Letters to the Editor
Ian Todd, School of Life Sciences, University of Nottingham, Nottingham, UK. E-mail: [email protected] Steven Burr, Plymouth University, Peninsula Schools of Medicine & Dentistry, Plymouth, UK John Whittle, School of Medicine, University of Nottingham, Nottingham, UK Lucy Fairclough, School of Life Sciences, University of Nottingham, Nottingham, UK Declaration of interest: The authors report no conflicts of interest.
References Tavakol M, Dennick R. 2014. Modelling the Hofstee method reveals problems. Med Teach 36:181–182. Cohen-Schotanus J, van der Vleuten CPM. 2010. A standard setting method with best performing students as point of reference: Practical and affordable. Med Teach 32:154–160.
Medical students without borders: The value of undergraduate placements abroad
Dear Sir We read with interest the article by Stys et al. (2013) about the value of global health electives. The clinical elective forms an integral part of the undergraduate curriculum in the UK. There are many benefits of travelling abroad during medical school to gain international experience in healthcare. The style of medical education varies between countries. Our own experiences of clinical electives in the USA showed us that students there tend to have greater involvement in the care of their patients compared to students in the UK. For example, in some American hospitals, senior students are allocated patients to follow for their entire in-patient stay. Students are actively encouraged to offer their input when devising management plans for patients and have greater clinical responsibility. Being thrust into this very different learning environment has the advantage of increasing one’s clinical confidence and promoting student initiative, which facilitates the transition into house officer jobs. Another variation between countries is the prevalence of different diseases. This allows students to gain experience in the diagnosis and management of conditions that they may not see commonly, if at all, in their own country. Such knowledge is transferable. They may later encounter these conditions in their home country in travellers or immigrants. This is particularly relevant to infectious diseases. Furthermore electives in developing countries allow students to gain a real understanding of the demands placed on healthcare staff in resource-limited settings. Students become more socially aware. This in turn may not only make them more empathetic but also increases appreciation of the resources that they have at their disposal in their home country. In the long-term, spending time abroad may greatly influence the direction of one’s career. International experience lends itself well to specialties such as public health and infectious diseases. A placement abroad may also help individuals to decide whether they wish to pursue their training in a foreign country after completion of medical school. Immersing oneself in the healthcare system of different countries may encourage individuals to transfer values between their own country and foreign countries. Such sharing of ideas between countries may lead to innovative and effective concepts being adopted across borders, ultimately helping to positively shape healthcare systems on an international scale.
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the upper-limits (UL) and lower-limits (LL) of pass-marks and fail-rates generate negligible changes in cut-scores (1–2%). We agree with Tavakol & Dennick’s conclusions and we have developed a substantially modified-Hofstee (MH) method that obviates subjective judgements. In the MH protocol, the UL and LL for fail-rates are set at 100% and 0% of the cohort, respectively, i.e. potentially all candidates could fail or pass, avoiding arbitrary pass/fail quotas. The LL for the pass-mark is also set at 0%, avoiding an arbitrary boundary for this value. The UL for the pass-mark is standard set an absolute percentage below the median percentage mark of the cohort (based on trials on historical data). The rationale for this is that cohort performance is an objective measure of exam difficulty when the cohort is sufficiently large and its selection is consistent year-on-year (as is likely for selection of medical students). (Others have similarly argued for using cohort data for setting borderlines (Cohen-Schotanus & van der Vleuten, 2010). A diagonal is drawn for the UL pass-mark on the X-axis to the UL of fails (100%) on the Y-axis; the intersection with the cumulative frequency curve of students’ marks gives the actual pass-mark. We applied the MH protocol to historical data of 49 summative assessments sat by cohorts of 4240 year 1–3 medical students over five years. The range of pass-marks generated by MH was 47%–60% (median 57%). We further examined the effect on 15 assessments of raising the UL of the pass-mark by 10%; this increased the cut-scores by 5.4%–8.5% (median 6.6%), which is substantially greater than reported by Tavakol & Dennick for CH. Furthermore, if the diagonal does not intersect with the frequency curve, this indicates that all students pass. Whilst Anghoff/Ebel are appropriate for ‘‘high-stakes’’, broad-based clinical exams, they may be impractical for multiple, subject-specific exams, where assembling and ensuring consistent operation of multiple panels of experts is not feasible. In such circumstances, the MH protocol may provide a viable and robust alternative for credible standard setting.
