Background: Medical students feel a significant amount of stress due to a variety of factors. Few studies have explored the relative size of these various stressors to identify which are most important. This study was undertaken to quantify the magnitude of various sources of stress among students of a medical college at Kolkata, West Bengal, and also to assess the reliability of Medical Students' Stressor Questionnaire (MSSQ-40) in this context. Methods: We evaluated the degree of stress along various dimensions using the MSSQ-40, a scale to measure stress among medical students that has been validated in other countries. Differences in stress and its causal factors were analyzed across demographic subgroups. The reliability of the MSSQ-40 was evaluated using Cronbach's alpha. Results: The overall prevalence of stress was 91.1% and the vast majority of students (94.9%) were stressed due to academic reasons. Academic related stress was found to be higher among students who are not conversant with the local language, experienced a change in medium of teaching from secondary school to medical school, and resided in a hostel. The MSSQ-40 in general, and its academic-related stress domain specifically, were found to be reliable in our setting. Discussion: Early detection and remedying stressors will help to build physical and mental health in medical students. Language training early during the medical course might reduce academic stress among our students. Further studies should relate individuals' stress with their academic performance.

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Background: There has been a worldwide movement toward competency-based medical education and training. However, this is the first qualitative study to analyze the perceptions of surgical trainees and surgeons toward competency-based education in the operating theatre. We aim to examine views toward the specific learning and teaching of the nine competencies of the Royal Australasian College of Surgeons (RACS) and to explore perceived ideal conditions and challenges for learning and teaching these competencies in the operating theatre. Methods: Individual semi-structured interviews with surgical trainees and surgeons in the specialty of General Surgery. Ten surgical trainees and surgeons who worked together were purposively sampled, for maximum variation, from an outer metropolitan public hospital in Melbourne, Australia, to identify emergent themes relating to learning and teaching surgical competencies in the operating theatre. Results: Five themes were identified as: (1) Learning and teaching specific surgical competencies is through relationship based mentoring and experiential learning; (2) Ideal conditions and challenges in the operating theatre are availability of time and personal attitude; (3) Level of pre-operative briefing was variable; (4) Intra-operative teaching is perceived as structured; and, (5) Post-operative debriefing is recognized as ideal but not consistently performed. Discussion: Professional relationships are important to both surgical trainees and surgeons in the process of learning and teaching competencies. Ad hoc apprenticeship style learning is perceived to remain prominent in the operating theatre. Sufficient time for training is valued by both groups. The surgical competencies are inherently different to each other. Some appear more difficult to learn and teach in the operating theatre, with technical expertise most readily identified and health advocacy least so. Elements of guided discovery learning and other educational models are described. Further emphasis on structured competency-based teaching methods may be beneficial for surgical trainees, surgeons and other specialties, both in Australia and worldwide.

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Background: Simulation-based interprofessional team training is thought to improve patient care. Participating teams often consist of both experienced providers and trainees, which likely impacts team dynamics, particularly when a resident leads the team. Although similar team composition is found in real-life, debriefing after simulations puts a spotlight on team interactions and in particular on residents in the role of team leader. The goal of the current study was to explore residents' perceptions of simulation-based interprofessional team training. Methods: This was a secondary analysis of a study of residents in the pediatric residency training program at the University of California, San Francisco (United States) leading interprofessional teams in simulated resuscitations, followed by facilitated debriefing. Residents participated in individual, semi-structured, audio-recorded interviews within one month of the simulation. The original study aimed to examine residents' self-assessment of leadership skills, and during analysis we encountered numerous comments regarding the interprofessional nature of the simulation training. We therefore performed a secondary analysis of the interview transcripts. We followed an iterative process to create a coding scheme, and used interprofessional learning and practice as sensitizing concepts to extract relevant themes. Results: 16 residents participated in the study. Residents felt that simulated resuscitations were helpful but anxiety provoking, largely due to interprofessional dynamics. They embraced the interprofessional training opportunity and appreciated hearing other healthcare providers' perspectives, but questioned the value of interprofessional debriefing. They identified the need to maintain positive relationships with colleagues in light of the teams' complex hierarchy as a barrier to candid feedback. Discussion: Pediatric residents in our study appreciated the opportunity to participate in interprofessional team training but were conflicted about the value of feedback and debriefing in this setting. These data indicate that the optimal approach to such interprofessional education activities deserves further study.

