However, because students debrief in groups, it is difficultto provide each student with individual feedback on hisor her clinical note. Student evaluations indicate that lackof individualised feedback on notes is the greatest weak-ness of this instructional format.What was tried? Arrangements were made for eachstudent’s clinical note to be printed immediately aftercompletion so that each student would have a copy of hisor her own note in hand during the debriefing discussion.In the debriefing room, a laptop computer with an LCDscreen projector was set up. One student served as typist torecord the group’s clinical note. The faculty memberasked the students to specify the information required ineach section of the note, why each element of informationshould be included, and how it helped in clinical decisionmaking. Efforts were made to include all students in thediscussion and to produce a final note that represented aconsensus of the students’ clinical decision making.What lessons were learned? After 18 months of experi-ence with the group clinical note, faculty facilitators con-tinue to be impressed with the level of diagnostic acumenthat students collectively demonstrate. The students consis-tently select high-value clinical features to include in theirnotes and can state which diagnoses are inferred by thepresence or absence of these features. Together, the stu-dents usually arrive at the correct diagnosis and are able toexplain the reasons for their choice and the reasons whythey excluded other candidate diagnoses.After participation in group clinical note exercises, studentcomments included: ‘The group notes were extremelyhelpful…’ and ‘I like that we debrief and write our notesas [a] group so I can learn what I missed in my own note.’Indeed, during the discussions it is common to hear stu-dents lament: ‘I forgot to ask that question’ or ‘I shouldhave checked for that finding.’ Working with their peersto successfully solve clinical cases has given studentsgreater confidence in their diagnostic abilities. Often, asstudents are crafting a note together, a competitive spiritwill emerge. They will vie to offer their interpretations anddeliberate the importance of particular clinical features.The faculty plans to continue group note writing after sim-ulated patient encounters, firstly so that each student canimmediately compare his or her own note with the groupconsensus note, secondly to provide a platform for studentdiscussion on clinical reasoning, and thirdly as a means ofbuilding student motivation and self-efficacy through col-laborative learning.

REFERENCE

1 Thurman J, Volet SE, Bolton JR. Collaborative, case-based learning: how do students actually learn fromeach other? J Vet Med Educ 2009;36 (3):297–304.

Correspondence: Gordon L Woods, Department of MedicalEducation, Texas Tech University Health Sciences Center,Paul L Foster School of Medicine, 5001 El Paso Drive,El Paso, Texas 79905, USA. Tel: (915) 215-4353;E-mail: gordon.woods@ttuhsc.edu

doi: 10.1111/medu.12165

Early clinical skills training: too much, too soon?

Anuj Chawla

What problem was addressed? Clinical exposure is intro-duced late in the undergraduate curriculum in manymedical schools around the world. A dearth of formalskills training for undergraduate medical students, espe-cially in the Asian subcontinent, perhaps accounts fortheir poor skills competence. The Medical Council ofIndia has proposed introducing clinical exposure andclinical skills training from the first year of the undergrad-uate medical curriculum from 2015. This is in line withthe global trends in medical education. However, thereare few data on long-term retention and transfer of theseskills to actual performance in real-life scenarios, whenthe skills taught are not regularly practised. There was,therefore, a need to assess skills retention objectively fol-lowing early introduction of skills training in the medicalcurriculum.What was tried? A basic cardiorespiratory resuscitation(CPR) training module was designed for first-year medi-cal students at a reputed medical college in India. First-year medical students (n = 134) volunteered for thetraining. The training, conducted in batches of 20 stu-dents, included a 1 hour lecture–demonstration followedby 2 hours of hands-on training on manikins. Studentswere assessed for knowledge and skills before and afterthe training session. This was carried out using a 10-itemmultiple-choice question written examination and anobjective structured practical examination with a standar-dised skills checklist. Following the CPR training,students continued with their regular first-year medicalcurriculum. The students were re-assessed for CPRknowledge and skills after a 3-month period duringwhich the skills were not practised. This was to gaugetheir knowledge and skills retention.What lessons were learned? There was a significantincrease in knowledge and skills about CPR immediatelyafter the training session. The mean knowledge scoresincreased by 164.5% and 84.7% of the studentssuccessfully met the required criteria for CPR skillscompetency.Following a 3-month period during which students didnot practise CPR skills, the re-assessment revealed thatonly 37.5% of the students successfully met the requiredcriteria for skills competency. This amounted to a 55.7%reduction in the skills competence. Analysis of the assess-ment results also revealed that although 43% of the stu-dents were able to perform the individual steps of chestcompressions and rescue breathing satisfactorily, theyfailed to integrate these steps of CPR in the correctsequence during a simulated real-life emergency. Interest-ingly, 65% of these students had satisfactory knowledgeof the components of CPR skills.These results suggest that imparting clinical skillstraining on a single occasion, in situations where theskills are not regularly practised, will probably result inpoor retention and transferability of these skills to areal-life scenario, despite satisfactory retention of theknowledge component of the skill. Curriculum design

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for early introduction of clinical skills training, there-fore, must include appropriately designed and posi-tioned refresher training modules. Skills training, alongwith appropriate refresher training modules is morelikely to improve skills competency of medical graduatesthan a single training session introduced early in thecurriculum.

