01.17 The newsletter of the Higher Education Academy Subject Centre for Medicine, Dentistry and Veterinary Medicine, Autumn 2008

Issues and news on learning and teaching in medicine, dentistry and veterinary medicine

Print: ISSN 1740-8768

Online: ISSN 1479-523X

IN THIS ISSUE:

Team learning in dentistry
The WikiVet community of practice
Intellectual property issues - coming to an institution near you!

In this issue we have articles which tackle some tricky subjects which we bump up against in learning and teaching again and again. Intellectual property issues is one such topic, and the team from the eLearning unit at St George’s, University of London have been doing some excellent work in this area as part of their EU funded project. I am sure there are lessons we can all learn from their research.

Sustainability is a word which has come to fore in the past couple of years, and we now understand it in terms of the relationship of education and healthcare to the green agenda. Benny Goodman from Plymouth University explains how the sustainability agenda might affect healthcare education.

The Inter-Disciplinary Ethics Applied Centre for Excellence in Teaching and Learning (IDEA CETL), based in Leeds offers a range of resources which can easily be customised to fit into local contexts for teaching ethics across a number of disciplines.

The range of articles we have submitted to us for inclusion in 01 is growing, and we try very hard to reflect the diversity of approaches to learning and teaching across our subject areas. Please continue to send us news of your projects and curriculum developments.This newsletter would not exist without them. Please send us your suggestions and ideas for future articles to: newsletter@medev.ac.uk

Suzanne Hardy
Senior Advisor (Information)

Game-based learning for the delivery of virtual patients in Second Life
Maria Toro-Troconis, Professor Martyn Partridge, Dr Michael Barrett, Faculty of Medicine, Imperial College, London; Professor Ulf Mellström, Department of Human Work Sciences, Luleå University of Technology, Sweden
Intellectual property issues – coming to an institution near you!
Angela Miller, Intellectual Property and Contracts Officer, Chara Balasubramaniam, eViP Programme Manager, Terry Poulton, Associate Dean for E-learning, St George’s, University of London
Climate change, sustainability and health
Benny Goodman, Faculty of Health and Social Work, University of Plymouth
CETL update: Resources for teaching ethics in your discipline
Kathryn Dalby, Centre Manager, Inter-Disciplinary Ethics Applied CETL, University of Leeds
Team learning in dentistry – a report of a pilot scheme to enhance the learning experience of clinical and technical skills teaching for student dentists and student dental technicians
Nick Grey, Head of School/Senior Clinical Teaching Fellow in Restorative Dentistry, Iain Mackie, Professorial Teaching Fellow Consultant in Paediatric Dentistry, Christopher Maryan, Head of Centre for Dental Technology Studies, Division of Health Science School of Biology, Chemistry & Health Science,Manchester Metropolitan University; Alan Jack,Teaching Fellow in Orthodontics, Ray Richmond,Teaching Fellow in Restorative Dentistry, University of Manchester
Integrating Intute services into your website or VLE
Jackie Wickham, Service Manager, Intute: Health and Life Sciences
The WikiVet community of practice
Tim Scase, Senior Lecturer in Veterinary Pathology, University of Cambridge; Gillian Brown, Educational Advisor, MEDEV Subject Centre; Brian Cox,Multimedia Developer, Nick Short, Head of eMedia Unit, Ken Smith, Professor of Companion Animal Pathology, Kim Whittlestone, Senior Lecturer in Independent Learning, Royal Veterinary College; Richard Hammond, Associate Professor of Pharmacology & Anaesthesia, School of Veterinary Medicine and Science, University of Nottingham; Susan Rhind, Professor of Veterinary Education, Royal (Dick) School of Veterinary Studies, University of Edinburgh
Student essay 2008 competition winners
Gillian Brown, Educational Advisor, MEDEV Subject Centre
End of life decision making Richard Sutcliffe,Medical student, University of Leeds
Conference report: The MedBiquitous annual conference 2008: Transforming healthcare education, Baltimore, Maryland, USA
Valerie Smothers, Deputy Director, MedBiquitous; Dr Rachel Ellaway,Assistant Dean Education Informatics, Northern Ontario School of Medicine
Workshop report: Developing a common vision, the development and delivery of the student selected components (SSCs) of the medical undergraduate curriculum
John Ellershaw, Professor of Palliative Medicine, Dr John Smith, Faculty of Medicine, University of Liverpool; Deborah Murdoch-Eaton, Professor of Medical Education, Medical Education Unit, University of Leeds; Patsy Stark, Professor of Medical Education, Academic Unit of Medical Education, University of Sheffield
Research teaching linkages in medicine, dentistry and veterinary medicine: A symposium report
Dr Anita Laidlaw,Teaching Fellow, Julie Struthers, Learning Technology Consultant, Bute Medical School, University of St Andrews
Towards POLY professionalism?
Sue Roff, Centre for Medical Education, Dundee University Medical School

Game-based learning for the delivery of virtual patients in Second Life

Maria Toro-Troconis, Professor Martyn Partridge, Dr Michael Barrett, Faculty of Medicine, Imperial College, London;
**Professor Ulf Mellström**, Department of Human Work Sciences, Luleå University of Technology, Sweden

Medical education faces difficult challenges in the 21st century. Increasing pressure upon doctors to deliver service targets, the European Working Time Directive and changes in the way in which we deliver healthcare (coupled with higher numbers of students entering medical education) have increased the demands on academics, resulting in less time for teaching.¹

Opportunities for building learning activities around real patients have decreased. Therefore, various forms of representative simulation have become an increasingly common alternative. Virtual patients has been one of the representative simulations developed to support the delivery of clinical teaching.²

Game-based learning has been considered as a new way of delivering clinical teaching more suited to the new generation of ‘digital natives’ – ‘native speakers’ of the digital language of computers, video games, mobile phones, and the Internet.³

Online Multi-User Virtual Environments (MUVE) offer rich interactive 3D collaborative spaces where users can meet and interact. One example of such an environment is Second Life (www.secondlife.com).⁴

The Faculty of Medicine at Imperial College London has developed a Virtual Hospital in Second Life (www.medev.ac.uk/dinky?dinky_id=865) that aims to design game-based learning activities for the delivery of virtual patients that can drive experiential, diagnostic, and roleplay learning activities supporting patients’ diagnosis, in youtube.com/watch?v=WnPYhSbSAB investigation and treatment.

The four-dimensional framework described by De Freitas and Martin,⁵ plus the learning types described by Helmer,⁶ as well as the different aspects of emergent narrative described by Murray⁷ have provided the basis for the design of these game-based learning activities for virtual patients under two different categories: context and learner specification; and narrative and modes of representation.

MedBiquitous is a consortium focused on the development of XML standards for healthcare education and training. It has been developing a data standard for the exchange and reuse of virtual patients, which is defined as the “MedBiquitous Virtual Patient (MVP) standard”.

The MVP standard has been used to define a reusable architectural model for the delivery of virtual patients.

Phase I

Phase I of this project focused on the delivery of one virtual patient in the area of Respiratory Medicine following the game-based learning model developed and implemented in Second Life.

The game-based learning activities for one virtual patient focused upon the management of pneumothorax. The module was also available as part of a respiratory emergencies e-module embedded in the year 3 medical undergraduate curriculum. Initial data about gaming competence was obtained from 118 full time undergraduate medical students of average age (22 years). A stratified sample (n=42) was selected according to gender and high and low gamer categories. One group (n=23) was given access to the game based learning activities in Second Life and the second group (n=19) was given access to the same content but delivered as an interactive e-module. After use of the modules students in both groups completed a questionnaire which involved twenty one statements related to affective components, perceived control, perceived usefulness and behavioural components which they scored on a five point Likert Scale.

The feedback received has informed the development of Phase II which incorporates a multi-patient approach.

During this phase an architectural model was developed based on the MVP standard. The text below discusses this architectural model relative to the MDV standard.⁸

MVP components

The five core MVP standard components (Ellaway et al 2006) are described below. These components are explained in the context of Second Life and how they have been implemented within this virtual respiratory ward during Phase I:⁹

“Virtual patient data (VPD): the VPD provides the personal and clinical data that is relevant to the clinical scenario being simulated.” A series of ‘notecards’ are provided in Second Life, with information about patient history and patient information.
“Media resources (MR): media resources are all of the images, animation, videos and audio files that are associated with the virtual patient at any point during the simulated patient scenario.” The respiratory ward provides various multimedia files, such as: breath sounds, slideshows for patient management information and images to represent different investigations to be purchased, as well as images showing the results of different investigations, such as chest X-ray.
“Data availability model (DAM): this component enables the sequencing and progressive disclosure of data embedded in the VPD and associated media resources.” Data within each section in the respiratory ward in Second Life are tagged with identifiers so that patient data can be disclosed progressively. User decisions determine which state is reached next and when.
“Activity model (AM): this component encodes how the learner will be able to engage with the virtual patient. A number of different learner activities are possible with the same underlying virtual patient dataset, ...” Some examples of activity models are: observation, free navigation, diagnosis formulation and decision making. The decision-making approach was implemented in the design of the activities for virtual patients in Second Life. In the decision-making approach the learner is asked to make clinical decisions based on current information and acquires new information as a result of different decisions.
“Global state model (GSM): this component provides the top-level modelling of student activity and the logic for the allocation and regulation of activities.” At the virtual respiratory ward, GSM provides information about how a particular virtual patient interacts with the learner.

In the case of the game-based learning activities developed at the respiratory ward in Second Life, patient data and media resources are referenced in an activity model accessed through a DAM.

Phase II

Phase II introduces a multi-patient approach. Five virtual patients suffering from different respiratory problems: asthma, lung cancer, COPD, pneumonia and pneumothorax have been implemented. The same narrative and Activity Model is applied for all these patients including different modes of representation. The learner is asked to make decisions based on current information and acquires new information as a result of different decisions.

More general feedback and guidance for cyclical content have been introduced in this phase. The Imperial College London badge has been introduced as an option for learners to wear. The badge provides feedback from the system. Feedback will be delivered to the learners if they have not carried out any activity for the last 5 minutes informing the students about the patient they last treated and the last activity carried out on that patient.

‘Demanded feedback’ for cyclical content have also been introduced by the patient’s area. By selecting the ‘Resume where left off ’ sign, learners receive feedback on where they were left last time they accessed the patient.

More control over each activity has also been implemented. Signs titled ‘Re-start this virtual patient’, are available near the patients allowing the learner to reset the virtual patient activity in case they want to start all over again.

A web world environment has been implemented consisting of a three-tier architecture based on J2EE’s Model View Controller (MVC) design pattern – tier 1: web-server; tier 2: application server; and tier 3: database. This model accommodates the delivery of a one-to-many relationship between the user/student and several virtual patients.

