Challenges for educationalists
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38952.701875.94 (Published 07 September 2006) Cite this as: BMJ 2006;333:544
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As a practical matter, video of patients with unusual clinical signs
can be an excellent tool to expedite and assist clinical learning.(1) It
can also be used in assessment.
Such videos can allow students to potentially see several different
presentations of what might otherwise be fairly scarce or difficult to
observe phenomena. Furthermore, it allows them to observe these signs
many times in a very short period of time - with full explanation.
It also would allow for assessment of students' abilities
to recognize such signs in a consistent and efficient manner.
Videos could also be helpful for patient care :
1) Videos of key examination findings and signs could
allow for enhanced rapid consultation across physical
distance and time.
While - clearly - seeing a video is not as useful
as being physically present, it can still be a useful,
rapid, inexpensive and straightforward supplement to
verbal reports and/or notes.
2) Videos of key findings could allow for better
comparison of a patient's changing status over time.
3) Such videos could also be helpful communication tools for various shifts of medical staff.
4) Such videos might even occasionally be helpful as aids
in patient education and in communicating with
patients and their families.
Video recording is now readily available on many
mobile phones and other devices. Storage of video is
also inexpensive.
Videos of key findings (or even "video-patient-notes") might provide
many benefits for teaching, consultation, documentation, and communication
- and may merit further
consideration.
(1) For example, the CD-Rom in :
The Neurology Short Case, 2nd Edition 2005 by John G.L. Morris provides
very useful video of many important neurological signs.
Competing interests:
The author used to be a lecturer, and is currently a medical student.
Competing interests: No competing interests
Editor – The issue of the BMJ on 9th September 2006 had several
relevant articles regarding medical education(1,2). We would agree with
Paice’s view (2) that in the current climate, training will have to be
undertaken in a modular structure away from the work-place and include
online support – a “blended” learning approach.
Schuwirth et al address the problem of practical aspects of
postgraduate training, and conclude that a close collaboration between
doctors and educationalists is required for the development of good
medical education (1); in many cases medical education is based on
traditional techniques without regard to the application of educational /
teaching principles.
In 1994, The Royal College of Surgeons of England (RCSE) introduced
the Surgeons in Training Education Programme (STEP(TM)). This was designed
as a distance learning programme with standard black and white printed
modules providing surgical trainees with basic science and clinical
knowledge relevant to pass the MRCS examination. Further revisions
occurred in 1997 and 2000. The current 2000 edition introduced an online
element (eSTEPTM website) creating a blended learning programme. The
concept of this edition was that the learning would be self-directed, i.e.
trainees would “do the work”; the eSTEP™ website would provide a degree of
interactivity to supplement the printed material and provide useful links
as well as serving a “community” function for collegiate support and
discussion.
In 2005, the STEP(TM) programme reached 7500 participants. However,
changes in postgraduate training and the introduction of the Foundation
Years led to a review of the distance learning programmes. Surveys of
trainees and regional focus groups revealed that 30% of trainees did not
have a formal training programme.(3) Other comments included poor
attendance by trainees and trainers, as well as a feeling that the
teaching did not always match the requirements of the MRCS. The trainees
still preferred studying with printed materials and used the online
material for the interactive elements of learning – a blended learning
method. These views form the basis of the revision of the STEPTM Core
programme for surgical trainees in their first two years (ST1 & 2).
This will be released in the Autumn of 2007.
To address the requirements of the Foundation trainees and changes in
the future of surgical training the STEPTM programme has been revised. In
November 2006, the RCSE will launch the STEP(TM) Foundation blended
programme, consisting of printed modules supported by the eSTEPTM
Foundation website. The modules have been developed with major input from
medical educationalists, to ensure that the programme is robust and fit
for purpose for distance learning. Importantly the programme covers the
whole curriculum for the Foundation years irrespective of the future
medical or surgical aspiration of the trainee.
We hope that by the use of this unique distance learning programme
both medical and surgical trainees will be supported and encouraged in
their training and learning.
Ref:
1. Schuwirth LWT, van der Mulen CPM. Challenge for educationalists.BMJ
2006;333:544-6.(9 September)
2. Kmietowicz Z. Keeping Paice with reforms.BMJ 2006;333:518. (9
September)
3. Larvin M, Haine L, Kamal T. STEP(TM) Survey: What trainees want from a
distance learning programme. Ann R Coll Surg Eng (Suppl) 2006; 88:230 -
231.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR – As OSCEs (Objective Structured Clinical Examinations) become
increasingly commonplace in the framework of undergraduate and
postgraduate medical education, the contributions of Frank and
Schuwirth/van der Vleuten prompt us to continue to research and implement
additional methods and delivery of assessments [1,2].
