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physicians. Participants were asked to solve five clinical problems by thinking aloud. The thinking expressed aloud was immediately transcribed into concept maps by one or two 'writers' trained to distinguish inductive and deductive links. Reliability was assessed by estimating the inter-writer correlation. The calculated rate of inductive reasoning, the richness score and the rate of exhaustiveness of reasoning were compared according to the level of expertise of the individual and the type of clinical problem.
Summary of results: The total number of maps drawn amounted to 60. A significant positive correlation was found between writers for all the scores (R = 0.52-0.95). Richness scores and rates of exhaustiveness of reasoning did not differ according to expertise level. The number of inductive links were higher in physicians (16.4 +/- 6.8 vs. 12.6 +/- 5.3 for year 1 and 13.4 +/- 5.4for year 3, p=0.05). The rate of inductive reasoning varied as expected according to the nature of the clinical problem and tend to be higher in expert physicians (65% versus
Conclusions: This new method showed a good reliability and may be a promising tool for the assessment of clinical reasoning in family medicine residents.
A scientific and humanistic look into the clinical and ethical reasoning of the 'physician of persons'
Maria de Jesus Ortiz Gonzalez (Facultad de Medicina "Dr. Ignacio Chavez". Universidad Michoacana de San Nicolas de Hidalgo, Research Committee, Francisco J. Mugica 113. Col. Felicitas del Rio. Morelia Michoacan, Morelia 58040, Mexico)
Cindy Yolotzin Perez Lopez (School of Medicine "Dr. Ignacio Chavez". Universidad Michoacana de San Nicolas de Hidalgo, Mental Health Department, Morelia, Mexico)
Background: This exciting and unaccomplished topic frequently occupies us clinicians and medical teachers from around the world. In almost all scenarios where the medical practice occurs, clinical and ethical competencies are also taught, in order to model competent physicians in the healthcare of people. Summary of work: Purpose: to discuss the professional competency of undergraduate students, from an integral scientific and humanistic perspective, and to examine the logic underlying in the understanding of this issue, as well as the main teaching-learning/assessment methodologies involved. Summary of results: The conceptual aspect was analyzed using a wide bibliography, authors and educative contexts. Thus I found many terms, some of them synonyms, others interchangeable or complementary (critical-thinking, physiological-thinking, clinical-reasoning, clinical-judgment, ethical-reasoning, professionalism... ) Then, the most relevant teaching-learning and assessment methodologies to promote clinical and ethical reasoning of undergraduate students turned out to be difficult to standardize.
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Conclusions: My proposal is to consider the critical thinking as a continuous historic-cultural activity during the whole process of professional competency, that is to say, the main capability. So, clinical reasoning integrated to ethical reasoning (critical-thinking, systemic-approach + physiological-thinking /physiopathology/ medical sciences + humanities), model the 'physician of persons': a doctor who cares people's health inspired on universal ethical principles.
Take-home messages: The competent 'physician of persons' can be modeled, since the beginning of the career and beyond, by medical teachers who have understood most meanings and master at least one of the possible methodologies.
Development of Small-Group Learning (SGL) at RUSM to deliver specific content on competencies and promote history-taking skills
V Thomas (Ross University School of Medicine, Integrated Medical Education, P.O Box 266, Picard, Portsmouth, Dominica)
R Sasso (Ross University School of Medicine, Integrated Medical Education, Portsmouth, Dominica) N Selfridge (Ross University School of Medicine, Integrated Medical Education, Portsmouth, Dominica) R St. Hilaire (Ross University School of Medicine, Integrated Medical Education, Portsmouth, Dominica) D Callender (Ross University School of Medicine, Integrated Medical Education, Portsmouth, Dominica) J Cannon (Ross University School of Medicine, Integrated Medical Education, Portsmouth, Dominica)
Background: At Ross University School of Medicine (RUSM), formerly, students would work through the vignettes of a PBL case on the whiteboard using the following column headings: Data, Analysis, Hypothesis, and Learning Issues a time-consuming repetitive exercise. PBL facilitators identified this as a limiting factor and reported this as a source of student frustration. In May 2012 the PBL program was renamed Small Group Learning (SGL) to reflect the directive nature of the process that had developed at RUSM. Summary of work: In May 2012 the SGL proces incorporated aspects of medical history taking . This included the subdivision of the data column into chief complaint, history of present illness, past medical history, medications, family history, social history, review of systems, physical exam and other data. A new column called "problem list" was also added. Summary of results: Anecdotal reports from SGL facilitators indicate that this method preferred by students as this format seems more clinical and seems more relevant to what they will be doing as doctors. Conclusions: The aims of this new process are to improve clinical reasoning as students place data where it belongs in the interview process, and to improve students' history taking skills. Clinical reasoning is further enhanced by students developing a problem list from the data given.