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Background: The increasing cost and inequitable access to quality healthcare, coupled with the merger of the information technology and health service sectors, has given rise to the modern field of telemedicine. Telemedicine, meaning medicine at a distance, allows us to transcend geographic and socioeconomic boundaries to deliver high quality care to remote and/or in-need patients. As technology becomes more affordable and a physician shortage looms, telemedicine is gaining attention as a possible solution to healthcare delivery. Simultaneously, telemedicine holds great promise with regard to medical education. Several studies integrating telemedicine in medical education have shown positive outcomes, demonstrating similar or greater efficacy compared with traditional educational methods with high student-reported enthusiasm. Other domestic and international telemedicine projects, largely spearheaded by universities, have also achieved great success. Discussion: In a novel approach, by pairing medical schools with in-need partner communities, utilizing similar faculty resources as traditional learning methods with standardized patients, students can gain valuable experience and skills while serving actual patients. This progressive approach to medical education fosters collaboration, communication, longitudinal care and teaches students needed skills for their future practices as 21 ^st Century healthcare providers.

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Background: The purpose of this manuscript is to present a newly instituted program for resident scholarly activity that includes a curriculum designed to enhance resident training with regard to research while meeting requirements established by the Accreditation Council for Graduate Medical Education (ACGME), the governing body responsible for regulation of post-graduate medical education and training in the United States. Methods: A scholarly activity program was designed with the following goals: (i) enhance the academic training environment for our residents; (ii) foster interests in research and academic career paths; (iii) provide basic education on research methodology and presentation skills. To guide program design, an electronic survey was created and distributed to the residents and faculty in the Department of Radiology and Radiological Sciences at the Medical University of South Carolina (MUSC), a 750-bed public teaching hospital in the state of South Carolina in the United States. Results: Survey respondents were in strong support of a required resident scholarly activity project (70% in favor), felt non-traditional projects were valuable (84.1% of respondents), and were proponents of required scholarly activity summary presentations (58%). This program requires that residents engage in a scholarly activity project under the guidance of a mentor. Resident success is maximized through in-house education initiatives focusing on presentation and research skills, protected time to work on the project, and oversight by a radiology research committee. All residents present a summary of their work near the end of their residency training. Discussion: Changes to the radiology resident certification process create an opportunity for incorporating new policies aimed at enhancing resident education. The scholarly activity program outlined in this manuscript is one such initiative designed to meet ACGME requirements, provide an introduction to research, and establish a scholarly activity project requirement.

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Background: Practice of family medicine and patient centeredness does not get the deserved attention in clinical practice and teaching in Sri Lanka. Non-availability of tools for assessment of patient centeredness deters the process of curricular development and research. The Patient-Practitioner Orientation Scale (PPOS) is a self-administered tool that assesses patient-centeredness in both health care professionals and patients. This study has translated and validated the PPOS to Sinhala language. Methods: Translation and cross-cultural adaptation were carried out using forward and backward translation method. The psychometric properties of a pretested new Sinhala version of PPOS (PPOS-Sinhala) was tested in a convenience sample of 1367 patients and health professionals. Temporal stability was tested in a sub-sample of 140 individuals. The comparability of the PPOS scores and association with sex and level of education with those reported for Western populations were examined to establish construct validity. Results: The sample included 543 medical students, 67 doctors, 335 allied health students and 422 patients. Cronbach's alpha for these groups ranged from 0.48 to 0.53 for sharing, 0.42 to 0.53 for caring, and 0.62 to 0.65 for total score. Intraclass correlation coefficients of 0.56, 0.6, and 0.4 were observed for the Total, Sharing, and Caring sub-scales, respectively. PPOS scores did not vary significantly for men and women. Health professionals exhibited higher scores than patients. Age was negatively associated and education level was positively associated with PPOS. Discussion: PPOS-Sinhala is stable, sufficiently valid and reliable to evaluate patient centeredness among Sinhala speaking health care professionals and patients. Lower internal consistency is found for a few items in the instrument which requires further development. PPOS scores and their correlates for this Sri Lankan population were more similar to that found in other populations in this region than for scores and correlates found in the US.

