively correlates to estimates of professional behaviour in undergraduate medical students. By comparing CI points awarded in year 1 and year 2 of study we were able to use the CI model to determine whether teaching and clinical exposure had any effect on students' conscientiousness.

METHODS

CI points were collected by administrative staff from 3 successive cohorts of students in years 1 and 2 of study. Points were awarded to students for activities such as submission of immunisation status and criminal record checks, submission of summative assignments by a specified date and attendance at compulsory teaching sessions. CI points were then converted to a percentage of maximal possible scores (CI %) to permit direct comparison between years 1 and 2 of study.

RESULTS

CI % scores were generally high with each year of study for each cohort showing negatively skewed normal distributions with peaks > 89%. There was a high degree of correlation of CI % scores between year 1 and year 2 of study for each cohort alone and when cohort data was combined. When the change in CI % from year 1 to year 2 for all students was compared there was no significant difference in conscientiousness observed.

CONCLUSIONS

We have provided evidence that use of a CI model in undergraduate medical students provides a reliable measure of conscientiousness that is easy to implement. Importantly this study shows that measurement of conscientiousness by the CI model in medical students does not change between years 1 and 2 study suggesting that it is a stable characteristic and not modified by teaching and clinical exposure.

Widening access to UK medical education for under-represented socioeconomic groups: modelling the impact of the UKCAT in the 2009 cohort

OBJECTIVE

To determine whether the use of the UK clinical aptitude test (UKCAT) in the medical schools admissions process reduces the relative disadvantage encountered by certain sociodemographic groups.

DESIGN

Prospective cohort study.

SETTING

Applicants to 22 UK medical schools in 2009 that were members of the consortium of institutions utilising the UKCAT as a component of their admissions process.

PARTICIPANTS

8459 applicants (24,844 applications) to UKCAT consortium member medical schools where data were available on advanced qualifications and socioeconomic background.

MAIN OUTCOME MEASURES

The probability of an application resulting in an offer of a place on a medicine course according to seven educational and sociodemographic variables depending on how the UKCAT was used by the medical school (in borderline cases, as a factor in admissions, or as a threshold).

RESULTS

On univariate analysis all educational and sociodemographic variables were significantly associated with the relative odds of an application being successful. The multilevel multiple logistic regression models, however, varied between medical schools according to the way that the UKCAT was used. For example, a candidate from a non-professional background was much less likely to receive a conditional offer of a place compared with an applicant from a higher social class when applying to an institution using the test only in borderline cases (odds ratio 0.51, 95% confidence interval 0.45 to 0.60). No such effect was observed for such candidates applying to medical schools using the threshold approach (1.27, 0.84 to 1.91). These differences were generally reflected in the interactions observed when the analysis was repeated, pooling the data. Notably, candidates from several under-represented groups applying to medical schools that used a threshold approach to the UKCAT were less disadvantaged than those applying to the other institutions in the consortium. These effects were partially reflected in significant differences in the absolute proportion of such candidates finally taking up places in the different types of medical schools; stronger use of the test score (as a factor or threshold) was associated with a significantly increased odds of entrants being male (1.74, 1.25 to 2.41) and from a low socioeconomic background (3.57, 1.03 to 12.39). There was a non-significant trend towards entrants being from a state (non-grammar) school (1.60, 0.97 to 2.62) where a stronger use of the test was employed. Use of the test only in borderline cases was associated with increased odds of entrants having relatively low academic attainment (5.19, 2.02 to 13.33) and English as a second language (2.15, 1.03 to 4.48).

CONCLUSIONS

The use of the UKCAT may lead to more equitable provision of offers to those applying to medical school from under-represented sociodemographic groups. This may translate into higher numbers of some, but not all, relatively disadvantaged students entering the UK medical profession.

