Medical education

The recent 100-year anniversary of the Flexner review and the release of the Australian Medical Education Study have stimulated vigorous debate about the role of bioscience knowledge in medical education. Two critical questions define debate in this area: does bioscience learning assist in educating medical students to become competent doctors, and, if so, what are the most effective teaching and learning methods to facilitate this outcome? There is tacit acceptance that specific bioscience knowledge is critical for the development of clinical expertise; however, there are few empirical data to support this notion. Two differing theories have been proposed to describe the role of bioscience learning in the development of clinical reasoning skills — the “two-worlds” model and the “encapsulation” model. A series of studies provides support for the encapsulation model. Some medical programs are now integrating bioscience teaching into the clinical years of the course. Evidence of the effectiveness of this on outcomes, such as improved clinical reasoning, is inconclusive.

Geoffrey J McColl MEd, PhD, FRACP · Justin Bilszta BAppSci(Hons), PhD, GradCertUniTeach · Stephen Harrap MB BS, PhD, FRACP

Selection processes for medical schools need to be unbiased, valid, and psychometrically reliable, as well as evidence-based and transparent to all stakeholders. A range of academic and non-academic criteria are used for selection, including matriculation scores, aptitude tests and interviews. Research into selection is fraught with methodological difficulties; however, it shows positive benefits for structured selection processes. Pretest coaching and “faking good” are potential limitations of current selection procedures. Developments in medical school selection include the use of personality tests, centralised selection centres and programs to increase participation by socially disadvantaged students.

Ian G Wilson MB BS, PhD, FRACGP · Christopher Roberts MB ChB, FRACGP, PhD · Eleanor M Flynn MB BS, FRACGP, FRACMA · Barbara Griffin BPsych(Hons), PhD, MAPS

Objectives: To describe the development and uptake of a new self-directed learning program for interns, and to evaluate interns’ attitudes towards the program.Design, setting and participants: Using design-based research methodologies, a facility education program was developed to provide flexible learning options, complement the situated learning that occurs at the bedside and foster the development of self-directed and self-regulated learning behaviour. From 2008 to 2010, interns at a large regional Australian hospital (Townsville Hospital) were required to accrue a minimum 100 continuing medical education (CME) points.Main outcome measures: Mean number of CME points accrued per intern and attitudes of interns towards the CME points system.Results: A total of 30, 39 and 59 interns participated in the program during 2008, 2009 and 2010, respectively. The mean number of points accrued by interns increased from 114 points (range, 60–168; median, 113) in 2008 to 132 points (range, 85–298; median, 127) in 2010. There was a corresponding decrease in failure to accrue 100 points, from 20% of interns (6/30) in 2008 to 8% of interns (5/59) in 2010. Evaluations showed that the majority of interns (surveyed at the end of 2009 [n = 22] and 2010 [n = 46]) liked the flexible learning options of the CME points system, and also felt that the professional development helped them gain better knowledge and skills and develop as a clinician. However, about half of them felt pressured to accrue points.Conclusions: A CME points system is acceptable to and used by interns. This system has the flexibility to be expanded to other junior doctor years and implemented in all Australian facilities to ensure that self-directed and self-regulated learning occurs across the entire prevocational continuum.

Allyson J Agnew MContempSc, GradDipEd, GradCertMedEd · Carl J O’Kane MB BS, FACEM, GradCertClinEd

Objective: To identify the financial costs and benefits associated with teaching in private general practice.Design: Cost–benefit analysis of teaching in private general practice across three levels of training — undergraduate medical training, prevocational training and general practice vocational training — using data from a 2007 survey of general practitioners in South Australia.Setting and participants: GPs and practices teaching in association with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide.Main outcome measure: Net financial outcome per week.Results: The net financial outcome of teaching varied across the training levels. Practices incurred a net financial cost from teaching medical students that was statistically significantly different from zero. With respect to vocational training and teaching junior doctors, there were small net financial benefits to practices, although the mean estimates were not statistically significantly different from zero.Conclusions: This study shows a net financial cost for practices teaching medical students, while at the prevocational and vocational training levels, adequate levels of subsidies and income generated by the trainees help offset the costs of teaching. Our results suggest that a review of subsidies for undergraduate teaching is necessary, particularly as the demand for teaching practices will increase substantially over the next 5 years.

