Writing-Skills Development in the Health Professions

This art icle was downloaded by: [ Universit y of California, San Diego] On: 04 April 2014, At : 17: 15 Publisher: Rout ledge I nform a Lt d Regist ered in England and Wales Regist ered Num ber: 1072954 Regist ered office: Mort im er House, 37- 41 Mort im er St reet , London W1T 3JH, UK Teaching and Learning in Medicine: An International Journal Publicat ion det ails, including inst ruct ions f or aut hors and subscript ion inf ormat ion: ht t p: / / www. t andf online. com/ loi/ ht lm20 Writing-Skills Development in the Health Professions Richard E. Rawson , Kat hleen M. Quinlan , Barry J. Cooper , Clare Fewt rell & Jennif er R. Mat low Published online: 15 Jun 2010. To cite this article: Richard E. Rawson , Kat hleen M. Quinlan , Barry J. Cooper , Clare Fewt rell & Jennif er R. Mat low (2005) Writ ing-Skills Development in t he Healt h Prof essions, Teaching and Learning in Medicine: An Int ernat ional Journal, 17: 3, 233-238, DOI: 10. 1207/ s15328015t lm1703_6 To link to this article: ht t p: / / dx. doi. org/ 10. 1207/ s15328015t lm1703_6 PLEASE SCROLL DOWN FOR ARTI CLE Taylor & Francis m akes every effort t o ensure t he accuracy of all t he inform at ion ( t he “ Cont ent ” ) cont ained in t he publicat ions on our plat form . However, Taylor & Francis, our agent s, and our licensors m ake no represent at ions or warrant ies what soever as t o t he accuracy, com plet eness, or suit abilit y for any purpose of t he Cont ent . Any opinions and views expressed in t his publicat ion are t he opinions and views of t he aut hors, and are not t he views of or endorsed by Taylor & Francis. The accuracy of t he Cont ent should not be relied upon and should be independent ly verified wit h prim ary sources of inform at ion. Taylor and Francis shall not be liable for any losses, act ions, claim s, proceedings, dem ands, cost s, expenses, dam ages, and ot her liabilit ies what soever or howsoever caused arising direct ly or indirect ly in connect ion wit h, in relat ion t o or arising out of t he use of t he Cont ent . This art icle m ay be used for research, t eaching, and privat e st udy purposes. Any subst ant ial or syst em at ic reproduct ion, redist ribut ion, reselling, loan, sub- licensing, syst em at ic supply, or dist ribut ion in any form t o anyone is expressly forbidden. Term s & Condit ions of access and use can be found at ht t p: / / www.t andfonline.com / page/ t erm s- and- condit ions Writing-Skills Development in the Health Professions Richard E. Rawson Department of Biomedical Sciences College of Veterinary Medicine Cornell University Ithaca, New York, USA Kathleen M. Quinlan Downloaded by [University of California, San Diego] at 17:15 04 April 2014 Office of Educational Development College of Veterinary Medicine Cornell University Ithaca, New York, USA Barry J. Cooper Department of Biomedical Sciences College of Veterinary Medicine Cornell University Ithaca, New York, USA Clare Fewtrell Department of Molecular Medicine College of Veterinary Medicine Cornell University Ithaca, New York, USA Jennifer R. Matlow Department of Biomedical Sciences College of Veterinary Medicine Cornell University Ithaca, New York, USA Background: Studies have found that students in the medical professions often lack the writing skills required during their education and career. One contributing factor to this deficiency is that writing tends to be discipline specific, rather than requiring general skills acquired in undergraduate schools. Purpose: To determine the extent to which a rigorous writing exercise impacted the quality of students’ medical writing based on a specified rubric. Method: In the context of a basic science course, we developed 6 weekly writing exercises called Question of the Week, along with a rubric for scoring students’work. The rubric evaluated 6 specific aspects of students’ writing including Comprehensiveness/Thoroughness, Accuracy, Conciseness, Logical Organization, Justification of Assertions, and Use of Appropriate Terminology. Results: Except for Justification of Assertions and Accuracy, which did not change, scores for all categories improved between Weeks 1 and 2. Use of Appropriate Terminology was the only category for which scores increased after Week 2. Conclusion: The clearest indication of writing development came from students’augmented ability to use medical terminology in appropriate ways. This is an important observation, given that each Question of the Week covered a separate body system, characterized by distinctly different terms and jargon. We concluded that students need much more practice to attain the level of proficiency outlined by our rubric. Teaching and Learning in Medicine, 17(3), 233–239 Copyright © 2005 by Lawrence Erlbaum Associates, Inc. We acknowledge the assistance of Dr. Kathleen D. MacLeod for helping with the scoring of Question of the Week assignments and Dr. Yryo Grohn for statistical consultation. Correspondence may be sent to Richard E. Rawson, DVM, PhD, Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY 14853, USA. E-mail: rer1@cornell.edu 233 Downloaded by [University of California, San Diego] at 17:15 04 April 2014 RAWSON ET AL Clear, concise, accurate writing is required for medical record entries, referral letters, discharge statements, and other activities in which medical professionals participate.1 In health professions education, writing has been used as a tool to promote a variety of learning goals. For example, writing in health sciences education has focused on promoting students’ reflections on clinical experiences and self-awareness of attitudes, on students’ critical appraisal skills including critiques of published research or intervention plans, and on writing for publication.2–11 Yet, a core skill required of health professionals and the focus of this study is the ability to write about scientific content concisely and accurately for their colleagues. It is well established in undergraduate education that many writing skills are domain specific or discipline specific and that all disciplines need to teach writing in the context of learning the discipline.12,13 Kovac and Sherwood14 described the incorporation of writing assignments into an undergraduate general chemistry course in which writing served as a learning tool and helped students develop specific scientific and technical writing skills. The same principle—that students need to learn to communicate in ways that are specific to a profession or discipline—can be applied to graduate health professions education. Students who wrote well in their undergraduate classes may produce inadequate writing in the new domain of medicine. Indeed, we noted writing shortcomings over several years of grading students’ exams in a problem-based learning (PBL) course at the Cornell College of Veterinary Medicine, consistent with others’ observations.15 The third course in our professional curriculum, Function & Dysfunction, provides the basic science background for internal medicine. To maintain consistency with the way students learn in a PBL setting, examinations in this course are case based, with questions that require students to explain and justify their answers in short essays. We have found that students’ answers tend to be verbose, poorly organized, and use terminology imprecisely, all of which makes it difficult for the faculty to judge their adequacy. We regarded these deficiencies as serious because writing is an important means by which medical professionals communicate with colleagues about technical, clinical, and scientific matters. We also suspected that poor writing might be related to poor content understanding. Obviously, students do not possess the knowledge base of experts or the complex interrelationships and organization that is characteristic of expert knowledge. Thus, medical education involves enhancing both the content and organization of students’ knowledge base. Students’ writing of pathophysiological explanations of medical problems is integrally related to their understanding of the subject matter and their clinical 234 reasoning. Hmelo16,17 has assessed the quality of students’ problem solving on the basis of the accuracy, coherence, reasoning strategies, and use of science concepts as evidenced in case-based written causal explanations of medical problems. Hmelo18 found that these criteria had strong face validity with physicians. Students whose writing does not display those characteristics may either lack the knowledge itself, or their content knowledge is not organized in a way that matches experts’ knowledge networks. Causal chains of reasoning are closely tied to the way that knowledge is organized. Didactic components of a course can deliver content, but writing affords students the opportunity to effectively organize that content.14 Although our course provides ample opportunity for verbal elaboration of students’ understanding of course content, students do not formally practice expressing their understanding of pathophysiological concepts in writing. Unless the tutor is particularly rigorous, oral explanations during tutorial sessions tend to be rather untidy in the interest of simply generating discussion. Furthermore, the paucity of lectures limits the exposure of students to teachers who can model the use of accurate medical terminology and concepts. Therefore, we developed a weekly writing exercise called Question of the Week, along with a scoring rubric, with the aim of improving the quality of students’ pathophysiological explanations. As this was a new assessment approach, we sought to evaluate its effect on students and their learning. Specifically, was there an improvement in students’ written essays over time, and on what dimensions did improvement take place? We hypothesized, based on the case-specificity effect,19 that on some dimensions, such as accuracy, there would be little or no improvement from week to week because each week the focus of the Question of the Week was new, reflecting the content of that week. On other criteria, though, such as conciseness and use of medical