Evaluating professionalism in medical undergraduates using selected response questions: findings from an item response modelling study

BACKGROUND

Professionalism is a difficult construct to define in medical students but aspects of this concept may be important in predicting the risk of postgraduate misconduct. For this reason attempts are being made to evaluate medical students' professionalism. This study investigated the psychometric properties of Selected Response Questions (SRQs) relating to the theme of professional conduct and ethics comparing them with two sets of control items: those testing pure knowledge of anatomy, and; items evaluating the ability to integrate and apply knowledge ("skills"). The performance of students on the SRQs was also compared with two external measures estimating aspects of professionalism in students; peer ratings of professionalism and their Conscientiousness Index, an objective measure of behaviours at medical school.

METHODS

Item Response Theory (IRT) was used to analyse both question and student performance for SRQs relating to knowledge of professionalism, pure anatomy and skills. The relative difficulties, discrimination and 'guessabilities' of each theme of question were compared with each other using Analysis of Variance (ANOVA). Student performance on each topic was compared with the measures of conscientiousness and professionalism using parametric and non-parametric tests as appropriate. A post-hoc analysis of power for the IRT modelling was conducted using a Monte Carlo simulation.

RESULTS

Professionalism items were less difficult compared to the anatomy and skills SRQs, poorer at discriminating between candidates and more erratically answered when compared to anatomy questions. Moreover professionalism item performance was uncorrelated with the standardised Conscientiousness Index scores (rho = 0.009, p = 0.90). In contrast there were modest but significant correlations between standardised Conscientiousness Index scores and performance at anatomy items (rho = 0.20, p = 0.006) though not skills (rho = .11, p = .1). Likewise, students with high peer ratings for professionalism had superior performance on anatomy SRQs but not professionalism themed questions. A trend of borderline significance (p = .07) was observed for performance on skills SRQs and professionalism nomination status.

CONCLUSIONS

SRQs related to professionalism are likely to have relatively poor psychometric properties and lack associations with other constructs associated with undergraduate professional behaviour. The findings suggest that such questions should not be included in undergraduate examinations and may raise issues with the introduction of Situational Judgement Tests into Foundation Years selection.

A qualitative study of student responses to body painting

One hundred and thirty-three preclinical medical students participated in 24 focus groups over the period 2007-2009 at Durham University. Focus groups were conducted to ascertain whether or not medical students found body painting anatomical structures to be an educationally beneficial learning activity. Data were analyzed using a grounded theory approach. Five principal themes emerged: (1) body painting as a fun learning activity, (2) body painting promoting retention of knowledge, (3) factors contributing to the memorability of body painting, (4) removal from comfort zone, and (5) the impact of body painting on students' future clinical practice. Students perceive body painting to be a fun learning activity, which aids their retention of the anatomical knowledge acquired during the session. Sensory factors, such as visual stimuli, especially color, and the tactile nature of the activity, promote recall. Students' preference for painting a peer or being painted is often dependent upon their learning style, but there are educational benefits for both roles. The moderate amounts of undressing involved encouraging students to consider issues surrounding body image; this informs their attitudes towards future patients. Body painting is a useful adjunct to traditional anatomy and clinical skills teaching. The fun element involved in the delivery of this teaching defuses the often formal academic context, which in turn promotes a positive learning environment.

Student attitudes to peer physical examination: a qualitative study of changes in expressed willingness to participate

BACKGROUND

A number of studies have explored student attitudes to examining each other (peer physical examination: PPE). Differences have emerged in whether students prefer to be examined by friends or strangers. Changes have been reported in how students feel about PPE if asked before or after the PPE programme commences. RESEARCH INTENTION: Since a Grounded Theory paradigm was employed, there was no formal research hypothesis: the research intention was to explore factors which might underlie changes in student willingness to undertake PPE following familiarity with the process.

METHODS

Students who had completed an Examining Fellow Students Questionnaire at the beginning and end of the academic year, and who had indicated a change in willingness to participate, were invited to attend focus groups. Four focus groups were convened and transcripts were analysed for common themes.

RESULTS

Surprisingly, students downplayed the significance of changes. Also unexpectedly, dichotomous views emerged on familiarity, with some students preferring friends for examination and others preferring strangers. Staff embarrassment also emerged as a factor inhibiting student participation.