Kartik Kumar, North Middlesex University Hospital NHS Trust, Sterling Way, London, N18 1QX, UK. E-mail: kartik.kumar@ cantab.net. Fangyi Xie, Buckinghamshire Healthcare NHS Trust, Mandeville Road, Aylesbury, Buckinghamshire, HP21 8AL, UK.
359
Letters to the Editor
Declaration of interest: The authors report no declarations of interest.
Reference Stys D, Hopman W, Carpenter J. 2013. What is the value of global health electives during medical school? Med Teach 35:209–218.
Student perceptions of rural placement – Australia to Aberystwyth
We conclude that students should experience a balance between rural and tertiary care settings. While rural placements can potentially increase P4P, the aforementioned detrimental features should be considered as these may negatively affect student satisfaction, learning opportunities and therefore reflect poorly on P4P. Furthermore, we call for an objective measure of P4P to determine whether students’ perceptions are reflected in subsequent clinical practice. Sophia Rosa Thompson, Beshlie J Richards and Kate Rebecca Harding, Cardiff University, Medical School, Cochrane Building, Cardiff, CF14 4YS, United Kingdom. E-mail: [email protected]
Declaration of interest: The authors report no conflicts of interest.
Reference Dear Sir As fourth year medical students from Cardiff University Surgical Society (CUSS) we discussed your article (Daly et al. 2013) with interest. We acknowledge that our experiences in this field differ from those in Australia. However, regarding medical education in the UK, placements allocated by Cardiff University are geographically vast and remote. These include exposure to rural South Wales and North Wales where Welsh language is predominantly spoken. Therefore, we feel uniquely positioned to comment on experiences of rural placements because such 5–8 week attachments are integrated into our core-curriculum. CUSS agrees with Daly et al. that rural placements may enhance preparedness for practice (P4P) specifically in reference to clinical skills, personal, professional and cultural development. Factors contributing to our increased P4P differ from those at Broken Hill. Anecdotally we have identified these as: increased devoted clinician teaching time, lower student-patient ratio, and a more culturally, pathologically and socially diverse spectrum of patients. Within CUSS we discussed various negative aspects of rural placements absent from the original article. We believe student experience is a key criterion in determining perceived placement success, which in turn may affect the knowledge and P4P acquired during attachments. Firstly, logistical obstacles specifically affecting Cardiff students include language barriers, unsubsidized travel costs and social isolation from peers. Additionally, in Cardiff, we rotate through specialty specific placement blocks each situated at discrete locations. This means rurally placed students will lack exposure to specialist teaching, patients requiring complex management and advanced procedures only offered at tertiary centres. Daly et al. mentioned using Video-conferencing to overcome these issues. This method is currently employed by Cardiff University. However, based on our experience this format is a poor substitute when compared to face-to-face interactions. 360
Daly M, Perkins D, Kumar K, Roberts C, Moore M. 2013. What factors in rural and remote extended clinical placements may contribute to preparedness for practice from the perspective of students and clinicians? Medical Teacher 35:900–907.
Preparing for practice with longitudinal integrated placements
Dear Sir We would like to thank the Cardiff University Surgical Students (Thompson et al. 2014) for drawing our attention to an international comparison of the student experience in shorter 5–8 weeks clinical placements in Wales, and the six months to one-year longitudinal clinical placements in New South Wales (Daly 2013a). We note the students’ endorsement of the many positive aspects of rural placements relating to Preparation for Practice such as quality of supervision, student-to-teacher ratios and diversity in patient population. In an earlier paper (Roberts et al. 2012) we explored rural extended placements in the context of career intentions of students. We also identified similar barriers to the Cardiff students, such as geographical isolation, family and relationship needs and limited opportunity for sub specialist practice. We feel that many of these issues can be overcome by medical schools investigating the opportunities provided by longitudinal placements, known as longitudinal integrated clerkships (LICs) in the US (Thistlethwaite et al. 2013). There is probably a national imperative as well to provide the supporting infrastructure that underpins the success of these placements in the long term. Over two decades a key policy response to rural workforce shortages in Australia has been substantial investment in educational initiatives, such as Rural
Copyright of Medical Teacher is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Ian Todd, School of Life Sciences, University of Nottingham, Nottingham, UK. E-mail: [email protected] Steven Burr, Plymouth University, Peninsula Schools of Medicine & Dentistry, Plymouth, UK John Whittle, School of Medicine, University of Nottingham, Nottingham, UK Lucy Fairclough, School of Life Sciences, University of Nottingham, Nottingham, UK Declaration of interest: The authors report no conflicts of interest.
