Introduction: There is a need to improve the validity of performance assessments and to develop better ways of identifying and assessing what students actually do in practice. Incorporating patients' assessments into OSCEs has the potential to offer both an expert assessment of aspects of the doctor-patient interaction and improve validity. Therefore, we held a trial using simulated patient (SP) assessments in history-taking, explaining and communication skills stations in third year OSCEs. Methods: SPs made two separate ratings of each student they saw in the OSCE. Examiners graded students using checklists and an overall 'borderline' grade. SP and examiners' marks were subject to statistical analysis. Results: The reliability of the SP ratings was .77. The reliability of the SP borderline grades was .68. The reliability of the ratings and grades combined was .86. SPs reached consensus on the characteristics of high and low performing students. Conclusions: SP assessments are reliable. Statistical analysis demonstrated that SPs and clinicians are assessing different aspects of students' performance. We concluded that, due to our approach to working with SPs, their assessments increased validity.

Background: Medical schools' instruction of skills is often found to be inadequate. In 1999, the American Association of Medical Colleges (AAMC) published a list of eight procedural skills that medical students are recommended to learn. This study aims to evaluate compliance with these guidelines and to examine the instruction of other skills to determine if the most important skills receive adequate instruction. Methods: In 2004, surveys were sent to 138 educational representatives at North American (AAMC) medical schools and 1208 Canadian family physicians. The survey addressed the importance of selected skills. Findings were analyzed by χ² testing. Results: Of the eight skills recommended by the AAMC, only four were taught by all schools. All eight, except for suturing, and most of the other skills, were taught at a higher rate than they were practiced. Only digital block anesthesia was practiced more commonly than it was taught. Conclusion: Although guidelines exist for skills instruction in medical school, they are not followed completely. Furthermore, the guidelines may reflect an emphasis on skills that are more suited to specialist rather than general practice. This may come at the expense of the instruction of other more practical skills.

Introduction: The goal of integrating a Public Health Certificate (PHC) into the medical school curriculum is meant to provide basic public health skills and knowledge to all future physicians, ultimately broadening the health workforce's capacity to address community health needs. The faculty at the University of New Mexico's (UNM) School of Medicine (SOM), in collaboration with multiple community stakeholders, created a PHC equivalent to 15 graduate level units. The PHC will be required of all medical students matriculating in 2010. Methods: The authors, community leaders, university administrators, faculty, staff, and students met to address the many tasks required of such broad curricular and policy change. The tasks required piloting innovations in curriculum design and implementation, working within the bureaucratic structure, fostering collaboration, nurturing leadership skills, marketing the new ideas, and designing credible evaluation strategies. Results: We have engaged the stakeholders; surveyed our resources; produced and implemented ongoing evaluation; examined implementation strategies; developed, implemented and pilot tested the PHC courses; and engaged faculty from the Department of Family & Community Medicine in faculty development seminars. Conclusion: Introduction of a PHC for all students is feasible with planning tools such as the Logic Model.

Innovative education: The FHS, Moi University has been an active member of Community Based Education and Service (COBES) network. To achieve this, FHS uses innovative educational strategies that encourage active learning and self-directed learning. However, since these educational strategies are very resource intensive, the faculty has been forced to establish links with health programs. Sustainability of innovations: Although higher learning institutions have been urged to become more innovative and responsive to a globally competitive knowledge market, support from governments has been declining. This has forced institutions to develop new links with service systems to enable them to sustain innovations. It is undisputable that investments in higher learning generate major community benefits through returns from research, technology application and service provision. Collaboration, which is a mechanism of working together in a harmonious and supportive way with other agencies, is vital for sustaining innovations. Potential Health Programs for collaboration: In Kenya, where programs such as Health Education and Maternal Child Health that undertake outreach health services exist, Higher Learning Institutions need to collaborate with these programs to enable them make best use of resources and increase efficiency. In this paper, a framework for collaboration in developing countries where resources are meager is suggested.

Purpose: the study was conducted in order to determine whether the level of motivation related to intrinsic (people-oriented) and extrinsic (external reward) value complexes in a class of massage therapy students changed during their professional education. Methods: the research was a quasi-experimental within-subject design, in which survey data was collected from students on their first day in the massage therapy program and again towards the end of their final term. The data were collated and summarized, and the differences in motivation scores were assessed using Fisher's Least Significant Difference procedure. Results: the results support the hypothesis that massage therapy students are motivated more strongly by intrinsic than extrinsic rewards both at the commencement of their studies and as they approach entry to practice. Also evident from the data is the fact that the students' motivation changed during their professional studies. This change involved a significant decrease in the level of intrinsic motivation and significant increase in the level of extrinsic motivation. Thus, although intrinsic motivation reduced while extrinsic motivation increased, the former remained the more powerful influence. Conclusion: professional programs should consider the balance between intrinsic and extrinsic student motivation and attempt to control influences that might shift this such that the humanistic / altruistic mission of health care is undermined.