CONCLUSIONS

The significance of reported changes in attitudes to PPE may have been exaggerated. Proposals for increasing the willingness of students to participate in PPE are developed from the emergent themes.

Exploring reflective 'critical incident' documentation of professionalism lapses in a medical undergraduate setting

BACKGROUND

Measuring professionalism in undergraduate medical students is a difficult process, and no one method has currently emerged as the definitive means of assessment in this field. Student skills in reflection have been shown to be highly important in the development of professional behaviours. By studying student reflections on lapses in professional judgement, recorded as 'critical incidents', it is possible to explore themes which are significant for the development of professional behaviour in an undergraduate setting.

METHODS

We examined critical incident reporting combined with optional written student reflection as a method for exploring professionalism in undergraduate medical students. 228 students split between Year 1 and 2 of one academic year of undergraduate medicine were studied retrospectively and a grounded theory approach to analysis was employed.

RESULTS

This year generated 16 critical incident reports and corresponding student reflections, all of which were considered. In addition to identifying the nature of the critical incidents, 3 principal themes emerged. These were the impact and consequences of the report having been made, student reactions to the events (both positive and negative), and student responses regarding future actions.

CONCLUSION

This study indicates that unprofessional behaviour can be identified and challenged by both the faculty and the students involved, and suggests that positive behavioural changes might be made with the aim of preventing future occurrences. We provide a low cost approach of measuring and recording professional behaviour.

The conscientiousness index: a novel tool to explore students' professionalism

PURPOSE

Measuring professional behavior is problematic not least because the concept of professionalism is difficult to define. The authors describe a measurement tool that does not rely on qualitative judgments from respondents but, nonetheless, clearly correlates with individuals' subjective views about what constitutes professional behavior.

METHOD

The authors devised the Conscientiousness Index (CI) of medical students' performance in years 1 (n = 116) and 2 (n = 108) in 2006-2007. The CI scores were based on a range of objective measures of conscientiousness, including attendance and submission of required information (such as immunization status or summative assessments) by a deadline. The validity of this instrument was tested against (1) staff views of the professional behavior of individual students and (2) critical incident reports.

RESULTS

The trait of conscientiousness, as measured by the CI, showed good correlation with the construct of professionalism as perceived by staff views of individual students' professional behavior. There was also a relationship with the frequency of critical incident reporting. Together, these observations support the validity of the approach. Reliability and practicality were also acceptable.

CONCLUSIONS

The results suggest that the CI measures a scalar objective trait that corresponds well with professional behavior as perceived by staff members in an undergraduate medical school. The individual decisions making up the CI are objective and easy to collect, making it a relatively simple and uncontroversial method for exploring students' professionalism.

The role of living models in the teaching of surface anatomy: some experiences from a UK Medical School

BACKGROUND

Despite recommendations stemming from the 1930s espousing the value of a living anatomy component in undergraduate medical education, living anatomy remains relatively under described.

AIM

In this article, we explore the role of the living anatomy model in living anatomy teaching.

METHOD

Our report is based on a larger ethnographic study of living anatomy classes, undertaken at Peninsula Medical School between 2002 and 2004. A Research Fellow participated as an observer in 24 Year One and Year Two anatomy classes in which living anatomy models were employed. The findings are based on field notes and conversations with models, students and tutors.

RESULTS AND CONCLUSIONS

Within the supervised context of the anatomy class the living models assisted students in the learning of structure, function, surface anatomy and body variation. Far from being 'passive sites' for the students to practice their anatomical knowledge, the living models were active participants in class, assisting students with their communication skills, sharing anatomical knowledge, offering guidance to staff and sharing their past medical history and experiences. Living anatomy models can foster an additional dimension of humanitarian thinking within the anatomy class; however, further research needs to focus on the power messages implicit in the organization of sessions.

