Medical Teacher, Vol. 19, No. 1, 1997

The preclinical eye: do senior medical students know what is normal?

ALBERT J. J. A. SCHERPBIER’, VIJAYA FABER’ & JET YSPEERT-GERARDS’ ‘Skillslab, University of Maastricht, The Netherlands 2Department of Gynaecology, University of Groningen, The Netherlands

SUMMARY At the University of Groningen, The Netherlands, medical students participate in a 12-week ski& training pro- gramme, the so-called introductory course, which immediately precedes the clinical clerkships. Fixed items in this course are the slide consultations, sessions in which students observe and inter- pret slides. Students appear to have dtficulty in distinguishing between slides with and without abnormalities. Is their preclini- cal eye not sufficiently trained, have they not been taught how to observe carefully, do they have insufficient knowledge of the normal anatomy, or have they seen too few abnormalities? In a pirot study we addressed the question of whether students can describe and correctly interpret slides of normal external female genitalia.

Introduction

During the fist four years of the medical curriculum students are shown many slides. Often these slides are used to illustrate a lecture. In the preclinical phase, students are not trained in observational skills. In the medical curricu- lum of the University of Groningen, The Netherlands, observational skills are taught in the introductory course, a 12-week clinical skills training programme preceding the clinical clerkships. The course comprises several so-called slide consultations, in which a slide is shown to a group of students, one of whom is asked to describe his or her observations. Afterwards, the teacher may give additional information. History, physical examination, interpretation and management strategy may be discussed (Scherpbier et al., 1991). As a result of their experiences in teaching the slide consultations, the education coordinators of the De- partment of Obstetrics and Gynaecology had serious doubts about the students’ knowledge of anatomy. Stu- dents seemed to have little knowledge of the normal anat- omy of the external female genitalia. This prompted a pilot study exploring the question: can students at the end of the preclinical phase of the medical curriculum correctly de- scribe and interpret slides showing normal external female genitalia? The results of this pilot study are presented in this article.

Method

Six slides were selected for use in the study. Five of these slides showed normal external female genitalia and one slide showed an abnormality. In selecting the ‘normal’ slides care was taken to ensure that the slides were clearly within the limits of what is generally considered normal. The slides were presented to 44 fifth-year medical students who were about to start the introductory course, 10 final- year clinical clerks who had nearly finished their obstetrics/ gynaecology rotation, and seven gynaecologists of the De- partment of Obstetrics and Gynaecology, University Hospital Groningen. The participants were asked to de- scribe the slides and interpret their observations. Three categories were used to classify the descriptions:

the description was systematic and covered the entire

the description was limited to the central part of the

the description was confined to the striking features.

For each slide the participants’ interpretations were classified as normal or abnormal.

slide;

slide;

Results

Description

Six different slides were observed and described by 44 fifth-year medical students, 10 clinical clerks, and seven gynaecologists. In all, 61 subjects participated in the study, each supplying six descriptions. The descriptions were classified into the three above-mentioned categories.

Table 1 presents the classification of the descriptions for each group of participants. The classification of the students’ descriptions is presented for male and female students separately. Most of the descriptions by the gynae- cologists (34 of 42) only referred to the striking features of the slide. The eight descriptions that were highly system-

Correspondence: A. J. J. A. Scherpbier, Skillslab, Faculty of Medicine, PO Box 616, 6200 h4D Maasmcht, The Netherlands. Tel: 31-43-3881771. Fax: 31-43-3618612.

0142-159X/97/010029-03 0 1997 Journals Oxford Ltd 29

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A. J. J. A. Scherpbier et al.

Table 1. Classification of the descriptions of the slides by the students, clerks and gynaecologists (the group percentage for each type of description is given in parentheses)

Students (n = 44) Clerks Gynaecologists

Description (n = 23 0 ) (n = 21 d) (n = 10) (n = 7)

Systematic, entire slide 25 (18) 7 (5) 59 (98) 8 (19) Systematic, centre of slide 41 (30) 26 (21) 1 (2) Only striking features 72 (52) 93 (74) 34 (81)

Total 138 126 60 42

atic were associated with uncertainty regarding the diag- nosis. When the gynaecologists were in doubt, their descriptions became more detailed. F&wine of the 60 descriptions by the clinical clerks were highly systematic. Apparently, clinical clerks have been well trained in de- scribing physical findings.

