Introduction: Graduate healthcare students experience significant stressors during professional training. Mindfulness-Based Stress Reduction (MBSR) is a behavioural intervention designed to teach self-regulatory skills for stress reduction and emotion management. This study examines the impact of MBSR training on students from five healthcare graduate programs in a quasi-experimental trial. Methods : A total of 13 students completed the MBSR program and were compared with 15 controls. Both groups answered validated questionnaires measuring anxiety, burnout and empathy at baseline, at conclusion of the course (week 8) and 3 weeks post-course completion (week 11). Results : Significant decrease in anxiety at weeks 8 and 11 compared with baseline (P<0.001 and P<0.01, respectively) was observed using the Burns Anxiety Inventory. Significant increase in empathy at week 8 (P<0.0096) was observed using the Jefferson Scale of Physician Empathy. Week 11 demonstrated a decrease in empathy from baseline (not statistically significant) across all subjects. No significant differences in burnout scores at weeks 8 and 11 were observed between those in the intervention and control groups. Conclusions : These results provide supportive evidence of MBSR as a behavioural intervention to reduce anxiety and increase empathy among graduate healthcare students.

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Context : There is growing interest worldwide in social accountability for medical and other health professional schools. Attempts have been made to apply the concept primarily to educational reform initiatives with limited concern towards transforming an entire institution to commit and assess its education, research and service delivery missions to better meet priority health needs in society for an efficient, equitable an sustainable health system. Methods : In this paper, we clarify the concept of social accountability in relation to responsibility and responsiveness by providing practical examples of its application; and we expand on a previously described conceptual model of social accountability (the CPU model), by further delineating the parameters composing the model and providing examples on how to translate them into meaningful indicators. Discussion : The clarification of concepts of social responsibility, responsiveness and accountability and the examples provided in designing indicators may help medical schools and other health professional schools in crafting their own benchmarks to assess progress towards social accountability within the context of their particular environment.

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Introduction : Reflection and reflective practice is of increasing importance in medical education curricula. The aim of this review is to summarise the literature published around facilitating reflection in a medical course, and to answer the question : W0 hat is the current evidence regarding learning and development moments across the medical curriculum in developing students' reflective practice? Methods : A review of the literature was undertaken using defined databases and the search terms 'medical students', 'medical education', 'reflection', 'reflect*' and 'medicine'. The search was limited to peer-reviewed published material in English and between the years 2001 and 2011, and included research, reviews and opinion pieces. Results : Thirty-six relevant articles were found, identifying enhancing factors and barriers to effectively teaching reflective practice within medical curricula, relating to: The breadth of the meaning of reflection; facilitating reflection by medical educators; using written or web-based portfolios to facilitate reflection; and assessing the reflective work of students. Discussion : A variety of reflective purposes was found in this literature review. Evidence indicates that, if students are unclear as to the purpose of reflection and do not see educators modelling reflective behaviours, they are likely to undervalue this important skill regardless of the associated learning and development opportunities embedded in the curriculum.

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Background: The Training for Health Equity Network (THEnet), a group of diverse health professional schools aspiring toward social accountability, developed and pilot tested a comprehensive evaluation framework to assess progress toward socially accountable health professions education. The evaluation framework provides criteria for schools to assess their level of social accountability within their organization and planning; education, research and service delivery; and the direct and indirect impacts of the school and its graduates, on the community and health system. This paper describes the pilot implementation of testing the evaluation framework across five THEnet schools, and examines whether the evaluation framework was practical and feasible across contexts for the purposes of critical reflection and continuous improvement in terms of progress towards social accountability. Methods: In this pilot study, schools utilized the evaluation framework using a mixed method approach of data collection comprising of workshops, qualitative interviews and focus group discussions, document review and collation and analysis of existing quantitative data. Results: The evaluation framework allowed each school to contextually gather evidence on how it was meeting the aspirational goals of social accountability across a range of school activities, and to identify strengths and areas for improvement and development. Discussion: The evaluation framework pilot study demonstrated how social accountability can be assessed through a critically reflective and comprehensive process. As social accountability focuses on the relationship between health professions schools and health system and health population outcomes, each school was able to demonstrate to students, health professionals, governments, accrediting bodies, communities and other stakeholders how current and future health care needs of populations are addressed in terms of education, research, and service learning.

