The Medical Education Research Group (MERG) was formed in 2006 to undertaken research aimed at informing curriculum development in the light of changes affecting both medical practice and medical education. MERG draws its members from the Primary Care Unit, the Clinical School and the East of England Deanery. MERG also undertakes a training role, providing support and guidance for doctors in training wishing to combine medical education research with clinical work. The current programme of research: “Making Good Doctors” comprises both long term studies and short investigations. The members of MERG incorporated within the General Practice Education group within the Primary Care Unit are included here.
The programme seeks to enable:
- Greater understanding of the relationship between students’ characteristics, attitudes, values and experiences and subsequent patient care.
- Greater understanding of the impact of the course provided on these characteristics, attitudes and values.
- Curriculum development.
The “Making Good Doctors” programme stems from awareness that performance at medical school may not necessarily equate with good patient care. The overarching concern of the programme is to identify those factors in undergraduate medical education which ultimately enhance the quality of patient care provided by students in their medical practice. The need for this work arises from of the impact of changes in health care provision and delivery, patient expectations and medical education on the concept of a “good” doctor. Trends in health care provision and delivery include: a shift from secondary to primary care, growing importance of chronic conditions associated with aging populations and life style factors, a more “consumerist” approach to health care provision aimed at empowering patient and increasing pace of development in drugs, therapies and medical technologies. Medical education has also changed. There has been a shift away from a purely scientific knowledge approach towards a more “holistic” approach, resulting in changes in course content and changes in learning approaches, with greater use of problem-based learning and experiential components. There is growing awareness that competence as a doctor involves not only biomedical knowledge and its application, and clinical skills and reasoning, but also communication skills, interpersonal skills, collegiality, professionalism and a demonstrated ability to continuously improve.
The projects within the programme can be grouped under three broad areas:
The Curriculum: its impact and content
A major component of the “Making Good Doctors” programme which also provides baseline data for a range of related studies is a longitudinal cohort study of all students entering Cambridge to study medicine: Data for the Improvement of Medical Education (DIME).
This study started in October 2007 and includes students entering at preclinical and clinical stages.
Factors identified as important to future patient care and examined on a longitudinal basis include:
¨ mental and emotional well being (anxiety, depression and burnout)
We hope to follow our graduating students into their foundation years and examine the impact of the transition from “student” to professional practice.
Main Longitudinal Cohort Study of D.i.M.e.
The study seeks to identify and observe changes displayed by students in attitudes, values and characteristics considered likely to affect the quality care they ultimately provide to their patients so as to inform curriculum development.
- How do empathy, mental and emotional wellbeing, and anxiety about death change in individual students they progress through the course?
- At what points in course do changes occur and are they permanent or temporary?
- How do these changes relate to attitudes towards end of life care?
- How do these changes relate to objective measures of clinical care.
- Questionnaire survey administered annually
- Validated generic and health care oriented instruments used:
Interpersonal Reactivity Index, Jefferson Scale of Physician Empathy (Clinical students only)
Mental and Emotional Wellbeing:
Hospital Anxiety and Depression Scale, Maslach Burnout Inventory (Stage 3 clinical students only)
Collett-Lester Death Anxiety Scale
Personal experience of bereavement,
Attitudes towards End of Life Care
Objective measures: OSCE scores (Clinical students only)
Quince T, Benson J, Wood D. Gender differences in trajectories of empathy. ASME Annual Scientific Meeting, July 2010 Cambridge, UK.
Wood D, Quince T, Benson J. High anxiety in medical students may adversely affect their attitudes towards patient care. AMEE Annual Conference August 2008, Prague, The Czech Republic
Related projects, incorporating data from the main longitudinal cohort study, seek to understand the development of, and influence on medical students' attitudes towards death and caring for patients at the end of life.
- How do medical students’ attitudes towards death and caring for patients at the end of their life change as they progress through the course?
- What is the extent to which students experience close personal loss prior to and/or during their course and does this experience influence their attitudes towards death and care of the dying?
- How do first year preclinical students’ relate to the cadaver?
- Does full cadaveric dissection influence student attitudes towards death and care of the dying?
