Publications by authors named "Amir H Sam"

45 Publications

A Weighted Evaluation Study of Clinical Teacher Performance at Five Hospitals in the UK.

Adv Med Educ Pract 2021 26;12:957-963. Epub 2021 Aug 26.

Institute for Medical Education, University Hospital Bonn, Bonn, Germany.

Introduction: Evaluation of individual teachers in undergraduate medical education helps clinical teaching fellows identify their own strengths and weaknesses. In addition, evaluation data can be used to guide career decisions. In order for evaluation results to adequately reflect true teaching performance, a range of parameters should be considered when designing data collection tools.

Methods: Clinical teaching fellows at five London teaching hospitals were evaluated by third-year students they had supervised during a ten-week clinical attachment. The questionnaire addressed (a) general teaching skills and (b) student learning outcome measured via comparative self-assessments. Teachers were ranked using different algorithms with various weights assigned to these two factors.

Results: A total of 133 students evaluated 14 teaching fellows. Overall, ratings on teaching skills were largely favourable, while the perceived increase in student performance was modest. Considerable variability across teachers was observed for both factors. Teacher rankings were strongly influenced by the weighting algorithm used. Depending on the algorithm, one teacher was assigned any rank between #2 and #10.

Conclusion: Both parts of the questionnaire address different outcomes and thus highlight specific strengths and weaknesses of individual teachers. Programme directors need to carefully consider the weight assigned to individual components of teacher evaluations in order to ensure a fair appraisal of teacher performance.
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http://dx.doi.org/10.2147/AMEP.S322105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8405096PMC
August 2021

Is Academic Attainment or Situational Judgement Test Performance in Medical School Associated With the Likelihood of Disciplinary Action? A National Retrospective Cohort Study.

Acad Med 2021 Jun 15. Epub 2021 Jun 15.

A.H. Sam is head, Imperial College School of Medicine, Imperial College London, London, United Kingdom; ORCID: https://orcid.org/0000-0002-9599-9069. L. Bala is clinical research fellow in medical education, Faculty of Medicine, Imperial College London, London, United Kingdom; ORCID: https://orcid.org/0000-0002-8242-379X. R.J. Westacott is senior clinical lecturer, Birmingham Medical School, University of Birmingham, Birmingham, United Kingdom; ORCID: https://orcid.org/0000-0001-9846-1961. C. Brown is associate professor in quantitative methods, Warwick Medical School, University of Warwick, Coventry, United Kingdom; ORCID: https://orcid.org/0000-0002-7526-0793.

Purpose: Disciplinary action imposed on physicians indicates their fitness to practice medicine is impaired and patient safety is potentially at risk. This national retrospective cohort study sought to examine whether there was an association between academic attainment or performance on a situational judgment test (SJT) in medical school and the risk of receiving disciplinary action within the first 5 years of professional practice in the United Kingdom.

Method: The authors included data from the UK Medical Education Database for 34,865 physicians from 33 U.K. medical schools who started the UK Foundation Programme (similar to internship) between 2014 and 2018. They analyzed data from 2 undergraduate medical assessments used in the United Kingdom: the Educational Performance Measure (EPM), which is based on academic attainment, and SJT, which is an assessment of professional attributes. The authors calculated hazard ratios (HRs) for EPM and SJT scores.

Results: The overall rate of disciplinary action was low (65/34,865, 0.19%) and the mean time to discipline was 810 days (standard deviation [SD] = 440). None of the physicians with fitness to practice concerns identified as students went on to receive disciplinary action after they qualified as physicians. The multivariate survival analysis demonstrated that a score increase of 1 SD (approximately 7.6 percentage points) on the EPM reduced the hazard of disciplinary action by approximately 50% (HR = 0.51; 95% confidence interval [CI]: 0.38, 0.69; P < .001). There was not a statistically significant association between the SJT score and the hazard of disciplinary action (HR = 0.84; 95% CI: 0.62, 1.13; P = .24).

Conclusions: An increase in EPM score was significantly associated with a reduced hazard of disciplinary action, whereas performance on the SJT was not. Early identification of increased risk of disciplinary action may provide an opportunity for remediation and avoidance of patient harm.
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http://dx.doi.org/10.1097/ACM.0000000000004212DOI Listing
June 2021

Thinking differently - Students' cognitive processes when answering two different formats of written question.

Med Teach 2021 Jun 14:1-8. Epub 2021 Jun 14.

Division of Health Sciences, University of Warwick, Coventry, UK.

Background: Single-best answer questions (SBAQs) are common but are susceptible to cueing. Very short answer questions (VSAQs) could be an alternative, and we sought to determine if students' cognitive processes varied across question types and whether students with different performance levels used different methods for answering questions.

Methods: We undertook a 'think aloud' study, interviewing 21 final year medical students at five UK medical schools. Each student described their thought processes and methods used for eight questions of each type. Responses were coded and quantified to determine the relative frequency with which each method was used, denominated on the number of times a method could have been used.