A user friendly web interface provides access to the tracking information stored in the database. A variety of reports can be easily produced by user or virtual patient selected.

Conclusion

Learning in immersive worlds is beginning to have a wider range of uses and applications.8 Second Life provides a space in which games can be created, and the infrastructure for the design of open-ended, game-based immersive 3D experiences.

The four-dimensional framework and development process discussed in this paper has helped implementation of the learning outcomes originally proposed for the delivery of game-based learning for a virtual patient in the area of respiratory medicine. The pilot has been extremely important in the evaluation of students’ attitudes towards learning using this delivery mode. The feedback received has informed the development of Phase II which incorporates a multipatient approach.

This article has also presented the five-component architecture for the MedBiquitous Virtual Patient which has been followed for the design of game-based learning activities for virtual patients in Second Life. It is anticipated this model will accommodate the delivery of different virtual patients following the same game-based learning approach as well as wide-scale authoring, reuse and adaptation of virtual patients in a MUVE such as Second Life.

It is also important to bear in mind that this project is still ongoing and the findings highlighted above form part of a larger research project.

References

Olson, L.G., Hill, S.R. and Newby, D.A. (2005) Barriers to student access to patients in a group of teaching hospitals, The Medical Journal of Australia, Vol 183, pp 461–463.
Begg, M., Ellaway, R., Dewhurst, D. and Macleod H. (2005). Virtual patients: considerations of narrative and game play, In Proceedings of the Fourth International Symposium for Information Design, Stuttgart Media University, Karlsruhe, June 2. www.medev.ac.uk/dinky?dinky_id=866 (accessed December 10, 2007).
Prensky, M. (2006). *Don’t bother me mom – I’m learning...* St Paul, Minnesota: Paragon House.
http://www3.imperial.ac.uk/pls/portallive/docs/1/40465710.PDF
De Freitas, S., and Martin, O. (2006) How can exploratory learning with games and simulations within the curriculum be most effectively evaluated?, Computers and Education, Vol 46, No. 3, pp 249–264.
Helmer, J. (2007) Second Life and Virtual Worlds, Learning Light Limited.UK. www.epic.co.uk/content/news/nov_07/Second_Life_and_Virtual_Worlds_JH.pdf (accessed December 10, 2007).
Murray, J. (1997). Hamlet on the Holodeck: the Future of Narrative in Cyberspace. MIT Press, Cambridge, MA.
Ellaway, R., Candler, C., Greene, P. and Smothers, V. (2006) An Architectural Model for MedBiquitous Virtual Patients, MedBiquitous, Baltimore, MD.
Toro-Troconis, M., Mellström, U., Partridge, M. and Barrett, M. (2008) An architectural model for the design of game-based learning activities for virtual patients in Second Life, In Proceedings of the European Conference on Game-Based Learning, The Universitat Oberta de Catalunya (UOC), Barcelona, 16–17 October. (In press)

For more information please visit www.elearningimperial.com or contact m.toro@imperial.ac.uk

Intellectual property issues – coming to an institution near you!

Angela Miller, Intellectual Property and Contracts Officer,
Chara Balasubramaniam, eViP Programme Manager,
Terry Poulton, Associate Dean for E-learning, St George’s, University of London

The increasing use of the Internet for learning and teaching brings into question the traditional approaches for the protection of digital content created with the intention of being shared.This is a persistent challenge in medical and healthcare education where, in addition to traditional ownership of the content and jurisdictional differences, there is the added complexity of ensuring patient anonymity.This article explores some of the obstacles faced by European institutions wishing to share digital content for medical and healthcare education and proposes a framework for a licensing model that will address some of these difficulties.

Background

Opportunities for student-patient contact, at the heart of clinical competency, are declining in most European Union (EU) member states. Training is hampered by two important factors:

The healthcare budget constraints that increasingly limit clinical teaching.
The reduction in the time that patients stay in hospital.

Electronic Virtual Patients (VPs) are now recognised by the medical education community as effective tools for addressing the lack of clinical training due to their ability to mimic real-life scenarios and empower students to make clinical decisions in a safe online environment.

A VP consists of many learning objects (e.g. text, images, animations and videos) and can be defined as an interactive computer simulation of real-life clinical scenarios for the purposes of clinical training, education, or assessment.¹ One limitation of VPs is that they are time-consuming and expensive to produce from ‘scratch’, and even leading e-learning institutions cannot produce a sufficient number to give full coverage of the medical or healthcare curricula.² A possible solution is for eLearning institutions to share existing VPs, an option being explored by the Electronic Virtual Patient (eViP) programme. eViP consists of a European consortium of eLearning medical and healthcare institutions, led by the eLearning Unit at St George’s, University of London.³ The aim of the three-year programme is to create a bank of repurposed and enriched multicultural VPs from across Europe.

In the main eLearning arena of learning objects, Griffith⁴ has described the chilling effects that copyright law is having on efforts to reuse learning materials.4 By exploring the obstacles presented by institutional and legal differences across the partnering member states, eViP aims to adopt a common licensing framework that will permit sharing and repurposing of digital content, specifically VPs, for use in medical and healthcare education.

Definitions

A few definitions are particularly important in any consideration of intellectual property and there is much confusion about their practical applications.

Intellectual property (IP) IP is a legal field that refers to creations of the mind such as inventions, literary, musical, and artistic works used in commerce, including copyrights, trademarks, patents, and related rights. Under IP law, the holder of one of these abstract ‘properties’ has certain exclusive rights to the creative work, commercial symbol, or invention by which it is covered.
Intellectual property right (IPR) IPRs are a bundle of exclusive rights granted to the creators’ works that are creations of the human intellect. The temporary monopoly granted to the owners of these rights is intended to provide an incentive for the inventor to develop and share the creation rather than keep it secret. IPRs exist in the form of patents, copyrights, trademarks and design rights.
Copyright Copyright essentially is the right to copy. This form of IP is applicable to any expressible form of an idea or information that is substantive and includes creative works such as books, movies, music, paintings, photographs, and software. Copyright gives the copyright holder exclusive right to control reproduction or adaptation of such works for a certain period of time. In addition, as per the current Berne Convention for the Protection of Literary and Artistic Works agreement, copyright also has certain moral rights that when asserted provide an individual with the right to be credited for the work, determine who may adapt the work, and perform the work financially.⁵

Harmonisation of European copyright law has taken some steps forward. However, there are still notable differences between many jurisdictions, often reflecting the cultural and historical differences underlying this form of protection. For example, there is much difference between the 27 countries of the European Union and their respective copyright duration terms.⁶

Findings from the eViP programme

The Electronic Virtual Patients programme (eViP) includes partners from institutions based in Sweden, Germany, The Netherlands, Poland, Romania, and the UK. Review of copyright laws between these partners identified conflicts relating mainly to ownership of content created and protectable by copyright and the duration of copyright protected works. These initial findings are not representative of differences in copyright present throughout Europe. However, it does indicate that obstacles faced to sharing copyright works are not insurmountable.

A common prerequisite to the use and pooling of VPs is the requirement for patient or contributor consent. Most consent obtained will only be for a limited purpose and only for use by the requesting institution. In the UK, all such requests need to fall in line with the 1998 Data Protection Act,⁷ this is mirrored by each EU member state.

The eViP partners plan to adopt a common consent form that complies with national regulations and institutional policies across the EU, thus permitting use by all members of the eViP programme. Importantly any such use will also take into account the future plans of the programme. These forms will be used within eViP for both new VPs as well as retrospectively applied to old VPs. For a working draft of this consent form, please visit: www.virtualpatients.eu/about/example/

The solution – an eViP common licensing model

The main licensing framework for the use and repurposing of VPs within eViP will be based on the Creative Commons (CC) licensing platform.⁸ CC is a widely recognised form of ‘open’ licensing for works generally protected by copyright.

Depending on the type of CC license chosen, the licensor may restrict only certain rights (Some Rights Reserved) or none of the work (No Rights Reserved). This approach is in sharp contrast to traditional copyright, which is more restrictive and is defined by what cannot be done to protected works.

The type or version of CC license is determined by a selection of four main conditions that can be used to restrict how the licensor may use the licensed work:9 whether the author licensee credits the author or licensor in any work involving the licensed work (Attribution); if the licensed work can be exploited (Noncommercial or Non-Commercial); whether the licensee can develop new work derived from the licensed product (No Derivative Works) and licensees may distribute derivative works only under a license identical to the license that governs the original work (Share Alike). In collaboration with CCLearn,10 the eViP team has initiated a licensing model for the sharing and repurposing of VPs based on the CC licensing platform.

Conclusion

Intellectual property in the form of copyright is not something to put on the back burner any longer. It is a ‘real’ issue that threatens academic collaboration. Provided the right steps are taken in preparation, such as the adoption of commons consent forms and licensing models, it may still be possible to facilitate the sharing of digital content, whilst protecting the liability of the respective institutions, regardless of geographic location.

References

Ellaway R, Candler C, Greene P and Smothers V (2006), An Architectural Model for MedBiquitous Virtual Patients. Baltimore, MD, MedBiquitous
Huang, G; Reynolds, R; Candler, C (2007), Virtual Patient Simulation at U.S. and Canadian Medical Schools, Academic Medicine
www.virtualpatients.eu (accessed 19th June 2008)
Griffiths, D (2005), Print to pixels: the implications for the development of learning resources, Vancouver, LORNET
www.wipo.int/treaties/en/ip/berne/trtdocs _wo001.html (accessed 19th June 2008)
www.eucopyright.org/2008/04/copyright_eu_list/ (accessed 18th June 2008)
www.opsi.gov.uk/acts/acts1998/ukpga _19980029_en_1 (accessed 19th June 2008)
creativecommons.org (accessed 19th June 2008)
creativecommons.org/about/license/ (accessed 19th June 2008)
learn.creativecommons.org (accessed 19th June 2008)

For more information please contact cbalasube@sgul.ac.uk

Climate change, sustainability and health

Benny Goodman, Faculty of Health and Social Work, University of Plymouth

The world’s population is facing, perhaps, an unprecedented challenge to its very existence with public health implications becoming clear. As the heating happens,¹ changes in temperature and sea levels for example, could bring shifts in living patterns we may not be prepared for.

In addition, global population growth may well be exacerbated by the ability of the world’s population to despoil the environment through an increase in per capita CO2 emissions and the intensification of ecologically disruptive economic activity.² This may take place in the context of a stabilising population growth but with environmentally damaging consumption patterns.