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Background: Individuals who are lesbian, gay, bisexual, transgender (LGBT), gender nonconforming, and/or born with differences of sex development have specific health needs and significant health disparities exacerbated by a lack of training among health professionals. The University of Louisville LGBT Health Certificate Program used an interdisciplinary approach to increase training, potentially enabling future physicians to provide quality healthcare to LGBT patients. Methods: A pretest-post-test design was used to investigate medical students' (n = 39) attitude and knowledge outcomes after program participation. Attitudinal items with Likert-type responses were analyzed using the Wilcoxon signed-rank test. Baseline frequency and percentage of correct responses were tabulated for knowledge questions. At both pre- and post-test, the 11 knowledge items were summed to establish a total knowledge score, creating two total scores. The paired sample t-test was used to evaluate the pre- and post-change, and Cohen's D was used to assess effect size. All P values were two-tailed. Statistical significance was set by convention at P < 0.05. Results: Students correctly answered 69% or less of the knowledge questions at baseline. Total correct knowledge scores significantly increased post intervention with the effect size being large (Cohen's D = 0.90, P < 0.001). Attitudes significantly increased post intervention on two items (P = 0.019 and P = 0.037). Some attitude items decreased post intervention: students felt it is more challenging to conduct a patient history with a LGB patient (pre-mean agreement = 2.44; post-mean agreement = 2.97, P = 0.018). Conclusions: Medical educators can play a critical role in decreasing LGBT healthcare disparities. The University of Louisville LGBT Health Certificate Program played an important first step in increasing medical students' knowledge and improving certain attitudes about LGBT patients.

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Background: Several predictors of medical school performance have been identified, yet more research is needed to select applicants who will perform well. Grit is a personality trait that is described as persevering through difficult tasks. Although it is hypothesized that this type of trait would be high in a medical student population, this has not been studied. The purpose of this study was to examine grit among medical students and to explore whether grit-predicted performance in medical school. Methods: There were 131 graduating medical students who completed a questionnaire in May 2014 on grit as well as demographic questions and involvement in other activities in medical school. Data on test scores, years in medical school, and class ranking were obtained from the medical school. Results: The average grit score among 130 medical students was high (mean = 4.01, standard deviation = 0.42). Those who completed the program in 4 years had higher grit scores than those who completed in 5 years (P = 0.01). Grit was related to medical school performance including clinical knowledge scores (P = 0.02). There was also a difference between the highest and lowest class rank (P = 0.03). Discussion: Medical students have high levels of trait-like perseverance and it appears that those with higher levels of grit are more likely to perform better in medical school.

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Context: Low back pain (LBP) is the most common orthopedic problem worldwide and is known to affect both younger and older adults. The stressful and time consuming curriculum of medical students predisposes them to this problem. Few statistics are available on prevalence rates of LBP among medical students in India. This study assesses the prevalence and risk factors of LBP in students of a medical college in Delhi. Methods: A cross-sectional study was carried out in a medical college in Delhi. The study subjects (n = 160; 100% participation) were selected via stratified random sampling from all undergraduate medical students (aged 17-25 years). A validated questionnaire was used to collect the data. Results: The overall prevalence of LBP among the students over the past one year was 47.5% (n = 76) with a prevalence of 32.5% at the time of data collection. Prevalence among males and females was 45.3% and 50%, respectively. Significant associations were found between LBP in the past year and coffee drinking (Regular = 57%, Occasional = 38.9%, Never = 65.2%, χ² = 7.24, P= 0.02), body posture (Normal = 32.6%, Abnormal = 75%, χ² = 18.97, P < 0.001), place of study (Study table = 33.8%, Bed = 58.6, Both = 61.5% χ² = 10.51, P = 0.01), family history of LBP (Present = 75%, Absent = 38.3%, χ² = 16.17, P < 0.001) and carrying backpacks (Regular = 50%, Occasional = 33%, Never = 0%, χ² = 16.17, P < 0.001). The mean scores of depression (2.7 vs. 1.6), anxiety (3.5 vs 1.9), and monotonous work (3.9 vs. 1.8) were found to be significantly higher in group with LBP than in the non-LBP group. However, no association with LBP was seen for weight lifting, watching television/working on computers, driving, wearing heels, or body mass index. Discussion: The high prevalence of LBP among medical students and its association with poor study habits, lifestyle habits, and psychological factors highlight a need for life skills training, education, counseling, and restructuring of the medical curriculum.

