nm0309: so [0.7] with that i shall introduce our [0.2] next speaker [0.7] Dr 
namex who's based at the undergraduate [0.4] er Department of [0.3] General 
Practice at namex University [0.6] he is a senior lecturer in medical education 
and the clinical [0.4] education [0.4] lead within [0.3] er the department of 
[0.4] general practice [0.4] and namex is going to talk to us about the impact 
of a special study module [0.4] on student attitudes [0.2] namex [0.5] 
nm0310: thank you [17.1] right i've cheated slightly [0.4] because at the time 
i was [0.2] er invited by namex [0.8] to give a talk [0.3] er [0.3] i was 
thinking something [0.3] slightly different from what i'm thinking at the 
moment [1.5] but [0.2] i hope that what i will provide you with is an attitude 
to consid-, er er an opportunity to consider [0.6] er [0.2] what we mean by 
attitudes and how we might measure them [0.9] and the means by which i'm going 
to do this is i'm going to [0.3] describe to you hopefully reasonably briefly 
[0.5] a course which i developed in conjunction with er [0.8] a a development 
charity based in namex called Skillshare International [1.3] and the er [0.6] 
the er principal aim of the charity [0.5] er is to work [0.3] in partnership 
with people [0.2] er and communities in Africa and India [0.5] er to promote 
development [0.4] and er [0.4] the means by which they do this is [0.2] partly 
by recruiting development workers to go [0.2] and work and share their skills 
hence the name [0.6] er [0.2] with people in those communities [0.6] but more 
recently they've developed er [1.1] an arm of the charity which looks at 
development education within the U-K [0.7] and jointly with David Weatherall 
who was at the time the development er education officer at er Skillshare [0.7] 
er we devised and developed a [0.2] er course for [0.5] er students in the 
special study module section of the phase one curriculum [0.4] er [0.7] now [0.
9] er [0.5] what the aim of the course was was to develop their understanding 
of issues around [0.2] health and international development [0.5] and er David 
and i were quite open er with the students that we obviously brought to this 
course a set of attitudes beliefs and 
orientation towards development issues [0.5] and we made those explicit we we 
made it quite clear that we didn't [0.3] necessarily expect them to agree with 
us and we were very happy to discuss [0.4] any conflicting or different 
opinions or attitudes towards development issues [1.8] er [0.3] in order to 
help you under sort of stand what we did the special study module is a twelve 
week course it occupies twelve consecutive weeks in semester five which in 
traditional terms is September through to December [0.6] of the third year [0.
6] and we have a day a week and generally the pattern of teaching that we 
adopted was [0.3] we were giving taught sessions in the mornings [0.4] er and 
they would have time in the afternoons for self-study [0.4] and to develop 
their assessment plans [1.4] and we set out er at the outset we had four themes 
that we wanted to study which sort of [0.3] kind of drew on the skills and er 
[0.4] of [0.3] the people within Skillshare who were able to teach on 
this course and [0.5] partly address some issues perhaps [0.2] er to do with [0.
4] er things i could bring to it which was issues perhaps more [0.2] tightly 
related to [0.3] becoming a doctor which is about disease control [0.5] 
treatment and elimination [1.8] and also [0.2] er we [0.5] er [0.4] we found 
that this was extremely popular module because as you're probably all aware 
issues of globalization are [0.4] have a high priority in the undergraduate [0.
2] student body at the moment er MEDSIN is a [0.3] very active organization [0.
5] er and is promoting very heavily [0.4] the teaching of these sorts of issues 
within the undergraduate curriculum [1.5] er [0.7] and again what Skillshare 
can bring is to get people to think about their skills and so [0.3] er help 
them to orientate themselves towards [0.4] er [0.7] where they're going [0.2] 
er in their course [1.1] er [1.2] and each theme [0.4] was taught [0.3] er 
around sessions [0.4] er that looked at different aspects of those themes [1.0] 
er [0.7] and again the particular aspects we chose depended more on the availa-,
the interest and availability [0.4] of the teachers who were going 
to do the sessions [0.3] and we expected things like [0.2] looking at the 
disease control of smallpox and malaria [0.2] to act as paradigm [0.3] 
conditions for [0.3] diseases that are prevalent in developing countries [2.6] 
right so that's a quick look at what we did [0.2] and [0.6] er we offered it er 
to twelve students [0.4] er of whom six were female and five were male the 
sixth stu-, the s-, the the twelfth student [0.3] came to our first session [0.