terminology, we anticipated that students would improve with practice, as these skills may be more transferable from one case to another. We also investigated the relation between students’ performance on the Question of the Week and their final exam scores. Students who developed their ability to use terminology accurately, to write concisely and logically, and to justify their assertions should perform better on exams. Methods Question of the Week Assignment The Question of the Week project was implemented in Function & Dysfunction in which all 83 first-year students at the Cornell College of Veterinary Medicine were enrolled. Each student earned 0.5% of the final Downloaded by [University of California, San Diego] at 17:15 04 April 2014 WRITING AS A TEACHING TOOL grade for each Question of the Week assignment completed, irrespective of the scores achieved. Function and Dysfunction is a 7-week, systems-based course that addresses the physiology, pathology, pharmacology, and clinical pathology of the neuromuscular, cardiovascular, respiratory, urinary, and gastrointestinal systems. Each Question of the Week addressed the content area specific to a given week of the course. The questions required that students use higher order thinking skills including analysis, synthesis, and evaluation.20 These types of questions are posed routinely on our examinations. Each Question of the Week consisted of a short case scenario followed by one question (Table 1). A word limit was supplied. Questions were posted on the course Web site on Friday of each week with a midday Monday deadline. Students were expected to complete the assignments individually within the word limits posted without the aid of books. A 30-min time estimate for completion was provided. No attempt was made to determine if students abided by the time estimates or “closed book” guidelines. Scoring Rubric An important component of the Question of the Week project involved providing students with timely and critical feedback. Students handed in papers on Monday, and evaluators marked them so they could be returned before the next question was posted on Friday. For evaluation purposes, the class was divided into four groups of approximately 20 students. Every week, each of four evaluators was assigned randomly to mark one group of papers. Evaluators marked a different group each week so that any student who wrote at least four assignments received feedback from at least four evaluators. All evaluators had scientific expertise in the content matter of the course. A scoring rubric (Table 2) was developed to formalize the criteria by which student work would be judged. Because five faculty members were involved in marking papers during the course, a rubric would improve consistency among evaluators. Further, we wanted to pro- vide students with detailed and meaningful feedback that could be used while writing subsequent assignments. The rubric applied a range of scores from 1 to 3 for each of six criteria: Comprehensiveness/Thoroughness, Accuracy, Conciseness, Logical Organization, Justification of Assertions, and Terminology. For the benefit of both the evaluator and the student, each of these criteria was defined precisely. Doing so allowed us to rate student performance consistently over the 6-week period. We collaboratively constructed the rubric during a 90-min workshop. We began with Hmelo’s17 criteria and our own observations of the qualities we sought in good student essays. A framework was developed by applying the emerging criteria to several examples of student essays until agreement was reached on the criteria and their interpretation. Two of the authors (R. Rawson and K. Quinlan) then completed the rubric by describing the standards for each of the three score levels for each of the criteria. The final rubric was discussed, evaluated, and agreed on by all of us. Two mechanisms were set in place to minimize interrater variability. First, because all of the evaluators participated fully in construction of the rubric, each was well acquainted with its intent and meaning. Second, the same evaluators marked student work throughout the course and were rotated such that each student’s work was marked by each evaluator. Statistics We examined student scores on each of the six criteria over the 6 weeks. Data were summarized as mean ± standard deviation. Repeated measures analysis of variance was conducted using a general linear model to test differences between means. Differences were considered significant at the p < .05 level. Results A total of 493 of a possible 498 (83 students × 6 weeks) papers (99%) were submitted for evaluation. Table 1. A Sample Question Used During the Question of the Week Project Dawkin’s Own is a horse with protein-losing enteropathy, a condition in which there is reduced absorptive capacity in the small intestine and loss of protein into the intestinal lumen. He has low plasma total protein and very low serum albumin, resulting in edema and ascites. [You may look up the meaning of these words, if necessary.] To treat this condition, he was given certain drugs orally, but these did not produce the expected effects. Assume that the drugs used to treat this horse were a rational choice to produce the desired effects. Taking into account the facts related to this case (provided above) how might the disposition of drugs have been altered in this animal, thus affecting their efficacy? (200 words) Focus: Consider those pharmacokinetic factors that are relevant to this scenario that could reduce the efficacy of any orally administered drug in this patient. 