Context: The maldistribution of physicians in sub-Saharan Africa is having serious impacts on population health. Understanding the effect requires investigation from both donor and recipient countries. However, investigation from the perspective of donor countries has been lacking. Methods: This brief communication describes a model process for the design of a research project that addresses medical migration issues from the perspective of eight African medical schools. During an international meeting, the participants designed an initial "ideal" study, and then rapidly tested its feasibility through a brief survey, and group discussion through a listserv, teleconferences and one face-to-face meeting. Findings and practical implications: Innovative research ideas can be followed-up with surveys to test the feasibility of an "ideal" research design, modifying the design accordingly. This is currently occurring with our medical migration survey study.

Context: Educational environment makes an important contribution to student learning. The DREEM (Dundee Ready Educational Environment Measure) questionnaire is a validated instrument for assessing educational environment, but used alone it has little value for identifying means of remediation of poor aspects of environment. Aims: This study used qualitative analysis, in association with the DREEM questionnaire, to evaluate the educational environment across all five years of a large undergraduate medical school, and identify areas for change to enhance student experience. Method: The DREEM questionnaire was administered to 968 undergraduate students, together with an open question asking for suggested changes to current medical school practices. Items of concern highlighted by this study were further defined through qualitative analysis, using focus groups, email questionnaires and introduction of Stressful Incident reporting. Results: Through responses to the open question, two items with low scores on the DREEM questionnaire were identified as requiring remediation. Focus groups and email questionnaires were used to define the underlying causes of poor scores, which varied by student year group. Stress resulting from experiences on clinical placement was highlighted by some students, but on closer investigation found to be rare. Remedial steps to improve student support are described. Conclusions: The qualitative data have substantially enhanced questionnaire interpretation, and allowed actions to address common causes for student dissatisfaction to be undertaken. This combined methodology is recommended to other institutions wishing to improve the educational environment, and thus the overall quality of educational provision.

Context In their postgraduate educational programs, residents are immersed in a complex workplace. To improve the quality of the training program, it is necessary to gain insight into the factors that influence the process of learning in the workplace. Methods: An exploratory study was carried out among 56 nursing home physicians in training (NHPT) and 62 supervisors. They participated in semi-structured group interviews, in which they discussed four questions regarding workplace learning. Qualitative analysis of the data was performed to establish a framework of factors that influence workplace learning, within which framework comparisons between groups could be made. Results: A framework consisting of 56 factors was identified. These were grouped into 10 categories, which in turn were grouped into four domains: the working environment, educational factors in the workplace, NHPT characteristics and supervisor characteristics. Of the factors that influence workplace learning, social integration was cited most often. Supervisors more often reported educational factors and NHPTs more frequently reported impediments. Conclusion: The educational relationship may be improved when supervisors explicitly discuss the learning process and learning conditions within the workplace, thereby focusing on the NHPT needs. Special attention should be paid to the aspects of social integration. A good start could be to answer the question regarding how to establish a basic feeling of 'knowing where you are' and 'how to go about things' to make residents feel comfortable enough to focus on the learning process.

Background: There is a growing need for appropriate training models in the area of cultural competence. An Objective Structured Clinical Exam (OSCE) format is ideal for this endeavor, since it allows for skills practice and feedback. As a result, we designed the first formative Culture OSCE at Maimonides Medical Center and have been implementing it since 1999. Program Development: An interdisciplinary committee developed the OSCE as a formative assessment. Stations were designed based on a review of the literature and real situations experienced in the hospital. A two-hour workshop introducing the concept of cultural competence precedes the OSCE. The emphasis is on skills that are generalizable to encounters with any culture. Standardized patients are recruited from the relevant cultural groups or are trained to understand specific cultural issues. Costumes and props are utilized to enhance the authenticity of the encounter. Faculty, recruited and trained to observe encounters, gives constructive feedback, thus enhancing faculty development in this area as well. A rating scale was developed which incorporates communication and cultural skills as two separate dimensions of the encounter. Program Evaluation: Written feedback is obtained from residents, the trained faculty observers and the standardized patients. Resident feedback has demonstrated good face validity. A post-OSCE debriefing session allows residents an opportunity to consolidate learning and give oral feedback. Conclusion: The Maimonides Medical Center Pediatrics Department designed the first Culture OSCE. This is deemed to be a valuable training tool, and serves to highlight the importance of cultural competence within the Department.

