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Medical Teacher
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Letters to the Editor
Online Publication Date: 01 December 2006
To cite this Article: (2006) 'Letters to the Editor', Medical Teacher, 28:8, 744 - 747
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Medical Teacher, Vol. 28, No. 8, 2006, pp. 744–747
Letters to the Editor
Problem based learning (PBL) case bank
Dear Sir
There are 41 medical schools in Korea and most of them
have implemented, at least to some degree, PBL programmes
into their respective curricula. However, medical schools
that lack experience of PBL among the staff usually have
difficulty in developing case problems. The solution to this
conundrum is to form a national consortium among the
medical schools.
In April 2004, under the auspices of the Korean Society of
Medical Education, a PBL study group hosted a symposium/
workshop for module development and the members of the
study group agreed to create the PBL Case Bank, which
would be available to all of the participating medical schools
to administer their PBL curricula. Thirty-eight of the 41
medical schools agreed to produce five modules by the end of
2004, and another five by the end of 2006. The annual fees
for participating medical schools amounted to US$500 and
one of the medical schools was designated to collect, control,
classify and compile all of the case modules. Participating
members are allowed to modify any of the pre-existing
modules but are required to indicate the module’s origin.
This is accomplished by coding systems of modules, and
modified problems are reintroduced into the Case Bank for
future use and reference. The ability of participating schools
to modify the case problems according to their needs was
reportedly a great success.
Contrary to expectations, examination of the initial 100
modules has shown that there was virtually no overlap in the
content of the modules that were produced. And even smaller
schools with no prior PBL cases or experience were extremely
enthusiastic about creating and submitting their own case
problems to the bank. In addition, inter-medical school
relations improved significantly as a consequence of imple-
mentation of the PBL Case Bank.
Future plans include an annual meeting for review and
revision of existing PBL modules, to assess their validity,
measure their feedback, and subsequently produce more
updated and effective PBL modules. Other long-term plans
include translation of our modules into English, in an effort
to allow medical schools in less developed countries to
benefit from our wealth of PBL modules.
Ducksun Ahn and Sowon Ahn
Department of Medical Education
College of Medicine, Korea University
126-1 5ga, Anam-dong, Sungbuk-ku
Seoul 136-705, Korea
E-mail: dsahn@korea.ac.uk
Implementation of the principles of holistic patient
care at the Nelson R. Mandela School of Medicine:
medical students’ perspectives
Dear Sir
In July 1997 the Nelson R. Mandela School of Medicine,
University of KwaZulu-Natal, adopted a proposal to replace
the traditional, discipline-based six-year programme with
a five-year problem-based learning programme (McLean,
2003). Students acquired knowledge, experience and
skills through small-group discussions, large-group
resource sessions, clinical rounds, research electives, rural-/
community-based medical education electives, family
medicine electives and other methods.
We conducted a qualitative study to assess medical
students’ perceptions as to whether the curriculum has
successfully implemented the principles of holistic patient
care, and whether these principles are being adequately
implemented in their clinical rotations. Email messages were
sent to randomly chosen students, from each level of study,
requesting them to participate in focus-group interviews.
Analysis of data was informed by Burnard’s (1991) method
of analysing interview transcripts in qualitative research.
The protocol was approved by the University’s Bio-Ethics
Committee.
Forty-seven students participated and eight initial themes
emerged from the focus-group interviews. Initial themes
were then collapsed, by combining similar ones, to derive
the following three major categories:
.Understanding of holistic patient care
‘Holistic medicine as we are taught comprises
a spiritual aspect and religion has a big influence.’
‘Holistic care regards viewing the patient as more
than just a disease entity and involves social,
spiritual and financial aspects.’
.Role of traditional,Chinese and alternative medicines and
circumstances that would necessitate referral to alter native
healers
‘I would refer to an alternative healer if the patient
actually believes in this system because this whole
holistic approach is to treat the patient as a person
not just a symptom.’
.Teaching methods encompassing the principles of holistic
patient care
‘In modules such as Cell Dysfunction and Diseases
of Lifestyle there are aspects of holistic patient
care. For example if you are doing cancer then you
744 ISSN 0142–159X print/ISSN 1466–187X online/06/080744–4 ß2006 Informa UK Ltd.
DOI: 10.1080/01421590601039901
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learn about different effects of cancer on the patient,
such as emotional needs.’