Most of the preclinical students, who were about to start the introductory course, gave a limited description. Many of them appear to confine their description to the central part of the slide. A striking finding is that female students gave a more systematic description than did their male colleagues.

Znterpreta tions

Of the six slides the participants were asked to describe, five showed normal external genitalia and one showed an abnormality. Table 2 presents by slide and by group of participants the number of participants who interpreted the slide as normal. Clearly, the clinical clerks’ interpreta- tions were superior to those of the students and the gynae- cologists’ interpretations were superior to those of the clinical clerks. A striking result is that the clerks, who at the time of the study were doing their final clinical rotation, interpreted a relatively large number of slides as abnormal. The students reported a great deal of pathology on the slides. Apparently their knowledge of anatomy is deficient.

To investigate whether female students are more fam- iliar with the female anatomy than their male counterparts, Table 3 presents the male and female students’ interpreta- tions classified as normal or pathology. The table shows

Table 2. The number of participants (students, clerks and gynaecologists) who interpreted slides 1 to 6 as normal (the percentage of subjects from each group of participants who

interpreted the slide as normal is given in parentheses)

Students Clinical clerks Gynaecologists (n = 44) (n = 10) UHG* (n = 7)

Slide 1 19 (43) 7 (70) 7 (100) Slide 2 10 (23) 8 (80) 7 (100) Slide 3 4 (9) 1 (10) 7 (100) Slide 4 4 (9) 3 (30) 6 (86) Slide 5 22 (50) 8 (80) 7 (100) Slide 6 11 (25) 5 (50) 7 (100)

Note: *UHG = University Hospital Groningen.

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that female students interpreted the normal slides as nor- mal more often than did the male students. Regarding interpretations of slides as pathology, female and male students differed per slide. If the total number of slides is taken into account, the difference is less marked. One slide (slide 5) showed an abnormality. This abnormality was not detected by any of the participants, including the gynaecol- ogists.

Discussion

The gynaecologists appeared to have sufficient knowledge of anatomy to interpret the slides as normal in most cases. Indubitably, they are the most experienced observers. The final-year clerks appeared to detect (too) many abnormali- ties on the normal slides. Apparently their frame of refer- ence is st i l l inadequate. If correct, this explanation gives some cause for concern. As stated above, the clerks had nearly finished their obstetrics and gynaecology rotation, i.e. they had completed their clerkships. Another expla- nation might be that students expect to see abnormalities when they are shown slides. The gynaecologists proved not to be susceptible to this type of ‘bias’. Nearly all the clinical clerks described the entire slide in detail, which may be attributable to their clinical training where they have learned to record history and physical findings systemati- cally. Like the gynaecologists, students often described only the striking features of the slide. As for the gynaecol- ogists, one might say that they are sufficiently experienced to be selective in their description. However, this does not apply in the case of the students. In the preclinical phase of

Table 3. Students’ interpretations of the slides classified as normal or abnormal (pathology) and for female (n = 23) and male (n = 2 1) students separately (the group percentages for

male and female students are given in parentheses)

Normal Pathology

Slide 0 d 0 8

Slide 1 8 (35) 11 (52) 15 (65) 10 (48) Slide 2 8 (35) 2 (10) 15 (65) 19 (90) Slide 3 3 (15) 1 (5) 20 (87) 20 (95) Slide4 2 (9) 2 (10) 21 (91) 19 (90) Slide 5 13 (57) 9 (43) 10 (43) 12 (57) Slide 6 9 (39) 2 (10) 14 (61) 19 (90)

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The preclinical eye

the medical curriculum they are not systematically taught how to observe. Also, preclinical students see hardly any patients, so that they cannot develop a frame of reference. In this respect the results for the students are not unexpec- ted. An interesting finding is that the female students interpreted the slides as normal more often than did the male students. If we had selected six slides of external male genitalia, the roles might have been reversed. None of the participants, including the gynaecologists, identified the abnormality on one of the slides. A possible explanation is that the abnormality was difficult to detect. Studies of diagnostic performance in interpreting visual information by dermatologists, radiologists and pathologists have re- vealed that even experts do make mistakes (Norman et al., 1992a, 1992b).