Caroline O Laurence BA(Hons), MHSM, PhD · Linda E Black BA(Psych), DipAppPsych, MAPS · Jonathan Karnon BSc(Hons), MSc, PhD · Nancy E Briggs BSc, MSc, PhD

Objective: To investigate whether interviewer personality, sex or being of the same sex as the interviewee, and training account for variance between interviewers’ ratings in a medical student selection interview.Design, setting and participants: In 2006 and 2007, data were collected from cohorts of each year’s interviewers (by survey) and interviewees (by interview) participating in a multiple mini-interview (MMI) process to select students for an undergraduate medical degree in Australia. MMI scores were analysed and, to account for the nested nature of the data, multilevel modelling was used.Main outcome measures: Interviewer ratings; variance in interviewee scores.Results: In 2006, 153 interviewers (94% response rate) and 268 interviewees (78%) participated in the study. In 2007, 139 interviewers (86%) and 238 interviewees (74%) participated. Interviewers with high levels of agreeableness gave higher interview ratings (correlation coefficient [r] = 0.26 in 2006; r = 0.24 in 2007) and, in 2007, those with high levels of neuroticism gave lower ratings (r = − 0.25). In 2006 but not 2007, female interviewers gave higher overall ratings to male and female interviewees (t = 2.99, P = 0.003 in 2006; t = 2.16, P = 0.03 in 2007) but interviewer and interviewee being of the same sex did not affect ratings in either year. The amount of variance in interviewee scores attributable to differences between interviewers ranged from 3.1% to 24.8%, with the mean variance reducing after skills-based training (20.2% to 7.0%; t = 4.42, P = 0.004).Conclusion: This study indicates that rating leniency is associated with personality and sex of interviewers, but the effect is small. Random allocation of interviewers, similar proportions of male and female interviewers across applicant interview groups, use of the MMI format, and skills-based interviewer training are all likely to reduce the effect of variance between interviewers.

Barbara N Griffin BPsych(Hons), PhD, MAPS · Ian G Wilson MB BS, PhD, FRACGP

Objectives: To evaluate whether the four criteria used by the University of Notre Dame Australia (UNDA) to select medical students are successful in selecting for graduates with the desired outcomes of academic excellence and Catholic “mission fit”.Design, setting and participants: Prospective cohort study of medical students selected for 2008 and 2009 entry to UNDA in Sydney, New South Wales.Main outcome measures: The statistical association between the two academic selection criteria of the Graduate Australian Medical School Admissions Test (GAMSAT) and grade point average (GPA) compared with the outcome of medical school examination performance, and the two mission selection criteria of a portfolio score and interview score compared with the outcome of a positive attitude towards serving underserved communities as measured using the Medical Student Attitudes Toward the Underserved (MSATU) test.Results: A total of 223 students were enrolled. GAMSAT section 3, GPA and the interview scores were significantly positively associated with academic performance (P < 0.05). However, none of the selection variables were significantly associated with a positive attitude towards serving underserved communities, as measured by the MSATU score.Conclusion: None of the four selection tools used were significantly associated with medical students who had a positive attitude towards serving underserved communities.

Julie A Quinlivan MB BS, PhD, FRANZCOG · Lawrence T Lam BSc(Hons), GradDipBiostat, PhD · Siu hong Wan MB ChB, MRCP, FRCP · Rodney W Petersen MB BS, FRANZCOG, MBA

Objective: To investigate the specific factors that graduates perceive to influence their success in obtaining primary training in a chosen field.Design, setting and participants: The New South Wales Medical Registration Board provided data on doctors who were registered to practise between 1995 and 2006. A brief, paper-based survey was sent to a random selection of 2000 doctors. Main outcome measures: Doctors’ self-reported perceptions on the impact of demographic details, specialty training applied for, university training and other factors on opportunities for further training after medical school.Results: Of the 375/1915 doctors (19.6%) who responded, most had completed a 6-year undergraduate degree from the University of Sydney, University of NSW or University of Newcastle, and most were at registrar level. Of 242/321 doctors (76%) who had applied for a training position, 240 (99%) had been accepted. The support of a mentor was considered the most positive influence on meeting long-term career goals (255/318 [80%]). Learning how to communicate with patients was valued as the most helpful aspect of medical school (270/318 [85%]).Conclusion: The personal attributes of graduates were considered more influential in achieving career goals and accessing further training than perceived features of a medical program. This suggests that more emphasis and research should be devoted to selecting the most appropriate candidates, rather than restructuring medical curricula to meet a presumed need for more content knowledge before graduation.

