Introduction: Whilst simulating clinical scenarios for the purposes of training is not a new concept, changes to the structure of medical training and working hours, technological advance and patient safety concerns have been responsible for intense interest and development of the use of simulation based medical education in recent years. The evidence base for the use of simulation is growing, with a number of studies demonstrating both learner satisfaction and improvements in self-reported confidence, as well as improvement in professional skill and knowledge. There are fewer studies which demonstrate an objective improvement in patient outcome however. Three linked studies in simulation are presented which explore the role of simulation in contemporary postgraduate medical training. 1) Temporary pacing: The first examined the use of simulation to teach the uncommon but potentially life threatening skill of temporary transvenous pacemaker insertion to trainees in General (Internal) Medicine. This demonstrated a significant increase in procedural success and learner self-reported confidence in their ability to complete the procedure, but a significant increase in the time required to do so following a single session intervention. The benefits of confidence appeared to decay somewhat over several months, although remained well above baseline. 2) ECG interpretation: The second examined the use of a novel online electrocardiography (ECG) interpretation simulator for medical students and foundation doctors. No significant difference was demonstrated in ECG interpretation between those using the simulation package and those who underwent traditional tutorial based training. There was a non-significant trend towards preference of the tutorial method. 3) Survey of attitudes to simulation: The third surveyed trainees across the United Kingdom to determine their experience of simulation, potential to access this learning modality and attitudes towards its incorporation into their training curricula. There appears to be considerable variation by region, specialty and seniority of what is available to trainees. The majority do feel that simulation has the potential to play a positive role within training but that curriculum integration, access and appropriate facilitation are issues which need to be addressed fully to optimise the benefit. Conclusions: There is evidence to support the use of simulation as a means to increase the knowledge and skill of doctors in training, although there is less evidence of direct improvement to patient outcome as a result. Trainees themselves do perceive simulation as a valuable adjunct to learning in the clinical environment when well-integrated into the curriculum, but there are variations in the accessibility and quality of what is offered. Future work should focus on addressing these issues.

The use of simulation in medical education, as well as the literature in the area, has increased dramatically in the past two decades. There is emerging evidence that simulation can be effective and the features of simulation which result in improved training and patient outcomes are becoming clearer. It is known that attitudes and motivation influence learner behaviour and outcomes, yet there is a paucity of evidence for the effectiveness of simulation which takes this into account. This work offers an original contribution by providing a theoretically underpinned insight into motivation for simulation. It also adds to the literature by reviewing current evidence on the effectiveness of simulation, reviewing the literature on motivation in medical education and qualitatively exploring the factors which can enhance or hinder motivation for simulation in a range of medical professionals. Twenty-three doctors and senior medical students, sampled in existing learning groups, including medical students, foundation doctors, anaesthetists and general practitioners, participated in seven group interviews: transcribed interviews were analysed for content and theme using framework analysis. The results demonstrated a range of simulation experiences, positive and negative value perceptions and pragmatic factors which can enhance or undermine motivation. Positive value perceptions of simulation included providing a rehearsal opportunity, an opportunity to experience rare situations, a trigger for feedback and reflection, and an opportunity for teamworking, in a context free from the risk of patient harm. Negative value perceptions included anxiety about role play, peer scrutiny, and making mistakes whilst observed by peers: ‘I don’t want to look like an idiot’, and issues about appropriate degree of realism. Some groups of learners, such as GPs indicated that simulation based courses were less relevant to their learning needs, in contrast with anaesthetic mid-career doctors who considered simulation highly relevant and a normal part of their experience. Pragmatic moderators were also identified, such as time, cost and location. These findings were consistent with existing theories of learner motivation. This thesis makes a further original contribution to the literature by identifying the importance of realism (particularly semantic realism) as a factor influencing motivation. In this study the influence of realism on learner motivation was not readily mapped to existing theories of learner motivation, identifying a gap in the literature. This thesis highlights the importance of recognizing anxiety in simulation, and ensuring appropriate realism. It recommends addressing anxiety as part of briefing and de-briefing for simulation, and recommends that course designers enhance internal consistency and semantic realism within simulation scenarios. Future research should take motivation and other learner attitudes into account when evaluating the effectiveness of simulation based educational interventions.

