Context  Medical educators internationally are faced with the challenge of teaching and assessing professionalism in their students. Some studies have drawn attention to contextual factors that influence students’ responses to professional dilemmas. Although culture is a significant contextual factor, no research has examined student responses to professional dilemmas across different cultures.

Methods  Semi-structured interviews inquiring into reactions towards, and reasoning about, five video clips depicting students facing professional dilemmas were conducted with 24 final-year medical students in Taiwan. The interviews were transcribed and analysed according to the theoretical framework used in prior Canadian studies using the same videos and interview questions.

Results  The framework from previous Canadian research, including the components of principles, affect and implications, was generally applicable to the decision making of Taiwanese students, with some distinctions. Taiwanese students cited a few more avowed principles. Taiwanese students emphasised an additional unavowed principle that pertained to following the advice of more senior trainees. In addition to implications for patients, team members or themselves, Taiwanese students considered the impact of their responses on multiple relationships, including those with patients’ families and alumni residents. Cultural norms were also cited by Taiwanese students.

Conclusions  Medical educators must acknowledge students’ reasoning in professionally challenging situations and guide students to balance considerations of principles, implications, affects and cultural norms. The prominence of Confucian relationalism in this study, exhibited by students’ considerations of the rippling effects of their behaviours on all their social relationships, calls for further cross-cultural studies on medical professionalism to move the field beyond a Western individualist focus.

Context  Over the last two decades, many medical educators have sought to define professionalism. Initial attempts to do so were focused on defining professionalism in a manner that allowed for universal agreement. This quest was later transformed into an effort to ‘understand professionalism’ as many researchers realised that professionalism is a social construct and is culture-sensitive. The determination of cultural differences in the understanding of professionalism, however, has been subject to very little research, possibly because of the practical difficulties of doing so. In this multi-region study, we illustrate the universal and culture-specific aspects of medical professionalism as it is perceived by medical practitioners.

Methods  Forty-six professional attributes were identified by reviewing the literature. A total of 584 medical practitioners, representing the UK, Europe, North America and Asia, participated in a survey in which they indicated the importance of each of these attributes. We determined the ‘essentialness’ of each attribute in different geographic regions using the content validity index, supplemented with kappa statistics.

Results  With acceptable levels of consensus, all regional groups identified 29 attributes as ‘essential’, thereby indicating the universality of these professional attributes, and six attributes as non-essential. The essentialness of the rest varied by regional group.

Conclusions  This study has helped to identify regional similarities and dissimilarities in understandings of professionalism, most of which can be explained by cultural differences in line with the theories of cultural dimensions and cultural value. However, certain dissonances among regions may well be attributable to socio-economic factors. Some of the responses appear to be counter-cultural and demonstrate practitioners’ keenness to overcome cultural barriers in order to provide better patient care.

Objectives  We reviewed papers describing the development of instruments for assessing clinical communication in undergraduate medical students. The instruments had important limitations: most lacked a theoretical basis, and their psychometric properties were often poor or inadequately investigated and reported. We therefore describe the development of a new instrument, the Liverpool Undergraduate Communication Assessment Scale (LUCAS), which is intended to overcome some of these limitations. We designed LUCAS to reflect the theory that communication is contextually dependent, inherently creative and cannot be fully described within a conceptual framework of discrete skills.

Methods  We investigated the preliminary psychometric properties of LUCAS in two studies. To assess construct and external validity, we examined correlations between examiners’ LUCAS ratings and simulated patients’ ratings of their relationships with students in Year 1 formative (n = 384) and summative (n = 347) objective structured clinical examination (OSCE) samples. Item–total correlations and item difficulty analyses were also performed. The dimensionality of LUCAS was examined by confirmatory factor analysis. We also assessed inter-rater reliability; four raters used LUCAS to rate 40 video-recorded encounters between Year 1 students and simulated patients.

Results  Simulated patient ratings correlated with examiner ratings across two OSCE datasets. All items correlated with the total score. Item difficulty showed LUCAS was able to discriminate between student performances. LUCAS had a two-dimensional factor structure: we labelled Factor 1 creative communication and Factor 2 procedural communication. The intraclass correlation coefficient was 0.73 (95% confidence interval 0.54–0.85), indicating acceptable reliability.

Conclusions  We designed LUCAS to move the primary focus of examiners away from an assessment of students’ enactment of behavioural skills to a judgement of how well students’ communication met patients’ needs. LUCAS demonstrated adequate reliability and validity. The instrument can be administered easily and efficiently and is therefore suitable for use in medical school examinations.

Context  Assessment centres used in evaluating the non-cognitive attributes of medical school candidates must generate scores that reflect as accurate a measurement as possible of these attributes. Thus far, reliability coefficients for such centres have been based on limited samples and individual administrations, without reference to the error of variance that may result from retesting, or from the existence of multiple centres designed to measure the same attributes.