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Introduction: Mentorship is a critical element of capacity-building for health research as it can support career counseling, promote interest in health research and build professional networks. Few studies of mentorship have taken place in low- and middle-income countries. This paper explores the mentorship dimension of the Fogarty International Center's (FIC) support to research training in Kenya and Uganda. Methods: This exploratory study documents the nature of mentoring that occurred within FIC programs, considers the outcomes of mentoring, and the strengths and weaknesses of FIC trainee mentorship during and after training. Two case studies were conducted, at the University of Nairobi in Kenya and Makerere University in Uganda. Semi-structured interviews were conducted with former trainees, principal investigators and institutional leaders, exploring their perceptions of mentoring and its effects. Results: Mentoring aspects of FIC programs were highly valued. Respondents felt that following formal training in the US there was much still to learn about conducting research, and mentoring relationships provided support in applying for and implementing research grants. Mentoring arrangements were initially with US collaborators, but over time relationships with senior African colleagues became critical, particularly in terms of navigating university administrative systems. Mentees were typically highly motivated to pass their skills on to others, and became eager mentors later in their careers. A minority of respondents raised concerns about directive approaches to mentorship that reflect more hierarchical rather than egalitarian approaches. Discussion: Mentorship during and after FIC research training programs, while largely informal in nature, appears to have very positive impacts upon career development and inclination to remain in health research. Local African mentors often play a critical mentorship role, and their contributions should be better recognized.

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Background: Community-based medical education (CBME) is the delivery of medical education in a specific social context. Learners become a part of social and medical communities where their learning occurs. Longitudinal integrated clerkships (LICs) are year-long community-based placements where the curriculum and clinical experience is typically delivered by primary care physicians. These programs have proven to be robust learning environments, where learners develop strong communication skills and excellent clinical reasoning. To date, no learning model has been offered to describe CBME. Methods: The characteristics of CBME are explored by the authors who suggest that the social and professional context provided in small communities enhances medical education. The authors postulate that meaningfulness is engendered by the authentic context, which develops over time. These relationships with preceptors, patients and the community provide meaningfulness, which in turn enhances learning. Results and Discussion: The authors develop a novel learning model. They propose that the context-rich environment of CBME allows for meaningful relationships and experiences for students and that such meaningfulness enhances learning.

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Background: There has been a worldwide movement toward competency-based medical education and training. However, this is the first qualitative study to analyze the perceptions of surgical trainees and surgeons toward competency-based education in the operating theatre. We aim to examine views toward the specific learning and teaching of the nine competencies of the Royal Australasian College of Surgeons (RACS) and to explore perceived ideal conditions and challenges for learning and teaching these competencies in the operating theatre. Methods: Individual semi-structured interviews with surgical trainees and surgeons in the specialty of General Surgery. Ten surgical trainees and surgeons who worked together were purposively sampled, for maximum variation, from an outer metropolitan public hospital in Melbourne, Australia, to identify emergent themes relating to learning and teaching surgical competencies in the operating theatre. Results: Five themes were identified as: (1) Learning and teaching specific surgical competencies is through relationship based mentoring and experiential learning; (2) Ideal conditions and challenges in the operating theatre are availability of time and personal attitude; (3) Level of pre-operative briefing was variable; (4) Intra-operative teaching is perceived as structured; and, (5) Post-operative debriefing is recognized as ideal but not consistently performed. Discussion: Professional relationships are important to both surgical trainees and surgeons in the process of learning and teaching competencies. Ad hoc apprenticeship style learning is perceived to remain prominent in the operating theatre. Sufficient time for training is valued by both groups. The surgical competencies are inherently different to each other. Some appear more difficult to learn and teach in the operating theatre, with technical expertise most readily identified and health advocacy least so. Elements of guided discovery learning and other educational models are described. Further emphasis on structured competency-based teaching methods may be beneficial for surgical trainees, surgeons and other specialties, both in Australia and worldwide.

