Purpose: To investigate, from the students' perspective, factors that may adversely affect student learning in the clinical environment. Method: Medical students evaluated the perceived effectiveness of the clinical learning environment at the end of various clerkship rotations, such as surgery, gynaecology, paediatrics, ophthalmology. After each clerkship students answered a standard questionnaire containing closed-ended questions about supervision, patient contacts, organisation, learning effectiveness and the learning climate, as well as one open-ended question about the clerkship-site's perceived weaknesses. Because supervision is crucial to the quality of clerkships but often lacking, we compared clerkship-sites with relatively low and high ratings on supervision and analysed students' comments on the weaknesses of their clerkship-sites. Results: Factors that students perceived were inhibiting learning were too few opportunities for students to examine patients independently and lack of time for supervision. In addition, lack of observation, insufficient feedback, negative attitudes of the staff towards students and teaching, the presence of too many students at one time, too few educational sessions, and poor organisation were mentioned as perceived weaknesses in open-ended comments. Conclusions: Based on these students' perceptions, effective clerkships should present students with patients with a variety of health problems who can be examined both independently and with supervision. Continuity of supervision is important and can be addressed by assigning a teacher or mentor to each student.

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Introduction: Doctors and medical students should know what to ask patients, should do so in a sensitive and caring manner and convey a supportive, non-judgmental attitude to their patients, especially with regard to sexual and reproductive issues. The Manipal College of Medical Sciences (MCOMS), Pokhara, Nepal admits students from Nepal, India, Sri Lanka and other countries to the undergraduate medical (MBBS) course. In the MBBS curriculum sexual and reproductive issues are not adequately covered. Methods: The Department of Medical Education at MCOMS organized a voluntary Medical Humanities module and conducted a session on social issues in the use of medications. Issues regarding sexual and reproductive health were explored using case scenarios and role plays. Results and conclusions: This manuscript describes selected case scenarios and various sexuality-related issues covered. The students and the faculty members were of the opinion that sexual and reproductive issues are a grey area in the curriculum. The case scenarios appeared to be successful in sensitizing students and faculty members about certain issues of sexuality. Participants felt the skills acquired would be useful in their future practice. Based on this experience, the module will be modified and strengthened, along with the evaluation process.

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Objectives: The preclinical years of undergraduate medical education provide educational content in a structured learning environment whereas clerkships provide clinical training in a more experiential manner. Although early clinical skills training is emphasized in many medical schools, students still feel unprepared and anxious about starting their clerkships. This study identifies the skills medical students perceive as essential and those skill areas students are most anxious about prior to starting clerkship rotations. Methods: Open-ended questionnaires were administered to two cohorts of students, preclinical students (PCS) completing their second year and clinical students (CS) in the ninth month of the clinical training of their third year at a single urban US medical school. The following questions were addressed in the survey: which three clinical skills do they perceive are most essential for the clerkships; which skills are students most anxious about as they enter clerkships; and what additional skills training should be provided to students to ease the transition into clerkships. Results: Response rate to the questionnaire was 84%. PCS (n=93) reported the three most essential skills to be prepared for clerkships are: history taking/physical examination (73%), proficiency in oral case presentations (56%), and generation of differential diagnosis (46%). CS (n=105) reported interpersonal skills (80%), history taking/physical examination (37%), and time management (26%) as most essential. PCS were most anxious about their oral case presentation skills (30%), but CS were most concerned about time management and self care (40%). Conclusions: This study identified the skills that students at one school regard as most important to have mastered before beginning clerkship training and the areas students find most anxiety provoking before and after they make the transition into clerkships. These results can inform medical educators about needed curriculum to facilitate this transition and decrease the anxiety of students entering the clinical realm.

