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Background: Comparing outcome of clinical skills assessment is challenging. This study proposes reliable and valid comparison of communication skills (1) assessment as practiced in Objective Structured Clinical Examinations (2). The aim of the present study is to compare CS assessment, as standardized according to the MAAS Global, between stations in a single undergraduate medical year., Methods: An OSCE delivered in an Irish undergraduate curriculum was studied. We chose the MAAS-Global as an internationally recognized and validated instrument to calibrate the OSCE station items. The MAAS-Global proportion is the percentage of station checklist items that can be considered as 'true' CS. The reliability of the OSCE was calculated with G-Theory analysis and nested ANOVA was used to compare mean scores of all years., Results: MAAS-Global scores in psychiatry stations were significantly higher than those in other disciplines (p<0.03) and above the initial pass mark of 50%. The higher students' scores in psychiatry stations were related to higher MAAS-Global proportions when compared to the general practice stations., Conclusion: Comparison of outcome measurements, using the MAAS Global as a standardization instrument, between interdisciplinary station checklists was valid and reliable., Practice Implications: The MAAS-Global was used as a single validated instrument and is suggested as gold standard., (Copyright © 2017. Published by Elsevier B.V.)

Background: Communication skills (CS) are commonly assessed using 'communication items' in Objective Structured Clinical Examination (OSCE) station checklists. Our aim is to calibrate the communication component of OSCE station checklists according to the MAAS-Global which is a valid and reliable standard to assess CS in undergraduate medical education., Method: Three raters independently compared 280 checklists from 4 disciplines contributing to the undergraduate year 4 OSCE against the 17 items of the MAAS-Global standard. G-theory was used to analyze the reliability of this calibration procedure., Results: G-Kappa was 0.8. For two raters G-Kappa is 0.72 and it fell to 0.57 for one rater. 46% of the checklist items corresponded to section three of the MAAS-Global (i.e. medical content of the consultation), whilst 12% corresponded to section two (i.e. general CS), and 8.2% to section one (i.e. CS for each separate phase of the consultation). 34% of the items were not considered to be CS., Conclusion: A G-Kappa of 0.8 confirms a reliable and valid procedure for calibrating OSCE CS checklist items using the MAAS-Global. We strongly suggest that such a procedure is more widely employed to arrive at a stable (valid and reliable) judgment of the communication component in existing checklists for medical students' communication behaviours., Practice Implications: It is possible to measure the 'true' caliber of CS in OSCE stations. Students' results are thereby comparable between and across stations, students and institutions. A reliable calibration procedure requires only two raters., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Background: Eight skills laboratories (skillslabs) were established by consensus of Vietnamese medical universities, with international support. A national list of basic skills needed for medical practice and suitable for skillslab training was developed; models, medical and teaching equipment were supplied; learning material was developed and core staff and teachers were trained. This study was designed to assess how closely eight schools in Vietnam came to implementing all recommended skills on list developed by educators of that country, and identify the facilitating factors and barriers to skillslab use within the country's largest school., Methods: Data were collected from reports from the eight skillslabs. Students and trainers from the largest university were surveyed for their perceptions of the quality of training on eight selected skills. Results of students' skill assessments were gathered, and focus group discussions with trainers were conducted. SPSS 16 was used to analyze the quantitative data and cluster analysis was used to test for differences., Results: Only one medical school was able to train all 56 basic skills proposed by consensus among the eight Vietnamese medical universities. Deeper exploration within the largest school revealed that its skillslab training was successful for most skills, according to students' postprogram skills assessment and to students' and trainers' perceptions. However, through focus group discussions we learned that the quantity of training aids was perceived to be insufficient; some models/manikins were inappropriate for training; more consideration was needed in framing the expected requirements of students within each skill; too little time was allocated for the training of one of the eight skills investigated; and further curriculum development is needed to better integrate the skills training program into the broader curriculum., Discussion: The fact that one medical school could teach all skills recommended for skillslab training demonstrates that all Vietnamese schools may be similarly able to teach the basic skills of the national consensus list. But as of now, it remains challenging for most schools in this developing country to fully implement a national skillslab training program.