- Quantitative: Questionnaire surveys incorporating:
Death Anxiety and Attitudes towards End of Life Care items administered annually
Attitudes towards dissection (Year 1 Preclinical students only)
- Qualitative work
In-depth interviews with 17 Year 1 preclinical students examining attitudes towards the cadaver, dissection, death and end of life care
Barclay S, Benson J
, Wood D, Brimicombe J,
Summers E, Quince T
(2008) Attitudes of first and fourth year medical students to caring for patients approaching the end of life. Palliative Care (Abstracts): 22: 10
Quince TA, Spear M, Wood DF, "Dissection not a common experience. " ASME Annual Scientific Meeting, July 2010, Cambridge, UK
Quince TA, Spear M, Wood DF, Student attitudes towards dissection (Poster) AMEE Conference, September 2010, Glasgow, UK
Barclay S, Benson J, Wood D, Brimicombe J, Summers E, Quince T. “Attitudes of medical students towards caring for patients approaching the end of life: a cross-sectional study in the University of Cambridge”. ASME Annual Scientific Meeting, July 2008, Leicester.UK
Barclay S, Benson J, Wood D, Brimicombe J, Summers E, Quince T “Attitudes of first and fourth year medical students to caring for patients approaching the end of life: interim analysis of a study in the University of Cambridge”. Society for Academic Primary Care London and South-East annual scientific meeting. Madingley Hall, January 2008,Cambridge, UK
Barclay S, Benson J, Wood D, Brimicombe J, Summers E, Quince T .“Death anxiety and recent experience of bereavement among fourth year medical students: interim analysis of a study in the University of Cambridge”. Society for Academic Primary Care London and South-East annual scientific meeting. Madingley Hall, January 2008,Cambridge, UK
Cotton P, Sharp D, Howe A; Starkey C, Laue B, Hibble A, Benson J.
(2009) Developing a set of quality criteria for community-based medical education in the UK. Education for Primary Care
: 20 (3) 143-151.
, Quince T
, Hibble A, Fanshawe T, Emery J. (2005) Impact on patients of expanded, general practice based, student teaching: observational and qualitative study. BMJ
: 331: 89-92
Leadership and Management Education in the Undergraduate Curriculum.
The need for doctors to develop leadership and management competencies is widely acknowledged and is reflected in the development by the NHS Institute for Innovation and Improvement of a “Medical Leadership Competency Framework” (MLCF). The MLCF has universal application across the NHS, however the learning and teaching objectives appropriate for undergraduate medical students remain to be developed.
Work comprises three projects:
¨ A systematic literature review of what is known about the knowledge, skills and attitudes of medical students with regard to leadership and management.
¨ A qualitative study, exploring medical students’ views, attitudes towards and suggestions about the MLCF and how to operationalise it at the undergraduate medical level.
¨ Collaboration with the NHS Institute for Innovation and Improvement in developing the MLFC’s Guidance for Undergraduate Medical Education.
Leadership and Management: Systematic literature review to describe what is known about the knowledge, skills and attitudes of undergraduate medical students with regard to leadership and management.
- What do medical students know about leadership and managing organisations in the health sector?
- What are medical students’ attitudes towards leadership and managers/management in the health sector?
- What skills in leading/managing organisation in the health sector or elsewhere for medical students possess?
- Would medical students value greater understanding of the leadership and managementof organisations in the health sector?
- Systematic literature review.
- Narrative synthesis of results of review.
Leadership and Management: Qualitative investigation of student suggestions for learning about leadership and management in the undergraduate curriculum.
This study aims to explore medical students’ attitudes, views and curricula suggestions concerning each of the five domains set out in the NHS Institute for Innovation and Improvement’s “Medical Leadership Competency Framework” (MLCF):
For each of the 5 domains: Personal Qualities, Working with Others, Managing Services, Improving Services and Setting Direction the following will be explored with medical students:
- What should be the learning outcomes in the undergraduate curriculum?
- What content should be included to achieve these learning outcomes?
- What teaching methods should be used?
- What should form the assessment strategy?
- What are considered to be the facilitators and inhibitors to the delivery and assessment in the domain?
- Qualitative: focus group discussions with clinical medical students.
- Systematic analysis of transcribed discussions.
,* Diana Wood. *Contact person and team leader
Medical Leadership Competency Framework: Guidance for Undergraduate Medical Education
Members of the Clinical School have contributed to the development of a suggested curriculum in medical management and leadership for undergraduate medical education
- To develop an undergraduate curriculum for Medical Management and Leadership
Consensus curricular development through a consortium of contributors from a range of institutions, including the NHS Institute for Innovation and Improvement, the Academy of Medical Royal Colleges, Medical Schools and Postgraduate Deaneries.