References Tavakol M, Dennick R. 2014. Modelling the Hofstee method reveals problems. Med Teach 36:181–182. Cohen-Schotanus J, van der Vleuten CPM. 2010. A standard setting method with best performing students as point of reference: Practical and affordable. Med Teach 32:154–160.
Medical students without borders: The value of undergraduate placements abroad
Dear Sir We read with interest the article by Stys et al. (2013) about the value of global health electives. The clinical elective forms an integral part of the undergraduate curriculum in the UK. There are many benefits of travelling abroad during medical school to gain international experience in healthcare. The style of medical education varies between countries. Our own experiences of clinical electives in the USA showed us that students there tend to have greater involvement in the care of their patients compared to students in the UK. For example, in some American hospitals, senior students are allocated patients to follow for their entire in-patient stay. Students are actively encouraged to offer their input when devising management plans for patients and have greater clinical responsibility. Being thrust into this very different learning environment has the advantage of increasing one’s clinical confidence and promoting student initiative, which facilitates the transition into house officer jobs. Another variation between countries is the prevalence of different diseases. This allows students to gain experience in the diagnosis and management of conditions that they may not see commonly, if at all, in their own country. Such knowledge is transferable. They may later encounter these conditions in their home country in travellers or immigrants. This is particularly relevant to infectious diseases. Furthermore electives in developing countries allow students to gain a real understanding of the demands placed on healthcare staff in resource-limited settings. Students become more socially aware. This in turn may not only make them more empathetic but also increases appreciation of the resources that they have at their disposal in their home country. In the long-term, spending time abroad may greatly influence the direction of one’s career. International experience lends itself well to specialties such as public health and infectious diseases. A placement abroad may also help individuals to decide whether they wish to pursue their training in a foreign country after completion of medical school. Immersing oneself in the healthcare system of different countries may encourage individuals to transfer values between their own country and foreign countries. Such sharing of ideas between countries may lead to innovative and effective concepts being adopted across borders, ultimately helping to positively shape healthcare systems on an international scale.
20 14
the upper-limits (UL) and lower-limits (LL) of pass-marks and fail-rates generate negligible changes in cut-scores (1–2%). We agree with Tavakol & Dennick’s conclusions and we have developed a substantially modified-Hofstee (MH) method that obviates subjective judgements. In the MH protocol, the UL and LL for fail-rates are set at 100% and 0% of the cohort, respectively, i.e. potentially all candidates could fail or pass, avoiding arbitrary pass/fail quotas. The LL for the pass-mark is also set at 0%, avoiding an arbitrary boundary for this value. The UL for the pass-mark is standard set an absolute percentage below the median percentage mark of the cohort (based on trials on historical data). The rationale for this is that cohort performance is an objective measure of exam difficulty when the cohort is sufficiently large and its selection is consistent year-on-year (as is likely for selection of medical students). (Others have similarly argued for using cohort data for setting borderlines (Cohen-Schotanus & van der Vleuten, 2010). A diagonal is drawn for the UL pass-mark on the X-axis to the UL of fails (100%) on the Y-axis; the intersection with the cumulative frequency curve of students’ marks gives the actual pass-mark. We applied the MH protocol to historical data of 49 summative assessments sat by cohorts of 4240 year 1–3 medical students over five years. The range of pass-marks generated by MH was 47%–60% (median 57%). We further examined the effect on 15 assessments of raising the UL of the pass-mark by 10%; this increased the cut-scores by 5.4%–8.5% (median 6.6%), which is substantially greater than reported by Tavakol & Dennick for CH. Furthermore, if the diagonal does not intersect with the frequency curve, this indicates that all students pass. Whilst Anghoff/Ebel are appropriate for ‘‘high-stakes’’, broad-based clinical exams, they may be impractical for multiple, subject-specific exams, where assembling and ensuring consistent operation of multiple panels of experts is not feasible. In such circumstances, the MH protocol may provide a viable and robust alternative for credible standard setting.