Sarah J Hyde BA(Psych)(Hons) · Pippa L Craig BSc, MHPEd, PhD · Ann J Sefton AO, MB BS, PhD, DSc · Greg L Ryan RN, MA, PhD · Stephanie J Arnold MB BS, BSc(Hons) · Vasi Naganathan MB BS, FRACP, PhD

Objective: To use data from an evaluation of the Flinders University Parallel Rural Community Curriculum (PRCC) to inform four immediate challenges facing medical education in Australia as medical student numbers increase.Design, setting and participants: Thematic analysis of data obtained from focus groups with medical students undertaking the PRCC, a year-long undergraduate clinical curriculum based in rural general practice; and individual interviews with key faculty members, clinicians, health service managers and community representatives from 13 rural general practices and one urban tertiary teaching hospital in South Australia. Data were collected in 2006 and re-analysed for this study in January 2009.Main outcome measures: Participants’ views grouped around the themes of the four identified challenges: how to expand the venues for clinical training without compromising the quality of clinical education; how to encourage graduates to practise in under-served rural, remote and outer metropolitan regions; how to engage in a sustainable way with teaching in the private sector; and how to reverse the current decline in altruism and humanism in medical students during medical school.Results: Participants’ views supported the PRCC approach as a solution to the challenges facing Australian medical education. The enabling capacity of the PRCC’s longitudinal integrated approach to clinical attachments was revealed as a key factor that was common to each of the four themes.Conclusions: The continuity provided by longitudinal integrated clinical attachments enables an expansion of clinical training sites, including into primary care and the private sector. This approach to clinical training also enables students to develop the skills and personal qualities required to practise in areas of need.

Ian D Couper BA, MB BCh, MFamMed · Paul S Worley MB BS, PhD, FACRRM

Objective: To determine the applicant characteristics that influence success at each application stage for entry to the University of Adelaide Medical School.Design, setting and participants: Retrospective analysis of characteristics associated with a successful outcome to an undergraduate-entry medical school for 6699 applicants from four cohorts (2004–2007).Main outcome measures: Offer of an interview, offer of a place, and acceptance of a place in the medical school.Results: Female applicants were less likely to gain an interview (odds ratio [OR], 0.88; 95% CI, 0.78–0.99) but more likely to receive an offer of a place (OR, 1.33; 95% CI, 1.07–1.66). Older applicants were less likely than younger applicants (OR, 0.78; 95% CI, 0.71–0.86) and non-school leavers (applying after leaving school) were more likely than school leavers (applying while at school) (OR, 9.54; 95% CI, 6.16–14.78) to receive an offer of an interview. Applicants from areas of high socioeconomic status were more likely to gain an interview (quartile 1 v 4: OR, 0.55; 95% CI, 0.45–0.68). The more interviews an applicant had, the more likely he or she was to be offered a place (OR, 1.49; 95% CI, 1.34–1.66).Conclusion: This study indicates that some applicant characteristics have a significant influence on the success of an application at particular stages, but overall there does not appear to be a large or inherent systematic bias in the selection process at the University of Adelaide Medical School.