Franks presents an eloquent and useful critique of current practice
in respect of itemised marking checklists for OSCEs. A key part of
quality assurance and enhancement in medical education is the continued
review of OSCE materials, alongside recognising limited formal processes
in their construction. Committee style ‘round table’ approaches to
reviews, shared good practice between institutions and the use of
reliability data are all important and existing contributions to this
process.
Can the huge amount of data generated by OSCEs compliment the
proposed evidence based approaches to reviewing checklists? It is common
to see the weight of OSCE data focussed into single, but vital measures of
reliability such as alpha coefficients, but with a feeling that the rest
of the data often lies fallow. We would suggest that reviewing this fallow
data will pay dividends – seeking out checklist items that have little or
no discriminatory value, or highlighting those domains that reliably
discriminate between candidates when read against global scores. Such an
enterprise allows a rethink about the scope and value of OSCE examinations
as we move to embrace work based assessment.
This allows a more critical, and evidence based review of existing
material, and in blueprinting how further assessments might be handled.
This allows us to grasp the challenges proposed by Schuwirth and van der
Vleuten, and explore a more dynamic approach to assessment, establishing
domains such as history taking, physical examination and practical skills
with work based settings based on the confidence of rigorous OSCE data.
Such an approach allows us to engage the expertise of different health
professionals in both the teaching and assessment of domains such as
communication and professionalism.
What then might be the role of the OSCE? Acute care, risk management
and error handling are all key components of medical practice, but less
easily assessable within a work based assessment scheme. Revision of our
assessment techniques through re-examination of ‘redundant’ data presents
a key opportunity to remedy this under-representation – and truly create a
blueprint of assessment that mirrors the entire range of competency
expected of our new graduates.
Richard Fuller, Sub Dean, Godfrey Pell, Statistician, Trudie Roberts,
Head of the School of Medicine
School of Medicine, University of Leeds, Leeds, LS2 9JT
R.Fuller@leeds.ac.uk
Competing Interests
Nil to declare
References
1. Frank C. Evidence based checklists for objective structured
clinical examination. BMJ 2006;333:546-548
2. Schuwirth LWT, van der Vleuten, CPM. Challenges for
educationalists. BMJ. 2006;333:544-546
Competing interests:
None declared
Competing interests: No competing interests
Dear editor
Few of the responses to the article showed the gap between
educationalists
and surgeons.
Educationalists do not fully understand the training needs of
surgeons.
Practical skills are essential to surgeons. However, they are only one of
many
skills which are required to be a good surgeon. While surgeons focus on
the
practical skills. Educationalists focus on everything else. The problem is
that
you can not become a surgeon without having the practical skills.
Surgeons are used to deal with the aspects of their work in certain
ways.
Training trainees is no exception. The reduction in working hours might
not
have helped training. However, adopting new methods of training, teaching
and learning will help to eleminate the drwabacks of EWTD.
Academic surgeons are involved in research and undergraduate medical
education more then postgraduate surgical education.
There is a big gap which needs to be bridged. Cooperation between
surgeons
and educationalists is essential to improve the quality and the delivery
of
postgraduate surgical education. More involvement of academic surgeons in
postgraduate surgical education is clearly needed. Creation of a new
branch
of medical education- postgraduate surgical education and training might
be
the answer.
By the way, many of the experts who gathered in Genoa for the
conference of
the association of medical education in Europe use practical skills to
treat
patients. I was the most junior among them!
Yours sincerely,
Zaher Toumi
SHO in General Surgery, The Royal Hallamshire Hospital, Sheffield, UK
Postgraduate student with the centre of medical education, University
of
Dundee, Dundee, UK
Competing interests:
None declared
Competing interests: No competing interests
The authors have nicely discussed the pros and cons of medical
education. When we talk on these issues in relation to countries like
india the problems are endless. we require more doctors. we need more
medical colleges. To meet this challange there is financial constraint. Of
course, because of increased privatisation things are improving. The
balance between patient care and teaching by the registrars is actually a
problem. Regarding research we lag behind. In the process of preparing for
pg entrance the valuable time of interns in learning clinical practice is
not possible. Most of them are not willing to go to rural areas. In medical
education the needs of the locality have to be stressed and students
should be taught the art of medicine which gradually is on the decline. All
medical educationists should see that more or less there should be
uniformity in medical education across the globe. In most of the countries
I am afraid, there is no separate department of medical education and
research related to this field is also scarce.
Competing interests:
None declared
Competing interests: No competing interests
Do any of the experts gathering for the annual meeting of the
Association for Medical Education actually use practical skills for
treating patients? Schuwirth and van der Vleuten's views about practical
training (BMJ 2006; 333: 544-546) are confused, jargonistic and
fundamentally flawed regarding the interests of doctors training in
specialties with a core involvement in practical skills.
