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Difficulties of separating cause and effect
- Adam Jacobs (27 August 1999)
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Selection bias and inappropriateness of learning style scores as outcome indicators
- Wai-Ching Leung (31 August 1999)
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Intercalated Degrees and Learning Styles
- Jessica Morse (10 September 1999)
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BSc in Primary Health Care may help address the current gap of some students wishing to intercalate
- Melvyn Jones (22 September 1999)
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BSc Students
- Sarah Matthews (24 September 1999)
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Medical School Course Structures: The Best approach for the future
- Srimathy Vijayan (12 May 2006)
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Adam Jacobs, Director Dianthus Medical Limited
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It is clear that, whatever the effect of intercalated degrees on student's career preferences, the students who take such degrees in the first place could be those more likely to want to pursue an academic or research career. Disentangling cause and effect here is no easy matter, and McManus et al are to be commended for their brave attempt to do so. However, I am not convinced by their confident assertion: 'Because our study is longitudinal, the hypothesis that the effects of an intercalated degree are due to self selection can largely be discounted.' Measuring students' attitudes at the start of their course undoubtedly goes some of the way towards studying the effect of the intercalated degree, but it needs to be borne in mind that the two questionnaires were completed six years apart. Surely it is a reasonable hypothesis that the way students' attitudes evolve over such a long and formative period of time will depend to a large extent on characteristics of the students. That the evolution of attitudes differs between those students who do and those who do not take the intercalated degree does not prove that the degree is responsible. It is noteworthy that the effect of the degree was smallest in those medical schools where taking the degree was more common. That lends weight to the idea that intrinsic characteristics of the students are at least as important as the degree course: if everyone takes the degree, regardless of their inclination towards research, then the effects of the students' attitudes will no longer contribute. |
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Wai-Ching Leung, Senior Registrar in Public Health Medicine Northern Region Public Health Medicine Training Scheme, Durham DH1 5XZ
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In their prospective longitudinal study of UK medical students, McManus et al (1) found that final year students who had taken intercalated degree had higher deep and strategic learning style scores than other students and that the effect was greatest in those gaining a first class degree and in medical schools with a smaller proportion of medical students taking the degree. These observations can be accounted for by the selection of students into the intercalated degree by the medical school, which usually occurs at the end of the second year based mostly on university examination performance. Although the authors took into account learning scores at application, this selection could still give rise to bias for two reasons. Firstly, the measurement of learning style scores was not perfect (reliability coefficients 0.53 - 0.72). Hence, initial learning style scores being equal, students whose scores were underestimated would be more likely to be selected for the intercalated degree. Secondly, the authors' data demonstrated remarkably well the highly dynamic nature of the learning style scores. For example, the mean strategic learning scores of those with no BSc dropped from 22.75 to 14.81 between application and the final year. This represented a drop of 1.9 standard deviation of the scores at application. It is likely that there is considerable heterogeneity in the rate of change of scores amongst students in their first two years of their course. This selection bias would account for the apparently greater effect of BSc degree on learning style scores amongst medical schools with a smaller proportion of medical students taking the degree. The highly selected BSc students at these medical schools would be expected to have better learning styles and show more interest in medical research than other BSc students. No conclusions regarding resource dilution should be drawn from this observation. Whilst the ratio of staff to students taking a BSc degree in a medical science discipline may be an appropriate indicator of resources available to the students, the proportion of medical students taking intercalated degree is not. In many universities, most students taking a BSc degree in a medical science discipline are not medical students. A startling finding in the data presented is that the learning style scores deteriorated drastically between application and the final year, which the authors attributed to maturational and age-related changes. For example, the mean benefit derived from a BSc course (+1.45) was less than 20% of the mean deterioration in strategic learning scores amongst those with no BSc (-7.94). In other words, a year spent on the BSc course could not even prevent a year's physiological deterioration in learning style! This observation surely casts doubt on the validity of learning style scores as a useful outcome measure of the intercalated degree. Whilst there is ample evidence showing the validity of learning style scores as a predictor of success in higher education (2), there is little evidence that they are valid as outcome measures of higher education. References 1 McManus IC, Richards P, Winder BC. Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students 2 Entwistle N. Styles of learning and teaching - an integrated outline of educational psychology for students, teachers and lecturers. London: David Fulton , 1988. |
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Jessica Morse, Medical Student Newcastle University