Take-home messages: Further research is needed to gather student and faculty feedback on the new SGL process. We are planning to survey facilitators to document these results.
The development of the clinical reasoning construct in undergraduate students in an internal medicine clerkship program
Azam S Afzal (Aga Khan University, Medicine & Dept. for Educational Development, Karachi, Pakistan) Tabassum Zehra (Aga Khan University, Medicine & Dept. for Educational Development, Karachi, Pakistan) Junaid Patel (Aga Khan University, Medicine, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan) Sara Sajid (Aga Khan University, Medicine, Karachi, Pakistan)
Syeda Kauser Ali (Aga Khan University, Dept. for Educational Development, Karachi, Pakistan) Saeed Hamid (Aga Khan University, Medicine, Karachi, Pakistan)
Background: In medical education, the curriculum is continually monitored to ensure quality standards. Often overlooked in Pakistan though are robust analysis of the assessments that give meaningful interpretation of the results. This study was done to explore the construct validity related evidence of clinical reasoning in the multi-method assessments used for assessing student performance in the undergraduate medicine clerkship program at Aga Khan University (AKU). Summary of work: The assessments scores of students 167 students were used, from two consecutive cohorts. Exploratory and confirmatory factor analysis was conducted to identify underlying constructs assessed by clerkship assessments; regression for direction of causality; and a multi-trait multi-method matrix for construct validity.
Summary of results: The reliability of the assessment instruments used were moderate to high (0.74 - 0.94). Factor analysis isolated an attribute which was identified as clinical reasoning ability. Construct validity was determined by applying the Campbell and Fiscke criteria to a multi-trait multi-method matrix. Conclusions: The AKU spiral curriculum, allows students first learn about the basic science information about clinical presentation in PBL tutorials. This primes learners for the clinical years and develops hypothetico-deductive reasoning. During third year they start interacting with patients and through experiences with real cases, this knowledge begins to transform into cognitive structures called illness scripts. During the clinical years clinical teaching ensures that Bowen's areas of common clinical reasoning deficiencies are addressed.
Take-home messages: The undergraduate assessment of clinical competence conducted by the department of medicine at AKU predominantly assesses students' clinical reasoning ability and this trait is essential to certify physicians.
ABSTRACT BOOK: SESSION 5 MONDAY 26 AUGUST: 1600-1730
SNAPPS case presentations in an internal medicine ambulatory care setting in a Thai medical school
Kittisak Sawanyawisuth (Khon Kaen University, Medicine, 123 Mitraparp Road, Khon Kaen 40002, Thailand)
Georges Bordage (University of Illinois, Chicago, Medical
Education, Chicago, United States)
Alan Schwartz (University of Illinois, Chicago, Medical
Education, Chicago, United States)
Terry Wolpaw (Penn State College of Medicine,
Educational Affairs, Hershey, United States)
Background: SNAPPS is a learner-centered approach to clinical case presentations that has been shown in American studies to facilitate the expression of clinical reasoning and uncertainties in the family medicine outpatient setting. The purpose of this study was to replicate the American study for an Asian medical school.