Lead authors: Members of the NHS Institute for Innovation and Improvement. Clinical School contributors: John Benson
*, Mark Abbas
Clinical School reviewers: Paul Siklos, Diana Wood, Jonathan Silverman, Mark Lillicrap, John Firth, John Clark
*Contact person/team leader
Abbas M, Benson J, Quince T, Wood D, Gillam S. Leadership and management for medical students. Intra-conference Workshop. ASME Annual Scientific Meeting, July 2009, Edinburgh.UK
Abbas M, Quince T, Benson J. "A systematic review to explorre what is known concerning the knowledge, skills and attitudes of medical students regarding leadership and management." AMEE Conference, September 2010, Glasgow, UK.
A qualitative study of Medical students’ descriptions of cases which raised ethical issues encountered on Paediatrics and Obstetrics & Gynaecology placement.
Dealing appropriately with ethical problems, including noticing when an ethical dilemma has arisen, is an important part of the work of junior doctors. In 1998, teachers of medical ethics in UK medical schools produced a consensus statement on the core curriculum that should be delivered to medical students in order to prepare them for this aspect of practice. This statement was reviewed and updated in 2010.
During their training at the University of Cambridge School of Clinical Medicine, medical students submit reports of ethical problems that they have encountered, on which educational discussions of medical ethics are based. These discussions are an important means of delivering the core curriculum during attachments in Paediatrics and Obstetrics and Gynaecology. The relationship between the topics that the students raise for discussion and those highlighted as important in the consensus statement on the core curriculum has not been described.
- What ethical themes and issues were identified by students?
- The extent to which these themes and issues are handled by the core curriculum?
- Systematic qualitative analysis of medical students’ reports of ethical problems encountered during a Paediatrics and Obstetrics & Gynaecology placement.
Donaldson T, Fistein E,
Dunn M. (2010) Case-based seminars in medical ethics education: how medical students define and discuss moral problems. Journal of Medical Ethics
Students’ attitudes towards post mortem and its utility in medical education.
Examination of the dead has been an essential element in the training of medical doctors. Anatomy has traditionally been taught through the process of dissection whereas, histopathy has traditionally been taught through students attending routine post mortem examinations. Despite the benefits ascribed to post mortem examination, its use in medical education has declined. While the reasons for the decline are not clear cut what is clear is that students no longer attend post mortems regularly, if at all, during their undergraduate medical education. Many pathologists and medical teachers still feel that the post mortem has great benefit in medical training. Students on the Cambridge Graduate Course still attend at least one post mortem during their course (in addition to regular anatomical dissection).
This study seeks to examine students’ attitudes towards post mortems and towards its use as part of their training so as to identify better ways of preparing and supporting students when visiting mortuaries.
- What are the attitudes of students to the post mortem examination in terms of its use:
1. As a technique in medicine and society?
2. For teaching?
3. On a personal level?
- What is the use of the post mortem as a tool for medical education?
- How can we better prepare students for the experience of a post mortem examination?
Primarily qualitative involving Cambridge Graduate Course students who will have experienced both dissection and post mortem examinations.
- Brief demographic and personal background questionnaire survey
- Nominal Group Technique to identify themes and issues.
- Two focus group discussion to explore in-depth themes and issues arising from nominal group discussions.
Teaching and learning methods
Student-doctors' experience of learning communication in the clinical learning environment: A case study
Traditionally, student-doctors have learnt clinical medicine through participation in apprenticeship style hospital attachments. The ward round is a key feature of this and provides an opportunity for student-doctors to learn clinical communication by observing role models interacting with their patients.
- How does the ward environment shape and constrain the learning of clinical communications?
- What learning opportunities related to clinical communication are made available to student-doctors who take part in ward rounds?
- What is the nature of clinical communication that student-doctors observe on ward rounds?
This case study draws upon the priniciples and methods of linguistic ethnography. Participants were observed and audio-recorded on medical and surgical rounds, (n=20), and interviews were conducted with 4th year student-doctors (n=9) and clinicians (n=4).
Sally Quilligan*, Jonathan Silverman *Contact person/team leader.