Background: Physicians consider breaking bad news (BBN) a difficult task, and training is therefore necessary. There is much variety in what schools consider to be best practice and best timing for such training. This article discusses BBN-programmes at the Dutch medical schools. We studied how students value their training and offer recommendations., Methods: We developed two questionnaires to obtain programme information from course co-ordinators and student opinions about BBN-training. We compared student opinions right after BBN-training (T1) and towards the end of the medical curriculum (T2)., Results: BBN-programmes in Dutch medical schools vary in timing, models used and training methods. Overall, students are satisfied with the timing. They appreciate feedback by physicians and simulated patients most. At T2, some groups of students reported that BBN-training had given them slightly less guidance than was reported by T1-students at the same institution., Discussion: T2-students perhaps realised they had not received the amount of support they needed and may have shifted from being unconsciously incompetent to being consciously incompetent., Recommendations: We recommend: (a) longitudinal programmes with experiential skills-training sessions and clinical practice, (b) to involve simulated patients, physicians and psychologists in training programmes as well as practising physicians who supervise students during clinical work and (c) to ensure ongoing support and feedback in the clinical phase.

Background: The role of deliberate practice in medical students' development from novice to expert was examined for preclinical skill training., Methods: Students in years 1-3 completed 34 Likert type items, adapted from a questionnaire about the use of deliberate practice in cognitive learning. Exploratory factor analysis and reliability analysis were used to validate the questionnaire. Analysis of variance examined differences between years and regression analysis the relationship between deliberate practice and skill test results., Results: 875 students participated (90%). Factor analysis yielded four factors: planning, concentration/dedication, repetition/revision, study style/self reflection. Student scores on 'Planning' increased over time, score on sub-scale 'repetition/revision' decreased. Student results on the clinical skill test correlated positively with scores on subscales 'planning' and 'concentration/dedication' in years 1 and 3, and with scores on subscale 'repetition/revision' in year 1., Conclusions: The positive effects on test results suggest that the role of deliberate practice in medical education merits further study. The cross-sectional design is a limitation, the large representative sample a strength of the study. The vanishing effect of repetition/revision may be attributable to inadequate feedback. Deliberate practice advocates sustained practice to address weaknesses, identified by (self-)assessment and stimulated by feedback. Further studies should use a longitudinal prospective design and extend the scope to expertise development during residency and beyond.

Background: The use of adolescents as standardized patients (SPs) in medical education has scarcely been reported. We evaluated the views of teachers, students and adolescent SPs with regard to the adolescent SP program in our under graduate curriculum and the changes that were made to the program in the past five years (from 2002-2003 until 2006-2007)., Method: Adolescent girls were recruited to portray roles of adolescents asking their general practitioner for an oral contraceptive.Students rated the quality of the adolescent SPs? role performance and feedback on a validated questionnaire (the MaSP). Both adolescent SPs and faculty teachers completed questionnaires on their experiences., Results: Over the past five years, 201 to 341 students gave the adolescent SPs? general performance a mean mark that varied from 7.5 to 8 out of 10. Generally, evaluations by teachers and adolescent SPs about the adolescent SP program were also very positive.The quality of the feedback by adolescent SPs has shown improvement over the past five years, although adolescents find it quite difficult to give feedback., Conclusions: Teachers, students and adolescent SPs have highly valued the adolescent SP program over the past five years.The program has been changed on the basis of the lessons learned and has become mature.

Objectives: The lack of published studies into effective skills teaching in clinical skills centres inspired this study of student views of the teaching behaviours of skills teachers., Methods: We organised focus group discussions with students from Years 1-3 of a 6-year undergraduate medical curriculum. A total of 30 randomly selected students, divided into three groups, took part in two sessions. They discussed what teaching skills helped them to acquire physical examination skills., Results: Students' opinions related to didactic skills, interpersonal and communication skills and preconditions. Students appreciated didactic skills that stimulate deep and active learning. Another significant set of findings referred to teachers' attitudes towards students. Students wanted teachers to be considerate and to take them seriously. This was reflected in student descriptions of positive behaviours, such as: 'responding to students' questions'; 'not exposing students' weaknesses in front of the group', and '[not] putting students in an embarrassing position in skill demonstrations'. They also appreciated enthusiasm in teachers. Important preconditions included: the integration of skills training with basic science teaching; linking of skills training to clinical practice; the presence of clear goals and well-structured sessions; good time management; consistency of teaching, and the appropriate personal appearance of teachers and students., Conclusions: The teaching skills and behaviours that most facilitate student acquisition of physical examination skills are interpersonal and communication skills, followed by a number of didactic interventions, embedded in several preconditions. Findings related to interpersonal and communication skills are comparable with findings pertaining to the teaching roles of tutors and clinical teachers; however, the didactic skills merit separate attention as teaching skills for use in skills laboratories. The results of this study should be complemented by a study performed in a larger population and a study exploring teachers' views.