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Intercalated Degrees, Learning Styles and Career Preferences: Prospective Longitudinal Study of UK Medical students Dear editor, McManus et al (1) concluded in their study that medical students taking an intercalated BSc have greater interest in research careers and demonstrate deeper and more strategic learning styles. Whilst the study’s appropriate design and large sample size minimised the effect of self- selection, a number of concerns remain. Applicants to five medical schools were surveyed, although these schools were not identified in the paper. Due to wide variation in medical curriculae between traditional and integrated courses, it is important to know which medical schools were included and what type of course they run. This lack of information questions the authors conclusions on the impact of a BSc. Integrated courses, by their nature, promote deep and strategic learning styles, attracting students who may already possess these qualities. The impact of a BSc on this type of student may be less, perhaps, than on those with no previous experience of this type of learning. Variation between medical schools also exists as to whether a BSc is optional or compulsory. This in itself has implications for self-selection, not only to the BSc course, but also to the type of medical school. Studying any group of students will cover a wide range of personalities, characteristics and experience (for example postgraduates) , therefore making comparisons of learning styles difficult. Thus it is difficult to identify a true comparison group. For this reason, the composition of the groups of respondents should have been taken into account in the analysis. Our final concern relates to the poor response rate (56%) from final year students. Perhaps this could be improved by a briefer questionnaire at a more appropriate time in the curriculum, ie. not immediately before final exams. As fourth year medical students, we appreciate the lack of enthusiasm towards an additional workload during this period. This study highlights the need for further research regarding both the effect of the intercalated BSc and learning styles. Yours sincerely, Julie Holgate, Jessica Morse, Sarah Pearson BMedSci(Hons), Sandra
Reynolds
1 McManus IC, Richards P, Winder BC Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students. BMJ 1999;319:542-546 |
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Melvyn Jones, Lecturer in General Practice Royal Free & University College Medical Schools, UCL, Royal Free Campus, Rowland Hill St, London NW3
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Editor, Re: intercalated degrees, learning styles and career preferences: Prospective longitudinal study of UK medical students McManus et al [1] report that students undertaking intercalated BScs had a higher preference for laboratory medicine and a lower preference for general practice. This may be because historically there has never been the option for 38% of graduates who go onto become GPs [2] to explore their career interest in more depth. The Royal Free & University College Medical School has been running an intercalated BSc in Primary Health Care for 2 years and so far we have produced 7 graduates (3 in 1998, and 4 in 1999) with good honours degrees and completed research dissertations. As awareness of this new course has increased, we have started attracting students from across the country, and recruited 9 students for 1999/2000 not only from London, but also Birmingham, Leicester and Southampton (with expressions of interest from Glasgow and Cardiff). Our students report that they actively avoided choosing laboratory based courses, but sought instead a course that maintains clinical contact and would develop their research skills in this domain of medicine. We would suggest that the association between attainment of a BSc with deeper learning styles would appear valid, but the association with a negative career aspiration towards general practice may merely reflect the absence of a BSc that reflects the career interests of over a third of undergraduates. Yours Dr Melvyn Jones Dr Margaret Lloyd Dr Richard Meakin Conflict of interest: Course organisers for BSc in Primary Health Care Reference List 1. McManus IC, Richards P, Winder BC. Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students. BMJ 1999;319:542-546. 2. Lambert TW, Goldacre MJ. Career destinations seven years on among doctors who qualified in the United Kingdom in 1988: postal questionnaire survey. BMJ 1998;317:1429-1431. |
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Sarah Matthews
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Sir, We read with interest the recent paper on the learning styles and career expectations of medical students who take BSc courses as opposed to those who do not (1). The conclusion that the reduced impact of these courses in those schools where they are available to most or all of the medical students is due to under-resourcing seems dubious in face of a more obvious alternative. It strikes us that the reason that deep and strategic learning styles are so enhanced in the few students of the schools where a smaller percentage take such courses is that they are a highly selected group, and so may have more natural ability in these skills. It also seems to us unsurprising that those students who take such courses have a stronger intention to move into research at year 5. Many courses now on offer to medical students are research, and more particularly laboratory, based. Both these features of available courses may influence the participating students' stated future intentions for research or hospital based specialty careers. There are few courses with community or general practice based modules. Those students with leanings towards the community may be less likely to take BScs. We would have hoped to see other ways in which those students with BScs could be divided and compared - for example those courses which were mainly research based, as opposed to mainly seminar or lecture based courses. It may be that the former are more likely to produce students with strong leanings towards research. Other factors, such as the amount of contact with primary care, have also been proposed as affecting specialty choice (2). The questions posed by this piece of research are many, and we hope McManus et al will follow up these students in a few years to reveal their actual, as opposed to intended career choices. If other follow-up shows that the shift in curricula generally towards self-directed learning reduces the impact of the BSc in subsequent generations of students, this would really be a positive result. The new curricula would then be providing the most useful skills to most of the students in the core course instead of the additional year. This would indeed be a very positive outcome of recent changes in many of our medical schools. Dr S Matthews Dr A Edwards Department of General Practice, Llanedeyrn Health Centre, Maelfa, Llanedeyrn, Cardiff CF23 9PN 1. McManus C, Richards P, Winder BC. Intercalated degrees, learning styles, and career preferences: prospective longitudinal study of UK medical students. BMJ 1999;319:542-6. 2. Senf JH et al. A hypothetical model of the effect of medical education on specialty choice. Family Medicine. 1997;29 (10): 724-729. |