The health implications are based on the changing relationship that human populations have with their physical and social environments. The BMA³ set out its vision of the challenges we face from such things as:

Heatwaves – thermal stress, death and injury from cyclones, bushfires.
Flooding - including chemical, oil and pesticide contamination.
Infectious diseases – vector, food and water born: e.g. malaria, dengue fever.
UV radiation – increases in skin cancers.
Air Pollution – increases in respiratory diseases.

The world is already beginning to face a further food production and distribution challenge as nations change agricultural patterns in their switch from food to biofuels. In addition to physical health impacts there are implications for the mental health of populations who experience traumatic events such as flooding.

The UK may not face the same severity of climate change as other parts of the globe, and the exact nature of the changes are yet to be fully understood or realised. However, in an interdependent world where we may see population displacement (possible in the billions) due to severe weather events, drought, famine and conflict, the UK would not be immune to these pressures. Indeed, the focus on climate change has not altered the political context in which the US may be acceding economic, cultural and military hegemony to China, India and Russia. The potential for the further development, proliferation and use of nuclear, biological and chemical weapons remains. Terrorists have more than shown willingness to upset the current global economy in pursuit of their own ends. The political context could be even more volatile given the changes in weather, agriculture and disease patterns that may emerge.

Health care professionals have often be challenged in the past4 for being too individualistic and reductionist in their approach to illness and disease. The public health and climate change agendas asks us to join the dots. Individual action is important and cycling to work, using low energy bulbs and reducing meat consumption may well be a good start. However, until we collectively tackle some of the underlying issues in a coherent way, it is deck chairs and Titanic time.

More positively, there are health gains to be had from changing lifestyles and consumption patterns (think car use and lack of exercise) and the Transition Towns⁵ movement for building sustainable and resilient communities may provide one model for the future.

References

Selby, D., As the heating happens: Education for sustainable development or education for sustainable contraction? Discourse, Power, Resistance Conference, Talking Truth to power. www.esri.mmu.ac.uk/dpr_07/abstracts_07/ index.php (2007) (Accessed 22nd April 2008).
McMichael, A. J., and Powells, J.W., Human numbers, environment, sustainability and health. (1999) BMJ; 319:977-980. www.bmj.com/cgi/content/full/319/7215/977 (Accessed 22nd April 2008).
Health professionals taking action on climate change www.bma.org.uk/ap.nsf/Content/climatechange (Accessed 22nd April 2008).
Illich, I., Medical Nemesis, the expropriation of health: London. Calder and Boyars (1975).
Transition Towns transitionculture.org (Accessed 22nd April 2008).

For more information please contact b.goodman-1@plymouth.ac.uk

CETL update: Resources for teaching ethics in your discipline

Kathryn Dalby, Centre Manager, Inter-Disciplinary Ethics Applied CETL, University of Leeds

At the Inter-Disciplinary Ethics Applied CETL,we believe that in order to teach ethics effectively, it is best for it to be properly integrated into programmes of study as this allows students to understand the relevance of ethical issues within the context of their discipline.

Our teaching materials have been developed with this in mind – they are easy to customise to suit different teaching needs, can provide the basis for short teaching sessions and can be easily assimilated into existing curricula. They can be used either by tutors who are new to teaching ethics, or by those who have more experience but want some further ideas and inspiration.

Launching in July 2008, this new section of our website comprises:

An introduction to ethical thinking: our web based customisable teaching package designed to help colleagues from a range of disciplines to integrate ethics into their programmes of study.
Online database of resources: contains teaching materials spanning a range of disciplines including business, medicine, engineering, biomedical sciences and sport.

Many of our resources provide the basis for short teaching sessions which can be easily assimilated into existing curricula. With an emphasis on discussion and independent thought, they will teach students the important skills of analysis, critical reasoning, argument and clarity of expression; skills which enable them to respond effectively to ethical issues and which can also be transferred to other areas of their work.

Within our resources database you will find:

Case studies.
Case scenarios and vignettes.
Lesson plans.
Reading lists and bibliographies.
Lecture slides.
Module outlines.
Guides to teaching ethics.

They mostly provide the user with a ready to use resource that can be taken from the database and used with little or no further fine-tuning required. Other materials, such as the lecture slides and reading lists are intended to play a more inspirational role: rather than providing users with a complete ready to use lesson plan, the intention is to provide a resource to inform the user, helping them to develop their own classes and/or courses, and to spark ideas.

To find out more please visit www.idea.leeds.ac.uk

Team learning in dentistry – a report of a pilot scheme to enhance the learning experience of clinical and technical skills teaching for student dentists and student dental technicians

Nick Grey, Head of School/Senior Clinical Teaching Fellow in Restorative Dentistry,
Iain Mackie, Professorial Teaching Fellow Consultant in Paediatric Dentistry,
Christopher Maryan, Head of Centre for Dental Technology Studies, Division of Health Science School of Biology, Chemistry & Health Science, Manchester Metropolitan University;
Alan Jack,Teaching Fellow in Orthodontics,
Ray Richmond,Teaching Fellow in Restorative Dentistry, University of Manchester;

Apart from a requirement to attain more and more academic knowledge, during their training, student dentists and student dental technologists also need to acquire a full range of highly precise manual and technical skills, including excellent hand/eye coordination, to enable them to visualise and understand how to prepare cavities, prior to placing restorations¹ and fabricate prostheses. Furthermore, unlike student doctors, student dentists are in the position of administering treatment to patients very early in their training. In addition, they are required to have a working knowledge of the various types of dental prostheses (e.g. dentures and bridges) that they provide to their patients.

The teaching of manual skills in dentistry has been confined traditionally to the early years of the BDS course. This discipline, as has in the majority of UK dental schools, been further separated in to technical skills and clinical simulation exercises. Much of the teaching of technical skills to student dentists has by tradition been undertaken by dental instructors in the University of Manchester (UoM), whereas the teaching of dental technology students has been carried out in the centre for dental technology studies at Manchester Metropolitan University (MMU). The MMU has approximately 230 undergraduates on a range of full-time and part-time courses which are delivered in a bespoke teaching environment and receive engineering, materials science and biological sciences support.

Both institutions had been reviewing their curricula and had set goals to improve communication between those within the dental team. Hence a pilot scheme was undertaken to foster improved links between the two institutions with the aim of enabling both cohorts of students to gain an overall understanding of the work carried out by other members within the dental team and also to engender an atmosphere of mutual collaboration that could be of value during their future careers.

The facilities for dental technology at MMU had recently been refurbished to being “state of the art” which enabled the delivery of quality teaching for students undertaking BSc. and PhD. postgraduate dental technology qualifications. Conversely, the clinical facilities at the UOM were in the process of refurbishment and both MMU and UoM had a desire to collaborate, the idea of utilising both clinical and technical teaching facilities to maximise learning and teaching opportunities for both student dental technicians and dentists was attractive.

A series of tasks relating to technical skills teaching for student dentists from UoM was timetabled in the new MMU facility. In January 08, second year BDS student dentists from UoM were taught (via a series of practical exercises and assignments) the technical stages of complete denture construction at MMU, the timing of which coincided with the treatment of their first complete denture patient at the UoM. Later on in the year, (March 08) third year BDS student dentists attended the facilities at MMU in order to learn the principles of partial denture design and orthodontic appliance construction.

Currently, the UoM is undergoing a one million pound renovation of its dental laboratories to complement its recently commissioned Clinical Skills Classroom (see over) the completion of which allows a reciprocal arrangement in the teaching of BSc. student dental technologists from MMU. These students will also shadow the dental students on clinic and undertake the technical work for their patients. Furthermore, it is envisaged that the student dentists will observe student technologists when constructing dental appliances such as crowns and bridges and also prostheses for orofacial cancer patients such as artificial eyes, obturators, noses and facial prostheses etc.

The link has enabled student dentists and technicians to make contact as the two groups are now sharing some time in the same physical space. Both cohorts of students have attended lecture theatre events relevant to both and the closer working links will further enable greater integration and exchange of learning resources. The raft of on-line learning material for both cohorts of students when shared with the other will only serve to enhance the knowledge and understanding for all students but also avoid duplication of learning material by both MMU and UoM.

In a bid to determine their opinion, a questionnaire was given to all 73 Third year BDS student dentists who attended the MMU for technical instruction. The questionnaire returned a 94% response rate. Feedback on the closer collaboration was collated the results of which are shown below:

100% rated the facilities at MMU to be better than those of the technical skills classroom based at School of Dentistry (UOM).
43% rated the facilities as ‘very good’ and 56% rated them as ‘good’.
84% thought that working at MMU would help to enhance their learning experience; the remaining 15% were unsure.
74% rated the quality of teaching as ‘very good’ and 26% rated it as ‘good’.
77% responded that they would like to see more technical skills exercises in the course; 10% felt that there was enough and the remaining 13% were unsure.
88% were in favour of having a student dental technologist shadowing them on the clinic and the remaining, 11% weren’t sure and 1% was not in favour.

When asked “As part of the Manchester Dental Programme the plan is to form dental teams consisting of a 1st year dental student, 2nd year dental student, 3rd year dental student, 4th year dental student, 5th year dental student, dental therapist, dental Technologist” 77% were in favour, 10% were unsure and 11% were not in favour.

Unfortunately, the student questionnaire was given out late in the final term of the BDS course hence it could not be given to the second year students dentists owing to the fact that they had finished for the summer. However, these initial results obtained from the third year students show a very positive response on the benefits of closer collaboration of the teaching of technical skills to student dentists. The pilot is now to be expanded to enable postgraduate dental students undertaking MScs in Restorative Dentistry and Orthodontic programmes of study at UoM to attend MMU for technical instruction. Conversely, the MMU is currently reviewing their programmes and are investigating the integration of MSc in Dental Technology with the post-graduate programmes at UoM. Hence this project presents further opportunities for collaborations with MMU postgraduates in such way that both cohorts will gain an appreciation of the work carried out by the other in a clinically relevant environment.

References

Welk, AC, Splieth C et al. (2004). DentSim - a future teaching option for dentists. Int J Comput Dent 7(2): 123-30

For more information please contact nicholas.grey@manchester.ac.uk

Integrating Intute services into your website or VLE

Jackie Wickham, Service Manager, Intute: Health and Life Sciences

Web 2.0 technologies are changing the way people use the internet, both to create and access information.The ability to integrate and repurpose information offers many opportunities in education. Intute has developed a number of integration services which allow users to exploit its resources and services within the context of their own websites and Virtual Learning Environments (VLEs).

Intute is a free online service funded by JISC which guides users to the best internet resources for education and research. It is created and maintained by subject specialists in universities and colleges in the UK.