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Background: The medical faculty of Ulm University has launched the postgraduate master online study programme Advanced Oncology (AO) in 2010. We describe the challenges in developing an e-learning module using the example of a medical biometry course, focusing the implementation of the course material and our single-loop learning experience after the first students have finished and evaluated the lecture. Methods: Programme participants are qualified medical doctors and researchers in biomedical areas related to the field of oncology. The study programme provides the majority of lectures online via didactic videos accompanied by one-week attendance seminars. Supplementary learning materials include review articles, supportive reading material, multiple choice questions, and exercises for each unit. Lecture evaluations based on specific questions concerning learning environment and information learned, each measured on a five-point Likert scale. Results: Lecture videos were implemented following the classical triad of the didactic process, using oncological examples from practice to teach. The online tutorial support offered to students was hardly used, thus we enhanced faculty presence during the face-to-face seminars. Lecture evaluations improved after revising the learning material on the basis of the first AO student cohort's comments. Discussion: Developing and implementing an online study programme is challenging with respect of maximizing the information students learn due to limited opportunities for personal contact between lecturers and students. A more direct interaction of lecturers and students in a blended learning setting outperforms a mere web-based contact in terms of learning advantage and students' satisfaction, especially for complex methodological content.

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Students who actively participate in the evaluation of their undergraduate medical curriculum become important stakeholders in decisions related to the design of the school's curriculum. Research and reports on student participation in curriculum change are scarce, and not much is known about how students personally benefit. We describe the structure and activities of engaging students in designing and improving the curriculum at the Faculty of Medicine and Health Sciences of Ghent University (Belgium). We present an example of a major curriculum change led by students, and we assess the perceptions of the students on how engagement in student curriculum committees strengthened their leadership skills. We encourage students at other schools to become active participants in the curriculum design and improvement processes of their institutions as a way to improve medical education.

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Interprofessional education (IPE) is increasingly recognized as a means to improve practice in health and social care. However, to secure interprofessional learning, it is important to create occasions in prelicensure health and social services curriculum so that students can learn with, from and about each other. This paper presents the process behind the development and implementation of an IPE curriculum in 10 health and social sciences programs by a team of professors from the faculties of medicine, nursing sciences and social sciences at Université Laval in the province of Québec, Canada. The pedagogical approach, description of primary objectives and issues related to its implementation in the curriculum programs are also described and discussed.

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Background: Research is critical to the training and practice of surgery and anesthesia in all settings, regardless of available resources. Unfortunately, the output of surgical and perioperative research from Africa is low. Makerere University College of Health Sciences' (MakCHS) surgical and anesthesia trainees are required to conduct research, though few publish findings or go on to pursue careers that incorporate research. We believe that early career experiences with research may greatly influence physicians' future conduct and utilization of research. We therefore sought to analyze trainee experiences and perceptions of research to identify interventions that could increase production of high-quality, locally led, surgical disease research in our resource-constrained setting. Methods: Following ethical approval, a descriptive, cross-sectional survey was conducted among anesthesia and surgery trainees using a pretested, self-administered questionnaire. Data were tabulated and frequency tables generated. Results: Of the 43 eligible trainees, 33 (77%) responded. Ninety-four percent identify research as important to career development, and 85% intend to publish their dissertations. The research dissertation is considered a financial burden by 64%. Also, 49% reported that their departments place low value on their research, and few of the findings are utilized. Trainees report that lack of protected research time, difficulty in finding research topics, and inadequate mentorship are the main challenges to conducting research projects. Discussion: Our anesthesia and surgery trainees spend considerable resources on research endeavors. Most have significant interest in incorporating research into their careers, and most intend to publish their work in peer-reviewed journals. Here we identify several challenges facing trainees including research project development, financing and mentorship. We hope to use these results to improve support in these areas for our trainees and those in other resource-limited areas.