Clerkships would benefit from teachers' improved understanding of the didactic aspects of their task. The purpose of this study is to identify factors that determine the teaching quality of clerkships and to examine the predictive value of these factors for students' global satisfaction. Thus, results would be further reflected to clinical teachers' tasks. These factors could then be taken into account in future clinical teaching. In this paper, a medical faculty's 2 year data set of student feedback from a systematic programme evaluation project was used. A factor analysis was performed on 11,780 student questionnaires. Factor loads, and the Cronbach's alpha coefficients of the questionnaire and factors were calculated. In order to examine the contributions of the factors to the students' global satisfaction, the study included a multivariate stepwise regression analysis. The analysis revealed four factors, which together explained 60.24% of the variance: Structure & Process (44.66%); Time (5.8 %); Outcome (5.35%) and Input (4.39%). The Structure & Process factor was found to be the best predictor of students' global satisfaction (R2 =( ).537). Our conclusion is that "efforts to improve clerkship quality should focus on students' learning processes and clerkship structure".

Context: The use of simulated patients (SPs) in teaching communication and practical skills at medical schools is mostly limited to single-case use: a student has 1 consultation with an SP and receives feedback afterwards. Very little literature is available that describes consecutive consultations between the same student and SP. In this study, we explored the experiences of SPs in a new, longitudinal SP programme in which SPs met the same Year 3 students ('GP') in 4 consecutive consultations during the year. The SPs suffered from a chronic disease in their patient roles., Methods: Four focus group discussions were conducted with 23 SPs (8 men, 15 women; average age 60.9 years) who had performed in the new programme. Discussions were semi-structured and followed a pre-established interview guide. Data were categorised by 3 independent raters., Results: The SPs described the development of a more familiar relationship with students under the new programme, compared with single-case consultations. They developed specific expectations of students' performances. The SPs enjoyed participating in the programme and felt it was more realistic than single-case consultations. Feedback changed and became more detailed as SPs were able to compare consultations; students' response to feedback could be experienced during the next consultation., Discussion: Practising the development of a realistic, longitudinal doctor-patient relationship may help prepare students for real practice. Longitudinal feedback is now possible; it may be of higher quality and of benefit to SPs as well. These findings suggest new possibilities for SP-based education and research. Future studies should focus on quantitative analysis and students' perspectives.

Objective: Previous studies have shown that people who act as simulated patients (SPs) experience negative effects caused by performing patient roles. This study was performed to further explore the impact of simulation and the factors that might affect this impact. The aim was to find ways of preventing negative effects of simulation impacting on our SPs., Methods: Focus groups interviews were conducted among 35 SPs at Skillslab, University of Maastricht. The discussion was guided by 6 pre-established items., Results: The majority of the SPs appeared to experience negative effects of performing a patient role. The effects were considered as inherent to acting as an SP or due to simulation being a strenuous activity. The impact was short-lived and did not affect SPs' enjoyment of their work. Factors that appeared to affect the impact of performing included: the type of role (whether it is emotionally complex or not); the number of consecutive performances; the length of time between performances; the giving of feedback; the amount of experience, and students., Discussion: Although the SPs were found to experience negative effects caused by playing patient roles, the frequency and intensity of the negative effects were minor. The focus group discussions led to various suggestions for measures to reduce the impact of simulation.

