impression is that they saw themselves `going it alone',

apart from a few friends who were in the same boat.

These ®ndings have usefully informed the latest set of

curricular developments at our school.

References

Chaput de Saintonge D M, Cushing A & Dunn D (1996) Medical

Teacher 16, 65±9.

Jump L & Dunn D M (1993) Nurse education today 13, 180±8.

DETERMINANTS OF AUTONOMOUS

LEARNING IN UNDERGRADUATES

D M Dunn & D M Chaput de Saintonge

Department of Therapeutics, The London Hospital

Medical College, Turner Street, London E1 2AD, UK

Many medical undergraduate courses aim to develop

and sustain student autonomy. However, there is no

consensus about what this autonomy actually means or

how its contribution to the process of learning might be

measured. We considered two factors which might af-

fect a student's ability and motivation to learn.

1 Self-ef®cacy, which re¯ects the concept that a learner

feels they can control what they do and can set and

continue to attempt to achieve high-level objectives.

Differing levels of self-ef®cacy have been found to in-

¯uence learning and achievement. We measured this

general concept on a multi-item scale adapted to

medical education (Bandura & Wood 1989).

2 A factor relating to students' attribution of causes to

the effects of their actions. These can be classi®ed as

external or internal, stable or transient and global or

speci®c. Students who feel that bad outcomes are

caused by themselves and are global and permanent will

learn helplessness and become depressed. We measured

this using a purpose-designed version of the Attribution

Style Questionnaire (ASQ) (Peterson et al. 1982). This

consists of six positive events, e.g. `A fellow-student

compliments you on your presentation' and six negative

events, e.g. `The registrar fails to attend for scheduled

teaching'. These events were taken from House Of®-

cers' re¯ections on their student experiences.

In this pilot study we explored the following hy-

potheses.

� The experience of self-directed small group learning

can change a student's attribution style.

� Students who have high levels of perceived self-ef-

®cacy will show low levels of helplessness.

� Students' learning will be enhanced by high levels

of perceived self-ef®cacy and low levels of help-

lessness.

Subjects were 10 medical students attached to their

®rst general medical ®rms. Learning on the ®rm was

designed around the students as an emancipatory ac-

tion research group (Kemmis 1985). Psychometric in-

struments were completed before the start of the ®rm

and at the end 8 weeks later. Students completed all

items without dif®culty. Initial results show that our

ASQ scale achieved a reliability of alpha � 0á72 for

both good and bad items compared with Peterson's

estimates of alpha � 0á75 for good and alpha � 0á72

for bad events. Students showed a signi®cant trend to

attributing bad events to internal causes over the course

of the ®rm (P < 0á02). However, there were no changes

in the stable/transient or global/permanent dimensions.

Improvements in perceived ef®cacy were associated

with a perception that bad events were more local

(r � 0á79, P < 0á006) and more transient (r � 0á61,

P < 0á06) than they were at the start of the ®rm. These

results suggests that, whilst students felt themselves

more responsible for bad events, their ability to cope

with them increased as their perceived ef®cacy as

learners increased.

References

Bandura A & Wood R (1989) Journal of Personality and Social

Psychology 56, 805±14.

Kemmis S (1985) Action research and the politics of re¯ection. In

Turning Learning Into Experience (eds D. Boud, R. Kough & D.

Walker). Kogan Page, London.

Peterson C P, Semmel A, Abramson L Y, Metalsky G & 1 Seligman

M E P (1982) Cognitive Therapy and Research 6, 287±99.

CREATING A CURRICULUM

DEVELOPING A CORE CURRICULUM

Anne S Garden & John A Smith Faculty of

Medicine, Duncan Building, Liverpool L69 3BX, UK

The concept of a core curriculum is one which has been

promoted by the General Medical Council (GMC) in

215 MEDICAL EDUCATION 1998, 32, 209±221 Ó 1998 Blackwell Science Ltd

ASME annual meeting 1997 Abstracts

its report `Tomorrow's Doctors' (General Medical

Council 1993, pp. 8±9). Although the concept as dis-

cussed in the GMC document implies a complete in-

tegration of pre-clinical and clinical sciences, in practice

there are two aspects to a medical student's learning ±

the theory which must be adequate as a platform for the

understanding of all aspects of health, and the clinical

conditions with which it is essential for all medical

practitioners to be familiar. In the development of the

new undergraduate medical curriculum in Liverpool,

much consideration has been given to identifying `core'

clinical experience. This core should be relatively nar-

row but supported by a broad scienti®c base allowing

students to apply principles from one disease process to

another.