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Background: Empathy is a crucial component of medicine. However, many studies that have used quantitative methods have revealed decline of learners' empathy during undergraduate and postgraduate medical education. We identified medical students' and residents' conceptual structures of empathy in medicine to examine possible differences between the groups in how they conceive empathy. Methods: We conducted a qualitative study with two focus group discussions in which six medical students and seven residents participated separately. The transcripts of the focus group discussions were analysed combining qualitative data analysis and theoretical coding. Results: Medical students and residents had different conceptual structures of empathy. While medical students thought that sharing emotions with patients was essential to showing empathy, residents expressed empathy according to their evaluation of patients' physical and mental health status. If the residents thought that showing empathy was necessary for the care of patients, they could show it, regardless of whether they shared the patients' emotions or not. Conclusions: The comparison of medical students' and residents' conceptual structures of empathy reveals a qualitative difference. Residents show more empathy to their patients by a cognitive decision as clinicians than medical students do. Communication skills training should consider the qualitative change of students' and residents' empathy with clinical experience. We should consider the change when we evaluate learners' empathy and introduce methods that cover the qualitative range of empathy.

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Background: Medical students feel a significant amount of stress due to a variety of factors. Few studies have explored the relative size of these various stressors to identify which are most important. This study was undertaken to quantify the magnitude of various sources of stress among students of a medical college at Kolkata, West Bengal, and also to assess the reliability of Medical Students' Stressor Questionnaire (MSSQ-40) in this context. Methods: We evaluated the degree of stress along various dimensions using the MSSQ-40, a scale to measure stress among medical students that has been validated in other countries. Differences in stress and its causal factors were analyzed across demographic subgroups. The reliability of the MSSQ-40 was evaluated using Cronbach's alpha. Results: The overall prevalence of stress was 91.1% and the vast majority of students (94.9%) were stressed due to academic reasons. Academic related stress was found to be higher among students who are not conversant with the local language, experienced a change in medium of teaching from secondary school to medical school, and resided in a hostel. The MSSQ-40 in general, and its academic-related stress domain specifically, were found to be reliable in our setting. Discussion: Early detection and remedying stressors will help to build physical and mental health in medical students. Language training early during the medical course might reduce academic stress among our students. Further studies should relate individuals' stress with their academic performance.

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Introduction: One of the newest teaching modalities in health education is the use of human patient simulators (HPS). A simulation scenario creates a software program vignette in which nursing, medical, and other students interact with a manikin to practice caring for patients in a risk-free environment. Although used extensively in schools of nursing, there is little research that examines if these expensive simulators improve the clinical decision-making ability of nursing students. The purpose of this quasi-experimental differentiated treatment study was to assess if HPS technology leads to greater clinical decision-making ability and clinical performance compared to the teaching modality of a paper and pencil case study. Methods: Students (n = 133) learning about the care of a patient with a myocardial infarction at four licensed practical nursing programs (LPN) in Pennysylvania, USA were randomly assigned to one of two groups at each site: an HPS simulation group or a paper and pencil case study group. One-tailed, independent t-tests were used to compare learning gains measured by differences in pre- and postclinical decision-making exam scores and clinical performance. Results: Results indicated that students in the simulation groups were significantly more likely to score higher on the clinical decision-making exams and to respond clinically by performing CPR more quickly on the manikin than students in the case study groups. On the 100-point exam, the simulation groups had a 20-point gain, while the case study groups had a 12-point gain (P < 0.001). Students in the simulation groups provided CPR to a manikin 30 seconds faster, on an average (P < 0.001). Discussion: Results validate the use of HPS technology in nursing education. Ultimately patients may benefit from increased knowledge and speed of care from practical nurses whose training was improved through the use of HPS technology.

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Background: Due to widespread awareness of global inequities in health and development, participation and interest in International Medical Electives has grown. However, it has been suggested that the benefits of these electives for students and communities may not outweigh the harms. Pre-departure training (PDT) has been proposed as a route through which participants can adequately prepare for their elective experience. Methods: Through a review of the current literature, this article explores the ethics of international medical electives using a social accountability framework and assesses the success of PDT in mitigating harms for students and communities. Results: We find that the literature on PDT is limited. What is clear from completed studies is that the focus of PDT has often been centered on the clinical experience, while theories of development and health inequity remain minor topics. We argue that a greater benefit for students and communities could be gained from framing health inequity from a critical perspective, and integrating mandatory global health education into medical school curricula. Discussion: We suggest that attention to only PDT is not enough. In a socially accountable program, community partnerships must be bilateral and respect communities as primary stakeholders in the training of students and in program evaluation. Unfortunately, research to-date has focused on the student experience; further studies of the community perspective would help to elicit how PDT and partnership models can be strengthened, improving the experiences of both students and communities. Finally, individual medical schools and organizations that offer global health elective experiences must ensure that they take responsibility for monitoring PDT.

