Medical Education 2012: 46: 97–106
Objectives This study aims to review, critically, the suitability of Kirkpatrick’s levels for appraising interventions in medical education, to review empirical ...evidence of their application in this context, and to explore alternative ways of appraising research evidence.
Methods The mixed methods used in this research included a narrative literature review, a critical review of theory and qualitative empirical analysis, conducted within a process of cooperative inquiry.
Results Kirkpatrick’s levels, introduced to evaluate training in industry, involve so many implicit assumptions that they are suitable for use only in relatively simple instructional designs, short‐term endpoints and beneficiaries other than learners. Such conditions are met by perhaps one‐fifth of medical education evidence reviews. Under other conditions, the hierarchical application of the levels as a critical appraisal tool adds little value and leaves reviewers to make global judgements of the trustworthiness of the data.
Conclusions Far from defining a reference standard critical appraisal tool, this research shows that ‘quality’ is defined as much by the purpose to which evidence is to be put as by any invariant and objectively measurable quality. Pending further research, we offer a simple way of deciding how to appraise the quality of medical education research.
Outcome based or competency based education (OBE) is so firmly established in undergraduate medical education that it might not seem necessary to ask why it was included in recommendations for the ...future, like the Flexner centenary report. Uncritical acceptance may not, however, deliver its greatest benefits. Our aim was to explore the underpinnings of OBE: its historical origins, theoretical basis, and empirical evidence of its effects in order to answer the question: How can predetermined learning outcomes influence undergraduate medical education? This literature review had three components: A review of historical landmarks in the evolution of OBE; a review of conceptual frameworks and theories; and a systematic review of empirical publications from 1999 to 2010 that reported data concerning the effects of learning outcomes on undergraduate medical education. OBE had its origins in behaviourist theories of learning. It is tightly linked to the assessment and regulation of proficiency, but less clearly linked to teaching and learning activities. Over time, there have been cycles of advocacy for, then criticism of, OBE. A recurring critique concerns the place of complex personal and professional attributes as “competencies”. OBE has been adopted by consensus in the face of weak empirical evidence. OBE, which has been advocated for over 50 years, can contribute usefully to defining requisite knowledge and skills, and blueprinting assessments. Its applicability to more complex aspects of clinical performance is not clear. OBE, we conclude, provides a valuable approach to some, but not all, important aspects of undergraduate medical education.
Context
Empathic physician behaviour is associated with improved patient outcomes. One way to demonstrate empathy is through the use of non‐verbal communication (NVC) including touch. To date, ...research on NVC, and specifically touch, has been relatively limited in medicine, which is surprising given the central role it plays in conveying affective and empathic messages. To inform curriculum development on NVC, this study aimed to examine physicians' experiences of communicating by touch.
Methods
We conducted an interpretative phenomenological study. A total of 15 physicians (seven women and eight men) from different specialties, including both recent graduates and experienced doctors, described in detail specific instances of touch drawn from their clinical practices. Interview prompts encouraged participants to recall exact details such as the context, their relationship with the patient they touched and their physical experience of touching. Interviews (45‐100 minutes) were analysed with template analysis, followed by a process of dialectic questioning, moving back and forth between the data and researchers' personal reflections on them, drawing on phenomenological literature to synthesise a final interpretation.
Results
Participants described two dimensions of the experience of touch: ‘choosing and inviting touch’ and ‘expressing empathy.’ Touch was a personal and fragile process. Participants interpreted non‐verbal patient cues in order to determine whether or not touch was appropriate. They interpreted facial expressions and body language in the present to make meaning of patients' experiences. They used touch to share emotions, and to demonstrate empathy and presence. Participants' experiences of touch framed it as a form of embodied empathic communication.
Conclusions
Touch is a powerful form of NVC that can establish human connection. Phenomenological accounts of empathy, which emphasise its embodied intersubjective nature, can be used to theoretically enrich pedagogical approaches to touch in medical education and to deepen our understanding of empathy.
If a picture is worth a thousand words, what value hath a touch? The authors of this study describe how doctors communicate empathy through touch, raising awareness of why non‐verbal communication skill should be incorporated into communication skills training.
Highlights • This research provides a rich description of caring. • Patients experienced caring when competent professionals communicated effectively. • They did so also, when professionals formed ...relationships, engaged emotionally, and displayed positive attitudes. • These findings could underpin education for collaborative, interprofessional practice.
Touch mediates health professionals’ interactions with patients. Different professionals have reported their practices but what is currently lacking is a well-theorized, interprofessional synthesis. ...We systematically searched eight databases, identified 41 studies in seven professions—nursing (27), medicine (4), physiotherapy (5), osteopathy (1), counseling (2), psychotherapy (1), dentistry (1)—and completed a meta-ethnographic line-of-argument synthesis. This found that touch is caring, exercises power, and demands safe space. Different professions express care through the medium of touch in different ways. They all, however, expect to initiate touch rather than for patients to do so. Various practices negotiate boundaries that define safe spaces between health care professions and patients. A metaphor—the waltz—integrates the practice of touch. Health care professionals connect physically with patients in ways that form strong relationships between them while “dance steps” help manage the risk that is inherent in such an intimate form of connection.
Context
Emotional intelligence (EI) is a term used to describe people's awareness of, and ability to respond to, emotions in themselves and other people. There is increasing research evidence that ...doctors’ EI influences their ability to deliver safe and compassionate health care, a particularly pertinent issue in the current health care climate.
Objectives
This review set out to examine the value of EI as a theoretical platform on which to base selection for medicine, communication skills education and professionalism.
Methods
We conducted a critical review with the aim of answering questions that clinical educators wishing to increase the focus on emotions in their curriculum might ask.