To identify the core clinical cases, an iterative process

was used. Representatives of hospital specialties were

asked to supply a list of cases which they considered

core for their specialty. The lists obtained were circu-

lated to clinical teachers, both in hospital and general

practice, who were asked to give their opinion on which

cases were truly core. The lists circulated to the hospital

clinical teachers did not include the cases in their own

specialty whereas those sent to the general practitioners

were complete. From these replies, some cases were

removed and the remainder divided into those cases for

which the students only required a theoretical know-

ledge and those which they should be able to diagnose

or manage. The differentiation between diagnosis and

management was whether a pre-registration house of-

®cer would be expected to initiate treatment or to call a

senior or specialist to do so. In line with the GMC's list

of `Attributes of the Independent Practitioner' which

cites a `willingness and ability to deal with common

medical emergencies¼' (General Medical Council

1993, pp. 25±7), we drew up a separate list of life-

threatening emergencies for which all students must be

able to initiate management.

A total of 270 cases were de®ned by specialists as

being `core'. The list was sent to 149 clinicians and a

response received from 51 (34%). Three cases were

universally agreed as core, namely asthma, hyperten-

sion and normal labour! The number of cases excluded

by individual practitioners varied from 0 to 214 (from a

pathologist). The highest number of exclusions from a

general practitioner was 204. There was no real dif-

ference in the cases which received votes for exclusion

between the hospital and general practitioners. On the

basis of this process, we identi®ed 60 cases which stu-

dents should be able to manage, 109 cases which they

should be able to diagnose and 37 further cases of

which they should have a theoretical knowledge. Six

emergency situations were identi®ed.

It is important when developing a new curriculum to

have a sense of ownership among as many as possible of

those who are delivering it. The process described here

not only re®nes the list of core clinical cases but also

helps to give that sense of ownership.

References

General Medical Council (1993) Tomorrow's Doctors. GMC,

London.

INTEGRATED TEACHING ± WHAT DO WE

MEAN? A PROPOSED TAXONOMY

R M Harden Centre for Medical Education, Tay Park

House, 484 Perth Road, Dundee, UK

Educational strategies continue to be a matter of con-

siderable interest and debate in medical education.

Harden et al. (1984) described in the SPICES model

six current trends each of which can be viewed as a

continuum between two extremes. One such trend is

the move from discipline-based teaching to integrated

teaching. The importance of this is emphasized in the

General Medical Council's document `Tomorrow's

Doctors' (GMC 1993).

In the debate about the advantages and disadvantages

of integrated teaching there is a danger of polarization,

with those in favour looking at the bene®ts and those

resisting a change considering the disadvantages. The

question to be asked is not whether one is for or against

integration, but rather where in the continuum between

the two extremes would one place one's own teaching.

Various terms have been used to describe integra-

tion and the intermediate steps between the two ex-

tremes. This paper described a taxonomy for inte-

grated teaching, building on previous descriptions of

integrated curricula notably the work of Jacobs

(1989), Foggarty (1991) and Drake (1993) Eleven

steps are proposed.

1 Isolation ± the teacher is unaware of what is taught or

learned in other subjects.

2 Awareness ± the teacher is familiar with the content

of other courses.

3 Harmonization ± there is discussion, for example in a

curriculum committee, about what is being taught.

4 Nesting ± within his or her own subject the teacher

includes generic skills and other disciplines.

216 MEDICAL EDUCATION 1998, 32, 209±221 Ó 1998 Blackwell Science Ltd

ASME annual meeting 1997 Abstracts