Methods  The National Institute for Testing and Evaluation in Israel has developed and administered two assessment centres: MOR is used by two medical schools and one dental school, and MIRKAM by another medical school. Each centre comprises eight or nine behavioural stations, a standardised biographical questionnaire, and a judgement and decision-making questionnaire. We calculated generalisability coefficients for each centre’s eight or nine stations by year, composite reliability coefficients for the overall assessment centres, test–retest correlation coefficients for repeaters, and a correlation coefficient between the centres.

Results  Between 2006 and 2009, 2662 and 2023 examinees participated in MOR and MIRKAM, respectively; 1479 of these participated in both. The average generalisability coefficients for the stations were 0.69 for MOR and 0.67 for MIRKAM. The composite reliability coefficients for the full centres (behavioural stations plus questionnaires) were 0.79 and 0.76 for MOR and MIRKAM, respectively. The correlations for repeaters, corrected for restriction of range, were 0.59 and 0.43 for MOR and MIRKAM stations, respectively, and 0.72 and 0.65 for the full MOR and MIRKAM assessments, respectively. The correlation between scores on the MOR and MIRKAM stations was 0.56 (0.75 for the overall score).

Discussion  The minimal reliability desirable for high-stakes decision making (0.80) was obtained only for 14 or 15 stations with questionnaires. Nevertheless, the values obtained are considerably higher than reliability coefficients for single interviews. The questionnaires contribute significantly to the accuracy of the measurement. These reliability measures constitute an upper threshold for measures of validity.

Objectives  Using a large image bank, we systematically examined how the use of different ratios of abnormal to normal cases affects trainee learning.

Methods  This was a prospective, double-blind, randomised, three-arm education trial conducted in six academic training programmes for emergency medicine and paediatric residents in post-licensure years 2–5. We developed a paediatric ankle trauma radiograph case bank. From this bank, we constructed three different 50-case training sets, which varied in their proportions of abnormal cases (30%, 50%, 70%). Levels of difficulty and diagnoses were similar across sets. We randomly assigned residents to complete one of the training sets. Users classified each case as normal or abnormal, specifying the locations of any abnormalities. They received immediate feedback. All participants completed the same 20-case post-test in which 40% of cases were abnormal. We determined participant sensitivity, specificity, likelihood ratio and signal detection parameters.

Results  A total of 100 residents completed the study. The groups did not differ in accuracy on the post-test (p = 0.20). However, they showed considerable variation in their sensitivity–specificity trade-off. The group that received a training set with a high proportion of abnormal cases achieved the best sensitivity (0.69, standard deviation [SD] = 0.24), whereas the groups that received training sets with medium and low proportions of abnormal cases demonstrated sensitivities of 0.63 (SD = 0.21) and 0.51 (SD = 0.24), respectively (p < 0.01). Conversely, the group with a low proportion of abnormal cases demonstrated the best specificity (0.83, SD = 0.10) compared with the groups with medium (0.70, SD = 0.15) and high (0.66, SD = 0.17) proportions of abnormal cases (p < 0.001). The group with a low proportion of abnormal cases had the highest false negative rate and missed fractures one-third more often than the groups that trained on higher proportions of abnormal cases.

Conclusions  Manipulating the ratio of abnormal to normal cases in learning banks can have important educational implications.

Context  Retroactive interference occurs when newly acquired information inhibits recall of previously learned information. This has been shown to influence recall of sounds, tastes and word associations, and is typically seen when learners receive training on one area of content and are then exposed to new content before being evaluated on the original content. Thus far, retroactive interference has received little attention in medical education and has not been studied during simulation training. Our objective was to evaluate whether retroactive interference occurs during simulation training.

Methods  We randomised 167 Year 1 medical students to one of two training protocols. After training on a cardiac murmur, participants were tested either on the same cardiac murmur followed by a novel murmur (the non-interference protocol), or on the novel murmur followed by the training murmur (the interference protocol). We evaluated performance on both murmurs at 1 hour and 6 weeks post-training.

Results  We found a significant interaction between training protocol and diagnostic performance on training versus novel murmurs at both testing time-points. Students in the non-interference protocol had increased odds of achieving success on the training murmur relative to the novel murmur at 1 hour (odds ratio [OR] 4.96; p < 0.001) and at 6 weeks (OR 4.23; p = 0.001) after training. By comparison, students in the interference protocol did not demonstrate improved performance on the training murmur relative to the novel murmur at either evaluation (1 hour post-training: OR 0.56 [p = 0.08]; 6 weeks post-training: OR 0.66 [p = 0.23]).