Caroline O Laurence BA(Hons), MHSM, PhD · Deborah A Turnbull MPsych(Clin), PhD, MAPS · Nancy E Briggs BSci, MSci, PhD · Jeffrey S Robinson BSc, MB BCh BAO, FRANZCOG

Objective: Community-based medical education is growing to meet the increased demand for quality clinical education in expanded settings, and its sustainability relies on patient participation. This study investigated patients’ views on being used as an educational resource for teaching medical students.Design: Questionnaire-based survey.Setting and participants: Patients attending six rural and 11 regional general practices in New South Wales over 18 teaching sessions in November 2008, who consented to student involvement in their consultation.Main outcome measures: Patient perceptions, expectations and acceptance of medical student involvement in consultations, assessed by surveys before and after their consultations.Results: 118 of 122 patients consented to medical student involvement; of these, 117 (99%) completed a survey before the consultation, and 100 (85%) after the consultation. Patients were overwhelmingly positive about their doctor and practice being involved in student teaching and felt they themselves played an important role. Pre-consultation, patients expressed reluctance to allow students to conduct some or all aspects of the consultation independently. However, after the consultation, they reported they would have accepted higher levels of involvement than actually occurred.Conclusions: Patients in regional and rural settings were willing partners in developing skills of junior medical students, who had greater involvement in patient consultations than previously reported for urban students. Our study extends the findings from urban general practice that patients are underutilised partners in community-based medical training. The support of patients from regional and rural settings could facilitate the expansion of primary care-based medical education in these areas of workforce need.

J Nicky Hudson BM BS, MSc, PhD · Kathryn M Weston PhD · Elizabeth E Farmer FRACGP, BSc, PhD · Rowena G Ivers FRACGP, MPH, PhD · Russell W Pearson FRACGP, FACRRM

Objective: To ascertain the teaching load of general practices, the capacity for expansion of general practice-based teaching and the support required to achieve this.Design, setting and participants: Questionnaire-based survey of general practitioners and practices who were teaching medical students, junior doctors or GP registrars in partnership with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide in South Australia in 2007.Main outcome measures: Current teaching load of general practices; GPs’ reasons for teaching; capacity of practices to increase teaching loads; and support required to realise practices’ full teaching capacity.Results: In 2007, the 76 practices involved in the survey taught, in total, 326 medical students, 39 junior doctors and 84 GP registrars. Exposing students and doctors to general practice was cited most often by the 194 GP respondents as the reason for teaching. Few practices rated the support payments for teaching as adequate or fairly adequate. A number of practices were able to increase their teaching load within their current levels, with most being able to teach more medical students (39% of practices) or registrars (42% of practices). All practices able to increase their teaching load stated that their capacity to expand was conditional on extra resources, including more physical space, subsidies and teachers.Conclusion: Scope exists to increase teaching in the general practices surveyed and is related to the level, or levels, of teaching undertaken by the practices. Targeted support seems essential if practices are to increase their teaching load.

Caroline O Laurence BA(Hons), MHlthServMg, PhD · Linda E Black BA(Psych), DipAppPsych, MAPS

Major developments in medical education in Australia include increasing the numbers of students and educating more students within the community and in regional, rural and remote settings. Rapid growth of student numbers and the rural orientation of the James Cook University medical school course has meant that northern Queensland had to deal with these issues earlier than other regions. One solution has been to transform some rural hospitals into teaching health services. Two hospitals that have successfully made this transformation, and another on its way, suggest that important factors include local commitment to quality clinical services, medical and academic leadership, coordination of local resources, community support, and strategic links between key organisations. Transformation to a teaching health service involves senior doctors functioning as true consultants with cascading supervision as in the traditional consultant–registrar–resident model. As both clinical and teaching capacity develops, the workforce may stabilise, infrastructure and teaching culture are established, and long-term recruitment and retention strategies emerge. Applying these models in other rural and community settings may make it possible to manage the increased training capacity and address workforce needs without compromising the educational experience — indeed, it may be enhanced.

Tarun K Sen Gupta FRACGP, FACRRM, PhD · Richard B Murray FRACGP, MPHTM, FACRRM · Neil S Beaton MRCGP, DA, FACRRM · David J Farlow FACRRM · Clare B Jukka FACRRM, GCET · Natasha L Coventry BSc, DRANZCOG, FRACGP