Results: Students were more likely to use analytical reasoning methods (specifically identifying key features) when answering VSAQs. The use of test-taking behaviours was more common for SBAQs; students frequently used the answer options to help them reach an answer. Students acknowledged uncertainty more frequently when answering VSAQs. Analytical reasoning was more commonly used by high-performing students compared with low-performing students.

Conclusions: Our results suggest that VSAQs encourage more authentic clinical reasoning strategies. Differences in cognitive approaches used highlight the need for focused approaches to teaching clinical reasoning and dealing with uncertainty.
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http://dx.doi.org/10.1080/0142159X.2021.1935831DOI Listing
June 2021

Synacthen Stimulation Test Following Unilateral Adrenalectomy Needs to Be Interpreted With Caution.

Front Endocrinol (Lausanne) 2021 11;12:654600. Epub 2021 May 11.

Department of Endocrinology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.

Background: Cortisol levels in response to stress are highly variable. Baseline and stimulated cortisol levels are commonly used to determine adrenal function following unilateral adrenalectomy. We report the results of synacthen stimulation testing following unilateral adrenalectomy in a tertiary referral center.

Methods: Data were collected retrospectively for 36 patients who underwent synacthen stimulation testing one day post unilateral adrenalectomy. None of the patients had clinical signs of hypercortisolism preoperatively. No patient received pre- or intraoperative steroids. Patients with overt Cushing's syndrome were excluded.

Results: The median age was 58 (31-79) years. Preoperatively, 16 (44%) patients had a diagnosis of pheochromocytoma, 12 (33%) patients had primary aldosteronism and 8 (22%) patients had non-functioning adenomas with indeterminate/atypical imaging characteristics necessitating surgery. Preoperative overnight dexamethasone suppression test results revealed that 6 of 29 patients failed to suppress cortisol to <50 nmol/L. Twenty (56%) patients achieved a stimulated cortisol ≥450 nmol/L at 30 minutes and 28 (78%) at 60 minutes. None of the patients developed clinical adrenal insufficiency necessitating steroid replacement.

Conclusions: Synacthen stimulation testing following unilateral adrenalectomy using standard stimulated cortisol cut-off values would wrongly label many patients adrenally insufficient and may lead to inappropriate prescriptions of steroids to patients who do not need them.
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http://dx.doi.org/10.3389/fendo.2021.654600DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8147556PMC
May 2021

A remote access mixed reality teaching ward round.

Clin Teach 2021 Aug 30;18(4):386-390. Epub 2021 Mar 30.

Imperial College School of Medicine, Imperial College London, London, UK.

Background: Heterogeneous access to clinical learning opportunities and inconsistency in teaching is a common source of dissatisfaction among medical students. This was exacerbated during the COVID-19 pandemic, with limited exposure to patients for clinical teaching.

Methods: We conducted a proof-of-concept study at a London teaching hospital using mixed reality (MR) technology (HoloLens2™) to deliver a remote access teaching ward round.

Results: Students unanimously agreed that use of this technology was enjoyable and provided teaching that was otherwise inaccessible. The majority of participants gave positive feedback on the MR (holographic) content used (n = 8 out of 11) and agreed they could interact with and have their questions answered by the clinician leading the ward round (n = 9). Quantitative and free text feedback from students, patients and faculty members demonstrated that this is a feasible, acceptable and effective method for delivery of clinical education.

Discussion: We have used this technology in a novel way to transform the delivery of medical education and enable consistent access to high-quality teaching. This can now be integrated across the curriculum and will include remote access to specialist clinics and surgery. A library of bespoke MR educational resources will be created for future generations of medical students and doctors to use on an international scale.
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http://dx.doi.org/10.1111/tct.13338DOI Listing
August 2021

Exploring the feasibility of using very short answer questions (VSAQs) in team-based learning (TBL).

Clin Teach 2021 Aug 24;18(4):404-408. Epub 2021 Mar 24.

Imperial College School of Medicine, Imperial College London, London, UK.

Background: Team-based learning (TBL) currently relies on single best answer questions (SBAQs) to provide immediate feedback. Very short answer questions (VSAQs) are a reliable and discriminatory alternative that encourage learners to use more authentic clinical reasoning strategies compared to SBAQs. However, the challenge of marking VSAQs has limited their integration into TBL; we therefore explored the feasibility of VSAQs within a TBL session.

Methods: An online platform was developed to allow immediate marking of VSAQs during the TBL sessions. As part of the readiness assurance process, students completed VSAQs and SBAQs, which were marked in real time.