Kartik Kumar, North Middlesex University Hospital NHS Trust, Sterling Way, London, N18 1QX, UK. E-mail: kartik.kumar@ cantab.net. Fangyi Xie, Buckinghamshire Healthcare NHS Trust, Mandeville Road, Aylesbury, Buckinghamshire, HP21 8AL, UK.
359
Letters to the Editor
Declaration of interest: The authors report no declarations of interest.
Reference Stys D, Hopman W, Carpenter J. 2013. What is the value of global health electives during medical school? Med Teach 35:209–218.
Student perceptions of rural placement – Australia to Aberystwyth
We conclude that students should experience a balance between rural and tertiary care settings. While rural placements can potentially increase P4P, the aforementioned detrimental features should be considered as these may negatively affect student satisfaction, learning opportunities and therefore reflect poorly on P4P. Furthermore, we call for an objective measure of P4P to determine whether students’ perceptions are reflected in subsequent clinical practice. Sophia Rosa Thompson, Beshlie J Richards and Kate Rebecca Harding, Cardiff University, Medical School, Cochrane Building, Cardiff, CF14 4YS, United Kingdom. E-mail: [email protected]
Declaration of interest: The authors report no conflicts of interest.
Reference Dear Sir As fourth year medical students from Cardiff University Surgical Society (CUSS) we discussed your article (Daly et al. 2013) with interest. We acknowledge that our experiences in this field differ from those in Australia. However, regarding medical education in the UK, placements allocated by Cardiff University are geographically vast and remote. These include exposure to rural South Wales and North Wales where Welsh language is predominantly spoken. Therefore, we feel uniquely positioned to comment on experiences of rural placements because such 5–8 week attachments are integrated into our core-curriculum. CUSS agrees with Daly et al. that rural placements may enhance preparedness for practice (P4P) specifically in reference to clinical skills, personal, professional and cultural development. Factors contributing to our increased P4P differ from those at Broken Hill. Anecdotally we have identified these as: increased devoted clinician teaching time, lower student-patient ratio, and a more culturally, pathologically and socially diverse spectrum of patients. Within CUSS we discussed various negative aspects of rural placements absent from the original article. We believe student experience is a key criterion in determining perceived placement success, which in turn may affect the knowledge and P4P acquired during attachments. Firstly, logistical obstacles specifically affecting Cardiff students include language barriers, unsubsidized travel costs and social isolation from peers. Additionally, in Cardiff, we rotate through specialty specific placement blocks each situated at discrete locations. This means rurally placed students will lack exposure to specialist teaching, patients requiring complex management and advanced procedures only offered at tertiary centres. Daly et al. mentioned using Video-conferencing to overcome these issues. This method is currently employed by Cardiff University. However, based on our experience this format is a poor substitute when compared to face-to-face interactions. 360
Daly M, Perkins D, Kumar K, Roberts C, Moore M. 2013. What factors in rural and remote extended clinical placements may contribute to preparedness for practice from the perspective of students and clinicians? Medical Teacher 35:900–907.
Preparing for practice with longitudinal integrated placements
Dear Sir We would like to thank the Cardiff University Surgical Students (Thompson et al. 2014) for drawing our attention to an international comparison of the student experience in shorter 5–8 weeks clinical placements in Wales, and the six months to one-year longitudinal clinical placements in New South Wales (Daly 2013a). We note the students’ endorsement of the many positive aspects of rural placements relating to Preparation for Practice such as quality of supervision, student-to-teacher ratios and diversity in patient population. In an earlier paper (Roberts et al. 2012) we explored rural extended placements in the context of career intentions of students. We also identified similar barriers to the Cardiff students, such as geographical isolation, family and relationship needs and limited opportunity for sub specialist practice. We feel that many of these issues can be overcome by medical schools investigating the opportunities provided by longitudinal placements, known as longitudinal integrated clerkships (LICs) in the US (Thistlethwaite et al. 2013). There is probably a national imperative as well to provide the supporting infrastructure that underpins the success of these placements in the long term. Over two decades a key policy response to rural workforce shortages in Australia has been substantial investment in educational initiatives, such as Rural
Copyright of Medical Teacher is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