Rationale: Although the Basic Life Support (BLS) ability of a medical student is a crucial competence, poor BLS training programs have been documented worldwide. Better training designs are needed. This study aims to share detailed descriptions and the test results of two cognitive-constructivist training models for the BLS skills in the first year of medical curriculum., Method: A BLS skills training module was implemented in the first year curriculum in the course of 6 years (1997-2003). The content was derived from the European Resuscitation Council Guidelines. Initially, a competence-based model was used and was upgraded to a cognitive apprenticeship model in 2000. The main performance-content type that was expected at the end of the course was: competent application of BLS procedures on manikins and peers at an OSCE as well as 60% achievement in a test consisting of 25 MCQ items. A retrospective cohort survey design using exam results and a self-completed anonymous student ratings' questionnaire were used in order to test models., Results: Training time for individual students varied from 21 to 29 hours. One thousand seven hundred and sixty students were trained. Fail rates were very low (1.0-2.2%). The students were highly satisfied with the module during the 6 years., Conclusion: In the first year of the medical curriculum, a competence-based or cognitive apprenticeship model using cognitive-constructivist designs of skills training with 9 hours theoretical and 12-20 hours long practical sessions took place in groups of 12-17 students; medical students reached a degree of competence to sufficiently perform BLS skills on the manikins and their peers. The cognitive-constructivist designs for skills training are associated with high student satisfaction. However, the lack of controls limits the extrapolation of this conclusion.

Purpose: To evaluate the effectiveness of undergraduate medical education in the domains of psychiatry and behavioural sciences, we examined the growth of knowledge in those disciplines in a 6-year, problem-based learning (PBL) curriculum. Psychiatry and behavioural sciences are taught in the 4 preclinical years and in the psychiatric clerkship. The integrative nature of this PBL curriculum led us to hypothesise that the knowledge growth curves for these disciplines are similar and show a steady upward trend throughout the curriculum., Methods: All items pertaining to psychiatry and behavioural sciences in the progress tests administered in the period from September 1993 through May 2001 were identified. For those items, the percentage of correct scores in the 6 year groups were considered a multivariate observation reflecting knowledge growth across the 6-year programme., Results: Knowledge growth for psychiatry and behavioural sciences increased significantly, from 12% to 59% and from 28% to 60%, respectively, between Year 1 and the end of Year 6. Apparently, students know more about behavioural sciences than about psychiatry when they enter medical school, but this difference vanishes in the last 2 years of training. Moreover, the growth curves for psychiatry and behavioural sciences started to level off after Years 3 and 4, respectively, with no additional significant growth in any of the later years., Conclusions: Psychiatry and behavioural sciences showed different patterns of knowledge growth and the 2 growth curves levelled off in Years 5 through 6. Because a student-centred, horizontally and vertically integrated PBL curriculum is aimed at effecting steady growth in knowledge in all disciplines, the slowdown in growth in the later years was among the reasons for initiating a major curricular innovation in 2001.

Introduction: During the first 4 years of the 6-year undergraduate medical curriculum at Maastricht University, the Netherlands, students practise clinical skills in simulated patient (SP) encounters at the Skillslab. Generally, these encounters are instructive and enjoyable for both students and SPs. However, in conversations with SP trainers, some SPs have mentioned experiencing adverse symptoms due to performing a patient role. Some published studies have reported similar findings in SPs. We explored the seriousness of this problem by surveying SPs on the occurrence and severity of stress symptoms related to performing patient roles. We also examined by which variables the symptoms were influenced., Methods: An anonymous questionnaire was developed to investigate factors related to stress symptoms and the frequency and severity of stress symptoms. A burnout scale was also included in the questionnaire. All SPs who had performed between March 2000 and March 2001 were asked to participate., Results: The response rate was 84%. Of the SPs, 73% were found to have experienced stress symptoms, with a mean of 4 symptoms per SP. No significant correlations were found between the occurrence of symptoms on the one hand and factors that might influence symptoms or the burnout scale on the other hand., Discussion: An unexpectedly high number of SPs reported symptoms. Fortunately, the symptoms were relatively mild (2.2 on a 5-point scale). Future studies should address the connection between work as an SP and symptoms, and measures should be taken to prevent and treat the symptoms. Debriefing sessions might play a role in this respect.