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Background: Current teaching in pharmacology in undergraduate medical curriculum in India is primarily drug centered and stresses imparting factual knowledge rather than on pharmacotherapeutic skills. These skills would be better developed through active learning by the students. Hence modules that will encourage active learning were developed and compared with traditional methods within the Seth GS Medical College, Mumbai. Methods: After Institutional Review Board approval, 90 second year undergraduate medical students who consented were randomized into six sub-groups, each with 15 students. Pre-test was administered. The three sub-groups were taught a topic using active learning modules (active learning groups), which included problems on case scenarios, critical appraisal of prescriptions and drug identification. The remaining three sub-groups were taught the same topic in a conventional tutorial mode (tutorial learning groups). There was crossover for the second topic. Performance was assessed using post-test. Questionnaires with Likert-scaled items were used to assess feedback on teaching technique, student interaction and group dynamics. Results: The active and tutorial learning groups differed significantly in their post-test scores (11.3 ± 1.9 and 15.9 ± 2.7, respectively, P < 0.05). In students' feedback, 69/90 students had perceived the active learning session as interactive (vs. 37/90 students in tutorial group) and enhanced their understanding vs. 56/90 in tutorial group), aroused intellectual curiosity (47/90 students of active learning group vs. 30/90 in tutorial group) and provoked self-learning (41/90 active learning group vs. 14/90 in tutorial group). Sixty-four students in the active learning group felt that questioning each other helped in understanding the topic, which was the experience of 25/90 students in tutorial group. Nevertheless, students (55/90) preferred tutorial mode of learning to help them score better in their examinations. Discussion: In this study, students preferred an active learning environment, though to pass examinations, they preferred the tutorial mode of teaching. Further efforts are required to explore the effects on learning of introducing similar modules for other topics.

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Background: As per the present curriculum in India, pre- and paraclinical subjects are taught away from the clinical setting. Therefore, students fail to connect the subject taught through didactic lectures to the clinical setting. Team-based learning (TBL) can be used in conjunction with lectures to teach applied microbiology. This study aims to evaluate the effectiveness of TBL sessions in conjunction with lectures to enhance learning of applied microbiology, among Indian students. Methods: All students enrolled in the study were taught systemic bacteriology through lectures. Of the 88 students, 49 students (study group) attended TBL sessions on the topics of diarrhea, fever of unknown origin, urinary tract infection and 39 students (control group) preferred self-study on the topics without attending the TBL sessions. Students' feedback on their perception on TBL sessions was collected using a questionnaire of 10 items. The performance of both the groups on the pre- and post-test were analyzed using unpaired t-test and analysis of variance (ANOVA). Gender-wise performance within the teams was analyzed by paired t-test using SPSS version 12. Results : The TBL group outperformed the self-study group on the post-test [F ₁ = 5.521, P = 0.021]. Female students as a whole performed better than males on the pre-test, scoring higher within both the TBL and self-study groups. Male students in the TBL group performed significantly better on the post-test than female students who participated in TBL sessions (P = 0.013). Students generally enjoyed and appreciated the TBL sessions. Discussion : TBL sessions can be used judiciously in combination with the lectures to enhance learning of applied microbiology in India. In this study, TBL improved the performance of male students over self-study, but performance for female students following TBL was no better than when they simply studied by themselves.

