Summary: In his latest blog Professor Harden looks into the issues of prisoners, soldiers, and simulation, choosing images for presentations, advice about physical activity, and more Description: Prisoners, soldiers, and simulation
I have been interested in simulation since working in 1969 with a simulated patient presented on the mainframe computer at Glasgow University. The huge progress that has been made since then was highlighted at the recent Society for Simulation in Healthcare Conference in San Antonio in January. While much of the emphasis was on a wide range of sophisticated simulators there were also interesting demonstrations of augmented and virtual reality. I was honoured to be presented at the conference with a Pioneer in Simulation Award. There was interest shown at the meeting in our AMEE stand.

Sue Roff drew my attention to a description of the role of prisoners and soldiers as simulated patients in realistic practice scenarios by Tom McConnachie, lecture in nursing at Dundee in The Conversation article “How prisoners and soldiers are preparing student nurses for life on NHS frontline” ( The school had been looking for volunteers from more marginalised groups to make the simulated experience more authentic for students. The answer was to involve prisoners who had a wealth of knowledge about complex health needs, experience of poor mental and physical health, and the experience of being in the NHS system. More than 60 prisoners have taken part, with benefits both to the students and the prisoners. The prisoners served initially as actors but soon became involved in helping design, deliver, and evaluate the simulation activities, which included diabetes, sexual health, and substance abuse. Local soldiers have also been enlisted to contribute a series of authentic real-life scenarios tackled by student nurses working as a team.

Choosing images for presentations
Pat Thomson in her Patter blog ( of 18/2/19, laments the poor quality of visuals in many presentations and the lack of thought given by the presenter to them. She describes how images can tell a story and how they may complement the oral commentary. She described three different relationships between the image and the oral commentary.
  • Overlap. The words and images tell the same story, dealing with complementary aspects.
  • Displacement. The words and images represent different action components for the same event, for example, when the words are about a policy and the image is about its effects.
  • Dichotomy. The words and images say different things, for example, where the text is about an exam and the image is of a university league table.
I spend a lot of time preparing the images for my presentations but had not thought formally about their role.

Do students not accepted to medical school reapply?
Griffin et al looked at students in Australia who, after an initial failure, chose to reapply to study medicine ( In 2013, 4007 applicants to undergraduate medical schools in the largest state in Australia were unsuccessful. 665 chose to reapply and 3342 did not reapply. The authors compared the profile of those who did not reapply with those who did reapply. The odds of reapplying to medicine were 55% less for those from rural areas and 39% more for those from academically selective schools. Concern was expressed that this may reduce the diversity of medical student cohorts in terms of rural background and educational background.

Advice about physical activity
One of the Scottish Government health priorities is physical activity. Sam Ritchie, an orthopaedic surgeon and chair of the Health and Social Care Physical Activity Development Group reported at a meeting of the Scottish Deans Medical Education Group how physical activity is now being integrated as a subject within the curriculum in Scottish medical schools.

There is a need for doctors to be better trained on how to advise their patients about physical activity. At a recent survey of UK General Practitioners more than 60% reported that they were unsure about advice they should give regarding physical activity. I remember at an OSCE station many years ago students were asked to advise a patient and his wife to be discharged from hospital following a myocardial infarction. Only a few highlighted issues relating to physical activity.

The threat of national licensing examinations
Despite serious opposition, planning continues to implement in the UK a national written licensing examination. At present, it is the responsibility of each school to certify that their graduates have the necessary competencies for practice as specified by the UK General Medical Council. The GMC also monitor the assessment process in each school and external examiners from other schools participate. The argument, however, is that no longer can a school be trusted with this responsibility and that there is a need for standardisation across the country with implications for patient safety. There is no evidence, however, that in countries where there is a national licensing exam the number of errors committed by doctors decreases and the quality of care delivery is better. There is evidence that a national exam may, in fact, have an undesired effect on the curriculum.

Writing in the Spring 2019 issue of Research Intelligence, the British Educational Research Association Newsletter, Ruth Dann notes “In virtually all countries where there are high-stakes assessment systems, there is evidence that the curriculum is narrowed to what is tested.” Despite reassurances to the contrary it is often perceived by students that the clinical skills and “soft” skills are less valued with the education increasingly focused on summative assessment data.

In an article in the same issue Mark Priestly reviews the transformational change with regard to Scotland’s Curriculum for Excellence in schools. He points out the importance of moving from an intended curriculum to an implemented curriculum. Many teachers have only limited understanding of the core principles and purposes of the curriculum, and have not the required professional knowledge about the means to develop their practice in accordance with these. To what extent is this true in medical education?

Should attendance at lectures be mandatory?
The jury is still out on the role of lectures in the curriculum and developments such as the use of the flipped classroom. Some schools require mandatory attendance at lectures, others do not. This issue is discussed by Joe Gerald and Benjamin Brady in ChronicleVitae ( They argue that this creates a false dichotomy – that instructors should either mandate attendance or have no policy at all, “Such reasoning implies that faculty members cannot simultaneously respect students’ autonomy and structure course policies to compel attendance. Students seem to share a dichotomous view. Multiple surveys have shown that undergraduates tend to dislike a mandatory-attendance policy but admit they would miss class more frequently without one. Similarly, most students think that regularly attending class improves their grades but also believe that it is ultimately their decision whether or not to attend.” The authors have introduced an alternative approach. Students were offered one or two attendance policies “the old ‘optional’ one, which offered extra-credit incentives to encourage attendance, or a new ‘mandatory’ one that would reward constant attendance but penalize frequent absences.” Perhaps surprisingly, students overwhelmingly selected the mandatory attendance policy, revealing their desire to hold themselves accountable for attending class regularly. Under the old policy class attendance at lectures averaged 51%. With the new arrangements attendance averaged 88%, including a 92% attendance among the large group of students who had chosen the mandatory policy. There seemed, however, also to be a spill-over effect since attendance also improved to 71% on average among students who picked the old policy.

Spring is here
The temperature here in Dundee is surprisingly high for February, about 18 degrees and the daffodils are already in bloom.