Silverman J. (2011) Clinical communication training in continuing medical education: Possible, do-able and done? (Editorial) Patient Education and Counseling,
Quilligan S and Silverman J. Student-doctors' experience of learning communication in the clinical learning environment: A case study. Symposium European Association for Communication in Healthcare, 2010 Verona.
Silverman J, and Kinnersley P. (2010) Doctors' non-verbal behaviour in consultations: Look at the patients before you look at the computer. (Editorial) British Journal of General Practice
Rosenbaum M, and Silverman J. "How to run effective workshops" ASME Annual Scientific Meeting, July 2010, Cambridge, UK.
Silverman J. "Teaching clinical communications: a mainstream activity or just a minority sport? Keynote address. International Clinical Skills Conference, May 2011, Prato, Italy.
Silverman J. "Feedback in experiential sessions: managing the differences in 1:1 learning, small group and video work, SPs." UK Council of Clinical Communication in Undergraduate Medical Education Conference, March, 2011, Manchester, UK.
Silverman J. "Teaching clinical communications - success story or endangered species? National Conference on Medical Communications. Oslo, Norway.
Silverman J, Rosenbaum M, Anvik T, Deveugele M, Jarvis R, van Weel-Baumgarte E. "tEACH symposium: integrated modules in communications skills." European Association for Communication in Health Care, International Conference, September, 2010, Verona, Italy.
Silverman J. "Breaking Bad News" Foundation eLearning Project (000-1036). DH e-Learning for Healthcare. 2010.
Reflective practice is widely used in healthcare professionals’ education and is being used increasingly in undergraduate medical education. However, little is known about whether short reflective educational interventions are able to affect a students’ ability for self-reflection. One study showed that a short course in clinical ethics, which included reflection had no effect on the student’s capacity for self-reflection. This course was based on small group discussion and its primary aim was not reflection. More research is needed to discover how to increase a student’s capacity for reflection most effectively. This study seeks to investigate the extent to which a reflective educational intervention can increase undergraduate medical students’ capacity for self-reflection.
- Did final year medical students' scores on two domains The Self-Reflection and Insight Sale (SRIS) change following a short reflective educational intervention?
- Can medical students’ capacity for reflection be increased?
- Quantitative: questionnaire survey comprising The Self-Reflection and Insight Scale administered before and after short reflective educational intervention.
Morris R, Benson J. "Increasing the reflective capacity of medical students requires more than a brief intervention".ASME Annual Scientific Meeting, July 2010, Cambridge, UK.
To what extent do risk-taking, responsibility and error enhance the learning experience? - A study of final year medical undergraduates in one institution?
Students currently do not always feel prepared for practice. Learning medicine is complex and cannot solely be learned from sitting in a classroom but needs to be learned within workplace. Allowing students to engage in real-world practices will inevitably lead to risks. With the current risk-averse medical culture students are being denied authentic learning experiences and are peripheral to the practice of medicine.
- What were the lived experiences of final year medical students with respect to risk- taking, errors and responsibility
- Did how students believe these experiences impacted on their learning.
Qualitative: Focus group discussions and face to face interviews with final year students.
Helen Leisa Smith*, Clare Morris. *Contact person/team leader
Caring for patients approaching the end of life is an important part of the work of junior doctors: in their first year after qualification, it is estimated that an average junior doctor will care for 40 patients who die and a further 120 patients in the last 6 months of life. Past research studies have found that palliative care is a source of considerable stress for many junior doctors: they feel unprepared and unsupported. Little is known about the extent to which medical students can be encouraged to reflect on their future role in caring for the dying, and the degree to which such reflection can prepare students for this challenging and important aspect of their future work. This project sought to look at how students viewed professional values and the concept of "a good" death.
- What were students’ thoughts, feelings and attitudes prior to meeting patients approaching the end of life?
- How were these thoughts, feelings and attitudes affected by meeting patients approaching the end of life in terms of professional and personal issues raised?
- What are the implications for training medical students of such reflection?
- Systematic qualitative analysis of two reflective items written by final year medical students after meeting patients approaching the end of life.
Borgstrom E, Barclay S, Cohn S. (2010) Good death from the perspective of medical students after meeting patients in palliative care.Palliative Medicine 24(2):213. Palliative Care Congress Abstracts.