Results: Instructors were able to mark all VSAQs during the individual readiness assurance test (iRAT), which facilitated the provision of immediate feedback during the team readiness assurance test (tRAT). The mean time to mark five VSAQs was 422 seconds (SD 73 seconds). For VSAQs, the number of attempts to reach the correct answer ranged from 1 to 38, compared to 1 to 4 for SBAQs. In total, 71.6% of students agreed that using VSAQs in TBL helped to emphasise group discussions.

Discussion: The wide range of attempts at, and students' perspectives of VSAQs are suggestive of their positive impact on student discussion during TBL. We demonstrate how new technology allows VSAQs to be feasibly integrated into TBL with the potential to enrich group discussions.
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http://dx.doi.org/10.1111/tct.13347DOI Listing
August 2021

Supplementation: An Improved Approach to Question-Based Collaborative Learning [Response to Letter].

Adv Med Educ Pract 2021 9;12:251-252. Epub 2021 Mar 9.

Imperial College School of Medicine, Imperial College London, London, UK.

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http://dx.doi.org/10.2147/AMEP.S306372DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955738PMC
March 2021

Development of a Virtual Three-Dimensional Assessment Scenario for Anatomical Education.

Anat Sci Educ 2021 May 5;14(3):385-393. Epub 2021 Mar 5.

Center for Innovation of Medical Education, Leiden University Medical Center, Leiden, the Netherlands.

In anatomical education three-dimensional (3D) visualization technology allows for active and stereoscopic exploration of anatomy and can easily be adopted into medical curricula along with traditional 3D teaching methods. However, most often knowledge is still assessed with two-dimensional (2D) paper-and-pencil tests. To address the growing misalignment between learning and assessment, this viewpoint commentary highlights the development of a virtual 3D assessment scenario and perspectives from students and teachers on the use of this assessment tool: a 10-minute session of anatomical knowledge assessment with real-time interaction between assessor and examinee, both wearing a HoloLens and sharing the same stereoscopic 3D augmented reality model. Additionally, recommendations for future directions, including implementation, validation, logistic challenges, and cost-effectiveness, are provided. Continued collaboration between developers, researchers, teachers, and students is critical to advancing these processes.
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http://dx.doi.org/10.1002/ase.2055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8252734PMC
May 2021

Question-Based Collaborative Learning for Constructive Curricular Alignment.

Adv Med Educ Pract 2020 5;11:1047-1053. Epub 2021 Jan 5.

Imperial College School of Medicine, Imperial College London, London, UK.

Introduction: We designed a curriculum mapping tool which enables medical students to access intended learning outcomes (ILOs) on their iPads in the workplace. Students were encouraged to use the online curriculum map in a specially planned teaching session: question-based collaborative learning (QBCL). The aim of the session was to empower medical students to constructively align their experiential learning with the learning outcomes of the undergraduate curriculum. In doing so, our session aimed to provide students with a greater understanding of the curriculum, improve their insights into assessment and their question-writing abilities.

Methods: The QBCL pre-session preparation involved reviewing a patient with a presentation that aligned to the year-specific ILOs. During a 150 minute QBCL session, students received training on how to write high quality multiple choice questions (MCQs) delivered by a faculty member of Imperial College School of Medicine. They then worked collaboratively in groups and created MCQs based on their clinical encounters. Their questions were tagged to the relevant learning objective and submitted online via the curriculum map. The student-generated MCQs were analyzed using an adjusted version of Bloom's taxonomy. We also conducted a quantitative evaluation of the session.

Results: One hundred and sixty-three questions were submitted, with 81% of questions being tagged to ILOs considered to show evidence of learning consistent with the "Apply" tier of Bloom's taxonomy. The majority of students agreed that the session was interactive (80%), thought-provoking (77%) and improved their team-working skills (70%). It gave them a greater understanding of the undergraduate curriculum (65%), improved their question-writing and insight into assessments (76%), and provided an opportunity to learn from their peers (86%). Students agreed that this session covered a variety of cases (82%) and deepened their understanding of medical conditions and presentations (87%).

Conclusion: We encouraged students to actively interact with the curriculum map. Students were able to achieve their own constructive alignment by writing assessment items based on real patients and linking them to the appropriate intended learning outcomes.
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http://dx.doi.org/10.2147/AMEP.S280972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802018PMC
January 2021

Undergraduate exposure to patient presentations on the acute medical placement: a prospective study in a London teaching hospital.

BMJ Open 2020 11 26;10(11):e040575. Epub 2020 Nov 26.

Imperial College School of Medicine, Imperial College London, London, UK

Objectives: To identify the availability and variability of learning opportunities through patient presentations on an acute medical placement at a teaching hospital.

Design: A prospective study evaluating all acute admissions to the Acute Medical Unit over 14 days (336 hours). Clinical presentations and the day and time of admission were recorded and compared with the learning outcomes specified in the medical school curriculum.

Setting: An Acute Medical Unit at a London teaching hospital.