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Background: During the course of their education, medical students learn to attend to the quality of life of their patients. However, their own quality of life can begin to decrease early in medical school. The purpose of this study was to compare the quality of life of medical students to that of others their age, taking into account the medical school phase and gender. Methods: We used the short version of the World Health Organization Quality of Life Instrument to assess psychological well-being, physical health, social relationships and environmental conditions. The quality of life among 206 medical students was compared to that of 199 young people from a normative population using independent sample t- tests. In addition, the effects of medical school phase and gender on quality of life domains were also assessed by two-way between-groups analysis of variance. Results: Medical students showed worse psychological well-being and social relationships than young people in the normative sample. About one-half of the students revealed a low quality of life in the psychological and social domains and one-quarter showed a low quality of life in the physical health and environment domains. Medical school phase did not influence quality of life, however, gender had a large effect, where female students showed worse physical and psychological well-being than male students. Discussion: Poor psychological well-being and social relationships can have implications that exceed the doctor's personal well-being. Future doctors with a low quality of life may translate into their poorer performance, impairing patient care.

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Scientific paper authorship is an important academic achievement for all research professionals. Being designated as an author of a paper has academic, research, social and financial implications. Signing of a manuscript as an author does confer credit but also transfers responsibility. While authors get credit for the published work, they must accept the public responsibility that goes with it. Over the past few years, there has been a rising trend in authorship abuses. The prevalent culture of "publish or perish" appears to be responsible for this. In an endeavor to ensure honest practice, the International Committee of Medical Journal Editors (ICMJE), the Vancouver Group, developed the criteria for authorship and said that "all persons designated as authors should qualify for authorship and all those who qualify should be listed." However, authorship irregularities continue to exist and are a cause of concern. Budding authors should be enlightened about concurrent problems in authorship, during their formative years and encouraged toward fair practices in publications.

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Background: The concept of the social accountability of medical schools has garnered many followers, in response to a broad desire for greater social justice in health care. As its use has spread, the term 'social accountability' has become a meta-narrative for social justice and an inevitable and unquestionable good, while at the same time becoming increasingly ambiguous in its meaning and intent. In this article, we use the lenses of postmodernism and critical reflexivity to unpack the multiple meanings of social accountability. In our view, subjecting the concept of 'social accountability' to critique will enhance the ability to appraise the ways in which it is understood and enacted. Discussion: We contend that critical reflexivity is necessary for social accountability to achieve its aspirations, and hence we must be prepared to become accountable not only for our actions, but also for the ideologies and discourses underlying them.

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Context: The Medical Education Partnership Initiative (MEPI) is a $US 130 million program funded by the United States government supporting 13 African medical schools to increase the quantity, quality, and retention of physicians in underserved areas. This paper examines how community-based education (CBE) is evolving at MEPI schools to achieve these goals. Methods: We utilized data from the first two years of site visits and surveys to characterize CBE efforts across the MEPI network and provide detailed descriptions of three models of CBE among the MEPI programs. Results: There is widespread investment in CBE, with considerable diversity in the goals and characteristics of training activities among MEPI schools. Three examples described here show how schools are strengthening and evaluating different models of CBE to achieve MEPI goals. In Nigeria, students are being sent for clinical rotations to community hospitals to offload the tertiary hospital. In Uganda, the consistency and quality of teaching in CBE is being strengthened by adopting a competency-based curriculum and developing criteria for community sites. At Stellenbosch University in South Africa, students are now offered an elective year-long comprehensive rural immersion experience. Despite the diversity in CBE models, all schools are investing in e-learning and faculty development. Extensive evaluations are planned to examine the impact of CBE strategies on the health workforce and health services. Discussion: The MEPI program is stimulating an evolution in CBE among African medical schools to improve the quality, quantity, and retention of physicians. Identifying the strategies within CBE that are reproducible, scalable and optimize outcomes will be instructive for health professions training programs across the continent.