To the Editor: Attachments to general practices offer medical students exposure to patients and to the prevention, diagnosis, treatment and palliation of the spectrum of illness in the community. However, medical schools face the challenge of retaining, recruiting, training and supporting teaching practices that can provide high-quality learning experiences for increasing numbers of medical students, and can keep student teaching manageable and rewarding for the general practitioners themselves. We conducted semi-structured interviews with 55 of Brisbane’s practice-based GP teachers, to explore their views about teaching third-year University of Queensland medical students. Interviewees identified a number of rewards and challenges associated with supervising a medical student in the context of the “busyness” and business of everyday general practice (Box). Rewards included the intrinsic joy of teaching and mentoring; the satisfaction of a sense of obligation to teach; the opportunity to showcase high-quality general practice; the intellectual stimulation of having their practice observed and, at times, questioned; the exposure to current medical knowledge and young enthusiastic students; and an appreciation that patients themselves benefit from their participation in a teaching consultation. Other attractions identified were the availability of continuing medical education points, the federal government’s Practice Incentives Program payment of $100 per teaching session,1 and access to the University of Queensland library resources. Challenges frequently cited included managing the extra time taken to teach without excessive delays for waiting patients; and the extra workload of addressing the students’ learning needs while ensuring that the patients’ needs are given priority. Other challenges included losing income from the reduction in patient load during teaching consultation sessions; anxiety about patient acceptance of active student participation in consultations; concerns about potential negative impacts on patients of inappropriate or inexpert student comments or skills (and possible medicolegal implications); and the extra demands of supervising a relatively weak or apparently unenthusiastic student. There were also problems related to practice infrastructure, with only a third of the GPs consistently having access to a room for student consultations and study. We have identified a number of factors that motivate GPs to teach, and others that act as disincentives. The difficulties of recruitment and retention of high-quality teaching practices in the current climate of general practice workforce shortage and increased medical student numbers are likely to increase, unless practice-based teaching remains manageable and rewarding for GPs. Strategies to promote and enhance the rewards of practice-based teaching, and overcome perceived obstacles, will be needed. Themes identified in responses of 55 general practitioners to an open question about rewards and challenges of teaching (in order of frequency of expressed theme) Time management: ”There’s the stress of running behind. I pride myself on keeping to time, and I tend to be further behind with more interested students — good students get better teaching.” Intellectual stimulation and reflection: “It keeps you up to date. Makes you concentrate on what you do, challenges you to think it through.” Negative impact on patients: “The patient can hold back when there’s a student present, maybe not raise important psychosocial or emotional issues, even if they were the primary reason for presenting.” Cognitive overload: “My brain’s ringing at the end of the day.” Intrinsic difficulties of teaching: “It’s challenging to teach general practice decision making and management in a single consultation because the process is often spread over several consultations . . . and an often long history with the patient.” Intrinsic satisfactions of teaching: “I enjoy teaching. Doctor actually means teacher; it’s part of the job.” Good company: “It’s fresh faces, and connections with new people. Often there’s no opportunity to speak to my colleagues. We can work through things together, bounce off ideas.” Less good company: “I had a rude student who said to me ‘General practice is just about patting people on the back — you don’t really do anything, do you?’ I found this offensive.” Exposure to student knowledge: “Students are someone to bounce ideas off, can keep you on the ball with their recent knowledge. Or students can help by researching a problem diagnosis.” Celebrating general practice: “It makes me more enthusiastic about general practice, reminds me what a highly privileged position a GP has.” Exposing general practice: “Students may see general practice as ‘too hard’ — but this may be realistic.” Obligation to teach: “Teaching is an obligation — people did it for us.” Positive impact on patients: “Patients appreciate the banter; they can see the process. Patients love the student being involved.”

Nancy J Sturman · Patricia M Régo · Marie-Louise B Dick

Medical education research is a relatively new but growing discipline. There is an overall perception of lack of confidence in the quality of the research, which is not entirely justified. The scientific quality of any research is defined by the appropriate application of method to a particular problem. There is a need for programmatic research focused on developing medical education policy. University medical education units need to be research-focused. Medical Deans Australia and New Zealand and the Australian and New Zealand Association of Medical Education (ANZAME: the Association for Health Professional Education) can provide leadership. Funding bodies need to develop their relationship with medical education research.