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Background: Understanding concepts of molecular mechanisms of drug action involves sequential visualization of physiological processes and drug effects, a task that can be difficult at an undergraduate level. Role-play is a teaching-learning methodology whereby active participation of students as well as clear visualization of the phenomenon is used to convey complex physiological concepts. However, its use in teaching drug action, a process that demands understanding of a second level of complexity over the physiological process, has not been investigated. We hypothesized that role-play can be an effective and well accepted method for teaching molecular pharmacology. Methods: In an observational study, students were guided to perform a role-play on a selected topic involving drug activity. Students' gain in knowledge was assessed comparing validated pre- and post-test questionnaires as well as class average normalized gain. The acceptance of role-play among undergraduate medical students was evaluated by Likert scale analysis and thematic analysis of their open-ended written responses. Results: Significant improvement in knowledge (P < 0.001) was noted in the pre- to post-test knowledge scores, while a high gain in class average normalized score was evident. In Likert scale analysis, most students (93%) expressed that role-play was an acceptable way of teaching. In a thematic analysis, themes of both strengths and weaknesses of the session emerged. Discussion: Role-play can be effectively utilized while teaching selected topics of molecular pharmacology in undergraduate medical curricula.

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Background: It is common knowledge that patients seek treatment for psychiatric illnesses from various sources including the alternative medicine. Views and attitudes of clinicians often influence the provision of appropriate mental health care for these patients. In this context, it was intended to study the views of the practitioners of alternative medicine toward psychiatric disorders, patients and interventions. Methods: The study was conducted as a questionnaire-based survey among a sample of practitioners of alternative medicine specifically Ayurveda and Homeopathy, who were practicing in Solapur and adjoining areas of Maharashtra and Karnataka states in India. A semi-structured Attitudinal Inventory for Psychiatry questionnaire was used. Demographic and professional data were collected. Results: Out of 62 practitioners approached, 50 responded (80.6%). There were no significant differences in the views of practitioners toward psychiatry and psychiatrists based on respondents' gender, place of residence, location of practice, type of alternative medicine, exposure to psychiatric patients, or if they knew someone with psychiatric illness. Attitudes were generally positive, but variable. Among negative observations were that approximately 60% of respondents felt that a patient can be disadvantaged by being given a psychiatric label and 58% believed that emotions are difficult to handle. A considerable proportion (40%) of the respondents felt doctors other than psychiatrists were unable to identify psychiatric disorders. Discussion: This study's findings suggest that practitioners of alternative medicine have mixed views about mental illness, patients and treatment. Some of their negative views and perceived inability to identify psychiatric disorders may be addressed through further training, information sharing and collaborative work.

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Background: In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model's collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training. Discussion: Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.

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Background: Body image is an important aspect of the complex creation of one's self-identity. The relationship between nutritional disorders, like obesity, and one's perception of her or his body is well documented. Obesity among medical students and health personnel is on the rise. Identifying and measuring the magnitude of distortion in body image self-perception among medical students is particularly relevant, as they are future healthcare providers. This paper assesses self-perceptions of body mass index (BMI) and physical activity among medical undergraduate students in an Indian medical school. Methods: A cross-sectional study was conducted among 161 sixth semester medical undergraduate students in a school in Delhi, India. A pretested questionnaire was used. Anthropometric measurements were taken. The participation rate was 93.6%. Results: Out of the total 161 students, there were 60.9% males and 39.1% females. Most participants were classified as normal (55.9%) according to BMI. The proportions of actual obese, overweight and underweight students were 4.4%, 30.4% and 9.3%, respectively. However, the proportion of students perceiving themselves as obese or overweight was only 37.3%. A significantly higher proportion of females (57.2%) than males (20.4%) perceived themselves as overweight (P < 0.001). The agreement between actual BMI and perceived weight was poor (kappa statistic: 0.33). Among actual overweight and obese students, only one-third were physically active. Conclusions: Students who were overweight or obese often failed to perceive themselves as such and, perhaps consequently, were not engaging in weight control practices. There is a need to develop health promotion interventions that help build healthy body habitus perceptions among this group of Indian medical students.

