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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. [ABSTRACT FROM AUTHOR]

Context The clinical learning climate affects undergraduate medical students’ behaviour, satisfaction and success. Most studies predominantly describe aspects of the clinical learning climate using quantitative methodologies, such as questionnaires. This study aimed to illuminate medical students’ perceptions of the clinical learning climate, and which factors and their interactions explain differences in clinical learning climates. Methods We carried out a multi-method case study. Twelve departments of obstetrics and gynaecology distributed the Postgraduate Hospital Educational Environment Measure (PHEEM), a reliable questionnaire measuring the clinical learning environment, among medical students. After analysis (usinganova and post hoc tests), 14 medical students from the highest- and lowest-scoring departments participated in semi-structured interviews. We analysed the transcribed recordings using a content analysis approach. Researchers agreed on coding and an expert group reached consensus on the themes of the analysis. Results We found a significant difference between departments in PHEEM scores. The interviews indicated that department and medical student characteristics determine the clinical learning climate. For departments, ‘legitimacy’, ‘clerkship arrangements’ and ‘focus on personal development’ were the main themes. For medical students, ‘initial initiatives’, ‘continuing development’ and ‘clerkship fatigue’ were the principal themes. The amount and nature of participation played a central role in all themes. Conclusions Differences between clinical learning climates appear to be related to differing approaches to participation among departments. Participation depends on characteristics of both departments and students, and the interactions among them. The outcomes give valuable clues to how a favourable clinical learning climate is shaped. [ABSTRACT FROM AUTHOR]

Objective To test hypotheses regarding the longitudinal effects of problem-based learning (PBL) and conventional learning relating to students’ appreciation of the curriculum, self-assessment of general competencies, summative assessment of clinical competence and indicators of career development. Methods The study group included 2 complete cohorts of graduates who were admitted to the medical curriculum in 1992 (conventional curriculum, n = 175) and 1993 (PBL curriculum, n = 169) at the Faculty of Medicine, University of Groningen, the Netherlands. Data were obtained from student records, graduates’ self-ratings and a literature search. Gender and secondary school grade point average (GPA) scores were included as moderator variables. Data were analysed by a stepwise multiple and logistic regression analysis. Results Graduates of the PBL curriculum scored higher on self-rated competencies. Contrary to expectations, graduates of the PBL curriculum did not show more appreciation of their curriculum than graduates of the conventional curriculum and no differences were found on clinical competence. Graduates of the conventional curriculum needed less time to find a postgraduate training place. No differences were found for scientific activities such as reading scientific articles and publishing in peer- reviewed journals. Women performed better on clinical competence than did men. Grade point average did not affect any of the variables. Conclusions The results suggest that PBL affects self-rated competencies. These outcomes confirm earlier findings. However, clinical competence measures did not support this finding. [ABSTRACT FROM AUTHOR]

Objective To determine the differential effects of a paper-based versus a web-based portfolio in terms of portfolio quality, user-friendliness and student motivation. Methods An experimental design was used to compare Year 1 medical students' reflective portfolios. The portfolios differed in presentation medium only (i.e. web-based versus paper-based). Content analysis, a student questionnaire and mentor interviews were used to evaluate portfolio quality, user-friendliness and student motivation. A total of 92 portfolios were scored independently by 2 raters using a portfolio quality-rating instrument. Results Portfolio structure, quality of reflection and quality of evidence showed no significant effects of presentation medium. Multi-level analysis showed a significant effect for student motivation: web-based portfolios scored 0.39 more than paper-based portfolios ( P < 0.05; effect size 0.76). The mentors reported no differences in portfolio quality, except that there were more visuals in web-based portfolios. Students spent significantly more time preparing the web-based than the paper-based portfolios (15.4 hours versus 12.2 hours; t = 2.1, P < 0.05; effect size 0.46). The 2 student groups did not differ significantly in terms of their satisfaction with the portfolio. The mentors perceived the web-based portfolios as more user-friendly. Conclusions The web-based portfolios were found to enhance students' motivation, were more user-friendly for mentors, and delivered the same content quality compared with paper-based portfolios. This suggests that web-based presentation may promote acceptance of portfolios by students and teachers alike. [ABSTRACT FROM AUTHOR]

