Context: Globally, as medical education undergoes significant reform towards more "learner-centred" approaches, specific implications arise for medical educators and learners. Although this learner-centredness is grounded in educational theory, a point of discussion would be whether the application and practice of these new curricula alleviate or exacerbate student difficulties and levels of stress. Objectives: This commentary will argue that while this reform in medical education is laudable, with positive implications for learning, medical educators may not have understood or perhaps not embraced "learner-centredness" in its entirety. Discussion: During their training, medical students are expected to be "patient-centred". They are asked to apply a biopsychosocial model, which takes cognisance of all aspects of a patient's well-being. While many medical schools profess that their curricula reflect these principles, in reality, many may not always practice what they preach. Medical training all too often remains grounded in the biomedical model, with the cognitive domain overshadowing the psychosocial development and needs of learners. Conclusions: Entrusted by parents and society with the education and training of future healthcare professionals, medical education needs to move to a "learner-centred philosophy", in which the "whole" student is acknowledged. As undergraduate and post-graduate students increasingly apply their skills in an international arena, this learner-centredness should equally encapsulate the gender, cultural and religious diversity of both patients and students. Appropriate support structures, role models and faculty development are required to develop skills, attitudes and professional behaviour that will allow our graduates to become caring and sensitive healthcare providers.

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Introduction: The study explores the anticipated willingness of teacher credential candidates at one California public university in the U.S. to perform cardiopulmonary resuscitation (CPR) or foreign body airway obstruction (FBAO) skills in a school setting. Objectives included (1) identifying reasons that credential candidates would elect or decline to perform CPR, (2) assisting schools to remediate cardiac/respiratory emergency preparedness, and (3) assessing CPR training courses to determine how they may influence teachers' willingness to perform CPR. Method: Participants included 582 teacher credential candidates, who were 95.2% of those surveyed after completion of a health science course and CPR certification. Participants described their attitudes regarding the importance of CPR, the CPR training course, and their willingness to perform CPR in a school environment. Results: Based upon chi-square analysis, an association was found between the willingness to perform CPR and the presence of any one concern regarding training, with 68.6% of those expressing concerns willing to perform CPR compared to 81.9% of those expressing no concerns (p<.0005). Participants certified multiple times stated that they were more likely to perform FBAO skills on both conscious (89% vs. 78.9%, p=.025) and unconscious victims (80% vs. 72%, p<.001), as were participants who believed CPR to be an important skill for teachers (76.9% vs. 43.5%, p<.001). Males were more likely to express willingness to perform CPR than females (84.6% vs. 72.1%, p<.001). Conclusions: Attitudes regarding CPR training may influence teachers' willingness to perform CPR. Recommendations based on these findings include pedagogical changes to CPR curricula, focusing on the importance of CPR as a teacher skill and additional time for hands-on practice. Future research should include U.S. and international participants from a broader geographic area and assessment of both learning and affective outcomes.

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Objective: To describe the development, process and outcome evaluation of a culturally tailored diabetes prevention education program for community healthcare workers (CHCWs) in Thailand. Methods: A tailored diabetes prevention education program was designed based on formative research and implemented with 35 CHCWs in semi-urban areas in Chiang Mai province, Thailand. Modules were delivered over eight group classes and eight self-directed E-learning sessions (www.FitThai.org). The program incorporated problem-based learning, discussion, reflection, community-based application, self-evaluation and on-line support. The frequency that students accessed on-line materials, including videotaped lectures, readings, monthly newsletters and community resources, was documented. Participant satisfaction was assessed through three questionnaires. Knowledge was assessed through pre-post testing. Results: Three-quarters of participants attended all eight classes and no participant attended fewer than six. On-line support and materials were accessed 3 to 38 times (median 13). Participants reported that program information and activities were fun, useful, culturally-relevant and applicable to diabetes prevention in their specific communities. Participants also appreciated the innovative technology support for their work. Comfort with E-learning varied among participants. Scores on pre-post knowledge test increased from a mean (sd) of 56.5% (6.26) to 75.5% (6.01) (p < .001). Conclusions: An innovative diabetes prevention education program was developed for CHCWs in Thailand. Interactive classroom modules and self-directed E-learning were generally well-received and supported better knowledge scores. Ongoing access to web-based materials and expert support may help sustain learning.