Context: Developing and sustaining medical schools in developing countries can be challenging. Some collaborations between medical schools in developing countries and one or more medical schools in developed countries have been helpful. However, medical schools in developing countries can be vulnerable to the sudden withdrawal of funds (particularly if they have only one partner). Also, uncoordinated support from multiple partners can lead to problems. Objectives: We describe the 15-year experience of a unique "Friends" consortium, which was established between Moi University Faculty of Health Sciences ("Moi") in Kenya and four medical schools in developed countries. Methods: Information about the Friends' activities with Moi and their relationships with each other was collected from key members of each institution during the annual Friends meeting and through e-mail correspondence. Results: Each school, under the leadership of a few individuals, has maintained a continuous collaboration with Moi. Most of the focus has been on education. Some institutions have been able to expand their activities. Others have maintained more limited but steady support. Coordination of activities of the partner institutions has been facilitated by annual joint meetings, leading to clarity about needs to be met as well as ways to avoid overlap. Discussion: We believe that effectiveness of the individual efforts of each institution have been enhanced through working cooperatively. Ongoing problems include gaps in support at Moi, with uneven program development in some areas. Conclusions: We have learned that working together cooperatively has increased the effectiveness of individual efforts, and encourage others to consider adopting a "Friends" consortium model through actively contacting other partners. National or international health education organizations may be able to play a role in facilitation of these relationships.

Objective: This study explored how future physicians who are early on in their training conceptualize treatment adherence issues for a disease with a high societal stigma (e.g. HIV/AIDS) versus a disease with little to no societal stigma (e.g. diabetes). Method: We surveyed 121 first and second year students enrolled in a BS/MD program. After observing a videotaped interview of a person with HIV/AIDS, students were asked to identify and resolve ethical dilemmas regarding treatment adherence, which were presented in the interview. This process was repeated for a videotaped interview of a person with diabetes. Students' responses to both interviews were compared. Results: Analysis of qualitative comments indicated that students had difficulty identifying treatment adherence issues for high and low stigmatized diseases. Regarding the students' abilities to identify psychosocial factors and dilemmas for people with HIV, multiple concerns were identified, whereas most students had difficulty identifying psychosocial concerns for the person with diabetes. Most students had difficulty differentiating psychosocial dilemmas from ethical ones. Conclusions: Results suggest that premedical students have difficulty identifying and resolving psychosocial and ethical dilemmas for individuals with differently stigmatized diseases. Their ability to understand and resolve treatment adherence issues is limited. Despite the fact that most students knew someone with diabetes, they had more difficulty identifying psychosocial issues associated with diabetes compared to HIV. Findings support the need for education and training in psychosocial/ethical issues related to HIV and diabetes for students to help them better serve patient populations with diseases that bear low and high societal stigma.

Introduction: Osteoporosis is a serious metabolic bone disorder that often results in hip fracture and is usually asymptomatic in its initial stages. Since the majority of bone formation occurs during childhood and adolescence, it is important to begin primary prevention at an early age, although the optimal way for instilling this preventive behavior in youth has not yet been defined. The purpose of this study was to assess the effectiveness of a health education intervention based on the Health Belief Model (HBM) in reducing the risk of osteoporosis development in female adolescents. Methods: The study population consisted of 206 female students from the middle schools of the city of Garmdsar, Iran. The students were randomly assigned to one of three groups. Students in Group 1, the experimental group, participated in two health education sessions of one hour, based on components of the HBM. Students in Group II took part in the traditional didactic health education curriculum on osteoporosis. Group III students had no specific educational program for osteoporosis prevention. Data were collected at three points: before the intervention, immediately after the intervention, and one month after the intervention. The data-gathering instrument was a validated and reliable questionnaire (67 questions) that was developed based on the following HBM domains: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and health behavior action for osteoporosis prevention). Results: Group 1's pre-tests, post- tests and one month follow up tests revealed a significant increase in the students' mean scores in the domains of knowledge (about osteoporosis) (p<0.001), perceived susceptibility (p<0.001), perceived severity (p<0.001), and perceived benefits of reducing risk factors (p<0.001)), as well as taking health action (p<0.001). The mean scores of Group II only improved significantly in the domains of knowledge and perceived susceptibility (p<0.001). Group III showed no significant changes. Discussion and Conclusion: The findings of this study support the feasibility of a health education program based on HBM to induce behavior change for osteoporosis prevention in middle school females.

Context: When using the Case Method in teaching situations, problem-solving is emphasized and taught, in order to acquire the skills and later be able to apply them in new situations. The basis of the learning process is the students' own activity in the situation and is built on critical appraisal and discussion. Objectives: To explain what the Case Method is, what it is not and to describe when and where to use the Case Method. The objective is also to describe how to write a 'case', how to lead a 'case' discussion and how to deal with problems. Why one should use the Case Method is also highlighted. Application The case used should be founded on a real life situation, containing a problem that must be handled. The structure and use of the white board plays a central part. It is important that the setting allows the teacher to interact with all the students. Groups of up to 30 students can be handled with ease, though larger groups are feasible in the right physical setting. Within the health professions, the Case Method can be used at all levels of training and to a certain extent the same case can be used - the depth with which it is addressed depends on the student's prior knowledge. Different professions and specialists can take part. A whole curriculum can be built up around the Case Method, but more often it is used together with other pedagogic methods. Conclusion: The Case Method is a well-structured, student-activating way of teaching, well-suited to hone problem-solving skills within health education programmes.