4] er and withdrew because she felt [0.4] that she didn't have enough expertise 
in the area [0.4] er unfortunately she did so by approaching faculty rather 
than me so i wasn't able to reassure her [0.4] that we didn't expect her to 
have expertise [0.7] what i think went wrong [0.3] is that in our round of 
introductions at the very start of the course [0.4] er six of the participants 
had actually lived or er in a developing [0.2] country during all or part of 
their childhood [1.4] and seven them seven of them had a pa-, parent one or 
more parent born outside of 
the U-K [0.3] and in two cases er these were students one from Africa [0.2] er 
one from Nigeria and one from er Egypt [0.3] whose parents er were were 
medically qualified [0.5] so i'm afraid we frightened off the one student who 
thought [0.3] that she was er th group within a group of experts er [1.0] as we 
found out from the assessment process [0.3] er [0.2] she was sincerely wrong 
about that although the students did reasonably good assessments they certainly 
didn't display any great expertise even after twelve weeks of our [0.5] 
[laughter] effective teaching [1.2] and the process we used was we asked them 
to write an individual essay of two-thousand words [0.4] on a topic of their 
own choosing [0.5] er [0.3] but [0.4] er we had offered them a menu of 
different essay titles [0.4] and in fact three of them [1.0] er [0.2] wrote 
essays about breastfeeding and H-I-V transmission [0.6] two about access to 
self water two about prescribing branded drugs [0.4] er two about education as 
the key to health and [0.2] one student wrote an essay about human rights and 
its effect on health [0.3] and 
another about participation [2.3] at the second phase of the assessment we 
divided them into two groups and we asked them [0.3] er to prepare three 
different presentations on the same topic one would be a formal fifteen minute 
presentation very similar to what i'm [0.5] doing here [0.7] the second would 
be a poster again similar to the thing you might prepare for a for a conference 
presentation on the theme [0.6] and the third and most interesting [0.2] and 
certainly the one they i think they enjoyed the best [0.7] was [0.4] what we 
called a resource poor presentation in other words [0.5] er we invited them to 
present on the topic er to a lay audience using no no resources whatsoever [1.
0] well [0.9] the topics they chose and this may reflect the fact we did quite 
a lot of teaching about H-I-V at the start of the course [0.3] was on the 
politics of H-I-V control in Kenya and Uganda [0.5] er and this was the group 
er doing their little role play both groups interestingly chose exactly the 
same tea-, [0.3] technique because the group that had wanted to talk about 
access to H-I-V treatment in South Africa [0.7] again had prepared a mini drama 
[0.9] er [0.5] and er [0.3] th-, as i say they certainly enjoyed it w-, i don't 
know about being resource poor because er [0.4] one group er brought a er an 
inflatable swimming pool [0.3] a plastic gun [0.3] and a large amount of props 
to the presentation [0.2] [laughter] er [0.7] i've given presentations to 
audience in Africa and er [0.4] you're doing pretty well if you've got a [0.3] 
er a chalkboard to write on [2.5] right moving on [0.5] to [1.3] towards what 
i'm hoping to get to [0.3] to give you [0.2] a [0.4] er [0.8] er [0.2] w-, 
wanting really to develop a discussion er hopefully in this half hour slot [1.
6] er but we've we asked them about their view of some of the elements within 
the course [0.5] er [0.4] and [0.5] this slide is is really about [0.4] oh 
sorry [0.2] want to go back again [0.3] er [1.7] had we got the balance right 
about teaching between er [0.3] development topics that related to health and 
global development [1.7] and [0.5] you know did we did they feel 
that er learning in this special study module which is outside the normal range 
of the curriculum [0.5] er [0.4] we were they were learning enough [1.9] er [0.
2] and [0.5] we also wanted them to reflect on the assessment process and as to 
whether that had helped [0.6] er to develop their understanding [3.0] and the 
last question was really the the counter mo-, the counter-question to the one 
about teaching on development topics [1.2] now m-, [0.2] er [0.9] we only got 
ten responses out of the eleven students because er [0.2] one responded by e-
mail so this is a caution if you send out e-mail questionnaires [0.5] er [0.6] 
i-, if students use a different program to [0.2] complete them and send them 
back to you to the one you sent them out in you get a garbled response so [0.4] 
er his [0.4] er s-, his responses to the free text questions were perfectly er 
[0.6] er [0.3] translatable but er the [0.3] the er [1.2] the crosses had 
appeared in the wrong boxes so we didn't know what he was actually saying [1.6] 
i mean my interpretation of these was that [0.4] we probably had for the 
students' view got the 
balance about right between teaching on specific health-related issues and 
development issues [0.7] er and that the course was generally [0.2] well 
received [0.2] er [0.2] and that students er enjoyed it and the informal 
feedback we got was that they'd had a lot of fun [0.6] doing the course and 
they felt they'd learned a lot [0.2] so as it's not my job to entertain them [0.
4] but it is my job to educate them i [0.2] regarded that as [0.4] a success [0.
6] er [1.0] and they felt that the presentations that they had prepared had 
helped them develop their understanding of the issues they'd chosen to study [1.