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Introduction: Beginning medical students' beliefs about the medical profession have been well studied internationally but have only been minimally studied in the United States (U.S.) recently. Up-to-date research on U.S. medical students' beliefs is warranted so educators can employ these predispositions as a baseline for curriculum and student professional development. Methods: We conducted focus groups with a first-year class (n=189) of U.S. medical students at the beginning of their academic year. In an iterative theming process, investigators worked in dyads and subsequently as a group to develop a list of preliminary themes expressed in the focus groups. Investigators individually sorted preliminary themes into similar categories. All sorted preliminary themes and categories were placed in a matrix from which final themes were derived. Findings: Investigators found eight themes for the question "Why pursue a career in medicine?" and six themes for "What makes a good doctor?" . Students expected medicine to be intellectually and personally fulfilling, they expected to be respected by the community, indicated that early experiences with medicine impacted their career choices, and anticipated that a medical career would yield financial security. A good doctor was described as a committed, smart, decisive leader who enthusiastically partners with patients via effective interpersonal skills. Discussion: Beginning U.S. medical students hold multi-faceted beliefs about medicine that are similar to international medical students' beliefs. Themes related to patient-centeredness, decisive leadership, and intellectual curiosity have particular utility in curriculum and professional development and should not be ignored. Administrators seeking to expand the physician workforce should consider early experiences, status, and monetary rewards.

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Background: Care and education have much in common, and work in the healthcare sector is closely associated with learning and teaching. It is felt that many in the healthcare and medical services are not aware of their pedagogic skills and how they can be developed. Frame of reference: Belonging to a community of practice means that you share perspectives, methods and language. Objective: The aim is to describe the pedagogical discourse by identifying pedagogical processes and studying the staff's awareness of such processes or situations in which a pedagogical approach would be useful in their work with patients and next of kin. Method: A qualitative study based on individual and group interviews. The analysis is directed by grounded theory. Results: The pedagogical processes varied in length and quality. Most were unplanned and were usually embedded in treatment. The pedagogical process is linear (planning, goal setting, teaching and evaluating) in an educational setting but we found that the beginning and end can be unclear and the goals can be vague or non-existent. The pedagogical process is best described using the concepts Read, Guide and Provide learning support. Discussion: The pedagogical discourse in healthcare is almost silent. Data indicate that at the collective level there is very little support for professional development of pedagogical ability. Tacit knowledge may therefore remain silent even though it may be possible to formulate and describe it. Conclusions: There is a strong need to focus on the pedagogical parts of the work and to encourage and support the development of professional pedagogical knowledge.

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Background: A portfolio is used to mentor and assess students' clinical performance at the workplace. However, students and raters often perceive the portfolio as a time-consuming instrument. Purpose: In this study, we investigated whether assessment during medical internship by a portfolio can combine reliability and feasibility. Methods: The domain-oriented reliability of 61 double-rated portfolios was measured, using a generalisability analysis with portfolio tasks and raters as sources of variation in measuring the performance of a student. Results: We obtained reliability (Φ coefficient) of 0.87 with this internship portfolio containing 15 double-rated tasks. The generalisability analysis showed that an acceptable level of reliability (Φ = 0.80) was maintained when the amount of portfolio tasks was decreased to 13 or 9 using one and two raters, respectively. Conclusions: Our study shows that a portfolio can be a reliable method for the assessment of workplace learning. The possibility of reducing the amount of tasks or raters while maintaining a sufficient level of reliability suggests an increase in feasibility of portfolio use for both students and raters.

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Context: Quality healthcare for diverse populations requires providers that understand the impact of culture on health and health seeking behaviors. Recruiting individuals from diverse cultures into healthcare professions facilitates this understanding. Although nursing education programs have been successful in recruiting such individuals, they often experience difficulties communicating with faculty and patients, which contributes to attrition from their first clinical course. Communicating Across Cultures is an innovative learning experience at our school to facilitate achievement of clinical competencies in the first nursing course. The purpose of this paper is to describe the teaching strategies used in this course that have increased achievement of clinical competencies and decreased the attrition rate of students from diverse cultures at our school. Suggested Teaching Strategies: First, assessing the students' specific communication difficulties guides what learning objectives and content are appropriate. Second, an immersion experience immediately before students begin their first clinical course provides experiential learning suited to acquiring new communication styles. Third, the experience and subsequent reinforcement are facilitated by faculty with expertise in teaching communication skills and with guiding the learning experiences of students from diverse cultures. Fourth, delineation of eligibility criteria allows students to self-identify their need to participate. Finally, an evaluation plan provides information to help make decisions about subsequent implementation of the learning experience.