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Context: There is considerable evidence that emotional intelligence, previous academic achievement (i.e. cumulative grade point average (GPA)) and personality are associated with success in various occupational settings. This study evaluated the relationships of these variables with psychological health of first year medical students during stressful periods. Methods: A 1-year prospective study was done with students accepted into the School of Medical Sciences, Universiti Sains Malaysia. Information on emotional intelligence, GPA and personality traits were obtained prior to admission. The validated Universiti Sains Malaysia Emotional Quotient Inventory and Universiti Sains Malaysia Personality Inventory were used to measure emotional intelligence and personality traits, respectively. Stress, anxiety and depression were measured by the 21-item Depression Anxiety Stress Scale during the end-of-course (time 1) and final (time 2) examinations. Results: At the less stressful period (time 1), stress level was associated with agreeableness and the final GPA, anxiety level was associated with emotional control and emotional conscientiousness and depression level was associated with the final GPA and extraversion. At the more stressful period (time 2), neuroticism associated with stress level, anxiety level was associated with neuroticism and emotional expression, and depression level was associated with neuroticism. Conclusions: This study found that neuroticism was the strongest associated factor of psychological health of medical students during their most stressful testing period. Various personality traits, emotional intelligence and previous academic performance were associated factors of psychological health during a less stressful period. These data suggest that early identification of medical students who are vulnerable to the stressful environment of medical schools might help them maintain psychological well-being during medical training.

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Background: Written health information is commonly used by health-care professionals (HCPs) to inform and assess patients in clinical practice. With growing self-management of many health conditions and increased information seeking behavior among patients, there is a greater stress on HCPs and researchers to develop and implement readable and understandable health information. Readability formulas such as Flesch Reading Ease (FRE) and Flesch–Kincaid Reading Grade Level (FKRGL) are commonly used by researchers and HCPs to assess if health information is reading grade appropriate for patients. Purpose: In this article, we critically analyze the role and credibility of Flesch formula in assessing the reading level of written health information. Discussion: FRE and FKRGL assign a grade level by measuring semantic and syntactic difficulty. They serve as a simple tool that provides some information about the potential literacy difficulty of written health information. However, health information documents often involve complex medical words and may incorporate pictures and tables to improve the legibility. In their assessments, FRE and FKRGL do not take into account (1) document factors (layout, pictures and charts, color, font, spacing, legibility, and grammar), (2) person factors (education level, comprehension, health literacy, motivation, prior knowledge, information needs, anxiety levels), and (3) style of writing (cultural sensitivity, comprehensiveness, and appropriateness), and thus, inadequately assess reading level. New readability measures incorporate pictures and use complex algorithms to assess reading level but are only moderately used in health-care research and not in clinical practice. Future research needs to develop generic and disease-specific readability measures to evaluate comprehension of a written document based on individuals' literacy levels, cultural background, and knowledge of disease.

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Introduction: Understanding the impact of culture on medical communication is particularly important for international medical graduates (IMGs) who enter health systems from different cultures of origin. This article presents data on IMGs' perception of the impact of cultural factors on IMG doctor−patient communication during their integration into the Australian health system. Methods: The methodology used was a descriptive qualitative methodology, using iterative, open-ended, in-depth interviews with a sample of 30 IMGs employed at a hospital in Brisbane, Queensland, Australia. Results: According to subjects' comments, understanding patient-centered communication is a major challenge faced by IMGs during integration in the Australian health system. They perceive that this difficulty is associated with the major shift from the culture of their country of origin (described as paternalistic doctor-dominated communication system; standard practice to talk to the family and not the patient) to the very different health care culture of Australia (perceived to be more educated and informed consumers that demand high levels of information and discussion). The findings detail IMGs' experience with learning about patient-centered communication at the point of arrival, during integration and practice. Subjects' perceived the need to provide education on patient-centered communication for IMGs integrating into the Australian health system. Conclusion: There is a significant need for IMGs to be educated in cultural issues including doctor−patient communication practices in Australia.

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Introduction: Cultural diversity among students in tertiary institutions in Australia and globally has increased rapidly in the last decade, and is continuing to do so. Methods: Focus groups were held at the University of Newcastle, NSW to: (1) examine the specific needs of international students in the Master of Pharmacy, Bachelor of Medicine and Bachelor of Nursing programs in relation to language and cultural considerations and (2) to understand the attitudes of domestic students to the cultural issues faced among their peers. The project explored these issues with the intention to inform curricula changes to accommodate the needs of culturally and linguistically diverse students. Results: The key themes emerging from international students were: difficulties in spoken language, differences in professional roles and expectations, differences in methods of learning, inadequate social interaction outside the classroom and acceptance of differences in cultural and religious practices. The domestic student views reinforced the comments from international students both in regard to social interaction and in regard to participation in class discussions. Although local students were interested in learning from international students about their culture and religious beliefs, there were limited initiatives from both sides. Discussion: There is a need for tertiary institutions that benefit economically from increasing the numbers of international students to help them to study and live in a new environment. Assistance needs to go beyond learning the English language to helping students understand its use in a professional context (health terminology and slang used by patients), the nuances of the health professional disciplines in a western society, the approach to study and problem-based learning styles and skills to assist with social interaction. The results of the present exploration have led to a series of proposed actions for the University of Newcastle. These recommendations are applicable to any "Western" teaching institution with a large number of international students from developing countries enrolled in their health programs.