Evaluating a poetry workshop in medical education

This study aimed at evaluating how doing poetry could affect students' understanding of medical practice and at assessing the effectiveness of the evaluation method used. Qualitative research was carried out on the experiences of medical students participating in a poetry workshop, followed by some quantitative analysis. The study was conducted at Peninsula Medical School and St Ives, Cornwall, UK, with three medical students, a poet and a pathologist as participants. Data were collected by interviews, observation and web access. "Doing poetry" with a professional poet was found to assist communication between doctors and patients as it enhanced skills of observation, heightened awareness of the effect of language and fostered deep reflection. Poetry was also found to offer an outlet for medics and patients. The voluntary workshop attracted three participants; however, it might have had an effect on the wider student community because the poetry website received 493 hits in four months. Qualitative methods worked well as a tool for evaluation. "Doing poetry for poetry's sake" seemed to foster the development of skills related to empathy. The opportunity to do poetry should be made available to medical students as part of a wider arts and humanities programme.

Anatomy teaching: ghosts of the past, present and future

INTRODUCTION

Anatomy teaching has perhaps the longest history of any component of formalised medical education. In this article we briefly consider the history of dissection, but also review the neglected topic of the history of the use of living anatomy.

CURRENT DEBATES

The current debates about the advantages and disadvantages of cadavers, prosection versus dissection, and the use of living anatomy and radiology instead of cadavers are discussed.

THE FUTURE

Future prospects are considered, along with some of the factors that might inhibit change.

"Over my dead body?": the influence of demographics on students' willingness to participate in peer physical examination

This study aims to explore quantitatively and qualitatively students' attitudes towards peer physical examination (PPE) and the influence of demographics on students' willingness to participate in PPE. A total of 296 first-year medical students from two consecutive cohorts at the Peninsula Medical School, UK completed the EFS questionnaire. Quantitative data from the questionnaire were analysed using univariate (i.e. Mann-Whitney and chi-squared tests) and multivariate statistics (i.e. stepwise multiple regression) and qualitative data were analysed using theme analysis. At least 92% of Peninsula Medical School students were willing to examine all 11 body parts (except breast and inguinal regions) of peers of same and opposite gender. Qualitative data support this by highlighting students' positive attitudes towards PPE. PPE was more acceptable within rather than across gender and students generally felt more comfortable examining their peers than being examined by peers. Qualitative data outline the range of student concerns with PPE. Significant relationships existed between students' attitudes towards PPE and various variables: gender, age and religious faith. The findings demonstrate that students may show a greater willingness to participate in PPE than previously thought. Further research is required to explore more fully the barriers to PPE.

Ethical permission for the publication of routinely collected data

BACKGROUND

Data collected from undergraduate medical students for routine purposes on a non-consented basis, but subsequently perceived as being potentially valuable for research purposes, lie in an ethical grey area. Currently, such data appear to be used routinely without explicit consideration of ethical considerations.

AIMS

This paper proposes a consistent framework that would permit the use of such data. It also provides an advance on current practice with regard to ethical considerations around the absence of consent.

DISCUSSION

We argue that students should be informed of generic possible uses of such data and given the opportunity to opt out, that researchers should be able to analyse such data retrospectively, but should then seek ethical permission for publication, and that an ethics committee should determine if ethical practices have been upheld before giving permission for any study incorporating such data to be submitted for publication.

FUTURE DIRECTIONS

It is hoped that these proposals will stimulate debate, and that the results of such debate will inform practice in medical schools and medical education publishing.

Assessment of progress tests

BACKGROUND

Progress testing is a form of longitudinal examination which, in principle, samples at regular intervals from the complete domain of knowledge considered a requirement for medical students on completion of the undergraduate programme. Over the course of the programme students improve their scores on the test, enabling them, as well as staff, to monitor their progress.

AIM

We aimed to review methods which have been used to assess the results of individual tests, and to make recommendations on best practice.