Background Growing and sustaining a healthcare workforce is an area for concern for all those working in today's health and education systems. Consequently, understanding the workplace and the learning that takes place within it is fundamental to ongoing strategy, planning and direction. Aim To explore how students learn in different healthcare settings. Method Case study research has been used systematically to examine five students' experience of learning in healthcare settings over a two year health studies study programme. These learning environments were investigated through critical incident interviews, observations, documentation; and data was collected and comparatively analysed. Results The findings of this study suggest the learning environment is unpredictable and the learning experience open to a set of random interconnected variables. With these intrinsically linked variables a model of workplace learning has been proposed and provides a useful way to review the complexities that exist within the learning environment, how they interact with each other and the possible impact they may have on learning in the workplace. As the learner engages in each new environment, the skills they develop are transferrable. Reflective practice is associated with learning in the workplace and is an important learning strategy for all health professionals. Confidence and acceptance was seen as essential pre-requisites to achievement in the workplace; and a positive staff-student relationship is crucial for students to feel accepted, included and valued. Students learn when allowed to take responsibility and self-confidence increases. Conclusion Workplace learning constitutes a significant part of healthcare education providing at least half the education experience. Workplace learning allows students to develop skills and experiences which they would not gain solely from an academic course. Understanding the nature of the learning environment is crucial to developing effective practitioners and education programmes. ' -.

This thesis is an anthropological study of the All India Institute of Medical Sciences (AIIMS), with a primary focus on undergraduate, or MBBS, education. Established in 1956, AIIMS is an enormous government-funded hospital, anomalous in the public healthcare landscape for employing many of India’s most respected doctors, who consistently provide a high standard of free or lowcost care to patients of low socioeconomic status. It also occupies an unassailable position atop the hierarchy of Indian medical education. AIIMS is a postcolonial institution, with origins in a colonial proposition, informed by global expertise, and realized with the support of international donors. Despite its profile, AIIMS has received little attention from social scientists. The same is true of medical education in India more broadly. Attending to these lacunae, I position my thesis in relation to literatures on hospital ethnography, and the training of health professionals in the Global South, as well as attending to other determinants of students’ experiences, including the dynamics of reservation-based difference, and their conceptions and experiences of aspiration and attainment. My analysis proceeds from an understanding of the All India Institute as simultaneously insulated from, permeated by, and complicit in the sociomedical landscape beyond its gates. Maintaining this perspective through a series of ethnographic chapters, I interrogate what is contained within the description of AIIMS and its students as ‘the best’. How is ‘the best’ defined and experienced? How does it inform articulations of aspiration and excellence, at global, national, and individual levels? And what implications might the ways in which India’s ‘best’ young doctors are produced contain for the politics and practice of health and medicine?

This thesis considers the experience of a group of medical educators undertaking an MA Education programme. At its heart is the notion that actions and thinking are determined by unacknowledged ideas and assumptions and the premise that if these can be unearthed and understood they can be examined, considered, changed and developed. Most medical educators are medical practitioners who, in addition to their role as clinicians, have become educators. They are in a unique position to influence the practice of their colleagues and so affect the quality of medical care that patients receive. Currently medical education is underpinned by an unacknowledged technical-rational approach which mistakes the nature of professional practice and the nature of education. Medical education is being pursued as a branch of medical practice, rather than as a branch of education. The MA Education (medical educators) programme at the University of Winchester embodies a very different approach to the one prevailing in medical practice and education. It is an approach that is acknowledged and critiqued and which recognises the nature of professional practice and education. Using a methodology derived from educational research, the response of medical educators to the MA programme is investigated through data collected from eleven semi-structured interviews. The response of the interviewees to the programme is analysed and its consequences and implications explored. Although the programme’s approach is initially surprising and uncomfortable for medical educators they recognise their practice within it and develop professionally, primarily as educators but also as clinicians. The findings show that medical educators and medical education need to acknowledge and shed the prevalent technical-rational approach and embrace an approach which embodies an appreciation of the nature of professional practice and of education and of practice is learnt. The MA programme experienced by the medical educators in this study is one example of how this can be achieved. The contribution of this thesis is to analyse one way in which medical educators can shed their technical-rational approach to professional practice and how and why they develop professionally through so doing. It emphasises the pivotal role of medical educators within medical practice and draw attention to the importance of the question of how practice is learnt.