2] but of course [0.3] these students had volunteered er they'd specifically 
opted to take this course and because this is a popular topic at the moment [0.
4] in medical education it was significantly oversubscribed and some special 
study modules [0.4] may only have two or three applicants [0.4] er [0.4] so to 
have more students wanting to do it than actually did it [0.4] er is perhaps 
not [0.2] er always typical [2.0] er [1.4] and then we wanted to ask them about 
their attitudes to 
the course and in in doing this i think we were hoping [0.5] that we would get 
some kind of handle [0.4] more generally on their attitudes [0.4] er to the 
issues that we wanted to talk about [1.7] so [0.9] again we felt that er [0.4] 
with a couple of exceptions er [0.2] they'd enjoyed the course [0.2] they felt 
[0.4] er challenged to think about deep-, [0.2] deeply about the issues [1.1] 
and that they were more motivated [0.2] er to learn about these issues er in 
the future [1.4] now it's not [0.3] it's it's in no way a an objective of ours 
to recruit people who wish to go and work in a developing country either [0.3] 
to undertake an elective within a developing country [0.6] er although [0.3] er 
we did say that students who w-, [0.3] weren't thinking of doing an e-, 
elective in a developing country would benefit greatly from [0.2] undertaking 
our course [0.9] er [1.0] but [0.2] because we knew we were dealing with 
volunteers and it's certainly one of Skillshare's objectives to get people to 
[0.5] offer their skills [0.2] and work abroad [0.4] it's [0.2] gratifying that 
the majority of them didn't feel 
put off from the no-, [0.2] from the idea of doing that [1.9] so that was their 
attitude to the course and moving on to whether [0.4] their general attitudes 
had changed as a result of the course we asked them [1.4] had they changed and 
ten of them said yes and one said no [1.8] er [1.4] and then when i analysed 
the free text [0.5] quest-, the responses to the free text question [0.7] seven 
of them talked about they felt more aware or more knowledgeable about the 
issues [0.9] three of them felt they had a better understanding [1.7] and four 
of them said they had an increased interest in the topic for the future [1.5] 
but actually very few of them had [0.5] ac-, responded to the question i'd set 
which is had their attitudes changed [2.2] er [0.5] these are the kind of these 
are just a sample of the responses that they made [0.5] er and i've chosen one 
[0.6] from each category [0.2] that i ended up with [2.1] so [0.8] possibly [0.
4] understanding that this is a much more complex issue than they started is er 
[0.2] does represent some sort of attitudinal shift [1.5] and [0.5] perhaps 
becoming 
more sympathetic to the plight of refugees and asylum seekers again [0.5] 
perhaps an attitudinal shift [0.8] er [0.3] and [0.9] if you increase 
somebody's motivation to go and do something [0.4] then [0.2] you perhaps can 
infer [0.2] that there may have been a change in their attitude [0.2] a 
positive change in their attitude towards [0.5] whatever you're asking about [2.
9] the student whose attitudes hadn't changed [0.2] now [0.8] of course that 
may not be a bad thing [0.2] 'cause he may have [0.2] entered the course with 
exactly the kind of attitudes that David and i [0.3] hoped students would 
develop during the course [0.3] and all we did was confirm in him in his 
previous attitudes that [0.4] were what we were interested in [2.2] so having 
sort of done this analysis of the course and realized that actually i'd 
absolutely failed in my objective was to measure attitude change amongst my 
students i went away well first of all what does the word attitude mean [0.9] 
so [0.5] course i headed across to the dictionary like we all do [0.9] and the 
first meaning in the dictionary is all to do 
with er [0.2] body posture [0.3] so i think i felt that definition wasn't 
particularly helpful to me [1.0] the second def-, definition is that a state of 
mind or a feeling [0.2] a disposition [0.6] and the example the dish-, the 
dictionary quotes is had a positive attitude about work [1.7] and the second [0.
2] er [0.6] definition which is probably one better understood by teenagers and 
young people [0.7] is an arrogant or hostile state of mind or disposition [1.6] 
now [0.6] that i find very interesting because it [0.2] made me remember 
something that Lesley Southgate said when she came to namex to give a 
presentation about poorly performing doctors [1.7] and what she found is that 
[0.2] that the s-, the doctors whom [0.5] that [0.4] process has identified as 
poorly performing [0.3] and whom they were having most difficulty [0.4] in 
reforming [0.3] into [0.7] doctors who would perform well in future [0.6] it 
was to do with attitude it was not about their knowledge [0.3] on the whole 
these doctors had good knowledge [0.4] nor was it 
about their skills they were often quite skillful [0.2] er surgeons for example 
where obviously [0.2] skill is [0.2] very important [1.1] and [0.6] they'd 
identified [0.3] this was the particularly different category of doctor to deal 
with [0.6] it also made me remember an incident with one of our students [0.4] 
who and one of our practice teachers rang up and said we're very concerned 
about this student [0.5] because er during the midpoint assessment [0.3] er 
which is [0.2] the clinical assessment with live patients in the doctor's 
surgery [0.4] the student [0.3] possibly a mistaken attempt to [0.2] create a 
light-hearted environment had told a patient [0.3] female patient getting 
undressed for [0.4] not a vaginal examination but an abdominal examination [0.