Context We addressed the assessment of professional behaviour in tutorial groups by investigating students' perceptions of the frequency and impact of critical incidents that impede this assessment and 5 factors underlying these critical incidents. Methods A questionnaire asking students to rate the frequency and impact of 40 critical incidents relating to effective assessment of professional behaviour on a 5-point Likert scale was developed and sent to all undergraduate medical students in Years 2–4 of a 6-year undergraduate curriculum. Results The response rate was 70% ( n = 393). Important factors underlying critical incidents are: lack of effective interaction; lack of thoroughness; tutors' failure to confront students with unprofessional behaviour; lack of effort to find solutions, and lack of student motivation. Confirmatory factor analysis showed a good model fit. Because the relationship between frequency of occurrence and degree of impediment varies, the best information about the true impact of critical incidents and the underlying factors is provided by the product of frequency and degree of impediment. Frequency of occurrence remains stable and degree of impediment increases in Years 2–4. Conclusions The results of this study can be used to design and improve faculty development programmes aimed at improving assessment of professional behaviour. Training programmes should motivate tutors by providing background information as to why and how sound assessment of professional behaviour is to be performed and encourage tutors to confront students with and discuss all aspects of professional behaviour, as well as provide appropriate feedback. [ABSTRACT FROM AUTHOR]

Purpose To ascertain whether the grade point average (GPA) of school-leaving examinations is related to study success, career development and scientific performance. The problem of restriction of range was expected to be partially reduced due to the use of a national lottery system weighted in favour of students with higher GPAs. Method We studied the students ( n = 398) admitted to the Faculty of Medicine, University of Groningen, the Netherlands in 1982 and 1983. Data concerning drop-out and study progress were derived from the student administration. Data about career development were obtained from annual interviews with graduates ( n = 318) between 1993 and 2000. Literature searches yielded data concerning scientific performance. Multiple linear regression and logistic regression were used to analyse the data. The variables ‘gender’ and ‘cohort’ and their interaction were included in the analyses to account for variation in the general level of the dependent variable and the effect of GPA on the dependent variable. Results GPA scores had no effect on drop-out rate. High GPA scores were associated with significantly less time to graduation, more chance of a preferred placement for specialist training and higher scientific output. GPA was not related to income. Gender differences were found for study duration and scientific output. Women graduated earlier and published less. Conclusion The GPA of school-leaving examinations was found to be related to study success, career development and scientific performance. In this study the usual problem of restriction of range was shown to be absent. The weighted lottery procedure even resulted in an over-dispersion of candidates relative to the applicants. The resulting effect sizes were in agreement with those reported in other studies. [ABSTRACT FROM AUTHOR]

Context The portfolio is becoming increasingly accepted as a valuable tool for learning and assessment. The validity of portfolio assessment, however, may suffer from bias due to irrelevant qualities, such as lay-out and writing style. We examined the possible effects of such qualities in a portfolio programme aimed at stimulating Year 1 medical students to reflect on their professional and personal development. In later curricular years, this portfolio is also used to judge clinical competence. Methods We developed an instrument, the Portfolio Analysis Scoring Inventory, to examine the impact of form and content aspects on portfolio assessment. The Inventory consists of 15 items derived from interviews with experienced mentors, the literature, and the criteria for reflective competence used in the regular portfolio assessment procedure. Forty portfolios, selected from 231 portfolios for which ratings from the regular assessment procedure were available, were rated by 2 researchers, independently, using the Inventory. Regression analysis was used to estimate the correlation between the ratings from the regular assessment and those resulting from the Inventory items. Results Inter-rater agreement ranged from 0.46 to 0.87. The strongest predictor of the variance in the regular ratings was ‘quality of reflection’ (R 0.80; R2 66%). No further items accounted for a significant proportion of variance. Irrelevant items, such as writing style and lay-out, had negligible effects. Conclusions The absence of an impact of irrelevant criteria appears to support the validity of the portfolio assessment procedure. Further studies should examine the portfolio's validity for the assessment of clinical competence. [ABSTRACT FROM AUTHOR]