Our students have moved beyond the limitation of viewing
the patient as a disease entity and are now aware of the need
for a complete assessment of the mind, body and spirit
of a patient. They recognize that ‘to heal a person, one must
first be a person’ (Heschel, 1966). To ensure that future
doctors provide patient-centred healthcare, it is important
to introduce the principles of holistic patient care early
in the medical curriculum. However, the problem arises
with the application of these principles in public health
settings. Students expressed the view that there is a gap
between students’ knowledge and tutors’ skills in applying
these principles in the clinics and/or hospitals. Therefore,
what remains is the difficult task of improving on the
reinforcement of these principles during clinical blocks.
Lehlohonolo J. Mathibe & Breminand Maharaj
Department of Therapeutics and Medicines
Management,
Nelson R. Mandela School of Medicine,
University of KwaZulu-Natal,
Private Bag X 7, Congella, 4013,
South Africa
Email: mathibel@ukzn.ac.za
References
BURNARD, P. (1991) A method of analysing interview transcripts
in qualitative research, Nurse Education Today, 11, pp. 461–466.
HESCHEL, A.J. (1966) The Insecurity of Freedom (New York, Noonday
Press/Farrar Struss).
MCLEAN, M.M. (2003) Communicating curriculum reform to students:
advice in hindsight, BMC Medical Education,3,p.4.
Attitudes towards organ donation among medical
students
Dear Sir
Transplantation medicine has been successful in prolonging
life but the shortage of donor organs is the main obstacle to the
expansion of transplantation programs. The Croatian law on
tissue and organ donation is based on a presumed consent law,
permitting organ and tissue removal unless the donor was
explicitly opposed to organ donation during his or her lifetime.
However, experience from our hospitals and from other
countries has shown that it is advisable to get family consent
for organ retrieval in individual cases (Donor Network
of Croatia, 2005). A previous study showed that the intentions
of health professionals to ask about donation were not as
strong as they should have been and that there is room for
upgrading this element of the organ transplantation system
(Brkljacic et al., 2003). Surveying attitudes of medical students
should provide essential information on perceptions of tissue
and organ donation among doctors-to-be, and help in
planning future educational and training needs.
Undergraduate medical students from Zagreb University
Medical School (n¼276) were surveyed using a question-
naire that included the following parameters: attitudes,
willingness to donate, feelings about making a request for
organ donation, and carrying a donor card. Participants
showed highly positive attitudes toward organ donation
and highly positive willingness to donate different tissues
or organs. Willingness to donate organs of a deceased family
member was still positive, but lower compared with the
willingness to donate one’s own organs to help a person
in need. In a situation where participants should ask for organ
donation, 65% would be able to handle their own negative
emotions, and 47% would feel uncomfortable. Almost 20%
of participants carried a donor card.
This study showed that there is a need for structured
education of medical students in the practical, legal and
ethical aspects of organ donation, but also education of
all healthcare professionals, and professionals from other
vocations ( psychologists, sociologists) in this field.
Gordan Grahovac
1
, Tihana Brkljacic
2
, Iva Topic
3
& Mario Habek
4
1
Department of Histology and Embryology,
3
Department of Anatomy,
4
Department of Neurology,
Zagreb University Medical School, Croatia
2
Ivo Pilar Institute of Social Science, Zagreb, Croatia
1
ggrahov@mef.hr
2
Tihana.Brkljacie@pilar.hr
3
itopic@mef.hr
4
mhabek@mef.hr
References
BRKLJACIC, T., FERIC,I.&RIHTAR, S. (2003) Development and testing
of promotion materials on tissue and organ donation, Croatian Medical
Journal, 44, pp. 225–233.
Donor Network Of Croatia (2005) Available at: http://www.hdm.hr
(accessed 27 January 2006).
A novel application of mobile phone cameras in
undergraduate pathology education
Dear Sir
Increasingly resourceful applications have been found for
mobile phones in diverse fields of medicine. These have
ranged from transmitting electrocardiographic records
(Vaisanen et al., 2003) to using short messaging services to
convey laboratory test results (Ferrer-Roca et al., 2004).
Camera phones with Internet access have been used to
transmit images for remote consultation. Surgical wound
snapshots (Tsai et al., 2004); radiological images (Eze et al.,
2005); and funduscopic photographs (Yogesan et al., 2000)
have been broadcast in the past.
We would like to share an unusual application of these
camera phones by undergraduate medical (MBBS) students
that we encountered recently. Part of the MBBS curriculum
in pathology is familiarization with the gross appearance of
various diseases by displaying jar-mounted organ specimens.
The total number of such specimens shown over 18 months
of pathology training is nearly 60. While the primary aim is to
teach gross pathology, these specimen jars are also important
for the purpose of assessment as the more important/classical
Letters to the Editor
745
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ones form the starting point of oral examinations. A small
number of ‘typical’ specimens such as the small contracted
kidney, Ghon’s focus in the lung and aortic atheroma are
also part of the ‘spotting’ exercise in practical examina-
tions. Unlike postgraduate pathology where the emphasis is
on a range of appearances, undergraduates are character-
istically exposed to the same ‘book-picture’ specimens year
after year.