The vast majority of students use the internet for their studies¹ but they need help to identify relevant content.² A high percentage use search engines for their academic research and many lecturers identify with the frustrations around student use of poor quality resources found through these tools.

One solution is to provide links³ to quality internet resources in course websites and VLEs but this requires considerable time and effort to regularly check and update the web links. Intute has developed a range of Integration Services which remove the need for this. Basically, we enable users to take content from Intute and embed it in their own website or VLE. There are a number of options:

Simple linking - The most obvious and easy way of integrating Intute into a website or VLE.
Embedding the Intute Search Box - The whole or parts of the Intute catalogue can be searched directly from your web pages.
RSS feeds - There are a number of RSS feeds to choose from e.g. new resources in specific subject areas, news from Intute.
Customising resources using MyIntute - Resources can be selected from the Intute catalogue and presented on web pages and VLEs. These are dynamically updated so there is no longer any need to check for dead links.

The advantage for end users is that they can use Intute in their own familiar web environment. Web administrators or e-learning staff can customise the set up to display their own look and feel resulting in a seamless experience. For example, the School Of Nursing in Nottingham has integrated the Intute Search box so that there is an option to search only the Nursing, Midwifery and Allied Health section:

The City of Bristol College has been experimenting with Intute on the Blackboard VLE. Olaf Raetsel, the ILT Support Officer, has imported selected websites from Intute using the MyIntute service. He has imported some dentistry catalogue records from Intute via RSS which have been recommended by a lecturer. When Intute does any updating to the records, these will be pulled through to the records on Blackboard, saving work for College staff.

We have set up an Exemplar scheme to showcase good examples of this type of activity – these are listed at: www.intute.ac.uk/integration/exemplars/. The variation in appearance on the different websites is clear but they are all using the same underlying technology.

Intute can support teaching and learning staff in encouraging students to use the internet effectively for their studies and our integration services can save time in providing access to high quality resources.

References

FDS International (2008) Intute Market Research, p7
Ciber, Information Behaviour of the Researcher of the Future : A Ciber Briefing Paper (UCL, 2008), p12
Wales, T. (2005) Library subject guides: a content management case study at the Open University, UK, Program: electronic library and information systems, Vol. 39, No.2, 2005, pp112-121

More information is available at www.intute.ac.uk/integration/ or e-mail Jackie Wickham on jacqueline.wickham@nott.ac.uk

The WikiVet community of practice

Tim Scase, Senior Lecturer in Veterinary Pathology, University of Cambridge; Gillian Brown, Educational Advisor, MEDEV Subject Centre; Brian Cox, Multimedia Developer, Nick Short, Head of eMedia Unit, Ken Smith, Professor of Companion Animal Pathology, Kim Whittlestone, Senior Lecturer in Independent Learning, Royal Veterinary College; Richard Hammond, Associate Professor of Pharmacology & Anaesthesia, School of Veterinary Medicine and Science, University of Nottingham; Susan Rhind, Professor of VeterinaryEducation, Royal (Dick) School of Veterinary Studies, University of Edinburgh

Wikis are one of the major applications under the umbrella of ‘web 2.0’ technologies which allow collaborative authoring, editing and sharing of information.‘WikiVet’ is a collaboration between the UK Veterinary schools facilitated by a Higher Education Academy funded community of practice (CoP) grant and also supported by JISC.

The veterinary education community has a strong history of collaborative developments in eLearning exemplified by the CLIVE consortium (www.clive.ed.ac.uk). Wikivet has re-energised this inter-institutional collaboration focussing on the use of web 2.0 technologies to develop a national resource and explore the power of these technologies in the veterinary education context (www.vetschools.ac.uk/).

There are currently 7 veterinary schools in the UK with a combined community (of both staff and students) of around 5,000 people. There are clear benefits of collaborative and communal approaches to teaching between these institutions. However, demands on time due to clinical commitments, research imperatives and teaching mean that these opportunities are often not fully realised.

The Wikivet community of practice (CoP) was established in April 2007 with ‘mediawiki’ being chosen as the platform for development (the same software as used for wikipedia – see en.wikipedia.org). The main method of communication for the group has been VOIP ‘skype’ calls and discussion group lists with occasional face-to-face meetings. A decision was taken early on to involve undergraduate students in the task of developing content in the wiki and a launch workshop was held in July 2007 at the new LIVE Centre (www.live.ac.uk) to begin this process.

The involvement of veterinary students in creating the content of the wiki with support of subject specialists has proved to be very successful. This has allowed sharing of lecture notes and related materials amongst the different schools. Students from the three ‘founding’ veterinary schools (Cambridge, Edinburgh and London) have now been joined by students from Nottingham and interest is spreading to all the other UK schools. We are encouraging pathology residents across all the schools to contribute by overseeing content and authoring some of the more challenging areas. In addition to lecture based content, we are beginning to explore the potential for the wiki to ‘signpost’ users to other online resources such as images, videos and other web links. In addition, the development of related educational resources such as ‘flash cards’ (where students can test themselves in given topic areas) and concept maps in order to link complex areas allows the wiki to be more than a content repository. Furthermore, clinical case development by a veterinary surgeon in practice has provided a strong link between undergraduate and work-based learning.

Now that the pathology section is nearing completion, the wikivet team are extending the subject areas covered to other disciplines such as anatomy and physiology. We are already receiving expressions of interest from experts in these fields from around the world.

In addition to developing the wiki, the project group are also building up personal reflections and insights into the processes involved in using these ‘Web 2.0’ technologies to develop a CoP supporting innovation in learning and teaching in veterinary education.

The main challenges encountered so far in the project include the availability of enough staff time to monitor and support student editing and concerns over accurate information on image ownership and permissions.

The unexpected successes include the extremely positive attitudes of everyone involved in the project, including everyone who has heard about it, as well as the development by students of more pedagogically challenging resources (such as the clinical cases and flashcards) to enhance the ‘encyclopaedic’ content.

The wikivet group are extremely grateful to the Higher Education Academy and the JISC for supporting this community of practice project which we believe has been an exciting initiative and has great potential for further development in the future.

For more information, please contact gillian@medev.ac.uk

Student essay 2008 competition winners

Gillian Brown, Educational Advisor, MEDEV Subject Centre

Congratulations to the winner and runners up of the 2008 MEDEV student essay competition, the title of which was What makes a good lecturer?

Anna Stienen-Durand from St Georges, University of London - received £250 cash towards her elective. Her essay is reproduced below.

There were three runners-up, who each received a £20 book token: - Kapil Sugand from Imperial College, London. - Alison Lennox from University College, London. - Daniel Murphy from Peninsula College of Medicine and Dentistry.

What makes a good lecturer?

Anna Stienen-Durand, St George’s, University of London

Over the past four years of my medical degree I have experienced the whole gamut of lecture theatre emotions. The contented sigh-‘oh it all makes sense now’ now moments as a difficult concept was clearly explained by an accomplished lecturer. The tutors whose eyes remain permanently fixed on the back wall of the theatre and spout a stream of obscure medical science to me and my fellow dozing students. However, it wasn’t until I started to teach students myself as a clinical skills tutor that I realised how challenging and essential the skill of lecturing is in the advancement of knowledge.

As a medical student I often feel overwhelmed by the information that I am expected to cram into my cranium. In moments of deep despair I have often questioned whether there really are enough neurones in any brain to memorise and apply this knowledge. So, if learning medicine involves learning and employing a significant amount of information a good lecturer in medicine should primarily endeavour to condense the necessary knowledge into memorable chunks. In the lecture theatre this should always be their priority.

Once the lecturer has ensured that he or she has emphasised and reiterated the essential facts there are numerous other qualities and skills that will ensure the attention of their eager learners. In the remainder of this essay I will consider a number of the attributes that make a good lecturer.

One would assume that any individual who lectures students is enthusiastic about their subject and dedicated to communicating that fascination to some fresh new faces. I believe that a keen interest and enthusiasm in the subject should be a pre-requisite for any lecturing post. How can a tutor expect to encourage his or her students to learn if they themselves appear bored by their subject material? However, all individuals who possess a keen interest in their subject will not necessarily convey this passion to their students. The accomplished lecturer will also have a passion for teaching and for the advancement of their field. Those young school leavers may be the future of the field of medicine that the lecturer has dedicated his or her professional life to.

In addition to a passion for teaching and an enthusiasm in their subject a good lecturer must ensure that their one hour of teaching and all those important facts are remembered by the students. The most interesting and memorable lectures that I have attended at medical school have involved enthusiastic lecturers engaging the students in activities in the lecture theatre. As opposed to listening to a one hour monologue we were encouraged to discuss key points with our fellow students and respond in groups to the rest of the auditorium. This more informal, active approach to teaching ensured that our one hour lecture was a talking point outside of the lecture theatre and therefore eminently unforgettable.

Another important aspect of teaching is ensuring that your subject matter is relevant to students. I often found it difficult to pay attention in the lectures that seemed unrelated to the practise of medicine. Lecturers who refer to clinical scenarios or their clinical experience have often fired my imagination and encouraged me to listen attentively and scribble down invaluable notes. In the same way I have often noticed that students, from their collective hunched position at 4p.m. on a Thursday afternoon, will sit up when the all important words ‘this frequently comes up in exams’ are uttered.

The methods used by the lecturer to convey information in a lecture is also extremely important. While studying medicine I have become increasingly aware that learning is an individual experience. There are three different types of ‘learner’ visual, auditory and kinaesthetic. In my pre-clinical years I was often discouraged from attending those lectures which I knew would consist of a tutor talking at length about a complicated scientific process and quickly flicking through forty overhead slides. As a visual learner I knew that my time would be better spent in the library, poring over brightly coloured books. I have even attended lectures where the lecturer has firmly stated that all students should put down their pens and cease writing because he would like us ‘just to listen’. A lecture such as this is wasted on me. I believe that we should be more sympathetic towards these different types of learning and students in the healthcare professions should fly the flag for ‘multi-sensory’ lectures. A truly excellent lecturer will aim to stimulate the visual, auditory and kinaesthetic learners individually in his or her auditorium.

At my medical school senior medical students such as myself are employed to teach clinical skills for one afternoon a week to preclinical medical students. In order to be afforded this position of responsibility clinical students must have scored consistently high in clinical exams and attend a training day. Until I was made a clinical skills tutor I had never really thought about how challenging it is to lecture. During my teaching sessions I aim to be the ultimate multi-tasker; knowledgeable, fully prepared, enthusiastic and engaging. I ensure that the students are interested and stimulated throughout our session and reiterate the important learning points at the end of our time together. Teaching these students has easily been my most rewarding experience at medical school and I now plan to pursue a career in medical teaching in the future.