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Introduction: Northern Ontario, like many rural and remote regions around the world, has a chronic shortage of health professionals. Recognizing that medical graduates who have grown up in rural areas are more likely to practice in rural settings, the Government of Ontario, Canada established a new medical school with a social accountability mandate to contribute to improving the health of the peoples and communities of Northern Ontario. Background: The Northern Ontario School of Medicine (NOSM) is a joint initiative of Laurentian University in Sudbury and Lakehead University in Thunder Bay, cities one thousand kilometers apart. The NOSM model of medical education is built on several recent educational developments including rural-based medical education, social accountability of medical education and electronic distance education. This paper describes these developments as background to presenting the Northern Ontario School of Medicine as a socially accountable, geographically distributed rural-based medical school. NOSM MD Program: The school actively seeks to recruit students for the MD program from Northern Ontario or similar northern, rural, remote, Aboriginal, and Francophone backgrounds. The holistic, cohesive curriculum is grounded in Northern Ontario and relies heavily on broadband electronic communications to support distributed, community engaged learning. Students, both in classroom and clinical settings, explore cases as if they were physicians in Northern Ontario communities. Clinical education takes place in a wide range of community and health service settings so that students can experience the diversity of communities and cultures in Northern Ontario. Conclusion: Although NOSM is still in the early stages of development, there are encouraging signs that the school's evidence based model of medical education will be successful in developing a sustainable, community responsive health workforce for Northern Ontario.

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Context: There is a maldistribution of pharmacists in the South African health system, with only 15.6% of pharmacists working in the public sector, while the public sector serves more than 80% of the population. Setting: University of Limpopo, Turfloop Campus, Pharmacy Programme. Objective: To establish the profile and career preferences of University of Limpopo pharmacy students and investigate factors likely to influence their choices. Design: Cross-sectional descriptive study of Bachelor of Pharmacy students, using a semi-structured questionnaire. Findings: The response rate was 93% (157/169), with 44% female and 69% between the ages of 21 to 25 years. Nearly 80% of respondents were of rural origin; 77% attended rural government schools, 18% urban government schools, and 4% attended private schools. Only 39% of students indicated pharmacy as their first choice and 47% as second choice. Forty-six percent of the responding students preferred to work in a government hospital, 36% in industry, and 7%, 6% and 3% in private hospitals, the retail sector and academia, respectively. About 40% indicated a preference to work in rural areas. Most of the students stated service to community and paying back their sponsor as their main reasons for government hospital preference. Money, in combination with other reasons (e.g., working conditions), influenced work sector preference for less than 15% of responding students - with non-monetary incentives apparently more influential in student public sector preferences. Conclusions: Most University of Limpopo pharmacy students intend to work in rural areas and the public sector, and are mainly motivated by the need to serve the community.

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Context: India has the highest number of medical schools in the world. Teacher shortages and inadequate training of existing faculty are a major problem. On-line faculty development and learning is a plausible component of developing medical teachers in the essentials of pedagogy. Methods: An on-line faculty development learning process utilized by Regional Institute Fellows of the Foundation for Advancement of International Medical Education and Research (FAIMER) is described. This faculty development program begins with a face-to-face meeting followed by an 11-month intersession on-line experience, then another face-to-face meeting and a second 11-month intersession on-line experience. During each on-line session, Fellows participate in discussions on topics which they identify based on their learning needs. The on-line program is highly interactive and Fellows and faculty serve as moderators. Discussions have a conversational tone and a semi-structured format which Fellows develop along with the faculty moderator. The participants share their personal and professional experiences and the moderator 'wraps up' with a summary of the learning posted at the end of the month. Faculty facilitate the discussion, sharing appropriate resources and clarifying issues when necessary. Conclusions: More than the content exchanged, the interpersonal learning environment facilitated effective learning, and rejuvenated the learning experiences and network established during the face-to-face sessions. In view of its cost-effectiveness and the flexible choices it offers, focused, moderated, interactive on-line faculty development and learning needs to be considered seriously as a medium offering opportunities to medical educators and other professionals.

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Context: Historically, Native Hawaiian elders have been recognized as the major sources of wisdom and transmitters of knowledge and training to younger generations. Yet, concerns exist today for these elders who experience shorter life expectancies, poorer health and greater disability than elders in other ethnic groups in Hawai`i. Objective: We describe Ha Kupuna: National Resource Center for Native Hawaiian Elders, established at the University of Hawaii to address disparate health and improve the access and delivery of services to these elders. Method: Ha Kupuna is described in accordance with the principles of community-based participatory (CBP) research with its unique emphasis on culturally competent practice. Results: Application of the CBP approach is illustrated in the following steps: community engagement; development of an infrastructure; implementation and dissemination of research and technical assistance projects; and evaluation. Discussion: The CBP approach is highly relevant for Native Hawaiians because of its alignment with cultural values, the mobilization of the community and the emphasis on reducing health inequities through social change. In adhering to a CBP approach to improve the health of elders, Ha Kupuna seeks to perpetuate the culture through the transmission of ha (breath) from older to younger generations.

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