MBBS students at our institution are now invariably
equipped with personal mobile phones and we have found
that many possess photographs of nearly all the typical
specimens they will encounter in exams. This photography is
usually done covertly at the end of or before the beginning of
teaching sessions when the tutor is not present.
Since no definite guidelines existed on the ethics of the
issue most students had perceived it to be a ‘borderline’
illegal activity. Cellular phones are, however, barred from
examinations and there is no possibility of the images being
used to aid memory in viva voce or the one-minute spotting
station examinations. Therefore the departmental authorities
have tended to consider this intriguing application of
technology by medical students akin to harmless note-taking.
We write this letter to make the point that technological
advancements can initiate subtle changes in the way we
learn. The separate question of how useful gross pathologic
appearances are to the undergraduate in understanding the
pathological basis of disease is of course open to debate.
Prashant Sharma & Vinay Kamal
Department of Pathology,
Maulana Azad Medical College,
Bahadur Shah Zafar Marg,
New Delhi 110002, India
Email: prashant.sh@gmail.com
References
EZE, N., LO, S., BRAY,D.&TOMA, A.G. (2005) The use of camera
mobile phone to assess emergency ENT radiological investigations,
Clinical Otolaryngology, 30, pp. 230–233.
FERRER-ROCA, O., CARDENAS, A., DIAZ-CARDAMA,A.&PULIDO, P. (2004)
Mobile phone text messaging in the management of diabetes, Journal of
Telemedicine & Telecare, 10, pp. 282–285.
TSAI, H.H., PONG, Y.P., LIANG, C.C., LIN, P.Y. & HSIEH, C.H. (2004)
Teleconsultation by using the mobile camera phone for remote
management of the extremity wound: a pilot study, Annals of Plastic
Surgery, 53, pp. 584–587.
VAISANEN, O., MAKIJARVI,M.&SILFVAST, T. (2003) Prehospital ECG
transmission: comparison of advanced mobile phone and facsimile
devices in an urban Emergency Medical Service System, Resuscitation,
57, pp. 179–185.
YOGESAN, K., CONSTABLE, I.J., BARRY, C.J., EIKELBOOM, R.H.,
MCALLISTER, I.L. & TAY-KEARNEY, M.L. (2000) Telemedicine screen-
ing of diabetic retinopathy using a hand-held fundus camera,
Telemedicine Journal, 6, pp. 219–223.
Association of Standardized Patient Educators
Dear Sir
The Association of Standardized Patient Educators (ASPE)
group (http://www.aspeducators.org) convened its annual
meeting in Chicago. Most of the 280 delegates were based
in Canada and the United States (US). We outline our
reflections on the meeting as United Kingdom (UK) based
delegates and recognize that our views are based on
a relatively small number of all sessions offered, are biased
by our personal interests, and do not represent the status
quo in standardized patient (SP) education but simply our
experiences.
Although SP terminology is defined in the literature
(Collins & Harden, 1998; Barrows, 1993; Adamo, 2003;
Ker et al., 2005), conversational use does not always have
a shared meaning. In the US, ‘SP’ is used to describe most
situations in which a person takes on the identity of another
for the purposes of creating a healthcare professional
encounter with a patient. This probably reflects the pre-
dominant function that SPs play in assessment in which
consistent performance is required. In the UK, the terms
‘simulated patient’ and ‘role-player’ are more commonly
used with the principal role in teaching and learning with
reference to ‘standardization’ in relation to SP performance
necessary for high-stakes assessments.
In the US, SPs are already widely used in high-stakes
assessments. Recent changes reinforce this assessment
function with medical students undertaking summative
SP-based clinical skills assessments. In the UK, simulated
patients are used in high-stakes assessments and may
contribute to the rating of candidates in contrast to the US
and Canada, where SPs are sometimes the only assessors.
Although the content and process of feedback from
SPs to learners varied, in the US SPs regularly provided
feedback using paper forms (content and communication
processes) that contain ‘professional’ language distant from
patient perspectives. That is, SPs gave feedback as if they
were clinical and/or communication teachers. Although
there are many advantages to this approach, it precludes
feedback from SPs as ‘patients’. This was another
important difference from that in the UK in which
simulated patients are usually called on to provide a
‘patient’ voice delivering feedback on communication and
professionalism and rarely on ‘medical’ content or physical
examination skills.
