There is ample evidence that clinical communication skills deteriorate in medical students without specific training, but are improved by training. However, little is known about how well-equipped students are to communicate with patients on entering medical school, and there is limited evidence about whether all students improve with tuition in communication skills. This thesis describes a longitudinal study into these issues at the University of Otago�s Medical School. It was hypothesised that the majority of participants would demonstrate significant improvement in communication skills over their first two phases of specific tuition in communication. However, a small minority of participants were expected to fail to develop adequate skills in communication over this time, and the researcher wished to investigate whether any of the variables measured at baseline (demographic characteristics, personal qualities, academic abilities, and demonstrated interaction and interview observation skills) would predict those participants who developed superior communication skills, or who failed to demonstrate sufficient improvement by the end of eighteen months of medical education. Participants were 232 new entrants to the Otago Medical School programme, who were evaluated at three time points over the first eighteen months of their medical training. After completing a range of baseline measures (including a pre-training videotaped interview with a simulated patient role-played by an actor), participants completed two phases of communication skills training and, at the end of each phase, undertook a further videotaped interview. Interviews were marked by trained raters, using a novel assessment tool, the Brown-Peace Interview Marking Schedule, developed specifically for this purpose. Actors and participants themselves also evaluated each interview. Results showed that there was considerable variation in participants� abilities to perform the pre-training interview, indicating that the communication skills required in a clinical setting were not present in the majority of participants before training. Analysis of participant performance over time indicated that, while certain skills improved with training (e.g., receptive listening skills, non-verbal expression, and degree of structure in the interview) others did not improve significantly (e.g., responsiveness to the patient�s needs). As a group, participants benefited from the training, but a small sub-group of participants exhibited significant deficits in communication, even after two phases of communication skills training. It was easier to predict those participants who would develop superior communication skills than those who would continue to experience difficulties with simulated interviews. However, a small number of qualities (such as lack of familiarity with the English language, and high levels of personal qualities such as aloofness) were useful predictors of poor performance in the videotaped interviews. Further research could clarify whether the same personal qualities influence student performance in later interviews, once students have had more experiential training and opportunities to practise interviewing in a range of settings. In terms of the practical implications of the research findings, a number of issues are highlighted, such as the range of skills required of those who teach and evaluate communication skills. Recommendations are made regarding the timing, content and implementation of communication skills training for medical students.

In the 1990s, despite empirical support for linking theory to practice in professional education, a theory - practice gap persisted in medical education. This dissertation presents three initiatives and their evaluation to address the theory - practice gap in medical education at an Australian medical school. Case Based Teaching ( CBT ), a teaching and learning initiative, was designed and implemented in the Department of Physiology at the University of Adelaide. It aimed to introduce students to clinical skills in a way that built student confidence ; to achieve integration of knowledge between medical and clinical sciences ; and to strengthen the link between theory and clinical practice. Students and their tutors reported that CBT was beneficial in their development, and realised its three major aims. Greatest support came from students on the verge of their clinical training. Few studies, with both internal and external validity, have demonstrated the potential of computer aided learning ( CAL ) in medical education. In the second initiative, a self - directed CAL resource linking theory to practice was designed in three different learning formats. A randomised controlled trial showed learning gains for CAL users ( in terms of ability to retain and apply knowledge ) compared to non - users, but the active CAL format did not prove superior to more passive ones. The study demonstrated the importance of using valid assessment tools to measure learning outcomes, and the difficulties of conducting randomised controlled trials in the real world of medical education. Finally, the utility of a novel integrated practical examination was evaluated, in terms of reliability, validity, acceptability, cost and educational impact. The large investment of time and effort that was required to reform assessment practice brought rewards. Good reliability was achieved, and validity was maximised by linking theory to practice, and an extensive item review process. Assessment reform was used to drive the integration of teaching and learning. Basic science and professional knowledge consist of two different worlds, the former being analytic and general and the latter, holistic and particular. This dissertation has addressed the challenge of linking these two worlds, with initiatives that embedded these two knowledge structures within the other, fostering professional competence that is founded on procedural, propositional and personal knowledge. / Thesis (Ph.D.)--School of Molecular and Biomedical Sciences, 2004.