Chris Roberts MB ChB, MRCGP, PhD · Jennifer J Conn BSc(Hons), MClinEd, FRACP

Contemporary medical education must train skilled and compassionate health care professionals who are rigorous in their approach to patient care and their pursuit of knowledge and solutions. Problem-based learning has been widely introduced, but there is no evidence that it leads to better outcomes than more traditional programs, and fundamental gaps in conceptual knowledge may result. Recently, emphasis has been placed on a solid grounding in underlying concepts combined with a systems-based approach, and ability to transfer information and solve problems. Integrating traditional scientific and clinical disciplines with progressive and continuous assessment, may be a better means of achieving the combined aims of clinically relevant curriculum design, vertical integration of medical knowledge, and facilitation of the continuum of training. Being adaptable and flexible, cognisant of costs, and driven by evidence are key features of delivering medical education and contemporary medical practice. Educational research should lead to continuous improvement, but innovation without evaluation and attention to costs may create as many, or more, problems as are solved.

Gary A Wittert MD, FRACP, FRCP · Adam J Nelson

Successful transition of students to competent work-ready health professionals requires an ability to work in health care teams. Poor communication and teamwork practice has been implicated as a contributing source of error affecting patient safety. Traditional university curriculum structures severely limit the time that students from different professions can spend together, learning about and from each other (interprofessional education [IPE]). IPE initiatives need to focus on whole-of-system impacts and organisational sustainability. The Health Care Team Challenge (HCTC) is a high-profile leadership strategy that engages students, academic staff, practising professionals, policymakers and industry in a whole-of-system approach to IPE and interprofessional practice. Interprofessional student teams compete at a live public event for a cash prize for the best management plan centred on a complex clinical case study. National and international HCTCs are planned for future years.

Rosalie A Boyce BSc, MBus, PhD · Monica C Moran MPhil(OT), GCertED, DSocSc · Lisa M Nissen BPharm, PhD, FSHP · Helen J Chenery BSpTher, MSpTher, PhD · Peter M Brooks MD, FRACP

Domestic medical graduate numbers will almost double between 2005 and 2012, necessitating substantial increases in supervision at prevocational and vocational levels. New approaches to resourcing and governance of training are needed to expand the capacity of the health system to deliver quality training; new settings will also be required to expand training capacity, while ensuring that trainees are exposed to a broad range of clinical experiences. With increasing demand for training placements, entry to specialty training is likely to become highly competitive; new vocational training positions must be created to ensure that bottlenecks in training do not occur and that training is not unnecessarily prolonged. Substantial increases in government funding will be required to employ the new prevocational workforce. The recent Modernising Medical Careers Inquiry in the United Kingdom offers important lessons for the workforce changes facing Australia, such as a “ring-fenced” budget that quarantines funding for medical education and training. Planning for the increasing cohorts must cover the training spectrum — from medical student to specialist. Students and trainees must be prospectively informed about how workforce changes will affect their career advancement.

Gregory J Fox MB BS(Hons), MIPH · Stephanie J Arnold BSc(Hons), MB BS(Hons)

Objective: To assess the practice effects from coaching on the Undergraduate Medicine and Health Sciences Admission Test (UMAT), and the effect of both coaching and repeat testing on the Multiple Mini Interview (MMI).Design, setting and participants: Observational study based on a self-report survey of a cohort of 287 applicants for entry in 2008 to the new School of Medicine at the University of Western Sydney. Participants were asked about whether they had attended UMAT coaching or previous medical school interviews, and about their perceptions of the relative value of UMAT coaching, attending other interviews or having a “practice run” with an MMI question. UMAT and MMI results for participants were compared with respect to earlier attempts at the test, the degree of similarity between questions from one year to the next, and prior coaching.Main outcome measures: Effect of coaching on UMAT and MMI scores; effect of repeat testing on MMI scores; candidates’ perceptions of the usefulness of coaching, previous interview experience and a practice run on the MMI.Results: 51.4% of interviewees had attended coaching. Coached candidates had slightly higher UMAT scores on one of three sections of the test (non-verbal reasoning), but this difference was not significant after controlling for Universities Admission Index, sex and age. Coaching was ineffective in improving MMI scores, with coached candidates actually having a significantly lower score on one of the nine interview tasks (“stations”). Candidates who repeated the MMI in 2007 (having been unsuccessful at their 2006 entry attempt) did not improve their score on stations that had new content, but showed a small increase in scores on stations that were either the same as or similar to previous stations.Conclusion: A substantial number of Australian medical school applicants attend coaching before undertaking entry selection tests, but our study shows that coaching does not assist and may even hinder their performance on an MMI. Nevertheless, as practice on similar MMI tasks does improve scores, tasks should be rotated each year. Further research is required on the predictive validity of the UMAT, given that coaching appeared to have a small positive effect on the non-verbal reasoning component of the test.