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Srimathy Vijayan, medical student School of Medicine, UEA, Norwich, NR4 7TJ
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I am currently a medical student in UEA, Norwich. Our course was only started 4 years’ ago and I am in the third year, making myself and my year the second lot of intake. The way our course is designed makes it a “modern” medical degree course and not the “traditional” style where medical student have 2 years pre-clinical lectures and 3 years clinical experience. Our course is taught in systems, and each system is taught in a 12 week block, where 8 weeks are comprised of lectures and 4 weeks are clinical attachment in the hospital. The main difference with our course and many of the traditional courses is that we are exposed to clinical medicine/practice right from the first year. I think this is an important aspect of our course because primarily as a doctor, the majority of us will be practising clinical medicine. And to have clinical exposure right from the first year helps you develop your skills, not to mention reminds you what our course is about, and that is to treat patients. Speaking to many medical students from courses in the traditional setup only further encourages me that the way in which we are taught medicine is perhaps the more appropriate approach. What I mean by this is that many students from universities conducting the traditional courses complain that they get fed up in the first 2 years as they are “stuck” in lectures. One part of the medicine which many students look forward to is being in hospital and seeing patients, and for those looking forward to this aspect, but having to do 2 whole years in lectures before this, it can be a test of patience and unfortunately in some cases has meant students drop of courses. Obviously this is extreme, but other students comment that they forget the reason as to why they are doing their course, that is medicine, because they have no patient contact, and lose the willingness to want to learn as it is “boring”. However by the time they reach their 3rd year, they are so happy with their choice of degree as the clinical side of it is introduced, and this motivates them to pass their course with flying colours. There are many other reasons why the traditional courses are hard to teach. I think it makes more sense to learn about a condition and to see it in clinical practice as it stays in your head, and that is what our course encourages us to do. For those stuck learning the basic medicine from lectures for the first 2 years, by the time they get to the hospital they would have forgotten what they had learnt and would end up having to re-learn a lot of the material once again. However medicine is a course where we will always be re-visiting and re-learning topics as there is just an indefinite amount of material we need to know. It brings up the question of what is the best method of learning as a medical student. Some people would argue that there is no point being exposed to clinical medicine until you know all the basic sciences/ anatomy / physiology etc… This is one reason why the way in which we are taught has been criticised. The fact we learn things in systems, means that we have no formal fundamental teaching on anatomy and physiology. This is one aspect of our course that many clinicians complain about to our medical faculty, “How is possible to send medical students to the hospital from their first year if they have no fundamental knowledge about the human body?” However, as we learn each system, we are expected to read the relevant anatomy and physiology and we are examined on this at the end of each module. I feel this is rather hypocritical of these clinician’s as it is the same clinicians who tell us that apart from the anatomy and physiology in the speciality you decide to go down, most of the other anatomy and physiology, although is still important, it never really sticks in your head. And I guess this is only normal, and that is why medicine is a field where there is specialization, how can we be expected to know everything about all the internal organs etc… However I do feel that specialization does not lie in the ability to be able to recall the anatomy of organs but rather, in the ability to be able to recognise the clinical picture of a patient who presents and to be able to manage/treat the patient effectively and efficiently. Keeping this in mind, surely a course that adopts clinical exposure to students from such an early stage in their medical careers should be praised if not adopted. Surely the question lies in what method an individual student learns by. Although our course does not officially teach much basic sciences, as a student on the course, I am constantly aware that my anatomy / physiology / biochemistry is weaker than my colleagues that are taking traditional courses. As a result I feel I should spend more time learning this. But at the same time I do not think learning this will help me in an emergency situation where I have to decide on how to treat a patient all by myself. In this situation, I will probably have benefited from my clinical exposure / teaching. However even with this approach, people would argue, unless you know the basic science you will not understand why you are acting in a certain way when treating patients. This aspect of medicine where you have the ability to understand why you are doing certain things is just as important as learning how to do them. The answer to what course structure is a better way to learn medicine can and should only be answered by us medical students as we are the ones undergoing these courses at present. Perhaps some studies looking at medical student attitudes about the way they are taught would be of great value in the future. No matter how you choose to look at this, it seems that there are advantages and disadvantages to being taught by different structures. It is up to us medical students to make the most of our time as students. If we are genuinely interested in reading around topics, we all have the time and methods to do so and only by doing so will we be diversifying our knowledge to find out what we are interested in practising once we have qualified. Ultimately, we will all end up in the same position, competing for the same jobs, and although we have been taught medicine differently, we all should function as a team to make treating patients successfully our main goal. Competing interests: None declared |
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