Objective To explore student perceptions of factors contributing to the effectiveness of discussions in the reporting phase of the problem-based learning (PBL) process, where students report and synthesise the results of self-study. Methods Forty-eight Year 1 and 2 medical students participated in 6 focus group interviews about the characteristics of effective group discussions and possible improvements. The data were analysed qualitatively in several stages. Results The analysis yielded 4 main characteristics of effective discussions: asking for, giving and receiving explanations; integrating and applying knowledge; discussing differences with regard to learning content, and guiding and monitoring the content and the group process of the discussion. Integrating and applying knowledge included structuring, relating and summarising information and providing examples from practice. Discussing different opinions included discussing a variety of literature resources and disagreements. The main learning effects mentioned by the students were retention, understanding, integration and application of knowledge. Conclusions Students have clear ideas about what promotes effective discussions during the reporting phase. Their PBL experience has provided them with some insights that are in line with theory and research on collaborative learning. Future research should examine differences between student and tutor perceptions of the quality of discussions. Introductions to PBL for students and tutors should include training in asking open but focused questions, supporting explanations with arguments and dealing with conflicts about learning content. Tutors should be trained in giving effective and personal feedback. Collaborative creation of external knowledge representations (i.e. concept maps) should be advocated, as should variety of literature resources. [ABSTRACT FROM AUTHOR]

Objective To investigate the effects of a virtual learning environment (VLE) on group interaction and consultation of information resources during the preliminary phase, self-study phase and reporting phase of the problem-based learning process in an undergraduate medical curriculum. Methods A questionnaire was administered to 355 medical students in Years 1 and 2 to ask them about the perceived usefulness of a virtual learning environment that was created with Blackboard for group interaction and the use of learning resources. Results The students indicated that the VLE supported face-to-face interaction in the preliminary discussion and in the reporting phase but did not stimulate computer-mediated distance interaction during the self-study phase. They perceived that the use of multimedia in case presentations led to a better quality of group discussion than if case presentations were exclusively text-based. They also indicated that the information resources that were hyperlinked in the VLE stimulated the consultation of these resources during self-study, but not during the reporting phase. Conclusions Students indicated that the use of a VLE in the tutorial room and the inclusion of multimedia in case presentations supported processes of active learning in the tutorial groups. However, if we want to exploit the full potential of asynchronous computer-mediated communication to initiate in-depth discussion during the self-study phase, its application will have to be selective and deliberate. Students indicated that the links in the VLE to selected information in library repositories supported their learning. [ABSTRACT FROM AUTHOR]

Background Whether teaching portfolios achieve their aim of stimulating teachers' professional development is favourably affected by the incorporation of a balanced structure and effective social interactions, such as coaching. We explored teachers' experiences with a teaching portfolio that was structured by teaching roles, portfolio assignments and conversation protocols. The related social interactions consisted of meetings with peers and personal coaches. Teachers' and coaches' opinions were sought about the benefits and the enabling and disabling factors of the portfolio structure and the social interactions involved. Method Five teachers and their personal coaches were individually interviewed about their experiences with the portfolio. Protocols were analysed using a top-down strategy. Results The teaching roles were helpful in analysing teaching, but the assignments and the conversation protocols were too detailed and directive. The social interactions were perceived as very valuable for professional development, particularly the meetings with personal coaches. Conclusions The portfolio structure and social interactions, especially personal coaching, appeared to be helpful for teachers in analysing their teaching practice. The assignments and protocols, however, were too detailed and directive. This may be resolved by using assignments and conversation protocols more flexibly and enabling adjustment to personal learning needs. The high appreciation of personal coaching might be related to the freedom for teachers to choose their own coach. The results can be used by portfolio designers as guidelines for how to achieve a balanced structure and effective social interactions and how these might be combined to increase the benefits of working with a portfolio to teachers. [ABSTRACT FROM AUTHOR]