3] go behind the sceen-, screens and get your kit off [1.0] now [1.3] this was 
a student who i by chance i actually had [0.2] in my small group [0.6] and he 
was a student who'd displayed very great weak-, [0.2] found it very difficult 
to get him to accept that one of the videotape consultations he'd looked 
at [0.4] there were problems in the behaviour and relationship of [0.2] the 
doctor [0.4] on the tape and the patient [0.4] and he was insisting that okay 
the doctor wasn't clinically very competent [0.4] but he was polite and 
therefore he thought this doctor was behaving very well with this patient [0.9] 
and the entire group eventually ended up siding against him [0.6] and he 
wouldn't shift his [0.2] attitude [0.3] towards this performance [1.7] now one 
of the advantages of our style of teaching and i suspect it's true for all the 
medical schools represented here is that our general practice teachers [0.3] 
are pretty good at picking up on these kind of issues [0.6] and generally [0.2] 
er they'll [0.2] they'll [0.3] refer them to us and we will try and get the 
faculty to take some notice of them [0.8] often some difficulty to John 
Cookson's credit when i wrote to him about the student and this incident he did 
call the student in and speak to him [1.1] now [0.5] the problem is [0.5] is 
i've really got no idea whether this student i'm sure the student's 
graduated [0.5] and although he probably said all the right things to John 
Cookson [0.3] i don't really know whether his attitudes have changed very much 
[3.4] so i then wondered what have other people done [0.3] about attitudes [0.
3] so i just did a quick [0.2] er flip through Medical Education [0.3] using 
the keyword attitude in the search [0.4] and came up with seventy-four articles 
where that's the [0.7] where that is a keyword that the author's used to 
describe the purpose of their work [0.4] since January nineteen-ninety-eight [0.
4] forty-six of which relate to undergraduate medical education [1.2] well 
twenty-two of these papers essentially are about the students' teaching and 
learning experience so it's nothing to do with their attitudes [0.9] nine of 
them are about their attitudes towards patients or patient groups almost pr-, 
almost entirely res-, these papers were written by psychiatrists who claim 
people were [0.4] vulnerable there's one paper by an epidemiologist but again 
that's no surprise that [0.5] these two groups of specialties in 
medical schools [0.3] get a bit sensitive about how students perceive their 
speciality [1.1] eleven of the paysh-, er the papers were about particular 
issues or topics er for example [0.5] er [0.9] about the doctor-patient 
relationship or their attitudes towards terminal illnesses er [0.5] as a topic 
on which they were being taught [0.5] and four related to something about their 
personal experiences [1.4] a majority the overwhelming majority of these er [0.
2] papers had assessed student attitude by use of questionnaires [0.3] i guess 
most of them derived [0.2] pr-, precisely the way i derive questionnaires [0.4] 
rather than the way that er Dr namex does [1.0] and many of them depended on 
scale questions and most of them didn't actually attempt to measure change 
although one of although one or two did [2.8] so [0.6] the issues that arose 
then for me is well [0.3] i'd wanted to measure attitude and i hadn't done it 
well okay we hadn't done a before and after questionnaire [0.5] but [0.5] if 
i'm going to measure attitude shift amongst my 
students [0.2] who take the module next September [1.4] these are all 
volunteers who want to study this topic so it [0.2] it may be that they already 
have all the right attitudes and nothing we can do can shift them [0.5] so [0.
3] do we need control groups and [0.2] and although i didn't look in detail at 
all the seventy-four papers [0.4] i didn't detect that any of the ones i do 
look at the abstracts of had actually used control groups when they were 
talking about attitude [2.0] and [2.4] this then relates back to something that 
i think is really much more [0.6] problematic and why i [0.2] related the 
anecdote i did about the student who said get your kit off [1.3] is [1.2] we 
talk about measuring knowledge and skills [0.3] within a medical education and 
there's [0.3] huge vast literature [0.2] about how you do that effectively and 
reliably [1.4] and that's actually quite relatively easy [1.0] but how do we 
measure attitude [0.7] er [1.4] i come from namex so [0.4] the example of Peter 
Green the doctor who sexually assaulted patients in his surgery is obviously a 
very live one for us [0.3] particularly as as he was a partner in one of our 
teaching practices [1.0] and this is a doctor who's regarded as very outgoing 
very cultured [0.5] regarded as a very competent general practitioner by all 
his colleagues [1.4] and [0.4] but [0.2] his attitudes towards his patients [0.