Barbara Griffin BPsych(Hons), PhD, MAPS · David W Harding BA(Hons), MClinPsych, MAPS · Ian G Wilson MB BS, PhD, FRACGP · Neville D Yeomans MD, FRACP, AGAF

Opportunities for using inpatients for learning physical examination skills have decreased. In peer physical examination (PPE), students act as models for each other to learn skills in physical examination and other non-invasive procedures. PPE is extensively used and has high acceptability, but nevertheless poses some challenges. PPE may be less acceptable among culturally and linguistically diverse students. In the light of our findings and the published literature, best practice points are described.

Suzanne Outram PhD · Balakrishnan R Nair FRACP

Objective: To evaluate the feasibility, reliability and acceptability of the mini clinical evaluation exercise (mini-CEX) for performance assessment among international medical graduates (IMGs).Design, setting and participants: Observational study of 209 patient encounters involving 28 IMGs and 35 examiners at three metropolitan teaching hospitals in New South Wales, Victoria and Queensland, September–December 2006.Main outcome measures: The reliability of the mini-CEX was estimated using generalisability (G) analysis, and its acceptability was evaluated by a written survey of the examiners and IMGs.Results: The G coefficient for eight encounters was 0.88, suggesting that the reliability of the mini-CEX was 0.90 for 10 encounters. Almost half of the IMGs (7/16) and most examiners (14/18) were satisfied with the mini-CEX as a learning tool. Most of the IMGs and examiners enjoyed the immediate feedback, which is a strong component of the tool.Conclusion: The mini-CEX is a reliable tool for performance assessment of IMGs, and is acceptable to and well received by both learners and supervisors.

Balakrishnan R Nair FRACP, FRCP · Heather G Alexander PhD · Barry P McGrath MD, FRACP · Mulavana S Parvathy FRACGP · Eve C Kilsby BA(Psych) · Johannes Wenzel MD, FACEM · Ian B Frank BA(Hons) · George S Pachev PhD · Gordon G Page PhD

Musculoskeletal conditions are a major contributor to the burden of disease globally and their impact is predicted to increase. Consistent with findings in other countries, the current standard of musculoskeletal education in Australian medical schools is inadequate to meet today’s musculoskeletal care requirements. A national multidisciplinary approach unifying the key musculoskeletal clinical and basic science disciplines has been adopted to provide clear, evidence-based education guidelines that are specifically aimed at priority musculoskeletal conditions; a direct link is therefore established between community health care needs and education at a national level. This “top-down” approach provides the potential for a far more effective and efficient delivery of musculoskeletal education by allowing the identification of the key basic knowledge and skills required to achieve core competencies and by providing appropriate direction for students. The Australian Core Competencies in Musculoskeletal Basic and Clinical Science are being developed for medical schools to incorporate into their curricula, with the ultimate aim of improving the standard of health care for Australians with musculoskeletal conditions.

Mellick J Chehade PhD, MB BS, FRACS(Ortho) · Aleksander Bachorski BE(Hons), GradDip(MW