This thesis explores whether a carefully designed educational program can impact unfavourably on a proportion of students, what the magnitude of this proportion may be, whether previously identified ???deep enhancing??? features could stimulate surface approaches in some students, and the possible reasons for such paradoxical impact. These questions are set within a context of continuing efforts to find the ???ideal??? medical curriculum, and where evaluation studies of these curricular methods have failed to demonstrate the expected degree of positive impact. This leads to the final question of the thesis, which is whether the phenomenon of different responses by different students, could help explain the less-than-expected positive impact of curricular innovations reported in the literature. The questions were explored through a series of three studies. The First study consisted of individual student interviews and surveys (using the R-SPQ-2F, Biggs et al 2001) during a traditional program in medicine and upon conclusion of an educational program designed along currently accepted principles associated with higher quality learning outcomes. The two follow up studies included surveying students in two other settings in medical education. These studies were useful to overcome some of the limitations of the First study, and to explore the possible wider prevalence of the findings of the First study. The findings of the First study indicated that one-third of the student group did respond unfavourable to a carefully designed educational program. The interview findings highlighted this phenomenon, and illustrated how these students responded to ???deep enhancing curricular features??? by changing to more surface approaches. The survey findings supported these findings, and helped cluster and categorise students into subgroups who responded to the Pilot program in distinct ways. The two follow up studies indicated similar patterns of response in the other settings of medical education, and suggested that this phenomenon may be more widely prevalent. The findings suggest an area of research that requires further exploration. If confirmed and extended by further work, the findings could have significant theoretical and practical implications for medical education. From a theoretical perspective, the findings enrich the current theory of student approaches to learning by beginning to unravel the complex interaction between student and context factors that lead to approaches. The thesis further contributes to the literature by its finding that some previously identified ???deep enhancing??? context factors could stimulate change to more surface approaches in some students, and by the finding that different students??? approaches could change in different directions, when measured before and after the same ???deep enhancing??? educational context. From a practical perspective, the findings could be relevant to designers and evaluators of medical curricula, and to facilitators of small group learning. An understanding of the different patterns of response that may be expected, and an understanding of different strategies that may better support these different subgroups, may help optimise the benefits of curricular design.

<p>Vårt sätt att kommunicera med varandra är i hög grad situationsberoende. Ett tillfälle när samtalets form kan ha stor betydelse är i kontakten mellan läkare och patient och då speciellt när läkaren behöver förmedla tråkiga nyheter till patienten. I denna studie undersöktes faktorer som påverkar hur läkaren upplever sin förmåga att genomföra samtal med ”bad news” för patienten. Nio läkare på två sjukhus i Mellansverige intervjuades. När materialet analyserades induktivt genom meningskoncentrering framkom det att patientens ålder och personlighet tycks ha större inverkan än kön, och att anhöriga ansågs kunna vara både ett värdefullt stöd och en belastning för informationsgivningen i svåra samtal. Eftersom de flesta studier om svåra samtal inom vården bygger på uppgifter ur vårdpersonalens synvinkel diskuterades vikten av att i framtida studier fokusera patientens egna upplevelser.</p>

Vårt sätt att kommunicera med varandra är i hög grad situationsberoende. Ett tillfälle när samtalets form kan ha stor betydelse är i kontakten mellan läkare och patient och då speciellt när läkaren behöver förmedla tråkiga nyheter till patienten. I denna studie undersöktes faktorer som påverkar hur läkaren upplever sin förmåga att genomföra samtal med ”bad news” för patienten. Nio läkare på två sjukhus i Mellansverige intervjuades. När materialet analyserades induktivt genom meningskoncentrering framkom det att patientens ålder och personlighet tycks ha större inverkan än kön, och att anhöriga ansågs kunna vara både ett värdefullt stöd och en belastning för informationsgivningen i svåra samtal. Eftersom de flesta studier om svåra samtal inom vården bygger på uppgifter ur vårdpersonalens synvinkel diskuterades vikten av att i framtida studier fokusera patientens egna upplevelser.

Il lavoro di ricerca verte sull'analisi del rapporto tra medicina e pedagogia, in una prospettiva di intervento educativo finalizzato alla formazione dei futuri medici. La ricerca si è avvalsa di una letteratura straniera per il segmento relativo all'affermarsi della pedagogia medica, a livello nazionale ed internazionale, cui è seguita un'indagine empirica tendente a "dare voce" ai protagonisti della ricerca, gli studenti delle Facoltà di Medicina. / The research analyses the relation between education and medicine, in order to plan an educational intervention for future doctors. The research work is based on an international bibliography on Medical Education. There is also an empirical part in order to study the 'real voice' of students and professors.