3] were [0.2] about as arrogant as you can get which is that i inject them with 
anaesthetics and i can sexually assault them [2.0] and of course [0.5] there 
were concerns about the attitudes of Harold Shipman [0.8] and because of 
behaviours in previous practices [0.4] but yet his colleagues regarded him as a 
competent doctor and he wasn't being flagged up by any other mechanisms that we 
generally [0.7] use to know and we [0.2] might not use in teaching practice or 
particular practice for teaching because we're concerned about the professional 
competence of the doctors there [1.4] and yet these were two of the most [0.4] 
attitudinally dangerous and [0.3] difficult doctors that we've that have come 
to light and heaven knows how many more 
there are out there that haven't come to light [2.0] so should we measure 
whether our students have appropriate attitudes when they start [1.6] and can 
we assess their attitudes during medical education [2.1] and how do we fine-, 
define what we mean by good and bad attitudes [1.0] and if it is desirable to 
assess them [0.5] how do we prevent students from playing the game [0.5] 'cause 
you can measure their knowledge and that's quite straightforward you can 
measure their skills and if they haven't got skills then they haven't got the 
skills [0.8] but it isn't very difficult if you're as bright as our students to 
spot what the socially desirable answer [0.3] to the question might be [1.4] 
sorry i'm i'm sorry i've overrun a few minutes so i've eaten into your 
discussion time but i will now shut up and [0.7] er hopefully that's sown some 
seeds of thought in your minds [5.1] 
nm0311: can i ask er if you if you if you were to do this again [0.6] would you 
actually have some sort of measure of attitudes before and after it [0.5] 
nm0310: 
yes if i had the time 
nm0311: and by what er [0.2] w-, what would be [0.3] what method would you use 
[0.9] 
nm0310: well if i had the time i'd [0.3] i'd in September i will [0.2] probably 
try to use three [0.2] three groups with the students who come on our module [0.
3] the students who expressed a desire to come on our module who don't get a 
place [0.5] er and the students who had no wish whatsoever to come on our 
module [0.6] er now whether i'll get [0.4] we've of-, we're offering this 
course to eighteen students so whether we'll get [0.7] eighteen students in 
each group i don't know [0.3] er [0.2] and i will design [0.2] er like an 
instrument or if i if i can't find one [0.3] that measures attitudes towards er 
[0.2] issues of global health and development [1.8] 
nm0312: i think the as you said namex the real problem with er measuring 
attitudes of medical students is they're all too clever to say say you devise a 
question like what is your 
attitude to the asylum seeking problem [0.3] no one's going to say well i think 
no-, nobody should be able to come to this country at all and [0.3] they're all 
going to say oh i do sympathize and it's difficult and [0.3] they're all too 
clever to give an answer which is actually going to be truthful aren't they 
which i-, it if it's a if it's an assessment tool [0.6] and that's the real 
problem isn't it how how do you measure it [0.2] 
nm0310: i think that's certainly one of the problems 
nm0312: yeah 
nm0310: yeah [0.6] 
nf0313: has anybody tried to define good and bad attitude 
nm0312: yeah [0.6] 
nm0310: er [0.3] er not that i'm not aware of and i've i've 
nf0313: 'cause surely that's a very subjective [1.5] call 
nm0310: i mean i think the G-M-C has tomorrow's doctors revisited [0.2] 
nf0313: mm 
nm0310: er [0.5] it's pretty obvious what [0.3] would be regarded by the G-M-C 
as er the appropriate set of attitudes er [0.4] and i suppose also in the [0.4] 
guide to good practice as well [0.2] er [1.7] what would be consensus about 
attitude 
is is embedded within them [0.3] but er but of course the more explicit you 
make it [0.4] the the the greater the problem of either of those two [0.2] er 
how do you stop people lying to you when you're asking them [0.4] 
nf0313: the the thing is with attitudes as well is that [0.2] flexibility in 
each area i'm just looking at general practice [0.4] some G-Ps that [0.8] are 
happy with [0.2] referring people for abortion say and some G-Ps that will not 
refer now is that a bad attitude or is that a good attitude you can just [0.4] 
it's [0.3] just very woolly in certain areas isn't it i just feel [0.7] if you 
go in to ha-, to try to create a scale [1.4] 
nm0310: yes and i think in a sense that talking about it is the first step [0.