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Background: In 2010, the Medical Council of India published the Vision 2015 document, which sought to create an 'Indian Medical Graduate' as a 'physician of first contact of the community while being globally relevant'. This vision for undergraduate medical education is proposed to be realised through a competency-based curriculum. We conducted a gap analysis using a cross-sectional survey to document surgeons' perceptions regarding competencies identified in surgery. Methods: Eight competencies specific to surgery are proposed, which formed the basis for the study. We defined sub-competencies for each of these and developed a questionnaire containing ratings of importance and ability for the sub-competencies from low to very high on a 4-point Likert scale. The questionnaire was administered to 450 surgeons attending a state-level annual conference in surgery asking them to provide the importance ratings and their own ability on those (sub) competencies when they graduated. The importance and ability ratings were ranked and a gap analysis was done. Results: The study response rate was 69.8%. While most competencies were perceived by the surgeons as being highly important, their self-ratings revealed a statistically significant gap between importance and ability when they graduated. They also rated themselves as being more competent on some than on others. Some competencies were high on importance as well as on ability, while others were high on importance but low on ability, revealing a gap. A low importance-high ability relationship was seen for a few competencies. Competencies related to emergency and trauma care and communication had the largest gaps. Discussion: The gaps identified in surgical competencies for graduating physicians are specific and have implications for the competency-based curriculum and implementation in terms of teaching, assessment and faculty development. It also has implications for seamless transition between undergraduate and postgraduate competencies, as all of these are prerequisites at the start of a surgical residency.

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Background: Small group sessions are regarded as a more active and student-centered approach to learning. Item analysis provides objective evidence of whether such sessions improve comprehension and make the topic easier for students, in addition to assessing the relative benefit of the sessions to good versus poor performers. Self-assessment makes students aware of their deficiencies. Small group sessions can also help students develop the ability to self-assess. This study was carried out to assess the effect of small group sessions on item analysis and students' self-assessment. Methods: A total of 21 female and 29 male first year medical students participated in a small group session on topics covered by didactic lectures two weeks earlier. It was preceded and followed by two multiple choice question (MCQ) tests, in which students were asked to self-assess their likely score. The MCQs used were item analyzed in a previous group and were chosen of matching difficulty and discriminatory indices for the pre- and post-tests. Results: The small group session improved the marks of both genders equally, but female performance was better. The session made the items easier; increasing the difficulty index significantly but there was no significant alteration in the discriminatory index. There was overestimation in the self-assessment of both genders, but male overestimation was greater. The session improved the self-assessment of students in terms of expected marks and expectation of passing. Discussion: Small group session improved the ability of students to self-assess their knowledge and increased the difficulty index of items reflecting students' better performance.

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Background: Residents are being increasingly challenged on how best to integrate diagnostic information in making decisions about patient care. The aim of this study is to assess the ability of residents to accurately integrate statistical data from a screening mammography test in order to estimate breast cancer probability and to investigate whether a simple alteration of the representation mode of probabilities into natural frequencies facilitates these computations. Methods: A multi-institutional randomized controlled study of residents was performed in eight major hospitals in the city of Athens. Residents were asked to estimate the positive predictive value of the screening mammography test given its sensitivity and 1-specificity as well as the prevalence of breast cancer in the relevant population. One version of the scenario was presented in the single-event probability format that is commonly used in the medical literature, while the other used the natural frequency representation. The two questionnaire versions were randomly assigned to the participants. Results: Out of 200 residents, 153 completed and returned the questionnaire (response rate 76.5%). Although more than one-third of the residents reported excellent or close to excellent familiarity with sensitivity and positive predictive value, the majority of responses (79.1%) were incorrect. However, a significantly higher proportion of residents in the natural frequency group (n = 88) selected the correct response compared with residents (n = 65) in the single-event probability group (28.4% vs 10.8%; 95% confidence intervals of the difference between the two proportions = 5.6-29.7%; P < 0.01). Discussion: Residents more often correctly understand test performance accuracy when test characteristics are presented to them as natural frequency representations than the more common approach of presenting single event probabilities. Educators and journal editors should be aware of this facilitative effect.

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