Novice medical practitioners commonly practice on live patients in real medical procedures. However, due to the inexperience of the practitioner, mistakes are likely which exposes the patient to undue risk. To improve the training of novices, medical simulators create a virtual patient providing a safe environment for the user to practice within. An important clinical skill is palpation, a physical examination technique. The practitioners use their hands to feel the body of the patient to make diagnosis. A virtual patient has a visual representation but as it is virtual, the patient is not physically present. Haptics technology provide additional benefits to the training session by stimulating the physical sense of touch. A novel technique has recently emerged for stimulating tactile sensation called acoustic radiation pressure from focussed airborne ultrasound. Acoustic radiation creates a focal point of concentrated acoustic pressure in a three-dimensional field producing a force in mid-air. Airborne ultrasound has several advantages over conventional technologies. It was also initially theorised that using airborne ultrasound to simulate palpation compared to a previous system called PalpSim which consists of a rubber tube filled with water permanently embedded in a block of silicone, will offer better controllability over the displayed sensation to simulate various tactile sensations. The thesis has investigated the feasibility of using focussed airborne ultrasound as tactile feedback in medical simulators. A tactile device called UltraSendo was completely custom built to simulate an arterial pulse and a thrill sensation. UltraSendo was integrated with an augmented reality simulator displaying a virtual patient for user interaction. The simulator was brought to Ysbyty Glan Clwyd hospital for user feedback. A wide range of user responses were gathered. The majority of responses felt the arterial pulse was not sufficiently realistic whilst there were higher ratings for the thrill sensation which is acceptably realistic. Positive feedback suggests that airborne ultrasound can indeed provide tactile feedback in a medical context and is better at simulating a thrill sensation compared to a pulse sensation.

This study examines the ethical reality of medical students, and ethical curricular aspects of medical school. The 'received curriculum' is analysed using a combined interdisciplinary theoretical framework of 'Ethics' and 'Curriculum'. Defined in terms of students' experience of the curriculum, and the participants' perceived moral reality, the study was framed within a phenomenological-interpretive research paradigm. Content analysis of the 'narrative corpus' obtained by 38 open questionnaires addressed to sixth-year medical students, and by 21 interviews with medical students and senior faculty members, was conducted. Based on students' interviews, holistic 'ethical profiles' were produced, and proved to be significantly informative. The study shows that during their clinical training years, medical students cope with daily contextual moral dilemmas that relate to their culture and status and involve subtle, elaborately-calculated decisions. The student's authentic, reflective and analytical accounts of their ethical dilemmas, lead to the novel concept of students' 'moral awareness'. This increasing awareness of ethical dilemmas complexity sheds light on an adult ethical-cognitive stage, characterised by pragmatic thinking focused on content, and by internalisation of relativism and contradictions. The study further demonstrates the significance of students' experience for viewing and evaluating curriculum: the students, who perceived their ethics 'received curriculum' in its totality, consequently offered important insights concerning ethical processes, thus enriching the 'traditional' medical school curricular thought.

Although women are half of the medical students' population, they may have, different values than men and may be faced with organizational constraints in their medical schools and barriers to their career once they graduate. The general aim of this study is to highlight the question of gender equality in the educational process and the implications for educational managers arising from this issue. The specific objectives of the study are to identify male and female medical students personal values, experiences with regard to the curriculum, career's preparation, mentoring and abuse during the medical education and gender effect after graduation. The research tries to suggest ways in which educational managers can address possible gender inequality. The research is carried out in two phases. The first phase is a survey of a sample of final-year medical students from three and of four medical schools in Israel. In the second phase, a case study of one of the medical schools is carried out. Interviews with students and faculty members provide data to triangulate and illuminate the findings of the survey. Documentary analysis of the school's official prospectus enables further triangulation. Based on the findings, the conclusions are that although women and men medical students tend to differ in their career goals, they are similar in other values. Yet, women medical students are discriminated against to some extend with regard to school experiences such as career's preparation, and student abuse. Surprisingly more men students than women complain on discrimination. Other gender differences are apparent with regard to career choices and opportunities. It appears that a culture of 'gender blindness' is prevalent at medical faculties. The recommendations are that just to wait for the 'critical mass' effect is not enough and educational managers should try to address barriers faced by female students.

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