2] because [0.5] we can agree er obviously as we did in nineteen-sixty-eight 
nf0313: mm 
nm0310: that we would allow doctors to hold both sets of attitudes and both 
would be regarded as socially [0.3] very acceptable it would be regarded as 
acceptable [0.4] what was necessary the [0.4] doctors were honest and explicit 
about their attitudes [0.3] towards the topic of abortion [0.6] er it's what 
you do about [0.5] the the doctors who are not prepared perhaps to be explicit 
[0.4] that they think [0.2] patients are a whingeing bunch of losers who 
shouldn't think of taking up their valuable [0.4] professional time [1.4] yet 
we all recognize them [0.2] yeah [0.4] 
nm0314: i was er i was just reflecting on [0.7] this from the point of view as 
as you're saying knowledge and skills are very easy things to assess aren't 
they [0.4] i'm i'm wondering with the increased [0.9] culture of [0.4] if you 
like political correctness and the issues that are being raised around the 
questionnaire and the the issues the gentleman raised here [0.3] that nobody's 
going to lie on those things [0.3] whether maybe a questionnaire's the right 
tool [0.3] even [0.4] to assess [0.3] in this day and age when people are so 
aware of it [0.3] one of one of the things that fascinated me [0.3] earlier on 
is when you were [1.8] is that is that your questionnaires themselves seem seem 
to give you those sorts of answers [0.2] in 
terms of attitude that reflect on the learning [0.3] 'cause there was a culture 
around an evaluation that says [0.3] what did you learn [0.3] what are the key 
learning issues that you've taken away from today's event [0.3] and maybe 
that's why the response in terms of attitude is that way as well because very 
often you're saying [0.3] how do you now feel [0.2] about working in different 
environments so [0.2] perhaps [0.3] the answer to some of that may be about [0.
3] one to one contact but that is a resource issue clearly [0.6] 
nm0310: yeah 
nm0314: yeah 
nm0310: i know that a very different questionnaire and i think 
nm0314: yeah [0.2] 
nm0310: your suggestions would be ones i would incorporate in writing it er [0.
6] yeah [0.9] 
nf0315: yeah i'm i'm really [0.2] pleased to see this whole issue about 
attitude coming up because i'm in the middle of doing my [0.3] well [0.3] 
towards the end of actually a very big literature search at the 
moment [0.4] about evalaution and various elements of of communication 
including [0.4] er professionalism and attitude which we're trying to 
encapsulate in assessment at the moment [0.5] and doing the full literature 
review the the results that you've just er shown for medical education [0.7] 
are reflected elsewhere and i was i was trying to find examples of papers 
whereby [0.3] external assessors or simulated patients had attempted some 
measure of attitude [0.4] i found about two papers [0.4] and that worked on the 
basis of giving somebody a checklist either an external examiner or a simulated 
patient [0.4] that said er [0.2] s-, on a scale of one to four [0.6] one bad 
four very good [0.4] rate the student's integrity [0.2] rate the student's 
altruism [0.6] on a clinical examination [0.4] i i i found myself reflecting on 
the the impossibility of that task from the point of view of the assessor [0.6] 
and it's obviously something that you've thought about as well and i wondered 
if you had any [0.9] any th-, i i i would be really 
interested to know whether you think it's actually possible to externally 
assess [0.5] er something like a student's integrity [1.7] 
nm0310: er w-, i think yes i think it is possible but how realistic it is that 
we assess this particularly if we were wanting to [0.4] make judgements about 
whether the student should progress in their education or not [0.5] i think 
that's the big difficulty i mean it's interesting what she's saying because [0.
6] the [0.3] process you described in those two papers that have attempted to 
do this probably is actually measuring patient satisfaction [0.3] 
nf0315: yes 
nm0310: which i think is a rather different [0.4] set of concepts to what i 
mean by [0.5] appropriate professional attitudes towards patients themselves 
nf0315: indeed well i think the the well one that i read most recently i can't 
remember the the names of the authors but 
nm0310: mm 
nf0315: i remember reading the paper [0.5] er they concluded that there's no 
point in having a separate measurement for attitudinal professionalism 
nm0310: mm 
nf0315: 'cause there's so many overlaps with their basic communication 
checklist 
nm0310: mm [0.5] 
nf0315: i thought what a shame 
nm0310: mm 
nf0315: because [0.3] every-, everything that you've [0.2] said in your 
presentation i think highlights a real need [0.6] 
nm0310: mm 
nf0315: to take this subject very seriously to find some way of dealing with it 
sensibly [1.0] 
nm0310: mm okay 
nm0316: in in general practice [0.2] er postgraduate education don't trainers 
assess [0.5] their registrars for attitude and and surely that's a more 
realistic 
nf0317: yeah [0.2] 
nm0316: opportunity to assess them by over a year by talking to patients and by 
observing them and [0.6] that's when if someone has got an attitude problem or 
a problem with er professionalism then it's going to get flagged up [0.6] 
nm0310: i'm sure you're right except it's not a field i know about [0.3] 'cause 
i [0.2] my 
background's entirely in [0.2] undergraduate education i mean i [0.2] i'd say 
that i get a feel for it in eight weeks of one to one practice based teaching 
[0.5] er with students er [0.5] 
nm0312: there's quite sorry 
nm0310: but you can have somebody from the back-, er some postgraduate 
background wants to 
nm0312: it's quite easy to mix up an attitude problem with a communication 
problem as well though isn't it patients may perceive that a registrar's [0.5] 
attitude is remiss and what it actually is is their ability com-, to 
communicate and their actual internal attitudes are fine but 
nm0318: mm 
nm0312: it's very difficult to assess isn't it [0.6] 
nf0313: do you thi-, 
nm0310: but is it er i met one of Harold Shipman's patients [0.6] who thought 
nm0312: that they loved him 
nm0310: 
nm0319: yeah [0.9] 
nm0310: er doctor he just [0.2] believed it was right to kill your patients [0.