Summary of work: We conducted a historical pre-test and experimental post-test, comparison trial, comparing the SNAPPS technique to the usual-and-customary method of case presentations (Usual) for fifth-year (M5) medical students in an ambulatory internal medicine clerkship rotation at Khon Kaen University, Thailand. Summary of results: SNAPPS users (90 case presentations), compared to Usual group (93 presentations), identified more problems (2.39 vs 1.22), had more diagnoses in their differentials (1.81 vs 1.42) and more differential justifications (0.90 vs 0.78), student-initiated diagnosis discussion (76.7% vs 59.1%) and student-initiated reading assignments (6.67% vs 0%). There was no maturation effect for the M5 students using Usual presentations (71 presentations). Conclusions: These results are similar to the American results and show that the use of the SNAPPS technique helped improve the expression of clinical reasoning for Thai medical students during an internal medicine ambulatory care rotations.
Take-home messages: SNAPPS technique is the helping tool for clinical reasoning teaching in internal medicine ambulatory care rotations in Thailand.
Reflective practice in Medicine: A comparison of the experience of participation in Balint groups for medical students and doctors in training
Ami Kothari (Avon and Wiltshire Mental Health Partnership, Addictions Psychiatry, 11 Oakfield Place, Clifton, Bristol BS8 2BJ, United Kingdom) Ane Gillett (Avon and Wiltshire Mental Health Partnership, General Adult Psychiatry and Psychotherapy, Bristol, United Kingdom) Claire Davis (Avon and Wiltshire Mental Health Partnership, Medical Psychotherapy, Bristol, United Kingdom)
Simon Downer (Avon and Wiltshire Mental Health Partnership, General Adult Psychiatry and Psychotherapy, Bristol, United Kingdom)
Background: Bristol medical students do not experience Balint groups within their curriculum. By contrast, doctors training in Psychiatry in the region are expected to attend a Balint group. Evidence from the long running UCL Medical Student Psychotherapy Scheme supports the effectiveness of psychodynamic approaches in teaching students in the UK; similar student Balint groups have been used in numerous countries. Summary of work: This work provides a comparison of students' first experience of participation in a Balint group with doctors' experiences. Two Balint group leaders ran parallel doctor and student groups. Process notes from five sessions of each group were analysed for themes, and compared. Participants completed a questionnaire to identify elements of their experience. Summary of results: Both groups had a comparable attendance; students were enthusiastic, and able to participate in the groups in a similar manner to the doctors. Common themes emerged from both the student and doctor groups. Differences were identified in terms of the challenges of leading the student group versus the doctor group. Group leaders found the experience of leading two different groups enriched the process.
Conclusions: Participation in Balint groups confers some similar benefits for students and doctors. Mirroring the doctors' experience, students found the opportunity to participate in reflective practice within a peer group to be valuable.
Take-home messages: Our findings are consistent with those of the UCL scheme. Participation can enhance the clinical placement for students. Wider installation of Balint group schemes for students throughout their clinical years would be beneficial.
Structured reflection while practicing with clinical cases may increase cognitive effort
Denise Utsch Goncalves (Federal University of Minas Gerais, Internal Medicine, Rua Rio de Janeiro, n° 2535, apto 101, Av. Prof. Alfredo Balena, n° 190, sala 199, Belo Horizonte 30160-042, Brazil)
Silvana Maria Eloi-Santos (Federal University of Minas
Gerais, Propedeutics, Belo Horizonte, Brazil)
Tamara van Gog (Erasmus University Rotterdam,
Psychology, Rotterdam, Netherlands)
Cassio Ibiapina (Federal University of Minas Gerais,
Pediatrics, Belo Horizonte, Brazil)
Jose Maria Peixoto (Jose Rosario Vellano University
(UNIFENAS), Medic Clinics, Belo Horizonte, Brazil)
Silvia Mamede (Erasmus University Rotterdam,
Psychology, Rotterdam, Netherlands)
Background: Structured reflection while practicing with clinical cases has been shown to foster medical students' diagnostic competence in the long term but hindered performance in immediate test, which may be
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due to generation of increased cognitive load. This study compared cognitive load and diagnostic accuracy in 3 experimental conditions: structured reflection, generating immediate and differential diagnosis. Summary of work: The study consisted of learning phase, immediate test, and one-week later test. Two different cases of jaundice and two of chest pain were diagnosed in each phase. Participants were 83 4th-year medical students. In the learning phase, they were randomly assigned to one of three groups: immediate decision (read the case and gave an immediate diagnosis), differential diagnosis (give alternative diagnoses before choosing the most likely one), structured reflection (listing confirmatory and contradictory evidence for alternative diagnoses before deciding the most likely one). In the immediate and delayed phases, all students were requested to simply diagnose the new sets of cases. Cognitive load was measured in each phase by using a 9-point mental effort rating scale.