At the most basic level, one does not need 'cognitive psychological
research' to realise that expertise is a product of many hours of
practice, but the attitude that repetitive tasks of little educational
value should be excluded from doctors in training has brought about a
generation of ward based doctors who are far less capable of venepuncture
and cannula insertion than their predecessors in the pre-educationalist
era.
When considering more complex surgical tasks supervision should
certainly be core at the incept, but in order to develop surgeons-in-
training into idependent practitioners, at some stage (and with patient
consent) the task must be undertaken solo. This vital leap from
supervised to unsupervised 'deliberate' practice has been undermined by
the 'more and more people who want to be involved in medical education'
who have invented the notion that patients might be regarded as learning
tools. Finally, far from being a good thing, the European Working Time
Directive is a disaster for training surgeons because it does not allow
for the ample opportunity to gradually improve performance that was craved
for in this article.
Competing interests:
None declared
Competing interests: No competing interests
While I applaud the authors in directly addressing the important
issues surrounding the improvement of medical education, they reflect a
very limited and biased viewpoint regarding education for procedures in
medicine. To quote:” Dummies and (computer) simulation tools are likely to
have only minor value.”
If the authors have any personal experience at all with simulation,
they would know that the computer controlled simulators (such as that
shown in the Figure ) used for teaching intubation, emergency
resuscitation, etc., are called mannequins, not dummies. The effectiveness
of such simulators, as well as those used for teaching endoscopy,
laparoscopy, and other minimally invasive surgical procedures is well-
documented 1-14. To say that “Most of the things doctors have to learn
cannot be taught on dummies or with simulations”, ignores the fact that
those things that can be taught are critical events that cannot be taught
through patient contact alone due to the relative infrequency of their
occurrence. In the setting of an acute emergency, such as a
cardiopulmonary arrest, it is quite clear that better outcomes result when
the clinicians involved have spent time rehearsing the scenario using
simulation. This helps develop not only the technical skills required, but
also the decision-making skills and teamwork that are crucial.
The reference cited by the authors supporting their opinion regarding
the limited use for simulation 15, in fact indicates that simulation can
be an important aspect of medical education and that "Simulation-based
medical education is best employed to prepare learners for real patient
contact."
It is unfortunate that such a well-intentioned article is diminished
by an evident lack of understanding about such an important aspect of
medical education.
Reference List
1. Gaba DM,.DeAnda A. The response of anesthesia trainees to
simulated critical incidents. Anesth.Analg. 1989;68:444-51.
2. Seymour NE, Gallagher AG, Roman SA, O'Brien MK, Bansal VK,
Andersen DK et al. Virtual reality training improves operating room
performance: results of a randomized, double-blinded study. Ann.Surg
2002;236:458-63.
3. Ritter EM, McClusky DA, III, Lederman AB, Gallagher AG, Smith CD.
Objective psychomotor skills assessment of experienced and novice flexible
endoscopists with a virtual reality simulator. J Gastrointest.Surg
2003;7:871-7.
4. Fried MP, Satava R, Weghorst S, Gallagher AG, Sasaki C, Ross D et
al. Identifying and reducing errors with surgical simulation. Qual.Saf
Health Care 2004;13 Suppl 1:i19-i26.
5. Haluck RS, Gallagher AG, Satava RM, Webster R, Bass TL, Miller
CA. Reliability and validity of Endotower, a virtual reality trainer for
angled endoscope navigation. Stud.Health Technol.Inform. 2002;85:179-84.
6. Ritter EM, McClusky DA, III, Lederman AB, Gallagher AG, Smith CD.
Objective psychomotor skills assessment of experienced and novice flexible
endoscopists with a virtual reality simulator. J Gastrointest.Surg
2003;7:871-7.
7. Holcomb JB, Dumire RD, Crommett JW, Stamateris CE, Fagert MA,
Cleveland JA et al. Evaluation of trauma team performance using an
advanced human patient simulator for resuscitation training. J Trauma
2002;52:1078-85.
8. Gaba DM. The future vision of simulation in health care. Qual.Saf
Health Care 2004;13 Suppl 1:i2-10.
9. Lee SK, Pardo M, Gaba D, Sowb Y, Dicker R, Straus EM et al.
Trauma assessment training with a patient simulator: a prospective,
randomized study. J Trauma 2003;55:651-7.
10. Edmond CV, Jr. Impact of the endoscopic sinus surgical simulator
on operating room performance. Laryngoscope 2002;112:1148-58.
11. Di Giulio E, Fregonese D, Casetti T, Cestari R, Chilovi F,
D'Ambra G et al. Training with a computer-based simulator achieves basic
manual skills required for upper endoscopy: a randomized controlled trial.