3] so [1.0] [laughter] albeit [0.2] er a hard case to make by law but [0.5] you 
know [0.2] bringing it back 
to the sort of real world that we live in you you know we all do have these 
vibes about students i mean even in group teaching [0.3] you have vibes about 
students and [0.4] and a student who's sat [0.6] putting data into his P-D-A [0.
3] during a [0.2] seminar [laughter] now [0.6] i mean it does annoy me [0.2] 
but [0.2] i [0.4] er other things about him annoyed me [0.5] er [0.5] now [0.3] 
you know how do i take that forward [laugh] [0.8] 
nm0319: can i just raise a issue to er [0.6] attitude i think is extremely 
difficult assess because [0.5] you're talking about right or wrong [0.6] some 
sort of judgement value isn't it [0.4] er [0.6] to me [0.7] some people might 
say [0.3] collecting a ticket [0.3] in those er [0.8] display car park that 
still [0.4] got time to expire and you take it [0.3] it's illegal but a lot of 
people do and think well that's okay [1.1] [laughter] to so i think sometimes 
issue is [0.2] to me it's more assessing that person what have they got inside 
[1.9] what 
nm0310: well 
nm0319: 
what have they got inside that [0.2] no i know that i might have prejudice [0.
3] because my religious my cultural background [0.3] but i know with my 
professionalism that won't affect [0.4] my performance [0.7] er with a patient 
that to me more important when people know inside like Shipman [0.2] they carry 
on doing it carry on doing it [0.2] eventually that's why they get caught [0.9] 
not because they are not clever enough [0.4] because they lost insight [0.8] 
that's what the police always say in in criminal things [1.1] 
nm0310: yeah it's probably how both Peter Green and Harold Shipman were caught 
i guess because [0.5] they just didn't believe they were going to get caught 
and so they became careless [0.5] i mean 
nm0319: so we all know our weakness ou-, ou-, er but once you know you 
nm0310: yeah 
nm0319: got insight it's no wonder you don't make mistake isn't it [0.8] 
nm0310: yes i mean i-, i-, whether things would have been different [0.2] you 
know [0.4] with [0.6] more robust 
and reliable systems of professional evaluation of your [0.4] peers and your 
colleagues 'cause within group practice [0.3] you would hope it's hard to get 
away with [0.4] i mean to bring it back again to the real world and it might be 
issues like [0.4] i mean overprescribing just because you want quick simple 
consultations now [0.5] you know i think that displays [0.2] remiss political 
atti-, er professional attitudes that need [0.4] to be tackled because [0.4] er 
[0.4] it's it's [0.2] underperforming quite seriously if your response to every 
patient is to prescribe them [0.3] something and finish the consultation in two 
minutes [0.4] but it's very common behaviour [1.3] er i mean one of the things 
that's interesting is is that [0.3] if you sit as i have done on finals exam 
board meetings [0.3] you have this discussion about students [0.4] er who are 
failing [0.5] and [0.4] usually what ha-, they usually fail because they don't 
attend and i think they usually don't attend either because they're ill [0.3] 
which is 
one set of issues or because they're actually they're not motivated to be there 
[0.7] er [0.4] and it's remarkable how people who've been around the system for 
a long time [0.3] have actually spotted these students in the first weeks and 
okay sits there and says yes i knew they were going to be a bad one [0.5] so 
there is something about the comportment the behaviour [0.3] the attitude even 
in a group of a hundred-and-eighty students arriving at the medical school 
people with experience [0.7] feel they can spot students whose attitudes cause 
concern and when they're called to account [0.2] for various reasons during the 
course [0.5] you know that concern is heightened [0.4] but the institution 
finds it very difficult to do anything with that concern [0.6] 
nf0313: how easy is it to change people's attitudes or is it the fact that 
you're [0.5] teaching someone that what they're thinking is wrong even though 
they still think it they should not act in that way [0.4] i don't know [0.8] 
nm0310: 
i i mean i [0.4] [laugh] [0.4] don't know whether anybody has a response to 
that question er [2.1] i mean i think it's difficult [0.3] er [0.2] because you 
can change behaviours i mean [0.7] 
nf0313: it's like your questionnaire you [0.2] when you were interested in 
attitudes before and attitudes afterwards 
nm0310: mm [0.3] 
nf0313: would that come from a knowledge point of view [0.3] [0.7] 
nm0310: i would think if i wrote the questionnaire carefully enough i probably 