Outcomes: (1) Number of clinical presentations to the Acute Medical Unit over 14 days and (2) differences between the availability and variation of admissions and presentations between in-hours and out-of-hours.

Results: There were 359 admissions, representing 1318 presentations. Of those presentations, 76.6% were admitted out-of-hours and 23.4% in-hours. Gastrointestinal bleeding, tachycardia, oedema and raised inflammatory markers were over three times more common per hour out-of-hours than in-hours. Hypoxia was only seen out-of-hours. Important clinical presentations in the curriculum such as chest pain and hemiparesis were not commonly seen.

Conclusions: There is greater availability of presentations seen out-of-hours and a changing landscape of presentations seen in-hours. The out-of-hours presentation profile may be due to expanded community and specialist services. Medical schools need to carefully consider the timing and location of their clinical placements to maximise undergraduate learning opportunities.
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http://dx.doi.org/10.1136/bmjopen-2020-040575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7692979PMC
November 2020

National inter-rater agreement of standardised simulated-patient-based assessments.

Med Teach 2021 03 16;43(3):341-346. Epub 2020 Nov 16.

Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK.

Purpose: The forthcoming UK Medical Licensing Assessment will require all medical schools in the UK to ensure that their students pass an appropriately designed Clinical and Professional Skills Assessment (CPSA) prior to graduation and registration with a licence to practice medicine. The requirements for the CPSA will be set by the General Medical Council, but individual medical schools will be responsible for implementing their own assessments. It is therefore important that assessors from different medical schools across the UK agree on what standard of performance constitutes a fail, pass or good grade.

Methods: We used an experimental video-based, single-blinded, randomised, internet-based design. We created videos of simulated student performances of a clinical examination at four scripted standards: clear fail (CF), borderline (BD), clear pass (CPX) and good (GD). Assessors from ten regions across the UK were randomly assigned to watch five videos in 12 different combinations and asked to give competence domain scores and an overall global grade for each simulated candidate. The inter-rater agreement as measured by the intraclass correlation coefficient (ICC) based on a two-way random-effects model for absolute agreement was calculated for the total domain scores.

Results: 120 assessors enrolled in the study, with 98 eligible for analysis. The ICC was 0.93 (95% CI 0.81-0.99). The mean percentage agreement with the scripted global grade was 74.4% (range 40.8-96.9%).

Conclusions: The inter-rater agreement amongst assessors across the UK when rating simulated candidates performing at scripted levels is excellent. The level of agreement for the overall global performance level for simulated candidates is also high. These findings suggest that assessors from across the UK viewing the same simulated performances show high levels of agreement of the standards expected of students at a 'clear fail,' 'borderline,' 'clear pass' and 'good' level.
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http://dx.doi.org/10.1080/0142159X.2020.1845909DOI Listing
March 2021

In Reply to Guragai.

Acad Med 2021 01;96(1):e1-e2

Vice dean (education), Faculty of Medicine, Imperial College London, and consultant obstetrician, Chelsea and Westminster Hospital, London, England.

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http://dx.doi.org/10.1097/ACM.0000000000003799DOI Listing
January 2021

Reflections on assessment in the wake of change from the COVID-19 pandemic.

Med Educ 2021 01 20;55(1):128-130. Epub 2020 Sep 20.

Imperial College School of Medicine, Imperial College London, London, UK.

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http://dx.doi.org/10.1111/medu.14368DOI Listing
January 2021

Digital Clinical Placement for Medical Students in Response to COVID-19.

Acad Med 2020 08;95(8):1126

Vice dean (education), Faculty of Medicine, Imperial College London and consultant obstetrician, Chelsea and Westminster Hospital, London, England.

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http://dx.doi.org/10.1097/ACM.0000000000003431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7179062PMC
August 2020

COVID-19 and programmatic assessment.

Clin Teach 2020 08 26;17(4):420-422. Epub 2020 Jun 26.

Faculty of Medicine, Imperial College London, London, UK.

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http://dx.doi.org/10.1111/tct.13207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361442PMC
August 2020

Pharmacodynamic Response to Anti-thyroid Drugs in Graves' Hyperthyroidism.

Front Endocrinol (Lausanne) 2020 12;11:286. Epub 2020 May 12.

Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom.