In conclusion, I believe that the future of medicine depends on good lecturers who should, most importantly, be proficient in condensing and emphasising the salient points of their lecture. However, an enthusiasm for their subject and for teaching and a desire to deliver a relevant and engaging lecture is also vital in ensuring the attention and interest of their students. I truly believe that ‘multisensory’ lectures should be introduced into the medical school curriculum and a good lecturer will aim to stimulate the different types of learners in the audience.

Further information

There was an excellent response to the competition and the standard of essays was higher than ever. The winner of the Subject Centre competition went forward to the national competition, and the overall winner was announced at the Higher Education Academy conference in Harrogate in July 2008.

First prize, a new laptop, was awarded to Warren Rieutort-Louis, a third year Engineering student from the University of Cambridge. His essay, What makes a good lecturer?, focused on the shared experience of learning and the passion, drive and enthusiasm demonstrated by excellent educators, you can read his essay at www.engsc.ac.uk/an/student_awards/archive/winner2008.asp

For more information please contact gillian@medev.ac.uk

End of life decision making

Richard Sutcliffe, Medical student, University of Leeds

The Jennifer Jackson prize is awarded to the best medical ethics report by a third year medical student at the University of Leeds. Outstanding papers are recommended by tutors. The important considerations are originality and independence of thought, depth and accuracy of understanding of the issues addressed by the paper, analytic ability, coherent argument and clarity of expression.We are very pleased to have permission to reproduce the winning essay from 2007.

For a Thursday it’s unusually quiet on the wards and so you take the opportunity to see Eleanor an elderly lady who’s been admitted this morning with pneumonia.

‘Good morning, my names Dr Rochester, and how are we this morning?’ you enquire whilst at the same time making a mental note to say ‘you’ rather than ‘we’ since you fear it sounds condescending.

‘I’m afraid Doctor the question is not ‘how am I?’ the question is ‘what do you know?’ And the answer is – you know nothing. You know nothing of life, and even less of death. You profess to an understanding of the human body when you don’t possess control over your own thoughts. In death it is not the act of departing that is of concern – it is the manner with which one departs’

Needless to say you didn’t expect such an eloquent retort from such a frail looking lady but as you look closer you notice a certain dignity in the manner in which she holds her head and a searing intelligence in her imperious gaze.

‘I’m not quite sure what you mean’ you lie.

‘You would have me lying here to the very last’ she sniped.

‘Eleanor as far as I’m aware you’re suffering from a mild case of pneumonia which, after treatment with the appropriate antibiotics, will be resolved. Other than that, for a lady of your age you are in perfect health.’

‘I’m perfectly aware of my condition Doctor. I’m also perfectly aware that prior to the advent of antibiotics this mild case of pneumonia may well have brought about my end. As an intelligent human being have you not entertained the idea that such an alternative may be preferable?’

‘Eleanor, as much as I’d like to discuss the ethical ramifications of advances in medicine the law dictates that if I decide not to treat a case of pneumonia then I’m not doing my job’. And although you could easily take your leave of Eleanor with some notion of being ‘terribly busy’ you find yourself intrigued by her words. After all those hours discussing hypothetical ethical situations at medical school here was a fluent spokesperson for the patient’s perspective.

‘The law Doctor...’ continued Eleanor ‘...is a blunt instrument, useless in matters of the human heart. As for advances in medicine – it is the tragedy of such advances that the flesh can be kept alive long after the will has gone. Medicine no longer understands the notion of futility’¹

‘I would argue that each case must be taken on its own merits, various issues must be considered – quality of life² for instance’ you find yourself floundering.

‘And what of my quality of life Doctor?’

‘Well, as I’ve already said other than your pneumonia you’re perfectly healthy’

‘I live alone and know no one. I nursed my husband for 5 years until he died of Alzheimer’s disease – a disease which I have also been diagnosed with. How’s that for quality of life Doctor?’

Fortunately, just as you realise you are getting totally out of your depth your bleeper goes and, somewhat shamefaced, you make your excuses and leave determined to be better armed the next time you meet. You resolve to spend the evening pouring over your ethics text books in search of answers to the conundrums put to you by Eleanor.

The rest of the day is largely uneventful however just as you prepare to leave the staff nurse informs you that whilst you where busy elsewhere in the hospital Eleanor’s condition deteriorated.

‘I’m afraid she suffered a stroke Doctor, fortunately there was a bed available for her in the ICU otherwise she probably wouldn’t have survived. They don’t know the full extent of the damage done by the stroke. Dr Wincanton, the neurologist will be doing a full assessment on her tomorrow.’

Despite your experience in such matters you find the news particularly hard to deal with. The irony of Eleanor being kept alive, when in reality she welcomed death is not lost on you. You thank the staff nurse for informing you of the situation and head home aware that the foundation on which your belief in medicine stands is perhaps not as solid as it once was. It dawns on you that an evening spent exploring the ethical dilemmas set for you by Eleanor was never for her sake – it’s for yours.

An evening spent pouring over the various ethics book you’ve acquired – more by accident than design – has done little to simplify your thoughts regarding the treatment of Eleanor. When, earlier in the day, you wouldn’t have thought twice about resolving her pneumonia with the appropriate antibiotics now even that seemingly straightforward act is something you’re not sure of. Medically, ethically and legally, as you explained to Eleanor at the time, you were doing precisely you what your vocation dictates ‘...diligence and the will to do the right thing’³.However what were the connotations for Eleanor?(assuming she hadn’t suffered a stroke). Yes, she would have walked from the hospital in good health but to what? An empty house and a gradual, inevitable mental deterioration with no hope of resolution. Perhaps she did have a point, maybe pneumonia was the preferable alternative? Perhaps such an end was God’s intention?

‘Christ’, you instinctively mutter as soon as you become conscious of the fact that the thorny subject of religion has inveigled its way into your thoughts. Despite, or perhaps, because of your ‘gentle’ Catholic upbringing you’ve never really bought into the idea that religion has a lot to do with God. Indeed Wilde’s quote ‘Religion is a fashionable substitute for faith’⁴ never fails to bring a smile to your lips, particularly when the opportunity of dropping it in conversation with those who ‘believe’ presents itself. Just as you entertain the idea of cracking open the hard stuff the phone rings.

‘Hi Johnny, Dicky Wincanton here, everyone’s favourite neurologist. Listen I found myself with a spare 5 this P.M so I gave that old girl of yours Doris...’

‘Eleanor’ you correct him

‘Whatever – I’ve given her the once over and although the situations not too pretty à le moment I reckon, via the magic of modern medicine, thee and me might be able to weave some magic on this one old boy’

For the first time in your career you find yourself wincing at the mention of ‘modern medicine’.

‘So basically what you’re telling me is that the damage resultant of the stroke is, well let’s not mince our words, devastating’ you respond.

‘Spot on Pedro – any worse and Doris would be the proud owner of a luxury apartment in PVS5ville if you catch my drift’.

Normally you find Dr Wincanton’s somewhat unorthodox method of communication amusing, however in this instance it just grates. You decide, however, not to bring him up on it aware that the psychiatrists would describe his extravagant manner as a ‘coping mechanism’. You know different, the poor man can’t help himself.

‘However’ he continued ‘I see no reason as to why two fine young chaps, that’s you and me, can’t bring the old girl back to a certain quality of life – lay on the healing hands – know what I mean cock?’

‘You are aware she’s 83’

‘Tis but a minor detail sire’

‘And lives alone’

‘Solitude, blissful solitude’

‘And has been diagnosed with Alzheimer’s’

‘I’m not sure I like your tone old man – sounds horribly like you’re losing your nerve’

‘I’m simply stating the facts – and the facts are that sometimes even modern medicine doesn’t have the answers’

‘Uh oh, smells like Pedro’s been at the ethics books again’ crowed Dr Wincanton

‘All I’m suggesting is that we need to recognise what is and what is not a futile situation’ you reply, aware that it’s becoming harder and harder to keep your cool.

‘Futile schmootile! – that’s loser talk and we’re not losers Johnny we’re winners. Champions of the fine art of Physick’

‘Is there any chance you could take at least some of this conversation seriously?’

‘Do you remember Megan?’ Dr Wincanton asked out of the blue, as he was oft prone to do.

‘No’

‘Yes you do, that old girl, came in a few months ago, didn’t know her arse from her elbow. What is it she had?...thats right she’d keeled over at home, been lying on the floor of her dingy little hovel for God knows how long before the neighbours got fed up of her cats going nuts outside. Came to us with a fractured you know what, hypothermia and a GCS⁶ of 6’

‘Oh you mean Elsa’

‘Yeh, whatever her face was, anyway, if I’m not very much mistaken – and I think you’ll find I rarely am – by the time we finished with her, the old girl was right as rain, happy as Larry she was, mad as a box of frogs I’ll admit but if you remember, on the days she recognised us she couldn’t thank us enough. And what is more my clean limbed friend she was not dispatched back to some flea pit. No Siree! A certain someone, mentioning no names, managed to pull a few strings and get her a place in that Hospice where she could keel over to her hearts content’

‘Yes that’s right to while away her last few miserable, confused days’ you interrupt

‘Not so Eldorado and don’t you start superimposing your own ideas as to what does and what does not constitute a ‘suitable quality of life’. From all reports I heard she was as happy as a pig in the proverbial – 3 square meals, nice cosy room, bingo nights and all that jazz. For all we know misery guts, they were at it like rabbits’.

‘You know I spoke to Eleanor before she had her stroke?’ you ask

‘I’m impressed you managed to squeeze some actual Doctoring in whilst studying for your Phd in sanctimony’

‘And she told me, in not so many words, that she welcomed death’

‘In her position, who wouldn’t? lying in a hospital bed, infested with pneumonia grieving over the recent expiration of her beloved and at the same time having to trade niceties with you – in those circumstances I’d feel like calling the whole thing off. In fact now I come to mention it, as much as I enjoy discussing euthanasia euphemistically with your good-self I do have other fish to fry, so pip pip, oh and Johnny’

‘What?’

‘Any chance you could crow bar a smile onto that ugly visage of yours by tomorrow?’

‘I’ll see what I can do’

As much as you hate to admit it you realise amongst Dr Wincanton’s maniacal ramblings lay grains of truth. With the appropriate treatment Eleanor’s condition may improve and with it her attitude to life. You’d learnt from experience that second guessing the future, particularly in medicine, was a fool’s game. Perhaps she would emerge from her stroke thankful for a second chance, indeed, was it your job to decide? If a consultant neurologist says the situation is not futile then who are you to argue. You idly reopen the nearest ethics tome;

‘Futility is any effort to achieve a result that is possible but which experience suggests is highly improbable and cannot systematically reproduced’⁷

However as much as you like the ‘maverick’ neurologist you were never totally convinced by his motives. Sure enough, his skills as a physician were never beyond doubt you just wondered whether his interests were always totally compatible with those of the patient. The simple facts were that beneath all of the bluff and bluster he was a fiercely competitive individual – you don’t reach the heady heights of consultant neurologist by being walked over. He was, in your eyes, the embodiment of modern medicine; intelligent, relentless and utterly terrified of failure.