The title of the association is also of interest. An SP
educator is at minimum responsible for the training of SPs
(performing the role and giving feedback). However,
these SP educators may also be responsible for case writing,
recruitment and administration. It was often unclear
whether these posts were academic, administrative or held
some other status. There are few such designated posts in
the UK.
In the US and Canada, SPs were usually paid, were not
professional actors (exceptions in New York and California),
were offered variable pay rates and sometimes held part-time
contracts. This reflects the diversity of UK-based practice.
Although we recognize that there is variability within
countries, there appeared to be greater differences between
them, which we attribute to different emphases in
curricula.
The conference was an excellent forum to raise key
issues on all aspects of SPs and simulated patients and,
given there is no parallel group in the UK, ASPE is to
be congratulated on formalizing its activities through
Letters to the Editor
746
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this professional organization from which there is much
to learn.
Debra Nestel
Senior Lecturer in Communication
Department of Biosurgery and Surgical Technology
Imperial College, London
Karen Barry
Administrator
Interactive Skills Unit
University of Birmingham
Email: d.nestel@imperial.ac.uk
References
ADAMO, G. (2003) Simulated and standardised patients in OSCEs:
achievements and challenges 1992–2003, Medical Teacher, 25(3),
pp. 262–270.
BARROWS, H.S. (1993) Overview of the uses of standardised patients
for teaching and evaluating clinical skills, Academic Medicine, 68(6),
pp. 443–444.
COLLINS, J.P. & HARDEN, R.M. (1998) AMEE Medical Education Guide
No. 13: Real patients, simulated patients and simulators in clinical
examinations, Medical Teacher, 20(6), pp. 508–521.
KER, J.S., DOWIE, A., DOWELL, J., DEWAR, G., DENT, J.A., RAMSAY, J.,
BENVIE, S., BRACHER,L.&JACKSON, C. (2005) Twelve tips for
developing and maintaining a SP bank, Medical Teacher, 27(1), pp. 4–9.
Structured, supervised ambulatory medical education
for junior doctors
In Singapore, most of the undergraduate and early post-
graduate training is done at tertiary hospitals, where teaching
and supervision are focused on inpatient care, yet supervised
outpatient teaching is lacking (Chew & Chee, 2005).
In view of the shortfall, a pilot project consisting of a
structured resident outpatient teaching clinic was set up in
January 2005 at our institution. Five to eight new case
referrals were accepted at each session. Residents were
instructed to take sufficient time to clerk each case, followed
by a 15-minute case presentation and case discussion with an
attending hepatologist, who was running a concurrent
outpatient clinic next door. The attending hepatologist
would then meet up with the patients and explain their
medical condition, and manage accordingly.
Teaching was case-based and opportunistic. For instance,
when a resident encountered a patient referred for chronic
active hepatitis B, discussion was focused on the role of HBV
DNA viral load testing, and indications for antivirals.
The emphasis was on rationale and principles, rather than
the correct investigation and management.
Since mid-2005, a standard list of reading materials
consisting of management guidelines for chronic hepatitis B
and C, and fatty liver, were distributed to the residents,
as these were common referral complaints. Extra reading
materials were also given if the need arose. For instance,
an ex-injection drug user was once referred for manage-
ment of chronic hepatitis C, and extra reading material
on this subject was printed for that resident after the clinic
session. To ensure residents obtain a comprehensive history,
a clerking template has also been provided since mid-2005.
From January 2005 till April 2006, 22 residents ran the
Resident Hepatology Clinics. Feedback forms were given to
all and 17 were returned. Median duration since graduation
was 3 (range 1–6) years, and only 1/17 was interested in
further specializing in gastroenterology. A total of 16/17
(94%) felt their interest, knowledge and competence in
hepatology had increased, teaching was above expectations
and the clinic was felt to be an effective and worthwhile
experience. All 17 (100%) felt the clinic was better than any
outpatient clinics run during their previous postings. The
residents particularly appreciated the liberty to assess the
patient first, the case-based teaching, and the opportunity
to observe the interaction between the hepatologist and the
patients. Since results of the feedback are positive, similar
ambulatory clinics are currently being set up for other
specialties.
Our experience showed that a structured, supervised
format of ambulatory care was welcomed by most residents,
and it should be further evaluated as the educational tool of
choice for junior doctors and medical students.
Chun-Tao Wai, Susan Tan & Dede S. Sutedja
National University Hospital
Singapore, Yong Loo Lin School of Medicine
National University of Singapore
Singapore
Email: mdcwct@nus.edu.sg
References
CHEW, C.H. & CHEE, Y.C. (2005) Postgraduate medical education and
specialist training in Singapore, Annals of the Academy of Medicine,
Singapore, 34, pp. 182C–189C.
Letters to the Editor
747