Barclay S, Reflective Practice – the Cambridge experience” National conference. Teaching tomorrow’s doctors about Palliative Care. St Gemma’s Hospice, November 2009, Leeds, UK.
Borgstrom E, Barclay S, Cohn S. Medical Students’ Reflective Portfolios after Meeting Patients Close to the End of Life – Reading Beyond the Words. Qualitative Research in the NHS – Annual Meeting, October, 2009, Cambridge
Borgstrom E, Cohn S. Exploring Medical Students’ Reflective Portfolios – The Need for Context. Explorations in Ethnography, Language and Communication Conference, September 2009, Birmingham, UK.
Borgstrom E, Barclay S, Cohn S. Or perhaps he’s in denial…: Medical students’ construction, use, and reaction to ‘denial’ in relation to dying patients. Annual Medical Sociology Conference September 2009, Manchester, UK.
Borgstrom E, Barclay S, Cohn S, ‘Good Death’: Medical Students’ Expectations and Realisations CRASSH Health and Welfare Symposium, June 2009 Cambridge, UK.
A comparison of didactic lecture-based teaching with case based discussion in teaching child and adolescent psychiatry to medical students: A randomised controlled trial.
The psychiatry component of the Clinical Medical Student programme has traditionally followed a didactic lecture-based model. However, medical students have consistently given feedback that they would enjoy and benefit more from real-life case based learning. We would therefore like to compare student enjoyment and learning from case-based teaching and traditional didactic lectures in two Child and Adolescent Psychiatry topics, namely Depression and ADHD.
Does case-based discussion offer medical students more enjoyment of, and effectiveness in, learning Child and Adolescent Psychiatry than traditional didactic lectures?
Randomised controlled trial. Quantitative analysis of feedback forms and quantitative analysis of end of attachment tests specific to material in teaching sessions.
Meinou Simmons*, Paul Wilkinson. *Contact person/team leader
Observational learning in secondary care: an investigation of positive and negative influences and perceived relevance to current training programmes for junior doctors.
Training in medicine has long been considered an apprenticeship, in which situational learning plays a major part. Throughout the many years spent as both a medical student and then a junior doctor, trainees work in close proximity to senior colleagues, and in so doing acquire not only the core knowledge, but also the necessary attitudes and values of a ‘good doctor’. Observational learning, i.e. learning that occurs through observing the attitudes and behaviours of others is a key part of this apprenticeship. The effects of recent substantial changes to UK junior doctor training programmes on opportunities for observational learning are currently unknown. These effects warrant further study to better inform the design of postgraduate medical training programmes.
1. How do senior (Consultants) and junior (Core Specialty Trainees) doctors perceive the relevance, benefit and importance of observational learning in current postgraduate medical training programmes?
2. Have the opportunities for observational learning changed as training programmes have evolved in recent years – and what factors are perceived by senior and junior doctors to exert either positive or negative influences on the quantity and quality of observational learning in current postgraduate medical training programmes?
3. Do senior and junior doctors perceive that there have been any changes in their ability to establish good working relationships with their trainees and trainers respectively, and how are any such changes potentially linked to the effectiveness of observational learning.
Part 1. On-line anonymous surveys: senior and junior doctors from differing secondary care specialties were asked a series of questions about their perceptions of observational learning, using 6-point Likert rating scales.
Part 2. In depth one-to-one semi-structured interviews were conducted with two senior and two junior doctors from each of two specialties (General Medicine and Emergency Medicine).
Dr Mark Gurnell, Dr Afzal Chaudhry (joint project leads/contact persons)
Data from the study is currently being analysed and will be submitted for presentation and publication in due course.
The skill of summary in clinician-patient communication revisited: A case study.
Student-doctors are now taught communication skills as part of their training. A key skill emphasised in teaching and assessment is summary. Summary is the deliberate step of making an explicit verbal precis to the patient of the information gathered so far.
- In student-doctor/simulated patient consultations what functions are summary used to perform?
- In student-doctor/simulated patient consultations how is the skill of summary received and responsed to during a simulated consultation?
Video recordings of ten consultations between simulated patients and student-doctors were analysed to identify types of summary used. Two contrasting cases were then micro-analysed and follow-up interviews were held with the 2 simulated patients and student-doctors involved in the consultations, using the video recording as a trigger.