But what did all this mean for Eleanor. After indicating to you that she was more than ready to accept death she had suffered a massive stroke and was currently being kept alive on a ventilator. From what Dr Wincanton had said aggressive medical treatment could restore her to a ‘certain quality of life’ but what precisely did that mean, and who would judge whether it was an acceptable quality of life? To your knowledge Eleanor had not made out an advanced directive8 and there were seemingly no family members to speak on her behalf. One of the scariest aspects of this case was the possibility of Eleanor being kept alive devoid of the means to communicate effectively – what sort of medicine did that constitute?

You notice how dark it’s getting outside and toy with the idea of not answering the phone that’s just started ringing but conclude that you’d better had, since it’s probably your Mother.

‘Hello Mother’ you guess

‘Now then, you sound tired. Are you eatin’ allright?’ asks your Mother instinctively

‘I’m eating fine’

‘Then what’s wrong? You sound hacked off’

You decide to come clean, fully aware that such an act may make the conversation ten times longer.

‘There’s a lady with us, she’s very sick’

‘And you’re fond of her are you?’

‘Well I spoke to her, Eleanor’s her name, briefly before she became very ill and she had some very interesting things to say. I’m just worried we’re going to try to keep her alive when her quality of life will be such that it may well not be worth living’

‘Well now, that’s not really your decision to make, remember Granny’

You wondered how long it would take before your Mother mentioned Grandmother, one of her favourite topics. At least in this instance it had some relevance since she had died of motor neurons disease when you were a child.

‘In the end, all she could do was move her eyelids. Your Father and I used to take turns at night to roll her over in bed so she wouldn’t get bed sores’

‘And how do you know what she wanted?’ you ask, both of you aware of the true meaning of the question.

‘I remember one day being very upset. Granny looked so ill and I just couldn’t imagine why she’d want to go on and your Father said to me ‘Just you watch her face every time she sees you children, her eyes light up. That’s what she’s living for’

‘Unfortunately Eleanor has no family and not a great deal to live for’

‘Oh, and you gathered all of that out of a five minute conversation did you? What people say and what people mean are often 2 very different things’

Your Mother’s ability to reduce you to the status of a naïve teenager never ceases to annoy you.

‘What you need to remember is that the decision as to how and when we depart this earth is one made by God...’

It was simply a matter of time before He made an entrance.

‘...and I think you and your clever medical friends would do well to remember that. Medicine is not all seeing and not all knowing and in many circumstances you’ll find it powerless. That’s when you need to look elsewhere for answers. I do think sometimes a little humility wouldn’t go amiss. I’m sorry to go on at you son, but sometimes you do ask for it. You’ve told me yourself, despite all the studies and statistics medicine is not good at predicting death9. Now I won’t harp on anymore because what you need is a good night’s sleep. So goodnight and don’t you be taking the troubles of the world on your shoulders’

It was the second time that day you’d been lectured to by a lady over twice your age and quite frankly, as experiences go, it was beginning to pall. Your Mother’s references to the Almighty were predictable but curiously refreshing to hear. It was nice to know that perhaps, just perhaps, someone else was in charge. Who knows, despite all the efforts that are made maybe the writing is already on the wall, perhaps many of the things we do in hospitals are for our own sake and not necessarily the patients, you pondered. Would we not be better off learning to accept the inevitable rather than perpetually fighting it? Once upon a time pneumonia was referred to as ‘the old mans friend’10 due to its efficiency in finishing off those in their ‘autumn years’. Now it was easily resolved via the magic of modern medicine – and thus our mastery over God was complete.

‘Christ’ you muttered ‘it’s time for bed’

You always regarded Friday mornings as an opportunity to get those jobs done for which there normally wasn’t time. It was whilst you toyed with the idea of simply deleting your entire inbox that a tall, thin, bespectacled man entered your office.

‘I’ve been told by the staff nurse to come here. I understand that you’ve been treating my Mother’

‘And your Mother’s name?’ you ask

‘Elizabeth, although sometimes she likes to call herself Eleanor’

You nearly fall off you seat.

‘I’m a little confused’ you say, aware that this is something of an understatement. ‘She informed me that she had no family’

‘Yes...’ the thin man smiled wryly ‘...and did she also say ‘in death it is not the act of departing that is of concern...’

‘...it is the manner with which one departs’ you finish

‘Yes, that’s one of her favourites. The thing is Doctor my mother has been suffering from a very rare form of dementia for a number of years. It results in her oscillating from extremes of utter lucidity to violent paranoia – verging on the psychotic. It is no surprise to me you didn’t spot the signs, it took her own Doctor sometime to arrive at the diagnosis. Perhaps I should explain, after my Father died I took it upon myself to provide support for my Mother. This task was made all the more onerous by dint of the fact that my Mother likes to regard herself a strong, independent woman – unfortunately nothing could be further from the truth. Her needs are such that I have asked her many times to come and live with my own family so that she might be looked after properly. Needless to say, she would hear nothing of it. As such I would have to make round trips of many miles to care for her. As you might imagine Doctor, this has placed an almost intolerable burden on both myself and my family. You may have noticed, I am not a well man. She despises assistance from any outside parties and has tried to take her own life more times than I care to mention. On the rare occasions that my Mother has agreed to see our own Doctor the conclusions he came to were not good. Due to the dementia, he was of the opinion that she had a life expectancy of 2 years, and that was 5 years ago.’

The ensuing silence was almost more than you could bear. Despite the fact that you had not completed a full examination of Elizabeth surely this was something you couldn’t and shouldn’t have missed. However, such things were for later.

‘Are you aware of her current condition?’ you ask quietly

‘I understand she’s very ill’

‘We think we might be able to...’ you stop, acutely aware that you’re wasting your breath.

You had been gearing yourself for a set-to with Dr Wincanton at the multi-disciplinary team meeting11 in which Elizabeth’s case was to be discussed. Your own thoughts had been reinforced by the conversation you’d just had with Elizabeth’s son. In the end though, there was no requirement. As a result of a second stroke Elizabeth suffered brain stem death12 and was pronounced dead 24 hours after she had been admitted. A day later you resigned your own post and left medicine for good.

References

Bell, D. The Concept of Futility. Critical Care Focus – Ethical Issues in Intensive Care. The Intensive Care Society. London 2007.

Beauchamp TL, Childress JF. The centrality of quality of life judgements. Principles of Biomedical Ethics – 5th Edition. Oxford University Press. New York 2001.

Gawande, A. A Surgeons Notes on Performance. Metropolitan Books. New York 2007.

Ackroyd, P. Table Talk Oscar Wilde. Cassell. London 2000.

Ashwal S, Cranford R. Medical aspects of the persistent vegetative state – a correction. The Multi-Society Task Force on PVS. N Engl J Med. 333(2): 1995

Kumar and Clark. Clinical Medicine – Fourth Edition. Saunders. Edinburgh 1998.

Jonsen, Siegler and Winslade. Clinical Ethics – 5th Edition. McGraw-Hill. New York 2002.

Schwartz, Preece and Hendry. Medical Ethics: a case based approach. Saunders. Edinburgh, New York 2002.

Hallenbeck, J. Palliative Care Perspectives. Oxford University Press 2003.

Zimmerman, RK. If pneumonia is the ‘old man’s friend’, should it be prevented by vaccination? – An ethical analysis. Vaccine 23(29) 3843 – 3849. 2005.

Melia, K. Health Care Ethics: Lessons from Intensive Care (Ethics in Practice series). SAGE Publications. London 2004.

Brady, BA. How much of the brain must be dead? Ethical Issues in Modern Medicine – 6th Edition. Mcgraw-Hill. New York 2003.

For more information please contact g.testa@leeds.ac.uk

Conference report: The MedBiquitous annual conference 2008: Transforming healthcare education, Baltimore, Maryland,USA

Valerie Smothers, Deputy Director, MedBiquitous;
Dr Rachel Ellaway,Assistant Dean Education Informatics, Northern Ontario School of Medicine

MedBiquitous is the only organisation dedicated to technology standards in healthcare education. Over two hundred twenty registrants from North America and Europe participated in the 2008 MedBiquitous conference May 13-15.The conference provided opportunities for indepth workshops on specific learning technologies as well as plenary sessions, software demonstrations, panel sessions, and a new ’unconference,’ thread where participants engaged in discussions on shared ideas on common topics.

Plenary sessions featured a number of thought leaders in healthcare education. Dr Darrell Kirch, President of the Association of American Medical Colleges, examined the need for cultural change in medical school and the opportunity for learning technologies to support that change. Dr Rachel Ellaway from Northern Ontario School of Medicine emphasised the need for openness and scholarship in education technology standards development. Dr Peter Greene, Executive Director of MedBiquitous, built on that theme in his update of the consortium’s activities. He also announced that MedBiquitous’ Healthcare Learning Object Metadata has been released as an official ANSI standard to facilitate cataloguing and discovery of learning resources.

Once you have those learning resources, how do you use them? Professor Ronald Harden of IVIMEDS and AMEE artfully articulated the core competencies of a teacher in the eLearning world. Dame Professor Lesley Southgate went on to examine the how the medical profession assesses clinician competence and offered a vision for a systematic approach to evaluation supported by common frameworks.

Those themes were echoed in a later talk by Dr Cary Sennett of the American Board of Internal Medicine.

A major theme in the meeting this year was the focus on virtual patient technologies, much of which is coordinated by the new MedBiquitous virtual patient data standard, which is just now starting its ANSI accreditation process. A team from St. George’s, University of London ran a number of sessions including an overview of virtual patients, a workshop focused on virtual patient authoring and a session on using virtual patients for summative assessment. Several other organisations also demonstrated their virtual patient systems, ranging from self-directed structured cases to simulations intended for classroom use all of which are involved in the pan-European Electronic Virtual Patient Project (eViP).

The conference provided several interactive sessions including MedBiquitous’ first unconference, where moderators lead group discussions on focused topics. Attendees are encouraged to share content and ideas. Topics included transforming healthcare education, lifelong learning portfolios, and registries for sharing educational content. The groups’ discussions were captured in real time on the MedBiquitous wiki (see groups.medbiq.org/medbiq/display/AC08/Home ). Throughout the meeting the seven active MedBiquitous Working Groups held open meetings to discuss their ongoing technology standards development activities.