Correspondence: Anuj Chawla, Department of Physiology, ArmedForces Medical College, Sholapur Road, Pune, Maharashtra411040, India. Tel: +91-9049940433;E-mail: anuj_chawla69@yahoo.com

doi: 10.1111/medu.12191

Undergraduate clinical inquiry and information seeking:needs analysis

Champica Bodinayake & Lauren Maggio

What problems were addressed? Evidence-based practice(EBP) skills are essential to direct health professionals tothe best available evidence in clinical practice. The firsttwo steps of EBP include formulating clinical questionsand performing literature searches. Yet, in Sri Lanka littleis known about medical students’ habits of inquiry andinformation access, which makes it difficult to design,implement and evaluate an EBP curriculum.What was tried? A needs analysis was undertaken in 2012at the Faculty of Medicine, University of Ruhuna, Sri Lankato understand student habits of inquiry and literaturesearching. A 12-item paper survey was distributed to allfinal-year clinical students; 121 of 135 students completedthe questionnaire (response rate: 90%). The survey probedstudent information use, eliciting details of off-campus In-ternet access, frequency of searching, and the informationsites preferred for obtaining patient care information. Inrelation to clinical inquiry, students were asked to identifythe frequency of questions that arise for them in patientcare, their self-perceived competency in this area and theirexposure to the role-modelling of inquiry in practice byfaculty staff. Students also completed the first item of theFresno Test related to clinical inquiry skills.What lessons were learned? Overall, 50% (61 of 121) ofstudents reported having at least one question per patientencounter, and 37% (45 of 121) reported having dailyquestions; students saw an average of five patients per day.Only 42% of students reported seeking answers from clini-cal teachers or staff. Only 31% (38 of 121) of studentsreported observing consultants asking for evidence-basedinformation. Overall, 76% of students rated themselves as‘competent’ in formulating clinical questions, but objec-tively student skill was measured as ‘limited’ (87%) or‘absent’ (2.6%) in this domain. Internet use was preva-lent; 45% (54 of 121) of students had off-campus onlineaccess and 45% (54 of 121) indicated laptop ownership.To answer patient care questions, students accessedWikipedia (81%), Google (77%), PubMed (48%) andUpToDate (9%). A total of 68% (78 of 115) of studentsassessed themselves as competent biomedical literaturesearchers; however, it was noted that the majority ofstudents seemed to rely on resources that provide

questionable access to information. Lastly, 97% (117 of 121)of students responded that they would like to receive train-ing in asking clinical questions and literature searching.These findings suggest the opportunity and need toapproach the design and implementation of EBP curric-ula from multiple angles that involve both students andfaculty staff and that leverage student access to technol-ogy. For example, we now recognise that students requiretraining in the formulation of clinical questions, but wealso realise the need to train faculty staff in this domainand to raise faculty members’ awareness of their power asrole models. Currently, students receive limited exposureto the asking of clinical questions by faculty role models,which transmits the message that clinical inquiry isundervalued in our clinical and teaching practice.From this needs analysis we have gained valuable insight,but we realise that there is a need for further explorationwith multiple EBP stakeholders, including students andfaculty staff. Lastly, we do not believe our findings to beunique to Sri Lanka and advocate for an exploration ofthese issues at the global level.

Correspondence: Dr Champica Bodinayake, Department ofMedicine, Faculty of Medicine, University of Ruhuna, PO Box 70,Karapitiya, Galle 8000, Sri Lanka. Tel: 00 94 91 223 2321;E-mail: bodinayake@gmail.com

doi: 10.1111/medu.12171

‘Speed-dating’ history taking

Laurence Leaver & Eleanor Whitaker

What problems were addressed? After a day of ‘dry’ lec-tures, 33 tired new students needed an engaging sessionon history taking to:

� meet tutors and one another in a supportive and funenvironment;

� be introduced to some typical clinical presentations;� practise communication skills;� gain insight into how patients respond to questions

and explain symptoms, and� desensitise themselves to the stress of ‘performing’

while inexperienced.

What was tried? We adapted the activity of speed-datingusing the four roles of Patient, Doctor, Observer andFacilitator at each of 11 stations. Stations depicted typicalcases (e.g. angina, appendicitis and pneumonia). We allo-cated each student a colour (green, pink or blue) for thesession. Green students moved one station clockwise, pinkmoved two stations clockwise, and blue moved one stationanticlockwise. Facilitators were tutors who remained attheir stations. Hence, all participants met three newpeople at each station.At each station, each role (Patient, Doctor or Observer) wasdescribed on paper coloured green, pink or blue. The col-our corresponded to different roles at different stations:for example, a ‘green’ student might be a Doctor at onestation, Patient at the next, Observer at the next, then aDoctor again. Patient descriptions explained symptoms in

522 ª Blackwell Publishing Ltd 2013. MEDICAL EDUCATION 2013; 47: 513–535

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