- Summary is more complex than the literature suggests.
- Further research is needed to investigate whether these findings are replicated within doctor-patient consultations.
- Micro-analysis of recordings of simulated patients may provide useful data about the impact of using communication skills.
- Teaching needs to consider type of summary, purpose, accuracy and patient's response.
Sally Quilligan*, Jonathan Silverman. *Contact person/team leader.
Quilligan, S. Silverman, J. Is the skill of summary of vallue in student-doctor/simulated patient consultations? European Association for Communication in Healthcare. 2010, Verona.
Standard clinical course medical students at Cambridge face a marked transition to more experiential and self directed learning on entering the Clinical School. Since 2001 Honey and Mumford's Learning Style Questionnaire (LSQ) has been used with medical students. This instrument has been used to construct a breadth of repertoire of learning styles index. Gender differences were found in respect of this index. The study aimed to explore the factors which may account for differences in breadth of repertoire of learning style.
- Was it possible to identify difference between two groups of students classified as "Narrow" and "Broad" on the basis of their responses to the LSQ?
- What if any were the nature of these differences in terms of factors influencing learning?
Qualitative: focus groups conducted "blind" with each group of students.
Quince T, Djuric Z, Benson J, Brimicombe J, Wood D. "Towards validating breadth of learning styles" AMEE Conference, September 2008, Prague, Czech Republic.
Quince T, Djuric Z, Benson J, Brimicombe J, Wood D. "Support for repertoire of breadth of learning styles." ASME Annual Scientific Meeting, July 2008, Leicester, UK.
Assessment forms an integral part of medical education. MERG is engaged in assessing the performance characteristics of EPSCALE, a rating scale that assesses the process of explanation and planning in the medical interview.
Evaluation of the validity of EPSCALE, a rating scale that assesses the process of explanation and planning in the medical interview.
Communication skills teaching programmes have traditionally concentrated on the first half of the interview, but recently programmes at undergraduate level have embraced the need to teach explanation and planning. This has led to a need to develop instruments to make a valid and reliable assessment of this component of the interview. There are few published instruments available that objectively assess process skills in the second half of the consultation specifically.
In an earlier study we established the content validaity, internal consistency and generalisability of EPSCALE. The need to explore the validity of EPSCALE beyond its content validity remains.
-What is the construct validity of EPSCALE?
-What is the concurrent validity of EPSCALE?
-To establish construct validity: comparison of EPSCALE scores for students in Stage 2 with a] their own scores in Stage 3 and b] scores for experience facilitators.
-To establish concurrent validity: comparison of EPSCALE scores for students in Stage 2 and for facilitators with scores achieved using an existing scale evaluating the explanation and planning section of the consultation: OPTION.
John Benson*, Jonathan Silverman*, Dan Edgcumbe, Julian Archer. *Contact person/team leader.
Initial evaluation of validity and reliability of EPSCALE.
Communication skills teaching programmes have traditionally concentrated on the first half of the interview, but recently programmes at undergraduate level have embraced the need to teach explanation and planning. This has led to a need to develop instruments to make a valid and reliable assessment of this component of the interview. There are few published instruments available that objectively assess process skills in the second half of the consultation specifically. To address this need we developed a new rating scale to measure communication skills in explanation and planning: EPSCALE.
- What is the content validity of EPSCALE?
- What is the internal consistency of EPSCALE?
- What is the generalisability of EPSCALE?
- Content validity: consensus exercise and expert review
- Internal consistency and generalisability: 124 clinical students undertaking 4 OSCE stations with simulated patients, with one observer (hospital specialist, GP or communication specialist) per station, during final examinations. Internal consistency estimated by coefficient alpha, generalisability estimated by generalisability coefficient and variance components using EPSCALE.
EPSCALE has content validity and high internal consistency when used to assess explanation and planning skills in the consultation. It shows reliability, in a 4 OSCE station examination, comparable to that observed with other assessments. Further work is needed to explore the scale's validity by a range of other measures.
Jonathan Silverman*, Julian Archer, Susan Gillard, Rachel Howells, John Benson
*. *Contact person/team leader.
Silverman J, Archer J, Gillard S, Howells R, Benson J.
(2011) Initial evaluation of EPSCALE, a rating scale that assesses the process of explanation and planning in the medical interview. Patient Education and Counseling