DISCUSSION

In assessing progress tests, there are a variety of choices that must be made. These include whether the test is norm- or criterion-referenced; whether marking is negative or "number-right"; whether the grades are reported on a continuous or a discontinuous scale, and whether the grades are weighted towards the most recent observations, or the entire set of grades is used to determine the final grade. Grade boundary setting in the context of progress tests is also considered, using a mathematical model to predict the consequences of different approaches. The relationships between boundary setting, progression and remediation rules are considered.

CONCLUSIONS

We concluded that norm referencing is preferable to criterion referencing, negative marking preferable to number-right marking, a discontinuous scale preferable to a continuous scale and that grades should be weighted to favour the most recent outcomes, although there should still be a degree of persistence (earlier grades should not disappear all together). Grade boundaries should be established with regard to rules on remediation and progression.

Teaching anatomy without cadavers

BACKGROUND

Anatomy learning is generally seen as essential to medicine, and exposure to cadavers is generally seen as essential to anatomy learning around the world. Few voices dissenting from these propositions can be identified.

AIMS

This paper aims to consider arguments relating to the use of cadavers in anatomy teaching, and to describe the rationale behind the decision of a new UK medical school not to use cadaveric material.

DISCUSSION

First, the background to use of cadavers in anatomy learning is explored, and some general educational principles are explored. Next, arguments for the use of human cadaveric material are summarised. Then, possible arguments against use of cadavers, including educational principles as well as costs, hazards and practicality, are considered. These are much less well explored in the existing literature. Next, the rationale behind the decision of a new UK medical school not to use cadaveric material is indicated, and the programme of anatomy teaching to be employed in the absence of the use of human remains is described. Curriculum design and development, and evaluation procedures, are briefly described. Issues surrounding pathology training by autopsy, and postgraduate training in surgical anatomy, are not addressed in this paper.

FUTURE DIRECTIONS

Evidence relating to the effect on medical learning by students not exposed to cadavers is scant, and plainly opportunities will now arise through our programme to gather such evidence. We anticipate that this discussion paper will contribute to an ongoing debate, in which virtually all previous papers on this topic have concluded that use of cadavers is essential to medical learning.

Exploring medical students' attitudes towards peer physical examination

With opportunities for dissection and examination of sick patients decreasing, the role of peer physical examination (PPE) is increasing. This study explores students' attitudes towards PPE and the relationship between attitudes and demographics. A total of 129 first-year medical students from the Peninsula Medical School completed the Examining Fellow Students (EFS) questionnaire. At least 97% of students were comfortable participating in PPE of all body parts except breast and inguinal regions. Over 20% of students were unwilling to participate in PPE of the breast and inguinal regions. Students were more comfortable with PPE within gender than across gender. Females were more likely to be uncomfortable with PPE. Further research with larger sample sizes is required to determine whether attitudes are related to age and religious faith.

Using models to enhance the intellectual content of learning in developmental biology

Models have been particularly useful in developmental biology over the last 30 years. At first, underlying control mechanisms were poorly understood, but over time a wealth of detailed information became available to provide an increasingly detailed knowledge of underlying mechanisms, at levels from genes through cells to organs, organisms and populations. Models are also of great value in teaching developmental biology, as they allow students to explore phenomena hard to perceive directly because of their scale, accessibility, expense or other considerations. A model may allow students to "experiment" in ways which would be impractical in real life, as well as give them a deep understanding of competing hypotheses of development. Lastly, students can be challenged to produce models of their own, whereas only rarely are they able to carry out original experiments. I discuss two main kinds of models and their uses in generating, testing and expounding hypotheses and point out dangers in the use of models in education. Models may draw upon and reflect the consensus paradigm in the field: a researcher may be able to appreciate that models are interim conditional statements of probability and use them to generate new knowledge. A student may be less able to do so and may fail to appreciate where new knowledge will come from. And unlike physics, biology is stochastic and contingent and can never be entirely deduced from first principles, implying that models can never be as perfect in any biological field as they can be in some other fields.

Hot male: can sex in humans be modified by temperature?