Graves' disease is the commonest cause of hyperthyroidism in populations with sufficient dietary iodine intake. Anti-thyroid drugs (ATD) are often used as the initial treatment for Graves' hyperthyroidism, however there is a paucity of data relating the dose of ATD therapy to the effect on thyroid hormone levels, increasing the risk of both over- and under-treatment. We aimed to determine the pharmacodynamic response to the ATD carbimazole. Retrospective cohort study. Participants were patients ( = 441) diagnosed with Graves' disease at Imperial College Healthcare NHS Trust between 2009 and 2018. The main outcome measure was change in thyroid hormone levels in response to ATD. Baseline thyroid hormone levels were positively associated with TSH receptor antibody titres ( < 0.0001). Baseline free triiodothyronine (fT3) were linearly related to free thyroxine (fT4) levels in the hyperthyroid state (fT3 = fT40.97-11), and fell proportionately with carbimazole. The percentage falls in fT4 and fT3 per day were associated with carbimazole dose ( < 0.0001). The magnitude of fall in thyroid hormones after the same dose of carbimazole was lower during follow up than at the initiation visit. The fall in thyroid hormone levels approximated to a linear response if assessed at least 3 weeks after commencement of carbimazole. Following withdrawal of antithyroid drug treatment, the risk of relapse was greater in patients with higher initial fT4, initial TSH receptor antibody titre, males, smokers, and British Caucasian ethnicity. We identify a dose-response relationship for fall in thyroid hormones in response to carbimazole to aid in the selection of dose for Graves' hyperthyroidism.
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http://dx.doi.org/10.3389/fendo.2020.00286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7236601PMC
May 2021

Clinical prioritisation questions: A novel assessment tool to encourage tolerance of uncertainty?

Med Teach 2020 04 9;42(4):416-421. Epub 2019 Dec 9.

Imperial College School of Medicine, Imperial College London, London, UK.

Uncertainty is a common and increasingly acknowledged problem in clinical practice. Current single best answer (SBA) style assessments test areas where there is one correct answer, and as the approach to assessment impacts on the approach to learning, these exams may poorly prepare our future doctors to handle uncertainty. We therefore, need to modify our approach to assessment to emphasize reasoning and introduce the possibility of more than one 'correct' answer. We have developed clinical prioritization questions (CPQs), a novel formative assessment tool in which students prioritize possible responses in order of likelihood. This assessment format was piloted with a group of medical students and evaluated in comparison with the more traditional SBA question format in a team-based learning setting. Students reported that they felt ongoing use would help improve their tolerance of uncertainty ( < 0.01). Furthermore, over 80% of students felt that CPQs were more reflective of real-life clinical practice. Group based discussions were significantly longer when answering CPQs ( < 0.01), suggesting they may promote richer discourse. CPQs may have a role in formative assessment to help equip students with the skills to cope with ambiguity and strengthen clinical reasoning and decision-making. Institutions may find them more practical to implement compared with other clinical reasoning assessment tools.
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http://dx.doi.org/10.1080/0142159X.2019.1687864DOI Listing
April 2020

Very Short Answer Questions: A Novel Approach To Summative Assessments In Pathology.

Adv Med Educ Pract 2019 4;10:943-948. Epub 2019 Nov 4.

Imperial College School of Medicine, Imperial College London, London, UK.

Background: A solid understanding of the science underpinning treatment is essential for all doctors. Pathology teaching and assessment are fundamental components of the undergraduate medicine curriculum. Assessment drives learning and the choice of assessments influences students' learning behaviours. The use of multiple-choice questions is common but is associated with significant cueing and may promote "rote learning". Essay-type questions and Objective Structured Clinical Examinations (OSCEs) are resource-intensive in terms of delivery and marking and do not allow adequate sampling of the curriculum. To address these limitations, we used a novel online tool to administer Very Short Answer questions (VSAQs) and evaluated the utility of the VSAQs in an undergraduate summative pathology assessment.

Methods: A group of 285 medical students took the summative assessment, comprising 50 VSAQs, 50 single best answer questions (SBAQs), and 75 extended matching questions (EMQs). The VSAQs were machine-marked against pre-approved responses and subsequently reviewed by a panel of pathologists, with the software remembering all new marking judgements.

Results: The total time taken to mark all 50 VSAQs for all 285 students was 5 hours, compared to 70 hours required to manually mark an equivalent number of questions in a paper-based pathology exam. The median percentage score for the VSAQs test (72%) was significantly lower than that of the SBAQs (80%) and EMQs (84%), p <0.0001. VSAQs had a higher Cronbach alpha (0.86) than SBAQs (0.76), and EMQs (0.77). VSAQs, SBAQs and EMQs had a mean point-biserial of 0.35, 0.30 and 0.28, respectively.

Conclusion: VSAQs are an acceptable, reliable and discriminatory method for assessing pathology, and may enhance students' understanding of how pathology supports clinical decision-making and clinical care by changing learning behaviour.
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http://dx.doi.org/10.2147/AMEP.S197977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6839581PMC
November 2019

Comparing single-best-answer and very-short-answer questions for the assessment of applied medical knowledge in 20 UK medical schools: Cross-sectional study.

BMJ Open 2019 09 26;9(9):e032550. Epub 2019 Sep 26.

Warwick Medical School (WMS), The University of Warwick, Coventry, UK

Objectives: The study aimed to compare candidate performance between traditional best-of-five single-best-answer (SBA) questions and very-short-answer (VSA) questions, in which candidates must generate their own answers of between one and five words. The primary objective was to determine if the mean positive cue rate for SBAs exceeded the null hypothesis guessing rate of 20%.