Is it possible to devise strategies in medical education that will produce better results than we found in this study? Is it possible to narrow the gap between experts and novices? In recent years, the differences between experts and novices have been studied extensively. Boshuizen & Schmidt (1 995) described their theory of cognitive devel- opment and its consequences for medical education. They claim that clinical reasoning should be taught in connec- tion with the development and integration of medical knowledge. They expect little benefit from teaching clinical reasoning in isolation. According to Boshuizen & Schmidt (1995), the most effective strategy would be self-activated learning combined with coaching by an experienced teacher who can help students analyse their performance to avoid repetition of mistakes. Norman et al. (1 992a) con- clude that the differences in observational skills between experts and novices are similar to those in problem solving. Differences can also be explained because, apart from cognition, perception plays a role in observation. For in- stance, it has been demonstrated that experts may differ about what is actually shown on a slide.

What are the implications of this study for medical education? Teaching observational skills by having stu- dents look at many images seems advisable. This should probably not be done separately from the acquisition of knowledge. Considering this, an integrated instructional method like the slide consultation could be introduced at an earlier stage in the medical curriculum. However, a diagnostic task requires more than visual information only. Therefore, integrating information from history and physi-

cal examination, including visual information, is essential. When doing a physical examination, physicians are also expected to identdy abnormalities that do not cause com- plaints. When studentdclinical clerks see patients, they should receive adequate feedback about what they did and did not observe. Whether students should see more pa- tients than they do in the current curriculum to develop a better frame of reference is not clear. However, we do believe that observing patients should receive more atten- tion in the medical curriculum. There are indications that seeing examples can contribute significantly to improving diagnostic performance based on visual information only (Allen et al., 1992; Norman, 1990; Norman et al., 1992a, 1992b).

Notes on contributors ALBERT SCHERPBIER is Head of the Skillslab at the University of Limburg, The Netherlands.

VIJAYA FABER is Education Coordinator in the Department of Gynaecology at the University of Groningen, The Netherlands.

JET YSPEERT-GERARDS is lVF physician at the University Hospital of Groningen, The Netherlands.

References ALLEN, S.W., NORMAN, G.R & BROOKS, L.R. (1 992) Experimental

studies of learning dermatologic diagnosis: the impact of exam- ples, Teaching and Learning in Medicine, 4(1), pp. 35-44.

BOSHUIZEN, H.P.A. & SCHMIDT, H.G. (1995) The development of clinical reasoning expertise, in: J. HIGGS & M. JONES (Eds) Clinic- al Reasoning in the Health R-ofesshns, pp. 2 4 3 2 (Oxford, Butter- worth-Heinemann).

NORMAN, G.R., BROOKS, L.R., ALLEN, S.W. & ROSENTHAL, D. (1990) Sources of observer variation in a dermatologic diagnosis, Academic Medicine, 65(9), pp. 19-20.

NORMAN, G.R., COBLENTZ, C.L., BROOKS, I.R. & BOBCOOK, C.J. (1992a). Expertise in visual diagnosis: a review of the literature, Academic Medicine, 67(10), pp. 79-83.

NORMAN, G.R., MUZZIN, C.J., SOMERS, S. & ROZENTHAL, D. (1992b) Visual perception in medical practice, in: H.G. SCHMIDT, Z. NOOMAN & E. EZZAD (Eds) Innovation in Medical Education: an Evaluation of its fiesent Status, pp. 20421’7 (New York, Springer Verlag).

SCHERPBIER, A.J.J.A., LUNSEN, H.W., YSPEERTS-GERARDS, M.H., SOETERS, D. & BENDER, W. (1991) The way we train the clinical eye through slides, Medical Teacher, 13, pp. 165-169.

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