Sex determination in many animals has an environmental component, particularly through temperature. In this article, it is argued that some evidence may by seen for this in humans, and it is proposed that the influence of temperature on sex determination may be a reason for the placing of testicles outside the body cavity in most male mammals.

Testing learning theories: the NUL hypothesis

INTRODUCTION

In the spirit of Scrooge and the Grinch, I describe the nasty unpalatable learning (NUL) hypothesis as a new theory of learning. This is an exercise to explore how difficult it would be to develop a new learning theory by reversing the social and altruistic tenets of most existing learning theories. THE NUL HYPOTHESIS: The NUL hypothesis has four propositions. These are: (1) the value of rote learning; (2) the usefulness of authority figures in teaching within a clear hierarchy; (3) the use of fear in teaching, and (4) the value of internal consistency without any necessary connection to the outside world.

CONCLUSIONS

The NUL hypothesis may promote reflection not only on the construction of learning theories, but also on the design of critical experiments. It also seems to imply that efficiency may be a better measure of learning success than effectiveness.

The Scottish doctor--learning outcomes for the medical undergraduate in Scotland: a foundation for competent and reflective practitioners

This paper describes a set of learning outcomes that clearly define the abilities of medical graduates from any of the five Scottish medical schools. The outcomes are divided into 12 domains that fit into one of three essential elements for the competent and reflective medical practitioner.

Marks, scores and grades: scaling and aggregating student assessment outcomes

The term marks conflates the concepts of scores (raw test performance) and grades (level of performance). Neither scores nor grades represent interval scales, and therefore properly speaking arithmetic means should not be calculated during aggregation. The distributions of scores from a variety of kinds of assessment are considered, and ways of converting scores to grades are discussed. Methods of aggregation are also considered, and several strategies for implementing these via spreadsheets are made available. It is recommended that: 1 Scores should always be converted to grades before aggregation. The process of converting scores to grades requires both subject-specific skills, and familiarity with educational principles. 2 Whatever grade scale is used, it should be readily distinguishable from scores. 3 The median should be calculated as the measure of overall performance, not the arithmetic mean. 4 The interquartile range should be calculated as the measure of dispersion. 5 Students should be informed of both their score and grade for each assessment. 6 Where possible, assessment should report performance by individual assessment, not by a single aggregated mark. 7 When aggregation takes place, it should be possible to aggregate student performance by type of assessment as well as by academic subject. 8 Students who perform inconsistently should receive particular scrutiny during assessment.

The use of models and metaphors in developmental biology

That models in science are of a variety of kinds and fulfil a variety of purposes has been particularly evident over the past 30 years in the field of developmental biology. At the beginning of this period, molecular and cellular mechanisms for developmental events were largely lacking, and theoretical models were developed faute de mieux. This gave way to a time in which a number of competing paradigms were present. Now, there is an increasingly detailed knowledge of underlying mechanisms, at a range of levels from genes through cells to organs and organisms. This is therefore a good time to review the usefulness of model making in general, with reference to this discipline. It is suggested that models are of two main kinds: models of structure and models of function. They fulfil three main roles, each of which operates at different stages of maturity of the field of interest. When the causes of some phenomenon are entirely mysterious, then a model may help generate hypotheses for subsequent testing. Second, when competing biological explanations are available, a model may help discriminate between hypotheses. Third, when a well-established hypothesis is available, models may facilitate use of the hypothesis. However, unlike physics, biology is stochastic and contingent, and cannot be entirely deduced from first principles. Mathematical modellers and biologists must remain in constant communication.

Computer-aided interactive three-dimensional reconstruction of the embryonic human heart

Despite the fact that development of the human embryo heart is of considerable clinical importance, there is still disagreement over the process and the timing of events. It is likely that some of the conflicting accounts may have arisen from difficulties in describing and visualising 3-dimensional structures from 2-dimensional sections. To help overcome this problem and to improve our understanding of the development of the heart, we have devised techniques for the production of interactive 3D models reconstructed from serial histological sections of human embryos. Our method uses commercial software designed for the creation of 3D models and virtual reality environments. The ability to construct interactive visual images which both illustrate and communicate complex 3D information contributes to our understanding of the complex developmental changes occurring in embryogenesis.