Gastrointest.Endosc. 2004;60:196-200.
12. Sedlack RE,.Kolars JC. Computer simulator training enhances the
competency of gastroenterology fellows at colonoscopy: results of a pilot
study. Am J Gastroenterol. 2004;99:33-7.
13. Fried GM, Feldman LS, Vassiliou MC, Fraser SA, Stanbridge D,
Ghitulescu G et al. Proving the value of simulation in laparoscopic
surgery. Ann.Surg 2004;240:518-25.
14. Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg
J, Funch-Jensen P. Randomized clinical trial of virtual reality simulation
for laparoscopic skills training. Br.J Surg 2004;91:146-50.
15. Issenberg SB, McGaghie WC, Petrusa ER, Lee GD, Scalese RJ.
Features and uses of high-fidelity medical simulations that lead to
effective learning: a BEME systematic review. Med.Teach. 2005;27:10-28.
Competing interests:
None declared
Competing interests: No competing interests
I enjoyed Schuwirth and van der Vleuten’s article in 9th September
2006 BMJ (Volume 333 Pg 544-546) Challenges to the educationalists
[analysis and comment, Medical education]. I do, however, have two
questions: who chose the picture ‘simulation has limited applications’ on
page 544? And what on earth is the gentleman in the white coat doing with
the defibrillator paddles?
I am sure that anyone that has completed their Advanced life support
course (I believe a requirement for most FY1/PRHO medicine jobs) will know
that the paddles are only ever on the defibrillator or the patient! Maybe
I have misread the photograph but this gentleman appears to be waving them
around in the air. If he is planning on defibrillating the patient could
we please ask the person ventilating the patient to step back and if
necessary remove the oxygen source.
I know it pedantic, and I swore I’d never get to the stage when I
noticed let alone commented on such things but in an age where everyone
has seen an American drama on TV and every staring doctor gels the paddles
and hold them both in one hand can we at least paint a picture or accuracy
and safety please?
Competing interests:
None declared
Competing interests: No competing interests
Editor,
We are very thankful to dr. Kilroy for having clarified some of the
issues of his RR and our reply. We agree completely that any new
educational intervention has to be studied rigorously and that any study
of which the only outcome is learner enjoyment does not contribute very
well to our understanding of what constitutes effective and efficient
learning approaches.
We could also not agree more with his suggestions that we need to distil
the best aspects from all available methodologies and combine them into a
pragmatic, feasible and acceptable solution.
In our field for example, assessment of medical competence, we have
advocated always to construct assessment programmes consisting of various
assessment instruments.(1) We also suggest that there are no intrinsically
‘bad’ assessment instruments, but there are mainly poor choices and
inadequate applications of instruments. In our opinion a good assessment
programme can only be established if the individual instruments are
rationally chosen on the basis of research outcomes, if the sampling
within and across instruments is sufficient, and if the way the
information is collated to summative decisions is rational.(2) As such,
the process of ‘diagnosing and remediating poorly performing students or
doctors’ is not really that different form diagnosing and treating
patients. And in both cases it is essential that all the ‘assessments’ are
carried out as they should, and are interpreted correctly.
So we think that not only doctors should learn from educationalists, but
also that educationalists should learn form doctors. In our own
institution we think we have been able to establish such an honest debate
and joined educational development and research between both parties in
many cases, and we are very pleased with this culture (3).
1. Van der Vleuten CPM, Schuwirth LWT. Assessing professional
competence: from methods to programmes. Medical Education 2005;39(3):309-
17.
2. Schuwirth L.W.T, Southgate L, Page G.G, Paget NS, Lescop J.M.J, Lew
S.R, et al. When enough is enough: a conceptual basis for fair and
defensible practice performance assessment. Medical Education 2002;36:925-
30.
3. Van der Vleuten CPM, Dolmans DHJM, De Grave WS, Van Luijk SJ, Muijtjens
AM, Scherpbier AJJA, et al. Education Research at the Faculty of Medicine,
University of Maastricht:
Fostering the Interrelationship between Professional and Education
Practice. Academic Medicine 2004;79(10):990 - 6.
Competing interests:
None declared
Competing interests: No competing interests
Need of the Hour in India
India recently saw a mushrooming of many medical schools and now
there are many MBBS doctors. Not all of them are able to do
Postgraduate study. As a result India now has many MBBS doctors. Sadly none
of these doctors are trained in treating common conditions and none of
them trained to do GP and work in primary health centres in India. Most
primary health centres in India as a result do nothing. The solution to
this problem lies in a separate curriculum for people who want to do
general practice with 2 year internship. I hope the Indian Medical Council
will listen to this.
Competing interests:
None declared
Competing interests: No competing interests