Summary of results: The SR group apparently presented a higher cognitive load in learning phase (p=0.08) with a higher diagnostic accuracy in immediate phase (p=0.06). An increase in diagnostic accuracy was not found in the delayed phase, which seemed to be due to upheavals in the school, which may have hindered the delayed test. Conclusions: Although borderline, the results suggested that reflection increased the cognitive effort and contributed indeed to higher learning performance soon after intervention.
Take-home messages: Structured reflection may induce germane cognitive load
Drawing: a new tool for reflection in undergraduate medical students
Sabih Momenul Hug (Newcastle University Medicine Malaysia, Medicine, No.1, Jalan Sarjana 1, Kota Ilmu, EduCity@Iskandar, Nusajaya, Johor 79200, Malaysia) Nur Faraheen Abdul Rahman (Newcastle University Medicine Malaysia, General Practice, Nusajaya, Malaysia)
Background: Reflection is an integral part of being a good doctor. It is encouraged, and assessed, at many medical schools. However students often dislike reflection. Underlying reasons for this are complex, but may be due to a mismatch between skills needed to reflect usefully, e.g. openness, and skills encouraged by methods used to capture reflection, e.g. essay writing. Our hypothesis was that a more creative 'right-brained' approach would make reflection more powerful, efficient and fun.
Summary of work: Voluntary 90 minute workshops were arranged for interested undergraduate medical students. First, a series of warm up activities 'got students in the mood' and helped them focus on significant events in the year so far. Students were then asked to produce, and present, a piece of art representing a difficult aspect of their life as medical students. Explanations were recorded digitally, then
transcribed. All artwork was photographed. Transcripts and artwork were thematically analysed using a constant comparison method. Pre- and post-session questionnaires were administered. Summary of results: Students (n=23) found the workshop positive ("therapeutic") and afterwards were more likely to agree with the statement 'I enjoy reflecting' (p<0.05). Emerging themes included time, uncertainty, blood, balance and family. We were struck by the depth, and beauty, of some of their work (see: www.drawing4reflection.info). Conclusions: Students enjoyed, and engaged with, the drawing for reflection workshop, and expressing difficulties graphically helped many make better sense of their experiences.
Take-home messages: Guided drawing stimulates personal reflection quickly and effectively, and may improve students' attitude to reflection in general.
ePortfolios in undergraduate medical education: does engagement predict performance?
Laura-Jane E Smith (University College London, Academic Centre for Medical Education, 4th Floor Holborn Union Building, Highgate Hill, London N19 5LW, United Kingdom)
Rosie Belcher (University College London Medical School, Academic Centre for Medical Education, London, United Kingdom)
Deborah Gill (University College London Medical School, Academic Centre for Medical Education, London, United Kingdom)
Background: Eportfolios are a core component of postgraduate medical education and training. Increasingly, undergraduates mirror postgraduates in the use of ePortfolios. ePortfolio assessment is usually a combination of grading individual components and a measure of engagement with the ePortfolio through setting a minimum content list. Anecdotally it has been claimed that engagement with an ePortfolio is a predictor for other outcomes such as performance in end of year written and OSCE examinations. Summary of work: We created a matrix to score ePortfolio engagement, including measures of students' use of compulsory and non-compulsory elements of the ePortfolio, and the students' organization of contents. We assessed 90 undergraduate ePortfolios and compared engagement scores to end of year summative assessment scores.