Although there are a number of medical education meetings with a greater or lesser focus on technology throughout the year, the MedBiquitous meeting is the only one where standards and therefore collaboration and sharing are the main themes.

Presentations from the conference will be available on the MedBiquitous website, www.medbiq.org

For more information about joining MedBiquitous or its mission and work, please contact Valerie Smothers at vsmothers@medbiq.org

Workshop report: Developing a common vision, the development and delivery of the student selected components (SSCs) of the medical undergraduate curriculum

John Ellershaw, Professor of Palliative Medicine, Dr John Smith, Faculty of Medicine, University of Liverpool;
Deborah Murdoch-Eaton, Professor of Medical Education, Medical Education Unit, University of Leeds;
Patsy Stark, Professor of Medical Education, Academic Unit of Medical Education, University of Sheffield

This workshop was held in November 2007 in the Centre of Excellence in Teaching and Learning (CETL) for Developing Professionalism in Medical Students at the School of Medical Education, University of Liverpool.The Facilitator was Professor John Ellershaw.

Purpose of the meeting

The purpose of the meeting was to explore and share experiences of SSC co-ordinators/deliverers across the UK. SSCs are a significant part of the Undergraduate Curriculum, however the original remit from the General Medical Council (GMC) allowed for diversity on the basis of local interest, availability and expertise to modify the curriculum. The Northern SSC Consortium has met for five years and reached consensus on the underpinning key purposes1 and assessable key tasks.²

The aims of the workshops were to:

Provide a forum for a consensus view on purpose and assessable key tasks in relation to the role of SSCs within the Undergraduate Curriculum and to allow exploration by participants into the relevance and fit of their experience of SSCs.
Overview the published literature.
Provide the opportunity to share experiences and best practice in relation to SSCs.
Provide a forum to identify key areas that participants wished to discuss.

Setting the agenda

As part of the introductory exercise, participants were asked to identify key areas that they wished to have opportunities to discuss during the day. These were identified as:

Academic focus - including rigor, assessment, issues in relation to progression, equity and fairness and use of SSC outcomes for ranking.
Organisational issues - especially in relation to provision and recruitment of adequate numbers of tutors.
Differing models of SSC timetabling through the undergraduate curriculum.
Is the experiment working? Reflective discussion around the underpinning premise behind the General Medical Council’s remit within Tomorrow’s Doctors and has that been met?
The scope of SSCs - including non medical topics within SSCs, diversity against unity both within SSCs and between SSC programmes.
Defining what was meant - whether SSC selection was truly student led or offered from available opportunities.
Sharing - best practice and networking.

Presentation on the themes and direction of the Northern SSC Consortium

A presentation was led by the Chair of the Northern SSC Consortium (Professor Deborah Murdoch-Eaton) setting the scene for consideration of the context of the GMC’s recommendations within Tomorrow’s Doctors (recommendations for undergraduate medical training) and the work of the Northern SSC group. The presentation then outlined the work of the Northern SSC consortium in identifying commonalities of the underpinning purposes of SSC programmes, but also noting areas where there was diversity and how this related to the delivery of core curricula within the participating medical schools. The identification of assessable key tasks and how this contributed to clarification of both students’ and supervisors’ outcomes from SSC programmes which underpin the second paper were outlined. The presentation concluded with a reminder of a clarifying premise of adult learning; i.e. to life long learning and students have opportunities to individualise personal development within their formal learning opportunities. The importance of reflective practice in contributing to development of generic life long learning skills was emphasised in the ensuing discussion.

First round – facilitated group work

The groups were free to explore issues and share their experiences, both positive and negative, in relation to the delivery, management and assessment of SSCs within their local curriculum. There were two main aims of these initial workshops:

To establish that the extent to which the experiences of the Northern SSC Group were generalisable nationally.
To identify issues that merited further consideration for the afternoon workshops.

Key themes from the initial groups are listed below.

Assessment

Issues of double marking.
Plagiarism.
Peer assessment.
Problem students, the use and strengths of SSCs in identifying students in difficulty, both generally weak students and students with specific problems that might be highlighted by SSCs.

Knowledge, Skills and Attitude

The importance of study skills.
Professional behaviour.
Ethics.

Student Selection of SSC

Offered or selected SSCs.
Selection of SSCs by students and how student input into selection might relate to career planning, what the implications might be for non medical SSCs.

Issues relating to supervision

Training for students participating in SSCs and also the training and monitoring of providers of SSCs (supervisors or convenors). This included issues over assessment, double marking, outcomes and the potential workloads created.
Payment for tutors.
Diversity of input from Supervisors and how this would affect the learning experience both for the student and for the programme overall.

Content of SSCs

Individual versus group SSCs.
Format of SSCs offered.
Subject matter of the SSC as opposed to reflective learning and refinement of skills.
How long should the SSCs be? Variability in the number or duration of time spent in SSCs that would be required to fulfil the underpinning purpose.
Diversity within SSC Programmes, both in individual SSC modules and in the programme as a whole.
Workload implications for differing types of SSCs and the implications of this for both student and supervisors.
The additional diversity that could be explored.

GMC Assessments

Some discussion around the conflict of feedback to different medical schools on acceptability of their SSC programmes from recent Quality Assurance of Basic Medical Education (QABME) assessments by the GMC.

Core

The discrepancies between identification of SSC and core material at different medical schools.
Difficulties identifying ‘core’ and identifying SSCs.
Different interpretations of the same experiences being labelled as core at some schools and SSCs at other.
Analysis of the issues identified in the morning workshops allowed 3 themes to be identified for workshops in the afternoon.
and progression.
Core vs SSC, structure and content.
Diversity and equity of experience.

Second round – facilitated group work

Group 1: Assessment and progression

Key aspects identified from this group were:

Fairness of assessment and ensuring that assessment criteria and methods were appropriate for the model of the SSC being delivered.
The importance of training of supervisors particularly in ensuring adequacy of application of assessment procedures and identification of progression issues. This was pertinent not only for failing students but for identification of excellence.
Identification and clarity of the criteria used for assessing SSCs, both in the components of the assessment process but also the level of detail required to enhance the reliability of the assessment tool.
The role of valid assessment tools in SSCs that identified excellence in performance and the opportunities to reward students producing outstanding pieces of work.
Incompetence, ensuring validity and reliability of the assessment tools in identification and appropriate feedback for those students struggling with the development of life long learning skills.

Group 2: Structure and content

This workshop debated the key issue of differences between core and SSCs. Issues defined as core were those considered to be ‘compulsory’ and ‘essential’.

Essential in terms of, Knowledge, Skills, Attitude, particularly in relation to professional learning.
The knowledge contained within SSCs was optional but the skills and attitudes were essential in relation to life long learning and professional learning.
Debate around the role of known medical SSCs and whether the knowledge acquired in SSCs needed to be assessed.
Whether there was an opportunity to have optional skills or attitudes.
Discussion around total time spent in SSCs; how much was enough to achieve the educational outcomes.
What is the educational value of students being given choices and how this might result in variation in sampling of career options.
Importance of the role of enthusing and motivating learning as well as enhancing life long learning skills and developing autonomy.
Reflection of future career choice in selection and justification of options chosen.
Inter-relationship between SSC and core and how choice might be given within the core so that options for students were not limited to the SSC curriculum.

Group 3: Diversity and equity of experience

Equity of the experience and the means to regulate this would be at the expense of limitation of the scope of SSCs.

Excessive control of the learning and the potential learning experiences would limit the diversity and thus the potential for personal development of students.

Comparison of workload diversity between different SSCs; two potential areas of solution for this may include:

Students auditing their individual work load as part of reflective practice; this would also provide feedback to staff. Staff also monitoring and reflecting on the workload involved in the individual SSCs might facilitate this.
Consideration of students submitting work plans which could be part of assessment; asking the students reflect on whether they had kept to the work plans as a valuable developmental tool.

There was considerable diversity amongst participants in models of funding for SSC components including:

Availability for external supervisors at some schools as opposed to allocation via SIFT/FTE models.
Clear views that the relationship between student and supervisor should be viewed as symbiotic win-win relationship and therefore direct payment was not considered appropriate.
Payment of pro rata fee per hour against a fixed sum per SSC.
Benefits of students being aware of amounts supervisors were being paid - both for their own recognition of the value of their own learning but also in some models students were required to select their SSCs on the basis of a budget.
Model identified of direct payments to students of nominal sums to try and assist with expenses directly related to SSCs not covered by other means e.g. travel, poster production, etc.
The role of portfolios in capturing the diversity of SSC experience of the students.
The value of facilitating a way for students to accumulate their SSC experiences and reflect on these cumulatively through the whole curriculum, both as a reflective exercise but also as potentially contributing to views on selection and choice in later years.
Encouragement of reflection across the student career and how this related to the development of skills within the core curriculum.
The encouragement of diversity of SSC choices.
Facilitation of diversity and its potential conflict with the element of student choice for example students pursuing a clear pattern of SSC selection in relation to potential future career and therefore following a narrow track of SSC selections.
Choice.

Experience was shared within the group of different models of providing students with choice within SSCs ranging from:

Random allocation, often by computer matching.
Allocation on the basis of previous academic performance ie those students performing well would be more likely to get their first choices, difficulties within this for the less motivated and poorly performing students.
Allocation of SSCs on the basis of looking at previous selection to ensure that students who weren’t getting their first or second choices were having opportunities later on, or ensuring a diversity of experiences.

Concluding plenary

The meeting concluded with a very clear need and willingness of those participating in curricular development and delivery of SSCs within their medical schools to continue networking. Perceived benefits were not only in sharing of experiences, models and good practice, but also potential participation in research projects intended to clarify the outcomes of SSCs particularly in regard to student development.

In conclusion, despite the wide variety of practice among medical schools in the delivery of SSCs, there was a consensus as to their utility and purpose. The themes of being able to define what is and is not core curriculum, of being able to give equity of experience despite a wide variety of provision, and of fairness in assessment, will remain for discussion for the future.