Design: This was a cross-sectional study undertaken in 2018.

Setting: 20 medical schools in the UK.

Participants: 1417 volunteer medical students preparing for their final undergraduate medicine examinations (total eligible population across all UK medical schools approximately 7500).

Interventions: Students completed a 50-question VSA test, followed immediately by the same test in SBA format, using a novel digital exam delivery platform which also facilitated rapid marking of VSAs.

Main Outcome Measures: The main outcome measure was the mean positive cue rate across SBAs: the percentage of students getting the SBA format of the question correct after getting the VSA format incorrect. Internal consistency, item discrimination and the pass rate using Cohen standard setting for VSAs and SBAs were also evaluated, and a cost analysis in terms of marking the VSA was performed.

Results: The study was completed by 1417 students. Mean student scores were 21 percentage points higher for SBAs. The mean positive cue rate was 42.7% (95% CI 36.8% to 48.6%), one-sample t-test against ≤20%: t=7.53, p<0.001. Internal consistency was higher for VSAs than SBAs and the median item discrimination equivalent. The estimated marking cost was £2655 ($3500), with 24.5 hours of clinician time required (1.25 s per student per question).

Conclusions: SBA questions can give a false impression of students' competence. VSAs appear to have greater authenticity and can provide useful information regarding students' cognitive errors, helping to improve learning as well as assessment. Electronic delivery and marking of VSAs is feasible and cost-effective.
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http://dx.doi.org/10.1136/bmjopen-2019-032550DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6773319PMC
September 2019

The relevance of cortisol co-secretion from aldosterone-producing adenomas.

Hormones (Athens) 2019 Sep;18(3):307-313

Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, 6th Floor Commonwealth Building, Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK.

Aims And Objectives: Adrenal adenomas are usually non-functioning, but can secrete aldosterone or cortisol. It has recently been suggested that many more adenomas than previously thought secrete more than one hormone. This has important implications for their clinical management. Our aim was to determine the frequency of cortisol co-secretion in primary hyperaldosteronism at our institution and investigate the difference in metabolic profiles and clinical outcomes between co-secreting and non-co-secreting patients.

Design And Patients: A retrospective study of 25 patients with primary hyperaldosteronism who also underwent formal dexamethasone suppression tests to determine cortisol co-secretion.

Measurements: Post-dexamethasone suppression test cortisol, serum ALT, total cholesterol, HDL-cholesterol, LDL-cholesterol, HbA1C (were recorded) and mean arterial pressure are reported in this cohort of patients with primary hyperaldosteronism.

Results: Four out of 25 patients with primary hyperaldosteronism failed dexamethasone suppression tests. This suggests a frequency of co-secretion ranging between 4 and 16%. No significant difference was found in serum ALT, total cholesterol, serum HDL-cholesterol, LDL-cholesterol and mean arterial blood pressure at presentation between co-secretors and non-co-secretors.

Conclusion: A frequency range of 4-16% suggests that a significant proportion of patients with primary hyperaldosteronism co-secrete cortisol. Co-secretors did not have a worse metabolic profile than non-secretors. The impact of co-secretion on metabolic profile and surgical management remains unclear and warrants further study.
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http://dx.doi.org/10.1007/s42000-019-00114-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797639PMC
September 2019

Using team-based revision to prepare medical students for the prescribing safety assessment.

Adv Med Educ Pract 2019 10;10:501-506. Epub 2019 Jul 10.

Medical Education Research Unit, Imperial College London, London, UK.

Background: The Prescribing Safety Assessment (PSA) is an online assessment of safe and effective prescribing, taken by final-year UK medical students. To prepare students for the PSA, we used a modified form of team-based learning, team-based revision (TBR), in which students consolidate previously learned prescribing knowledge and skills across a broad range of topics. We evaluated students' response to TBR and their perceptions of team working.

Methods: Eight TBR sessions based on the PSA blueprint were conducted over two days by three faculty members for final year medical students. During TBR sessions, students worked in small groups answering individual multiple-choice questions, followed by group multiple-choice questions. They subsequently answered open-ended questions in their groups, with answers written on a drug chart to increase authenticity. Students completed surveys using Likert-type items to determine views on TBR and their confidence in prescribing.

Results: The majority of respondents agreed that the sessions were useful for preparation both for the PSA (82%) and Foundation Year 1 (78%). 92% agreed that using drug-charts aided learning. Prescribing confidence increased significantly after TBR (median pre-TBR: 2, post-TBR: 5, <0.0001). TBR significantly improved attitudes towards "team experience" (<0.001), "team impact on quality of learning" (<0.01) and "team impact on clinical reasoning ability" (<0.001).