Aim Portfolios are often used as an instrument with which to stimulate students to reflect on their experiences. Research has shown that working with portfolios does not automatically stimulate reflection. In this study we addressed the question: What are the conditions for successful reflective use of portfolios in undergraduate medical education? Methodology/research design We designed a portfolio that was aimed at stimulating reflection in early undergraduate medical education, using experiences described in the medical education literature and elsewhere. Conditions for reflective portfolio use were identified through interviews with 13 teachers (mentors), who were experienced in mentoring students in the process of developing their portfolios. The interviews were analysed according to the principles of grounded theory. Results The conditions for successful reflective use of portfolios that emerged from the interviews fell into 4 categories: coaching; portfolio structure and guidelines; relevant experiences and materials, and summative assessment. According to the mentors, working with a portfolio designed to meet these conditions will stimulate students' reflective abilities. Conclusion This study shows that portfolios are a potentially valuable method of assessing and developing students' reflective skills in undergraduate medical training, provided certain conditions for effective portfolios are recognised and met. Portfolios have a strong potential for enhancing learning and assessment but they are very vulnerable and may easily lead to disappointment. Before implementing portfolios in education, one should first consider whether the necessary conditions can be fulfilled, including an appropriate portfolio structure, an appropriate assessment procedure, the provision of enough new experiences and materials, and sufficient teacher capacity for adequate coaching and assessment. [ABSTRACT FROM AUTHOR]

There are data that suggest that medical students do not feel sufficiently prepared for clinical practice in the clerkships. The transition from pre-clinical to clinical training causes problems. To seek quantitative verification of qualitative findings from an earlier focus group study on problems medical students encounter when entering the clinical phase of undergraduate training. At the start of the clinical phase, all Year 4 students at Maastricht Medical School were surveyed on the transition from pre-clinical to clinical training and its effects on workload, knowledge, skills and learning. The response rate was 67%. Students were uncertain as to how to behave and act, mainly because they did not know what was expected of them. They experienced a drastic increase in workload and a lack of time for studying. They considered themselves to be moderately prepared with regard to knowledge and they regarded their physical examination skills as satisfactory. Students reported having difficulty applying theoretical knowledge in clinical practice and perceived shortcomings in basic science knowledge. In addition, they felt compelled to change their learning strategies. The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education. [ABSTRACT FROM AUTHOR]

Problem-based learning (PBL) is widely used in higher education. There is evidence available that students and faculty are highly satisfied with PBL. Nevertheless, in educational practice problems are often encountered, such as tutors who are too directive, problems that are too well-structured, and dysfunctional tutorial groups. The aim of this paper is to demonstrate that PBL has the potential to prepare students more effectively for future learning because it is based on four modern insights into learning: constructive, self-directed, collaborative and contextual. These four learning principles are described and it is explained how they apply to PBL. In addition, available research is reviewed and the current debate in research on PBL is described. It is argued that problems encountered in educational practice usually stem from poor implementation of PBL. In many cases the way in which PBL is implemented is not consistent with the current insights on learning. Furthermore, it is argued that research on PBL should contribute towards a better understanding of why and how the concepts of constructive, self-directed, collaborative and contextual learning work or do not work and under what circumstances. Examples of studies are given to illustrate this issue. [ABSTRACT FROM AUTHOR]

Junior doctors have reported shortcomings in their general competencies, such as organisational skills and teamwork. We explored graduates' perceptions of how well their training had prepared them for medical practice and in general competencies in particular. We compared the opinions of graduates from problem-based learning (PBL) and non-PBL schools, because PBL is supposed to enhance general competencies.We analysed the responses of 1159 graduates from 1 PBL and 4 non-PBL schools to a questionnaire survey administered 18 months after graduation.Compared with their non-PBL colleagues, the PBL graduates gave higher ratings for the connection between school and work, their medical training and preparation for practice. According to the graduates, the most frequently used competencies with sufficient coverage during medical training were expert knowledge, profession-specific skills and communication skills. The majority of the PBL graduates, but less than half of the non-PBL graduates, indicated that communication skills had been covered sufficiently. All the graduates called for more curriculum attention on working with computers, planning and organisation, and leadership skills. More PBL graduates than non-PBL graduates indicated that they had learned profession-specific methods, communication skills and teamwork in medical school.Overall, the graduates appeared to be satisfied with their knowledge and skills. The results suggest that the PBL school provided better preparation with respect to several of the competencies. However, both PBL and non-PBL graduates identified deficits in their general competencies, such as working with computers and planning and organising work. These competencies should feature more prominently in undergraduate medical education. [ABSTRACT FROM AUTHOR]