could measure real change in attitudes of students who had become [0.2] much 
more positive in their views of [0.2] asylum seekers and refugees or much more 
positive about er [0.3] developing countries that want to [0.3] er [0.5] pr-, 
you know [0.4] er produce pate-, er patented drugs cheaply [0.4] so you could 
say [0.2] well [0.2] those are the attitudes shifts i want to see as a result 
of my course [0.4] er and i'll measure those and [0.2] i mean i can do a 
control group and i can check whether [0.3] they haven't changed in my control 
group [0.6] er [0.4] so you can do 
that [0.3] er [0.2] so you can [0.2] i think you can change attitude [0.4] but 
[0.3] obviously these are r-, relatively insensitive or [0.2] relatively safe 
attitudes to change so it's okay to say [0.3] well i now think more positively 
of asylum seekers because i've met them [0.3] and someone's given me a course 
about them and explained to me why they're here [0.5] and that's quite safe but 
how you deal with the much more serious [0.2] attitudes which is [0.6] 
basically patients are wasters and i don't like sealing seeing them [0.4] er 
because it's socially undesirable [0.4] er to say that [0.2] and yeah [0.3] we 
all know that [0.4] lots of doctors and even students [0.7] er think it [1.0] 
to a greater or lesser degree so [4.3] 
nf0320: colleges try to measure attitudes er because ti postgraduates [0.6] er 
[0.5] for example the M-R-C-G-P examination looks at er and consultation skills 
[0.3] and oral examinations [0.2] do you see that those kind of techniques 
might be wrong for undergraduates [0.8] 
nm0310: 
er [1.9] i think it's difficult because i would [0.4] [sigh] [0.2] i mean if i 
assess a student in [0.4] as i do quite frequently in cl-, in [0.2] using the 
LAP to assess their consultation skills i get [0.3] i feel i get a very [0.5] 
good insight into the [0.2] attitudes and [0.3] i can to some extent i can 
categorize their attitudes [0.4] within the c-, the category of behaviour and 
relationship with patients [0.5] er because i think students who have good 
attitudes towards [0.5] the professional role as a doctor [0.4] will s-, will 
score well in that category [0.4] and s-, [0.2] and it's unusual for students 
to score badly partly i think because when they're assessed using the LAP [0.5] 
as in the assessment tool [0.5] a weak student tends to get rewarded for being 
polite to a patient which is a very different really from what that category 
should be measuring because it should be trying to measure [0.5] a much more 
sophisticated view [0.3] of the relationship the pay-, the student develops 
with the patient [1.0] so i mean you a starting point could well be if you 
had [0.4] you know [0.3] well trained assessors is to [0.2] scrutinize students 
who scored badly in that category [0.2] because they would be flagged up as 
giving cause for concern [0.4] but i think you'd need to go on and develop 
probably more interactive teaching programmes with them [0.4] and you're saying 
look you've got to you've got to see [0.3] in behaviour and relationship that's 
the threshold for us focusing [0.5] on looking at what you do with patients and 
exploring your attitudes [0.4] perhaps i mean i [0.2] you know [0.4] 
psychologists [0.3] think they can devise questionnaires that spot people who 
are lying in questionnaires so [0.5] er maybe we could do that [0.5] but i i 
don't think it's easy but [0.5] given [0.2] the the havoc [0.5] that [0.2] even 
doctors just not [0.4] not the obvious criminals but even doctors who just 
underperform because they have the wrong attitudes [0.4] create through a whole 
of a professional lifetime [0.4] er [0.2] perhaps we should be making a more 
serious attempt to do it [2.6] 
nm0309: 
namex thanks very much [5.8] er [0.3] thank you also for the [0.2] top slide 
because that's [0.2] what our next session [0.4] after coffee [0.4] is going to 
address [0.5] er so we'll be specifically looking at that [0.5] next time [0.3] 
and i think [0.2] er s-, i thought that was absolutely fascinating you've 
raised such an important [0.4] subject 'cause we think a lot about knowledge [0.
4] and skills in [0.3] medical education during medical school training [0.4] 
but we don't [0.6] devote a lot of er [0.2] time to [0.4] what is happening to 
our students' attitudes both at the time of entrance and then what happens 
during their [0.2] training and even what happens in [0.3] during postgraduate 
training so [0.4] thank you very much 
nm0310: thank you [1.1] 
nm0309: we're now going to [0.3] move to coffee which will be in seminar room 
one [0.3] where you had coffee [0.3] at the beginning and then we'll reassemble 
at [0.4] twelve o'clock