Conclusions  Consistent with the theory of retroactive interference, students who encountered a novel murmur between training and evaluation on the murmur on which they had been trained showed no improvement in diagnostic performance following simulation training. These findings should serve to warn educators to consider retroactive interference when designing simulation training sessions.

Context  Empathy towards patients is associated with improved health outcomes. However, quantitative studies using self-reported data have not provided an in-depth opportunity to explore the lived experiences of medical students concerning empathy.

Objectives  This study was designed to investigate undergraduate medical students’ experiences of the phenomenon of empathy during the course of their medical education and to explore the essence of their empathy.

Methods  This was a descriptive, phenomenological study of medical student interviews conducted using the method of Colaizzi and Giorgi. The sample (n = 10) was drawn from medical students in Years 4 and 5. In-depth interviews were used to obtain a clear understanding of their experiences of empathy in the context of patient care. Interviews continued until no new information could be identified from transcripts.

Results  Five themes were identified from analysis: the meaning of empathy; willingness to empathise; innate empathic ability; empathy decline or enhancement, and empathy education. Empathic ability was manifested through two factors: innate capacity for empathy, and barriers to displaying empathy. Different experiences and explanations concerning the decline or enhancement of empathy during medical education were explored.

Conclusions  Empathic ability was identified as an important innate attribute which nevertheless can be enhanced by educational interventions. Barriers to the expression of empathy with patients were identified. Role-modelling by clinical teachers was seen as the most important influence on empathy education for students engaged in experiential learning.

Objectives  This study aimed to examine concepts of altruism and empathy among medical students and professionals in conjunction with health care initiatives designed to support the maintenance of these qualities.

Methods  We searched for the terms ‘altruism’, ‘altruistic’, ‘helping’, ‘prosocial behaviour’ and ‘empathy’ in the English-language literature published from 1980 to the present within the Ovid MEDLINE, PsycInfo and PubMed databases. We used conceptual analysis to examine the relationships among altruism, empathy and related prosocial concepts in health care in order to understand how such factors may relate to emotional and career burnout, cynicism, decreased helping and decreased patient-centredness in care.

Results  Altruistic ideals and qualities of empathy appear to decrease among some medical students as they progress through their education. During this process, students face increasingly heavy workloads, deal with strenuous demands and become more acquainted with non-humanistic informal practices inherent in the culture of medicine. In combination, these factors increase the likelihood that emotional suppression, detachment from patients, burnout and other negative consequences may result, perhaps as a means of self-preservation. Alternatively, by making a mindful and intentional choice to endeavour for self-care and a healthy work–life balance, medical students can uphold humanistic and prosocial attitudes and behaviours.

Conclusions  Promoting altruism in the context of a compensated health care career is contradictory and misguided. Instead, an approach to clinical care that is prosocial and empathic is recommended. Training in mindfulness, self-reflection and emotion skills may help medical students and professionals to recognise, regulate and behaviourally demonstrate empathy within clinical and professional encounters. However, health care initiatives to increase empathy and other humanistic qualities will be limited unless more practical and feasible emotion skills training is offered to and accepted by medical students. Success will be further moderated by the culture of medicine’s full acceptance of empathy and humanism into its customs, beliefs, values, interactions and daily practices.

Context  The inadequacy of self-assessment as a mechanism to guide performance improvements has placed greater emphasis on the value of testing as a pedagogic strategy. The mechanism whereby testing influences learning is incompletely understood. This study was performed to examine which aspects of a testing experience most influence self-regulated learning behaviour among medical students.

Methods  Sixty-seven medical students participated in a computer-based, multiple-choice test. Initially, participants were instructed to attempt only items for which they felt confident of their response. They were then asked to indicate their best responses to deferred items. Students were then given an opportunity to review the items, with correct responses indicated. Accuracy, the attempt/defer decision and the time taken to reach this decision were recorded, along with participants’ ratings of their confidence in each response and the time spent reviewing each item on completion of the test.

Results  Students correctly answered a larger proportion of attempted items than deferred items (71% versus 40%; p < 0.001), and indicated a higher mean confidence in responses to items they answered correctly compared with items they answered incorrectly (70 versus 46; p < 0.001). They spent longer reviewing items they had answered incorrectly than correctly (8.3 versus 4.0 seconds; p < 0.001), and paid particular attention to items for which the attempt/defer decision and accuracy were discordant (p < 0.01). The amount of time required to make a decision on whether or not to answer a test question was also related to reviewing time.

Conclusions  Medical students showed a robust ability to accurately and consciously self-monitor their likelihood of success on multiple-choice test items. By focusing their subsequent self-regulated learning on areas in which performance and self-monitoring judgements were misaligned, participants reinforced the importance of providing learners with opportunities to discover the limits of their ability and further elucidated the mechanism through which test-enhanced learning might be derived.