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Background: The number of places available in Ireland and the United Kingdom (UK) for graduate entry to medical school has increased in the past decade. Research has primarily focused on academic and career outcomes in this cohort, but attitudes towards professionalism in medicine have not been systematically assessed. The purpose of this study was to compare the importance of items related to professional behaviour among graduate entrants and their 'school-leaver' counterparts. Methods: This was a quantitative cross-sectional study, conducted in University College Cork (UCC), Ireland. A validated questionnaire was distributed to undergraduate-entry (UG) and graduate-entry (GE) students with items addressing the following areas: Demographic and academic characteristics and attitudes towards several classes of professional behaviours in medicine. Results: GE students ascribed greater importance, relative to UG students, to various aspects of professionalism across the personal characteristics, interaction with patients and social responsibility categories. Additionally, in UG students, a significant decrease in perceived importance of the following professionalism items was evident across the course of the degree programme: Respect for patients as individuals, treating the underprivileged and reporting dishonesty of others. Among both groups of students, individual mentoring was rated the most important method for teaching professionalism in medicine. Discussion: This study is the first comparison of attitudes to professionalism in UG and GE students. This study highlighted important group differences between GE and UG students in attitudes towards professional behaviours, together with different perspectives regarding how professionalism might be incorporated within the curriculum.

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Introduction: Teaching residents how to reflect and providing ongoing experience in reflection may aid their development into adaptable, life-long learning professionals. We introduced an ongoing reflective exercise into the curriculum of a family medicine residency program. Residents were provided 15 minutes, three times a week, to complete these reflective exercises. We termed these reflective exercises "clinical blogs" since they were entered into a web-based computer portfolio, though they were not publicly available. The aim of this study is to explore family medicine residents' responses to the introduction of an ongoing reflective exercise and examine strengths and challenges of the reflective process. Methods: We invited a cohort of family medicine residents (8 residents) who had all participated in the reflective exercises as part of their residency to participate in one of two offered focus groups to share their experience with the reflective exercise. An investigator not connected to the training program led each focus group using minimal structure in order to allow for the breadth of residents' experiences to be revealed. The focus groups were audio recorded, and the recordings were transcribed verbatim without identifying participants. We used a grounded theory approach, using open coding to analyze the focus group transcripts and to identify themes. Results: Four residents participated in each focus group. We identified four main themes regarding family medicine residents' responses of the reflective practice exercises: (1) Residents viewed blogging (reflecting) as a method of enhanced personal and professional self-development; (2) Despite the reflective exercises being valued as self-development, residents see an inherent conflict between self-development and professional duties; (3) Residents recognize their emotional responses, but writing about emotional issues is difficult for some residents; and (4) Clinical blogging in our residency has not reached its potential due to the way it was introduced. Discussion: The themes indicate that future efforts at integrating reflective practice should further test the methods through which regular reflective practices are introduced. Identified themes provide evidence for reflection as enhancing capacity for self-development and suggest the potential for clinical blogging as a method to build a cornerstone for the capacity for reflective practice in medicine.

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Background: Longitudinal integrated clerkships (LIC) in the first major clinical year in medical student training have been demonstrated to be at least equivalent to and in some areas superior to the "traditional block rotation" (TBR). Flinders University School of Medicine is starting a pilot changing the traditional teaching at the major Academic Medical Centre from TBR to LIC (50% of students in other locations in the medical school already have a partial or full LIC programme). Methods: This paper summarises the expected challenges presented at the "Rendez-Vous" Conference in October 2012: (a) creating urgency, (b) training to be a clinician rather than imparting knowledge, (c) resistance to change. Results: We discuss the unexpected challenges that have evolved since then: (a) difficulty finalising the precise schedule, (b) underestimating time requirements, (c) managing the change process inclusively. Discussion: Transformation of a "block rotation" to "LIC" medical student education in a tertiary academic teaching hospital has many challenges, many of which can be anticipated, but some are unexpected.

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