Summary of results: Mean engagement score was 5.4±1.75 (max 14). No correlation was found between engagement score and overall summative assessment results (r=0.11, p=0.31), or individual components of the engagement matrix.
Conclusions: As ePortfolio use increases in undergraduate medical education, caution must be exercised to ensure they are not used as surrogates of other outcomes without a robust evidence-base. The ePortfolio project is a collaboration between several medical schools. We plan to extend this study to
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investigate whether different types of engagement in other schools predicts outcomes in other assessments. Take-home messages: In this study there was no correlation between engagement with an ePortfolio as measured by a novel engagement score, and end of year summative assessment performance. A focus on maximising the benefit students can get from ePortfolio use in relation to formative assessment and lifelong learning skills is advisable.
A reflective logbook in a clinical undergraduate emergency medicine course
Arvid Puranen (Uppsala University, Medical Sciences, Uppsala, Sweden)
Martin Wohlin (Uppsala University, Medical Sciences, Uppsala, Sweden)
Background: Reflection in medical education as a means to prepare students for the complexity of medical practice is gaining increasing support. A variety of approaches are employed today, but evidence is scarce about how to best teach and encourage reflection in medical education. In particular, how to effectively facilitate reflection in daily practice at students' clinical rotations is largely unexplored.
Summary of work: We developed a paper-based semi-structured reflective logbook for students in a third year clinical emergency medicine course. The logbook included instructions and information on reflection and three weeks of daily "rounds" where assignments were ordered after increasing complexity. The last assignment involved writing an essay by expanding on reflections accumulated during the daily work with the logbook. To facilitate workability, the logbook was printed in a pocket format. Students volunteered to work with the logbook during a three week rotation at an emergency medicine unit. The logbooks and the essays were collected after completion of the course. Student opinions were evaluated by a questionnaire as well as by focus group interviews.
Summary of results: Work in progress. Results expected by May 2013.
Conclusions: Work in progress. Results expected by May
Take-home messages: Work in progress. Results expected by May 2013.
Taking the learning beyond the individual
Fiona Muir (University of Dundee, Tayside Centre for General Practice, Centre for Undergraduate Medicine, The Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, United Kingdom)
Mairi Scott (University of Dundee, Tayside Centre for General Practice, Centre for Undergraduate Medicine , Dundee, United Kingdom)
Kevin McConville (University of Dundee, Tayside Centre for General Practice, Centre for Undergraduate Medicine, Dundee, United Kingdom)
Background: This new post graduate inter-professional Diabetes Care and Education Master Degree programme designed by the University of Dundee & NHS Tayside, in partnership with the Dasman Diabetes Institute, Kuwait enables those working in the field of diabetes care to gain sound evidence-based knowledge of the clinical, education and organisational components associated with modern diabetes care. A key element within each module is to develop the student's reflective ability. Students are expected to reflect on practice and demonstrate their learning as part of each module assessment.
Summary of work: A case study using focus group interviews and documentary data examination was carried out to explore students' perceptions of the value of reflection within a post graduate degree programme in Kuwait. The purpose of this research was to explore its application to practice through the implementation of a Masters post-graduate programme and realise how innovative teaching interventions inform change in professional practice. Summary of results: Preliminary findings suggest that feedback from students is positive. Through organised, structured and assessed reflective learning the modules within the programme are valued. The learning provides useful information and support to the student, highlighting the role which reflection plays to enhance personal and professional development; the value of educational theory; continuing professional development; collaboration; enhancing patient education and practice.
Conclusions: Students in Kuwait value the opportunity to enhance their learning. Take-home messages: One of the key roles this education provides is for students to develop personally and professionally.