Over the past decade, there has been a turn in applied health research towards the use of performance as a tool for knowledge translation. The turn to performance in applied health sciences has emerged as researchers have struggled to find new and engaging ways to communicate complex research findings regarding the human condition. However, the turn to performance has occurred within the political landscape of the knowledge economy, and thus conforms to contemporary practices of knowledge production and evaluation. Recent studies about health-based performances exhibit two hallmarks of economized modes of knowledge production. First, these studies focus their attention on the transmission of knowledge to health care professionals through an exposure to performance. Knowledgeable, and thus more useful or efficient, health care providers are the end-product of this transaction. Second, many of these productions are created in the context of application, and thus are driven by an accountability and goals-oriented approach to knowledge acquisition. This thesis argues that economized and rationalized modes of knowledge production do great harm to performance’s pedagogical and ethical potential. By utilizing scientific evaluative methodologies to monitor performance’s ‘success’ as an evaluable, predictable and ends-oriented practice obscures performance’s libratory value, and thus misses performance’s potentially most potent and critical contributions. To mount this argument, I present a case study of Margaret Edson’s play Wit, which has been used widely in medical education. Drawing from the philosophy of Emmanuel Levinas, I critically explore the impact of the knowledge economy on arts-based pedagogical models within health research and education. Further, I seek to redress potential harms inflicted by the knowledge economy by developing the notion of ethical “response-ability.” Through this concept I argue that performance challenges normative conceptions of reason, rationality and scientific evaluation, making the use of theatre in contemporary educational settings at once troublesome and vital.

In Canada, residents’ views on which roles and tasks are effective to becoming a competent physician is not yet part of the research discourse. Ensuring that competency-based curriculum (CBC) objectives are aligned with competencies and evaluation methods is critical to build a curriculum that will produce competent physicians. This research reports on the residents' views of the current Orthopaedic Surgery curriculum (UofT) which is solely competency-based. The residents' views were explored about which CanMEDS Roles and Entrustable Professional Activities (EPA’s) would be important to develop for them to become competent physicians. This study employed a mixed methodology. The individual interviews were from CBC orthopaedic surgery residents and the survey respondents were orthopaedic surgery regular time-based stream and competency-based stream residents. This research provides a better understanding of the resident experience so that educational practice and residency education can influence decisions around the curriculum design in postgraduate competency-based medical education programs.

In Canada, residents’ views on which roles and tasks are effective to becoming a competent physician is not yet part of the research discourse. Ensuring that competency-based curriculum (CBC) objectives are aligned with competencies and evaluation methods is critical to build a curriculum that will produce competent physicians. This research reports on the residents' views of the current Orthopaedic Surgery curriculum (UofT) which is solely competency-based. The residents' views were explored about which CanMEDS Roles and Entrustable Professional Activities (EPA’s) would be important to develop for them to become competent physicians. This study employed a mixed methodology. The individual interviews were from CBC orthopaedic surgery residents and the survey respondents were orthopaedic surgery regular time-based stream and competency-based stream residents. This research provides a better understanding of the resident experience so that educational practice and residency education can influence decisions around the curriculum design in postgraduate competency-based medical education programs.

Over the past decade, there has been a turn in applied health research towards the use of performance as a tool for knowledge translation. The turn to performance in applied health sciences has emerged as researchers have struggled to find new and engaging ways to communicate complex research findings regarding the human condition. However, the turn to performance has occurred within the political landscape of the knowledge economy, and thus conforms to contemporary practices of knowledge production and evaluation. Recent studies about health-based performances exhibit two hallmarks of economized modes of knowledge production. First, these studies focus their attention on the transmission of knowledge to health care professionals through an exposure to performance. Knowledgeable, and thus more useful or efficient, health care providers are the end-product of this transaction. Second, many of these productions are created in the context of application, and thus are driven by an accountability and goals-oriented approach to knowledge acquisition. This thesis argues that economized and rationalized modes of knowledge production do great harm to performance’s pedagogical and ethical potential. By utilizing scientific evaluative methodologies to monitor performance’s ‘success’ as an evaluable, predictable and ends-oriented practice obscures performance’s libratory value, and thus misses performance’s potentially most potent and critical contributions. To mount this argument, I present a case study of Margaret Edson’s play Wit, which has been used widely in medical education. Drawing from the philosophy of Emmanuel Levinas, I critically explore the impact of the knowledge economy on arts-based pedagogical models within health research and education. Further, I seek to redress potential harms inflicted by the knowledge economy by developing the notion of ethical “response-ability.” Through this concept I argue that performance challenges normative conceptions of reason, rationality and scientific evaluation, making the use of theatre in contemporary educational settings at once troublesome and vital.