Cartilaginous development of the human craniovertebral junction as visualised by a new three-dimensional computer reconstruction technique

Serial transverse histological sections of the human craniovertebral junction (CVJ) of 4 normal human embryos (aged 45 to 58 d) and of a fetus (77 d) were used to create 3-dimensional computer models of the CVJ. The main components modelled included the chondrified basioccipital, atlas and axis, notochord, the vertebrobasilar complex and the spinal cord. Chondrification of the component parts of CVJ had already begun at 45 d (Stage 18). The odontoid process appeared to develop from a short eminence of the axis forming a third occipital condyle with the caudal end of the basioccipital. The cartilaginous anterior arch of C1 appeared at 50-53 d (Stages 20-21). Neural arches of C1 and C2 showed gradual closure, but there was still a wide posterior spina bifida in the oldest reconstructed specimen (77 d fetus). The position of the notochord was constant throughout. The normal course of the vertebral arteries was already established and the chondrified vertebral foramina showed progressive closure. The findings confirm that the odontoid process is not derived solely from the centrum of C1 and that there is a 'natural basilar invagination' of C2 during normal embryonic development. On the basis of the observed shape and developmental pattern of structures of the cartilaginous human CVJ, we suggest that certain pathologies are likely to originate during the chondrification phase of development.

The study of early human embryos using interactive 3-dimensional computer reconstructions

Tracings of serial histological sections from 4 human embryos at different Carnegie stages were used to create 3-dimensional (3D) computer models of the developing heart. The models were constructed using commercially available software developed for graphic design and the production of computer generated virtual reality environments. They are available as interactive objects which can be downloaded via the World Wide Web. This simple method of 3D reconstruction offers significant advantages for understanding important events in morphological sciences.

Problem-based examining: a different approach to assessment

An attempt to achieve problem-based examining by the structured assessment of presentations is described. Students can choose to participate in the scheme in teams and then elect to use their awarded mark instead of part of the formal examination assessment. The element of choice of the study or examination method is seen as being a valuable element of the scheme. The scheme can be introduced without radical revision of existing curricula or substantial investment of staff time, and meets some of the expressed desires of the UK General Medical Council in terms of the introduction of novel methods of assessment.

A proximo-distal gradient of FGF-like activity in the embryonic chick limb bud

In a microassay for anchorage-independent growth in soft agar, NR6 cells form colonies in a dose-dependent manner in the presence of fibroblast growth factor (FGF). Using this assay system, the ability of thin sequential slices of embryonic chick limb bud to promote colony formation was investigated. A functional gradient of colony-promoting ability along the proximo-distal axis of the developing chick limb bud (stages 22-26) was observed. The highest number of colonies was observed in the presence of the most distal slices, and colony number decreased progressively at proximal levels. This gradient was specifically eliminated by the addition of anti-FGF antibody to the assay, indicating that it was caused by a functional gradient of an FGF-like molecule. Limbs of stages 21-26 were assayed: before this time limb buds are too small to slice in the proximo-distal axis in the required manner. The FGF-like gradient was observed at stages 22 to 26.

World Wide Web access to the British Universities Human Embryo Database

The British Universities Human Embryo Database has been created by merging information from the Walmsley Collection of Human Embryos at the School of Biological and Medical Sciences, University of St Andrews and from the Boyd Collection of Human Embryos at the Department of Anatomy, University of Cambridge. The database has been made available electronically on the Internet and World Wide Web browsers can be used to implement interactive access to the information stored in the British Universities Human Embryo Database. The database can, therefore, be accessed and searched from remote sites and specific embryos can be identified in terms of their location, age, developmental stage, plane of section, staining technique, and other parameters. It is intended to add information from other similar collections in the UK as it becomes available.