References

Murdoch-Eaton, D., Ellershaw, J., Garden, A., Newble, D., Perry, M., Robinson, L., Smith, J., Stark, P. and Whittle, P. Student-selected components in the undergraduate medical curriculum: A multi- institutional consensus on purpose and learning outcomes. Medical Teacher 26, 33-38 (2004) )
Stark, P., Ellershaw, J., Newble, D., Perry, M., Robinson, L., Smith, J., Whittle,S. and Murdoch-Eaton, D. Student-selected components in the undergraduate medical curriculum: A multi-institutional consensus on assessable key tasks. Medical Teacher 27, 720-725 (2005)

For more information please contact joanneh@liverpool.ac.uk

Research teaching linkages in medicine, dentistry and veterinary medicine: A symposium report

Dr Anita Laidlaw, Teaching Fellow, Julie Struthers, Learning Technology Consultant, Bute Medical School, University of St Andrews

Research-teaching linkages: enhancing graduate attributes is the 2008 enhancement theme from the Quality Assurance Agency (QAA).The three professional disciplines of medicine, dentistry and veterinary medicine were brought together at this symposium to discuss this topic and inform a project report for the QAA by the symposium team from the Bute Medical School.

Some of the questions up for discussion:

What were research teaching linkages?
How could they help enthuse students towards research?
What research related graduate attributes were desirable in graduates from these disciplines?
Did institutions currently provide a research teaching nexus?
And if so, how was this achieved within the constraints of heavily subscribed curricula?

Delegates arrived at the Royal College of Physicians (Edinburgh) enjoying the imposing grandeur of the main hall and the studious atmosphere of the library where posters were displayed. A warm welcome by Julie Struthers (Project Director) was followed by a plenary by Andrea Nolan (Professor of Veterinary Pharmacology) describing the challenges posed by the theme.

The morning session topic was graduate attributes. Four case study talks from schools around the UK gave delegates a taster of how some institutions were instilling research related attributes in graduates. In the small group breakout session which followed, a list of graduate attributes, derived from interviews with faculty from all disciplines was discussed. Some attributes on the list were unceremoniously thrown out, new ones added, amalgamations took place and finally the surviving attributes were ranked in order of preference both from a research standpoint and that of a professional, a tough task!

Lunch and a poster session followed with lively debate on the issues raised in the morning’s session. The theme for the afternoon session moved on to Identifying opportunities and overcoming barriers for research teaching linkages in a professional curriculum. Four talks pointed out the need for such links to promote research amongst graduates, some of the barriers that exist and also how it can be successfully done. The final breakout session involved delegates discussing some thorny questions, such as Should those with responsibility for the curriculum ensure that that research teaching linkages are demonstrated at delivery level? and What are the implications for policy makers? This final question promoted intense debate as delegates noted that our professional graduates need to see a research career as an attractive option, and currently for some disciplines, it is not.

A final round up by Professor Simon Guild (Director of Teaching and Associate Dean) brought together the key points raised:

High level research and professional graduate attributes are very similar suggesting all graduates would benefit from such training.
Research experience is important in enthusing students to become interested in research.
In an already crowded professional curriculum it is possible to provide research teaching links, illustrated by the speakers.

The full report of the project incorporating the points raised at this symposium will be available from the QAA in the autumn of 2008.

For more information please contact ahl1@st-andrews.ac.uk or jes10@st-andrews.ac.uk

Towards POLY professionalism?

Sue Roff, Centre for Medical Education, Dundee University Medical School

Even before ‘poly clinics’ entered the debate in 2008, a new model of what we might call ‘POLY professionalism’ has been developing in UK health care delivery.

Sir Graeme Catto, President of the UK General Medical Council, told a Royal College of Physicians enquiry into medical professionalism:

Increasingly... the exclusivity of medical knowledge and skill is being broken down. Interprofessional learning is now commonplace in medical education and seems likely to increase. Professional boundaries are being blurred as more and more of the things that were once the sole domain of doctors are being undertaken by other health care professionals. None of us works alone any longer, but in multidisciplinary teams in which we depend upon the expertise of others. This is not a diminution of medicine, but a strengthening of health care...This democratisation of health care roles, and blurring of boundaries, raises the question of what, if anything, distinguishes doctors from other health professionals, and whether such a distinction really matters. Catto, March 2005.

The Royal College of Physicians recommended that the Academy of Medical Royal Colleges of the UK ‘initiates a review of how doctors can best be supported – for example through training – in their contributions to multiprofessional teams.’

Sir Nigel Crisp, then Chief Executive, Department of Health and NHS similarly told the RCP enquiry that the central issue in UK health professions training is:

the ability of doctors to work in teams of other professionals – to lead and to be led. We are beginning to turn aspirations about inter-professional learning and working into something more concrete. Learning from others, learning about others and sometimes learning with others provide the framework here. How far can we expect interprofessionalism to translate itself from the organisational wish list into tangible professional standards and values? Crisp, March 2005.

In fact ‘interprofessionalism’ is proceeding apace in the reality of the UK National Health Service. In their 2004 report to the King’s Fund, On Being a Doctor: Redefining medical professionalism for better patient care, Rosen and Dewar called for a new definition of ‘modern professionalism’ in the health care professions working in the UK where the European Working Time Directive restrictions on working hours has meant that clinical teamwork is replacing personal 24 hour responsibility of a doctor for a patient, and working patterns including shift working have meant ‘cross-cover’ and the sharing of clinical responsibility beyond doctors to other health care professionals. This is combined with increased specialisation of the medical work force ‘which means that doctors now have highly technical expertise in narrower fields – thus making them more interdependent.’ If anything, the process has proceeded even more quickly in Scotland.

Even the ‘clinical autonomy’ of the UK doctor has been modified with the increase in team-delivered care. The Royal College of Physicians stated in December 2005 in its report Doctors in Society: Medical Professionalism in a changing world that ‘Clinical autonomy might suggest that a doctor has the authority to act independently of both the wishes of the patient and the preponderance of medical evidence. Neither attitude can be supported, especially in an era of team-based care.’

Recently, Professor Alan Maynard of the University of York commented that ‘the Blair government in a direct challenge to the monopoly power of medicine began the licensing of nurses and pharmacists as prescribers. The emergence of nurse endoscopists, nurse anaesthetist, and the training of nurses to carry out minor surgery have the potential to reduce the demand for medical graduates. Primary care has also seen an increase in the employment of nurse practitioners and nurse prescribers. It is unclear if these are substitutes or complements to GPs, but tighter NHS resource constraints may lead to nurse led primary care...’ Lord Darzi’s report on NHS review, published in late June 2008, defines ‘clinicians’ as ‘those staff who provide clinical care to patients and the public, including doctors, dentists, nurses, midwives, health care scientists, pharmacists, allied health professionals, clinical support workers and paramedics’ and makes reference to expanded, extended, redefined and autonomous roles – ‘a diversity of professional roles within multi-disciplinary team to deliver effective evidence-based care’.

It may be that the health care workforce is moving rapidly from ‘uni-professionalism’ in hierarchical structures where the medical doctor is the senior practitioner, to team based care which require inter- and multiprofessional working. Individual practitioners at all levels may have to function as ‘POLY-professionals’ who are responsible in relation to:

Patients and Public

Other health care team members

and being responsible for one’s own

Lifelong learning

and for

Yourself as a safe, healthy, conscientious

and honest practitioner.

We need to identify and agree how these elements of POLY- professionalism are to be taught – and assessed. It may be that we will need stage specific (for early and later undergraduate and early and later clinical role) material for both learning and assessment. These will need to be not only valid and reliable but normed to acceptable practice, with peer, faculty, patient and public input. While there are scores of studies of teaching, learning and assessing professionalism ‘there is simply a lack of broad range of validated instruments..’ But there may be much of value in the present resources we have available. For instance, if may be that ‘Instead of creating new professionalism assessments, existing assessments should be improved... evidence of the scope and variety of available assessments should stimulate efforts to improve existing assessments.’ We plan to follow the advice of a recent systematic review : ‘Future studies should draw on the theoretical frameworks within the literature on attitudes and behaviour change in order to develop valid and reliable measures of attitudes and design effective interventions to change attitudes.’ Our goal will be to develop cost-effective procedures and instruments that both teach and assess fully normed professional values in a reflective learning process that may permit a sort of ‘progress test’ of maturing ‘POLY professionalism’ for all members of the health care team. Along the way we should be able to give guidance on sanctions for consistent fitness to practise procedures at undergraduate level, as recently called for by the General Medical Council.

We hope to be calling for collaborators in the validation of these resources early in 2009. Contact s.l.roff@dun.ac.uk if you want to be kept informed of our progress.

References

Verkerk, MA., Bree, MJ. and Mourtis, MJE. Reflective professionalism: interpreting CanMEDs ‘professionalism’. Journal of Medical Ethics 33, 663-666 (2007)
2. Lynch, DC., Surdyk, OM. and Eiser, AR. Assessing professionalism: a review of the literature. Medical Teacher 26 (4), 366-373 (2004)

3. Jha, V., Bekker, HL., Duffy, SRG. and Roberts, TE. A systematic review of studies assessing and facilitating attitudes towards professionalism in medicine. Medical Education 41, 822-829 (2007)

For more information please contact s.l.roff@dun.ac.uk

Workshop programme

Workshops are open to anyone involved in learning and teaching in undergraduate medicine, dentistry and veterinary medicine.They attract CPD points and there is currently no charge for attendance. The programme of workshops is designed and delivered by members of our constituency and thus reflect current concerns in the field.

Details of the workshops are available on the website and we place new ones on the site as soon as dates and venues have been finalised, so keep checking to see if there is something of interest to you. We also send email notification of each workshop to everyone on our mailing list as soon as it is finalised. If you are not on our contact list and would like to receive information about our workshops as well as our regular monthly update on current issues, funding opportunities etc then please go to www.jiscmail.ac.uk/lists/medev.html or email enquiries@medev.ac.uk To find out more or book your place on any workshop go to: www.medev.ac.uk/resources/meetings/workshops/

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01.17 The newsletter of the Higher Education Academy Subject Centre for Medicine, Dentistry and Veterinary Medicine, Autumn 2008

Contents

Game-based learning for the delivery of virtual patients in Second Life

Intellectual property issues – coming to an institution near you!

Climate change, sustainability and health

CETL update: Resources for teaching ethics in your discipline

Team learning in dentistry – a report of a pilot scheme to enhance the learning experience of clinical and technical skills teaching for student dentists and student dental technicians

Integrating Intute services into your website or VLE

The WikiVet community of practice

Student essay 2008 competition winners

What makes a good lecturer?

End of life decision making

Conference report: The MedBiquitous annual conference 2008: Transforming healthcare education, Baltimore, Maryland,USA

Workshop report: Developing a common vision, the development and delivery of the student selected components (SSCs) of the medical undergraduate curriculum

Purpose of the meeting

Setting the agenda

Presentation on the themes and direction of the Northern SSC Consortium

First round – facilitated group work

Second round – facilitated group work

Concluding plenary

Research teaching linkages in medicine, dentistry and veterinary medicine: A symposium report

Towards POLY professionalism?

Workshop programme

Resource groups

Recommended links

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