Objective: To investigate the effect of duration of clinical training placements in the Northern Territory on rate of return of medical students for an internship in the NT.Design, setting and participants: Retrospective analysis of medical school and hospital data on all medical students who completed a placement with the Northern Territory Clinical School (NTCS) between 1998 and 2007.Main outcome measures: Logistic regression analysis of weeks spent training in the NT against the binary category of return or non-return for an internship in the NT; number of weeks of placement in the NT required for one returning intern for training models with different placement duration and timing.Results: 683 students completed an NTCS placement: short-term Year 4 placements only, 538 (duration, 1–19 weeks, 534; and ≥ 20 weeks, 4); Year 3 40-week placements only, 16; and both Year 3 and Year 4 placements,129 (Year 4 duration, 1–19 weeks, 82; and ≥ 20 weeks, 47). For each student who returned for an NT internship, 122 weeks of placement were required. Placement length was a significant predictor of an NT internship (P < 0.05; odds ratio, 1.08; 95% CI, 1.07–1.09). The most efficient training models (fewest weeks per returning intern) were longer placements (≥ 20 weeks) in Year 4, both for students who also undertook a 40-week Year 3 placement and those who did not (90 and 47 weeks of training per intern, respectively). Students who spent only brief periods in the NT in Year 4 were less likely to return for an internship (P < 0.05).Conclusions: The rate of return increased with the total length of time spent training in the NT. Short-term Year 4 placements offered the least return for the total number of weeks of placement provided.

Anna McDonnel Smedts PhD · Michael P Lowe MD, FRACP

In 1997, the University of Sydney replaced its undergraduate medical course with a new 4-year graduate medical program. The course was reaccredited by the Australian Medical Council (AMC) in 2005. Suggestions for further development by the AMC led to a comprehensive review of the course, commencing in July 2006. This article describes the review process and outlines key recommendations that came out of the review that have been or are being implemented.

Kerry J Goulston MD, FRACP · R Kim Oates MD, DSc, FRACP

Objective: To assess how well prior academic performance, admission tests, and interviews predict academic performance in a graduate medical school.Design, setting and participants: Analysis of academic performance of 706 students in three consecutive cohorts of the 4-year graduate-entry medical program at the University of Queensland.Main outcome measures: Proportion of academic performance during the medical program explained by selection criteria, and correlation between selection criteria and performance. Selection criteria were grade point average (GPA), GAMSAT (Graduate Australian Medical School Admissions Test) score, and interview score. Academic performance was defined as overall total in all examinations combined, in first and fourth year examinations, and in individual written, ethics and clinical components.Results: Selection criteria explained 21.9% of variation in overall total score, falling from 28.2% in Year 1 to 17.7% in Year 4. This was highest for the written examination in Year 1 (30.5%) and lowest for the clinical examination in Year 4 (10.9%). GPA was most strongly correlated with academic performance (eg, for overall score, partial Spearman’s correlation coefficient [pSCC], 0.47; P < 0.001), followed by interviews (pSCC, 0.12; P = 0.004) and GAMSAT (pSCC, 0.07; P = 0.08). The association between GPA and performance waned from Year 1 to Year 4, while the association between interview score and performance increased from Year 1 to Year 4.Conclusion: The school’s selection criteria only modestly predict academic performance. GPA is most strongly associated with performance, followed by interview score and GAMSAT score. The school has changed its selection process as a result.

David Wilkinson FRACGP, FAFPHM, DSc · Jianzhen Zhang PhD · Gerard J Byrne MB BS, PhD, FRANZCP · Haida Luke PhD · Ieva Z Ozolins MB BS, PhD · Malcolm H Parker MLitt, LLM, FACLM · Raymond F Peterson PhD

Objective: To provide data on the career trajectories of medical students from rural and remote workforce programs at Flinders University (the Parallel Rural Community Curriculum [PRCC] and the Northern Territory Clinical School [NTCS]), comparing them with students at the urban Flinders Medical Centre (FMC).Design: Retrospective postal survey of all 150 graduates who undertook their Year 3 study in the period 1998–2000.Outcome measure: Associations with career preference, assessed using univariate analyses and multivariate regression.Results: PRCC and NTCS graduates were more likely to choose rural career paths than graduates from FMC. The odds ratios were 19.1 (95% CI, 3.4–106.3; P < 0.001) and 4.3 (95% CI, 1.2–14.8; P = 0.026), respectively, after adjusting for age and rural background. There was no difference in the specialty choices of graduates of the three programs.Conclusion: This study provides evidence that clinical attachments designed to increase the rural and remote medical workforce do fulfil this objective.

Paul Worley MB BS, FRACGP, FACRRM · Anne Martin PhD · David Prideaux BEd, PhD · Richard Woodman PhD, MBiostat, MSportsSci · Elizabeth Worley BN, MEd, GradCertCounsel · Michael Lowe MB BS, FRACP