Conclusions: Team-based revision is a resource-efficient addition to undergraduate prescribing teaching and can help with preparation for the PSA. A short course of TBR was effective in influencing students' attitudes towards teamwork.
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http://dx.doi.org/10.2147/AMEP.S204435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6628602PMC
July 2019

Using prescribing very short answer questions to identify sources of medication errors: a prospective study in two UK medical schools.

BMJ Open 2019 07 9;9(7):e028863. Epub 2019 Jul 9.

Medical Education Research Unit, Imperial College School of Medicine, Imperial College London, London, UK.

Objective: To assess the utility and ability of the novel prescribing very short answer (VSA) question format to identify the sources of undergraduate prescribing errors when compared with the conventional single best answer (SBA) question format and assess the acceptability of machine marking prescribing VSAs.

Design: A prospective study involving analysis of data generated from a pilot two-part prescribing assessment.

Setting: Two UK medical schools.

Participants: 364 final year medical students took part. Participation was voluntary. There were no other inclusion or exclusion criteria.

Outcomes: (1) Time taken to mark and verify VSA questions (acceptability), (2) differences between VSA and SBA scores, (3) performance in VSA and (4) SBA format across different subject areas and types of prescribing error made in the VSA format.

Results: 18 200 prescribing VSA questions were marked and verified in 91 min. The median percentage score for the VSA test was significantly lower than the SBA test (28% vs 64%, p<0.0001). Significantly more prescribing errors were detected in the VSA format than the SBA format across all domains, notably in prescribing insulin (96.4% vs 50.3%, p<0.0001), fluids (95.6% vs 55%, p<0.0001) and analgesia (85.7% vs 51%, p<0.0001). Of the incorrect VSA responses, 33.1% were due to the medication prescribed, 6.0% due to the dose, 1.4% due to the route and 4.8% due to the frequency.

Conclusions: Prescribing VSA questions represent an efficient tool for providing detailed insight into the sources of significant prescribing errors, which are not identified by SBA questions. This makes the prescribing VSA a valuable formative assessment tool to enhance students' skills in safe prescribing and to potentially reduce prescribing errors.
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http://dx.doi.org/10.1136/bmjopen-2018-028863DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6629393PMC
July 2019

FEEDBK: a novel approach for providing feedback.

Clin Teach 2020 02 10;17(1):76-80. Epub 2019 May 10.

Medical Education Research Unit, School of Medicine, Imperial College London, London, UK.

Background: High-quality feedback is fundamental to students' learning. We describe and evaluate FEEDBK, a novel feedback tool that encompasses the focus of learning, student self-evaluation (reflection), the encounter with the patient (professionalism), one task that the student should continue to do (reinforcement), one task that they could do better (improvement) and a key take-home message for self-directed learning.

Methods: Medical students received regular bedside teaching and feedback during a 9-week clinical placement at a teaching hospital. Teaching fellows gave feedback in their usual style during weeks 1-3 and then used the FEEDBK tool during weeks 4-9. Questionnaires and focus groups were used to evaluate the students' experience of feedback before and after the introduction of FEEDBK.

Results: FEEDBK significantly enhanced the feedback experience across six domains: identifying learning objectives, chance to reflect, feedback on communication skills/professionalism, specific suggestions for improvement, clear take-home message and personalised feedback. The analysis of the feedback from focus groups yielded four categories: (i) FEEDBK influenced the feedback process (delivering timely feedback); (ii) the nature of the feedback (enhancing both the quantity and the quality of the feedback received); (iii) the structure of the feedback; and (iv) the evolution of teaching and learning.

Discussion: FEEDBK may enhance both the quantity and the quality of feedback and has the potential to improve the quality of teaching. It provides teachers with a quick and easy-to-follow framework to signpost curriculum-aligned feedback.
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http://dx.doi.org/10.1111/tct.13026DOI Listing
February 2020

VISUAL VIGNETTE.

Endocr Pract 2019 Aug 18;25(8):862. Epub 2019 Jan 18.

Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College London, London, UK.

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http://dx.doi.org/10.4158/EP-2018-0579DOI Listing
August 2019

Clinical and biochemical characteristics of patients presenting with pituitary apoplexy.

Endocr Connect 2018 08 23. Epub 2018 Aug 23.

N Martin, Imperial College Healthcare NHS Trust, London, United Kingdom of Great Britain and Northern Ireland

Purpose: To review the clinical and biochemical characteristics and clinical outcome of patients presenting with pituitary apoplexy to a tertiary centre.

Methods: We retrospectively reviewed the clinical features, predisposing factors, biochemistry and clinical outcome of patients presenting with pituitary apoplexy to Imperial College Healthcare NHS Trust between 1991 to 2015.