We use a utility model to illustrate that, firstly, selecting an assessment method involves context-dependent compromises, and secondly, that assessment is not a measurement problem but an instructional design problem, comprising educational, implementation and resource aspects. In the model, assessment characteristics are differently weighted depending on the purpose and context of the assessment.Of the characteristics in the model, we focus on reliability, validity and educational impact and argue that they are not inherent qualities of any instrument. Reliability depends not on structuring or standardisation but on sampling. Key issues concerning validity are authenticity and integration of competencies. Assessment in medical education addresses complex competencies and thus requires quantitative and qualitative information from different sources as well as professional judgement. Adequate sampling across judges, instruments and contexts can ensure both validity and reliability. Despite recognition that assessment drives learning, this relationship has been little researched, possibly because of its strong context dependence.When assessment should stimulate learning and requires adequate sampling, in authentic contexts, of the performance of complex competencies that cannot be broken down into simple parts, we need to make a shift from individual methods to an integral programme, intertwined with the education programme. Therefore, we need an instructional design perspective.Programmatic instructional design hinges on a careful description and motivation of choices, whose effectiveness should be measured against the intended outcomes. We should not evaluate individual methods, but provide evidence of the utility of the assessment programme as a whole. [ABSTRACT FROM AUTHOR]

Comparisons of anatomy knowledge levels of students from various curricula show either no differences or small differences to the detriment of innovative schools. To pass judgement on the general level of students' anatomy knowledge, we need an absolute standard. The purpose of this study was to compare students' levels of anatomy knowledge as measured by a case-based anatomy test with standards set by different groups of experts.A modified Angoff procedure was used to establish an absolute standard against which the students' results could be evaluated. Four panels of 9 anatomists, 7 clinicians, 9 recent graduates and 9 Year 4 students, respectively, judged 107 items of an anatomy test. The students' results on these items were compared with the standards obtained by the panels.If the standard established by the panel of Year 4 students was used, 64% of the students would fail the test. The standards established by the anatomists, clinicians and recent graduates would yield failure rates of 42%, 58% and 26%, respectively.According to the panels' standards, many students did not know enough about anatomy. The high expectations that the Year 4 students appeared to have of their peers may contribute to students' uncertainty about their level of anatomy knowledge. [ABSTRACT FROM AUTHOR]

Written assessment techniques can be subdivided according to their stimulus format – what the questions asks – and their response format – how the answer is recorded. The former is more important in determining the type of competence being asked for than the latter. It is nevertheless important to consider both when selecting the most appropriate types. Some major elements to consider when making such a selection are cueing effect, reliability, validity, educational impact and resource-intensiveness. Open-ended questions should be used solely to test aspects that cannot be tested with multiple-choice questions. In all other cases the loss of reliability and the higher resource-intensiveness represent a significant downside. In such cases, multiple-choice questions are not less valid than open-ended questions. When making this distinction, it is important to consider whether the question is embedded within a relevant case or context and cannot be answered without the case, or not. This appears to be more or less essential according to what is being tested by the question. Context-rich questions test other cognitive skills than do context-free questions. If knowledge alone is the purpose of the test, context-free questions may be useful, but if it is the application of knowledge or knowledge as a part of problem solving that is being tested, then context is indispensable. Every format has its (dis)advantages and a combination of formats based on rational selection is more useful than trying to find or develop a panacea. The response format is less important in this respect than the stimulus. [ABSTRACT FROM AUTHOR]

To explore learning outcomes from international traineeships for undergraduate medical students. In-depth interviews were conducted with 24 undergraduate medical students at Maastricht University Medical School, the Netherlands. The 24 subjects were selected by purposeful sampling. Students reported meaningful learning outcomes in 6 domains: medical knowledge; skills; international health care organisation; international medical education; society and culture, and personal growth. International traineeships appear to provide good opportunities for students to meet the requirements of globalisation as well as some of the generic objectives of undergraduate medical education. The tentative findings of this study need to be confirmed by further studies. [ABSTRACT FROM AUTHOR]