Results
Although EI seems, intuitively, to be a construct that is relevant to educating safe and compassionate doctors, important questions about it remain to be answered. Research to date has not established whether EI is a trait, a learned ability or a combination of the two. Furthermore, there are methodological difficulties associated with measuring EI in a medical arena. If, as has been suggested, EI were to be used to select for medical school, there would be a real risk of including and excluding the wrong people.
Conclusions
Emotional intelligence‐based education may be able to contribute to the teaching of professionalism and communication skills in medicine, but further research is needed before its wholesale adoption in any curriculum can be recommended.
Discuss ideas arising from the article at ‘discuss’
Abstract Background Recent years have seen a significant drop in applications to surgical residencies. Existing research has yet to explain how medical students make career decisions. This ...qualitative study explores students' perceptions of surgery and surgeons, and the influence of stereotypes on career decisions. Methods Exploratory questionnaires captured students' perceptions of surgeons and surgery. Questionnaire data informed individual interviews, exploring students' perceptions in depth. Rigorous qualitative interrogation of interviews identified emergent themes from which a cohesive analysis was synthesized. Results Respondents held uniform stereotypes of surgeons as self-confident and intimidating; surgery was competitive, masculine, and required sacrifice. To succeed in surgery, students felt they must fit these stereotypes, excluding those unwilling, or who felt unable, to conform. Deviating from the stereotypes required displaying such characteristics to a level exceptional even for surgery; consequently, surgery was neither an attractive nor realistic career option. Conclusions Strong stereotypes of surgery deterred students from a surgical career. As a field, surgery must actively engage medical students to encourage participation and dispel negative stereotypes that are damaging recruitment into surgery.
Clerkship education has been called a ‘black box’ because so little is known about what, how, and under which conditions students learn. Our aim was to develop a blueprint for education in ambulatory ...and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. We identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers published over 7 years and synthesised a theory of how students learn. They do so when they are given affective, pedagogic, and organisational support. Affective support comes from doctors’ and many other health workers’ interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors’ teaching, supervision, and precepting. Organisational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase ‘supported participation in practice’ best describes the educational process. Much of the learning that results is too tacit, complex, contextualised, and individual to be defined as a set of competencies. We conclude that clerkship education takes place within relationships between students, patients, and doctors, supported by informal, individual, contextualised, and affective elements of the learned curriculum, alongside formal, standardised elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula as well as helping patients, students, and practitioners collaborate in educating tomorrow’s doctors.
Family Physicians' Experiences of Physical Examination Kelly, Martina Ann, MA, MBBCh, FRCGP, CCFP; Freeman, Lisa Kathryn, BSc (Hon), MD, CCFP, MPH, FRCPC; Dornan, Tim, MA, DM, FRCP, MHPE, PhD
Annals of family medicine,
07/2019, Volume:
17, Issue:
4
Journal Article
Peer reviewed
Open access
AbstractPurposeThe increased availability of reliable diagnostic technologies has stimulated debate about the utility of physical examination in contemporary clinical practice. To reappraise its ...utility, we explored family physicians’ experiences.MethodsGuided by principles of phenomenology, we conducted in-depth qualitative interviews exploring 16 family physicians’ experiences of conducting physical examination: 7 (44%) men and 9 women (56%) whose clinical experience varied widely, from 11 (69%) urban and 5 (31%) rural locations. We recorded the interviews, transcribed them verbatim, and identified initial themes using template analysis. We worked reflexively, critiquing our own and other team members’ interpretations, in order to synthesize and write a final interpretation.ResultsParticipants described 2 facets of physical examination: making diagnoses and estimating prognoses rationally and objectively; and responding subjectively and intuitively to patients’ illnesses, which formed relationships between doctor and patient that enacted medical care in the moment. Physical examination allowed physicians to use their own bodies to experience patients’ illnesses. Performing physical examination was integral to being a family doctor because it promoted rapport and developed trust.ConclusionsPhysical examination is part of the identity of family physicians. It not only contributes diagnostic information but is a therapeutic intervention in and of itself. Physical examination contributes to relationship-centered care in family practice.
Objectives(1) Systematically assemble, analyse and synthesise published evidence on causes of prescribing error in children. (2) Present results to a multidisciplinary group of paediatric prescribing ...stakeholders to validate findings and establish how causative factors lead to errors in practice.DesignScoping review using Arksey and O’Malley’s framework, including stakeholder consultation; qualitative evidence synthesis.MethodsWe followed the six scoping review stages. (1) Research question—the research question was ‘What is known about causes of prescribing error in children?’ (2) Search strategy—we searched MEDLINE, EMBASE, CINAHL (from inception to February 2018), grey literature and reference lists of included studies. (3) Article selection—all published evidence contributing information on the causes of prescribing error in children was eligible for inclusion. We included review articles as secondary evidence to broaden understanding. (4) Charting data—results were collated in a custom data charting form. (5) Reporting results—we summarised article characteristics, extracted causal evidence and thematically synthesised findings. (6) Stakeholder consultation—results were presented to a multidisciplinary focus group of six prescribing stakeholders to establish validity, relevance and mechanisms by which causes lead to errors in practice.Results68 articles were included. We identified six main causes of prescribing errors: children’s fundamental differences led to individualised dosing and calculations; off-licence prescribing; medication formulations; communication with children; and experience working with children. Primary evidence clarifying causes was lacking.ConclusionsSpecific factors complicate prescribing for children and increase risk of errors. Primary research is needed to confirm and elaborate these causes of error. In the meantime, this review uses existing evidence to make provisional paediatric-specific recommendations for policy, practice and education.
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