Results: We identified 64 patients with pituitary apoplexy (more complete clinical records were available in 52 patients). The median age at presentation was 46.7 years (IQR 31.5-57.0 years). Pituitary apoplexy was the first presentation of pituitary disease in 38/52 of patients and predisposing factors were identified in 28/52. Pituitary apoplexy predominantly occurred in patients with non-functioning pituitary adenomas (47/52). Headache was most commonly described as sudden-onset, severe, lateralising to the frontal or temporal regions. Symptoms of meningeal irritation were reported in 7/18 and visual abnormalities in 22/35. A pre-treatment serum cortisol <100nmol/l was recorded in 12/31 of patients. All patients with visual disturbance had some resolution of their visual symptoms whether managed surgically (14/14) or conservatively (5/5), although pituitary endocrine function did not fully recover in any patient.

Conclusions: In conclusion, these data describe the clinical features of pituitary apoplexy to aid the clinician in diagnosing this rare emergency presentation of pituitary disease. Prospective multicentre studies of the presentation of pituitary apoplexy are required to further characterise presentation and outcomes.
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http://dx.doi.org/10.1530/EC-18-0255DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6198188PMC
August 2018

Interpretation of Serum Gonadotropin Levels in Hyperprolactinaemia.

Neuroendocrinology 2018 16;107(2):105-113. Epub 2018 Apr 16.

Department of Investigative Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom.

Background/aims: Hyperprolactinaemia is a common cause of amenorrhoea due to hypogonadotropic hypogonadism. Prolactin is hypothesised to impede the reproductive axis through an inhibitory action at the hypothalamus. However, limited data exist to aid the interpretation of serum gonadotropins in the context of hyperprolactinaemia.

Methods: Serum gonadotropin values were reviewed in 243 patients with elevated serum monomeric prolactin due to discrete aetiologies at a tertiary reproductive endocrine centre between 2012 and 2015. The cause of hyperprolactinaemia was categorised by an experienced endocrinologist/pituitary multidisciplinary team, unless superseded by histology. The most frequently encountered diagnoses were microprolactinoma (n = 88), macroprolactinoma (n = 46), non-functioning pituitary adenoma (NFPA) (n = 72), drug-induced hyperprolactinaemia (n = 22) and polycystic ovarian syndrome (PCOS) (n = 15).

Results: In patients with prolactinoma and modestly raised serum prolactin levels (< 4,000 mU/L), increasingly FSH-predominant gonadotropin values were observed with rising prolactin level, consistent with a progressive reduction in hypothalamic gonadotropin-releasing hormone (GnRH) pulsatility. Patients with prolactinoma and higher prolactin values (> 4,000 mU/L) were more likely to have a reduction in serum levels of both FSH and LH, consistent with direct pituitary gonadotrope dysfunction. Patients with macroadenoma and extremes of serum gonadotropin values (either serum FSH or LH > 8 IU/L) were more likely to have NFPA than prolactinoma. Patients with PCOS and hyperprolactinaemia had LH-predominant secretion in keeping with increased GnRH pulsatility despite a raised prolactin level.

Conclusion: The pattern of gonadotropin secretion in patients with hyperprolactinaemia reflects the underlying aetiology.
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http://dx.doi.org/10.1159/000489264DOI Listing
January 2019

Very-short-answer questions: reliability, discrimination and acceptability.

Med Educ 2018 04 1;52(4):447-455. Epub 2018 Feb 1.

Medical Education Research Unit, Imperial College London, London, UK.

Context: Single-best-answer questions (SBAQs) have been widely used to test knowledge because they are easy to mark and demonstrate high reliability. However, SBAQs have been criticised for being subject to cueing.

Objectives: We used a novel assessment tool that facilitates efficient marking of open-ended very-short-answer questions (VSAQs). We compared VSAQs with SBAQs with regard to reliability, discrimination and student performance, and evaluated the acceptability of VSAQs.

Methods: Medical students were randomised to sit a 60-question assessment administered in either VSAQ and then SBAQ format (Group 1, n = 155) or the reverse (Group 2, n = 144). The VSAQs were delivered on a tablet; responses were computer-marked and subsequently reviewed by two examiners. The standard error of measurement (SEM) across the ability spectrum was estimated using item response theory.

Results: The review of machine-marked questions took an average of 1 minute, 36 seconds per question for all students. The VSAQs had high reliability (alpha: 0.91), a significantly lower SEM than the SBAQs (p < 0.001) and higher mean item-total point biserial correlations (p < 0.001). The VSAQ scores were significantly lower than the SBAQ scores (p < 0.001). The difference in scores between VSAQs and SBAQs was attenuated in Group 2. Although 80.4% of students found the VSAQs more difficult, 69.2% found them more authentic.

Conclusions: The VSAQ format demonstrated high reliability and discrimination and items were perceived as more authentic. The SBAQ format was associated with significant cueing. The present results suggest the VSAQ format has a higher degree of validity.
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http://dx.doi.org/10.1111/medu.13504DOI Listing
April 2018
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