Context: For more than two decades the Medical School in Maastricht, the Netherlands, has used simulated patients (SPs) to provide students with opportunities to practise their skills in communication and physical examination. In this educational setting a student meets a SP in a videotaped session. Feedback by the SP to the student at the end of the session is considered an important educational feature. We found no instruments to assess individual SP performance during those sessions., Objective: To develop a valid, reliable and feasible instrument to evaluate the performance of SPs., Methods: The content of the instrument was validated through interviews with students, teachers and experts who are involved with SPs. They were asked to indicate key features of good SP performance. Based on the interviews, a written checklist was developed to measure individual SP performance. The instrument was evaluated in a regular SP session at the medical school, involving 152 students and their teachers., Main Outcomes: All interviewees considered the scale to be satisfactory and the instrument to be valid. The feasibility and reliability of the checklists were investigated using the data of 398 returned checklists. Cronbach's alpha was found to be 0.73. Generalizability analysis showed that 12 completed checklists were required to obtain a reliable assessment of one SP., Conclusions: The Maastricht Assessment of Simulated Patients (MaSP) appears to be a valid, reliable and feasible tool to assess the performance of SPs in an educational setting.

Aim: This study was conducted to investigate the value of a written knowledge test of communication skills for predicting scores on a performance test of communication skills., Method: A paper-and-pencil test of knowledge about communication skills and a performance test of communication skills, consisting of four stations with standardised patients, were administered to students of two classes of the medical schools of Maastricht and Leiden, the Netherlands. The results on these tests were compared., Results: From the results of both instruments, the classes of the participating students could be recognised equally well: 60% correct qualifications of the classes by the knowledge test and 64% by the multiple station examination. Between the two tests an overall, disattenuated correlation of 0.60 was found (N=133, P < 0.01), suggesting moderate predictive value of the knowledge test for the performance test of communication skills. The correlation is stronger for students from Maastricht medical school than for their colleagues in Leiden. Correlation between the knowledge of communication skills test and other available test results of the participating Maastricht students is close to zero, suggesting that the test measures a distinct quality of students' competence., Discussion: The paper-and-pencil test of knowledge of communication skills has predictive value for the performance of these skills, but this value seems to be less pronounced than similar findings for clinical procedural skills. The stronger relationship between 'knowing how' and 'showing' in the Maastricht student group might be indicative of an effect of the training format.

Aim of the Study: The communication skills of students of the Dutch medical schools of Maastricht and Leiden were compared, to assess the effectiveness of these schools' different approaches to communication skills training. Both schools have a six-year undergraduate medical curriculum, divided into four preclinical years and two years of clinical clerkships. The Maastricht problem-based curriculum offers an integrated clinical skills training programme, including communication skills, which runs throughout the first four years. Communication skills training in Leiden is concentrated in courses in the preclinical phase, at the beginning of the clinical phase and preceding two clerkships., Method: Communication skills of fourth-year and sixth-year students (N = 161) of both universities were assessed using four OSCE stations in which students did entire consultations with standardised patients. Trained observers rated these consultations, using a checklist., Results: Maastricht students of both year groups obtained significantly higher checklist scores for their communication skills than their Leiden colleagues. The Leiden students' scores increase between years 4 and 6, whereas those of the Maastricht students showed no significant change., Discussion: The higher scores obtained by the Maastricht students indicate a greater overall effectiveness of a longitudinal, integrated approach compared with concentrated courses. Absence of formal training in the clinical phase in Maastricht leads to stabilisation of communication skills, whereas the increase in the Leiden students' scores between years 4 and 6 offers evidence that formal communication skills training during the clinical phase does pay off. These findings suggest that the preferred approach to communication skills training would be an integrated, longitudinal programme, which continues during the clinical years.

In the Skillslab at Maastricht Medical School students are prepared for their first encounters with patients. Students can focus on individual skills, separately mastering each skill in a controlled systematic manner. With this foundation students are better equipped to face the complex intellectual and emotional demands of real patients. A large proportion of training concerns communication skills. Features of Skillslab communication skills training programme are: (1) its continuity (once every 2 weeks, from year 1 to year 6); (2) a gradual increase of complexity in skills (basic interview skills, phases of interviews, entire interviews, problem patients); (3) a gradual increase of complexity in practice situations (apparatus, role-playing, simulated patients, real patients). Evaluation shows students' and teachers' satisfaction with the programme. Comparison with conditions required for interpersonal skills training shows that these are fully met. However, there are drawbacks, which are described.