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Context: Direct observation (DO) by teaching physicians of medical care provided by resident physicians offers a method to evaluate clinical skills beyond traditional measures that focus solely on medical knowledge assessment. Objectives: We sought to determine if the presence of the teaching physician observer affects parental satisfaction with care and to assess resident perceptions of DO in a general pediatrics residency clinic. Methods: A cross-sectional parent survey compared visit satisfaction of parents who experienced a DO with controls in a traditional clinic visit. Additionally, a pre-post survey measured resident perceptions of direct observation before and after implementation of DO in the clinic. Findings: Parents frequently described their overall satisfaction with care as "excellent" after DO and traditional visits (DO 70%, 95% CI, 50-86% and control 80%, CI 66-89%). However, parents in DO visits were less likely to rate their satisfaction with the amount of time spent in the room as excellent (DO 78%, CI 58-91%; Control 95%, CI 85-99%). Most resident physicians were in favor of the DO process (63%) and agreed that DO provides feedback about history-taking (94%), physical examination (94%) and interpersonal skills (91%). Conclusions: Direct observation by attending physicians does not decrease overall parental satisfaction during clinical encounters. Additionally, residents have a generally favorable opinion of direct observation and believe that it can provide useful feedback.

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Context: This paper presents the findings of qualitative research documenting the experiences in the Observer Program (OP) from the perspectives of international medical graduates (IMGs) entering the Australian healthcare system. Objectives: To examine the experience of IMGs participating in the OP. Methods: In-depth, open-ended interviews were conducted with nine IMGs who had been part of the OP. Findings: The feedback provided by the IMG participants about the OP was overwhelmingly positive. Participants identified a strong need for such a program, both from the perspective of increasing their confidence and competence and integrating them into and lifting their status within the Australian healthcare system. Positive outcomes reported to result from the program included increased confidence as a doctor in Australia, development of a sound knowledge of the Australian medical system, including basic medications used in local practice, familiarity with appropriate paperwork and the specialties of particular physicians, increased experience, refreshment of existing clinical skills and the opportunity to learn Australian idioms. However, some participants related difficulties created by their unpaid tenure whilst undergoing the program, as well as difficulties in relationships with particular supervising physicians within the program. Discussion: Findings provide insights into a hospital-based educational initiative designed to integrate IMGs into the Australian healthcare system. Conclusions: Responses from participants offer practical insights into the need for, strengths, weaknesses and outcomes of the OP.

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Context: At the University of Sharjah College of Medicine in the United Arab Emirates, clinical faculty are used as simulated patients (FSP) to assess students' communication, history taking and reasoning skills on summative Objective Structured Clinical Examinations (OSCEs). Objectives: The aim of this study is to evaluate student and faculty perceptions of using a faculty member simultaneously as both the simulated patient and the assessor in OSCEs. Methods: Two structured questionnaires were developed. The questionnaires measured, on a five-point Likert scale, the students' and faculty's agreement with statements related to the ability of the FSPs to convince students that they were real patients, to respond to students' questions, and to evaluate students' skills in questioning, communication and clinical reasoning. Responses to items were collapsed into three-point scales (3=Agree/Strongly Agree, 2=Neutral/Uncertain, 1=Disagree/Strongly Disagree). Students' and faculty's responses to the questionnaires' items were summarized and presented in frequencies, percentages and mean scores. Findings: A total of 412 students and 28 FSPs responded to the questionnaires with response rates of 98% and 93%, respectively. The encounter with a FSP was generally found not to be stressful by students and faculty. Students were able to think of the FSP as a real patient and faculty generally felt they were able to assess the students' reasoning processes, communication skills and history taking. The percentage of students who agreed or strongly agreed with the various positively-worded questionnaire items ranged from a lowest of 52% (mean = 2.32) to a highest of 78% (mean = 2.66) and among faculty ranged from a lowest of 61% (mean = 2.54) to a highest of 100% (mean=3.0). Conclusion: Student and faculty perceptions about the simultaneous use of faculty as simulated patients and assessors were generally positive. The results of this study encouraged the program to continue using FSPs on formative and summative OSCE assessments. Further studies are needed to assess its generalizability and application in other contexts.

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Introduction: This article describes the development of a community-based participatory research (CBPR) process conducted in the context of a randomized community health education trial utilizing community health workers (CHWs). Objectives: To present lessons learned from the utilization of CBPR methodology in a cardiovascular disease (CVD) prevention trial among Mexican American adults in a U.S.-Mexico border community and to disseminate the baseline results associated with risk factors for CVD and their associated demographic and psychosocial characteristics. Methods: Participants were 328 Hispanic adults ages 30-75 with at least one risk factor for CVD (overweight, smoking, high cholesterol, diabetic or hypertensive), who were recruited through approaching households in randomly selected census tracts within a specified zip code area. Results: CBPR methods were applied during the different stages of the research enterprise to support the development and implementation of the intervention trial aim at reducing cardiovascular risk factors for Mexican American adults. Data from baseline were used as an important component of dialogue with the community. Discussion: CBPR proved to be a good learning process for all partners involved. The risk profile of the participants demonstrated the "epidemic" nature of CVD morbidity conditions associated with Mexican origin populations living in a U.S.-Mexico border community. The CBPR dialogue was instrumental as a process to help disseminate to the community the need for projects like the one described in this article.

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