235 RAWSON ET AL Table 2. Rubric Used for Scoring Essays A. B. C. Downloaded by [University of California, San Diego] at 17:15 04 April 2014 D. E. F. Comprehensiveness/Thoroughness 3 = All of the relevant information is included. 2 = Some relevant information was not included. 1 = Much of the relevant information is not included. Accuracy 3 = All of the information stated is accurate. 2 = Some but not all of the information is accurate. 1 = There are gross inaccuracies. Conciseness 3 = There is no irrelevant information included. 2 = Some of the information included is irrelevant to this question. 1 = Much of the information included is irrelevant to this question. Logical Organization 3 = Logically connects related concepts appropriately and avoids repetition. 2 = Some evidence of logical organization but concepts are not related appropriately and/or some concepts are repeated. 1 = Little evidence of logical organization. Relationships among concepts are unclear. Justification of Assertions 3 = Makes assertion(s) that are supported by the data and gives supporting pathophysiological explanations. 2 = Makes assertion(s) that are supported by data, but doesn’t give adequate pathophysiological explanations. 1 = Makes assertions that are not supported by the data. Use of Appropriate Medical Terminology 3 = Uses medical terminology correctly and whenever possible. 2 = Sometimes uses medical terminology incorrectly or misses opportunities to use it. 1 = Little use of medical terminology. Mean scores for each category are shown in Table 3. For all but two categories (Accuracy and Justification of Assertions), scores improved significantly (p < .05) between Week 1 and Week 6. Scores for justification of assertions showed no change at all during the 6 weeks of this project, whereas Accuracy tended to decrease over time. After Week 2, Use of Appropriate Terminology was the only category that showed any further increase in mean score. The correlation between scores on each of the six criteria at Week 1 and performance on the final exam was poor (p > .1). By Week 6, scores for four of the six criteria were still only weakly correlated with final exam scores (p > .2). There was a stronger correlation between both Accuracy and Justification of Assertions and scores on the final exam (p = .09), but neither reached the selected level of significance (p = .05). Students who improved the most from Week 1 to Week 6 on justification of assertions performed better on the final exam (p = .03). Improvement in other areas did not have a similar relation to performance on the final exam. In an end-of-course survey, students described four main ways in which the Question of the Week was useful to them. First, a substantial portion (27%) commented on how helpful it was to use and think about the knowledge they had gained in a different way—to apply it to a problem different from the one used in their PBL groups, to reason with it, synthesize it, or integrate it. Second, students (24%) used the Question of the Week as a gauge of their content understanding. Third, students (23%) valued practicing writing their answers, with a focus on summarizing, being concise, or using appropriate terminology. Fourth, students (15%) referred to the value of the exercises in preparing them for the exam. Analysis of scoring indicated that there was some significant variation (p < .05) in the application of the rubric by the four evaluators. This finding provides justification for our decision to rotate evaluators. Inspec- Table 3. Mean Scores for Each of Six Criteria Used in the Evaluation of Student Writing Weeks Criteria Comprehensive & Thorough Accuracy Conciseness Logical Organization Justification of Assertions Medical Terminology 1 2 3 4 5 6 d 1.7 ± 0.7 2.4 ± 0.7 1.5 ± 0.5 2.0 ± 0.6 1.9 ± 0.6 2.0 ± 0.6b 2.1 ± 0.7a 2.2 ± 0.5 2.4 ± 0.7a 2.3 ± 0.6a 1.9 ± 0.7 2.2 ± 0.6 2.2 ± 0.6a 2.4 ± 0.6 2.4 ± 0.6a 2.5 ± 0.6a 2.2 ± 0.7 2.4 ± 0.6a 1.8 ± 0.6a 2.2 ± 0.6 2.3 ± 0.7a 2.4 ± 0.7a 2.1 ± 0.6 2.3 ± 0.6a 2.2 ± 0.7a 2.1 ± 0.7a 2.4 ± 0.6a 2.6 ± 0.5a 2.1 ± 0.7 2.8 ± 0.5a, b 2.1 ± 0.7a 2.2 ± 0.5 2.2 ± 0.7a 2.4 ± 0.6a 2.0 ± 0.7 2.7 ± 0.5a, b 0.5 0.5 1.1 0.7 — 1.2 Note: N = 83. Values represent mean score ± standard deviation; d = effect size. aSignificantly different from value at week 1. bSignificantly different from value at week 4. 236 WRITING AS A TEACHING TOOL Downloaded by [University of California, San Diego] at 17:15 04 April 2014 tion of mean scores for each evaluator for each of the six categories addressed by the rubric did not suggest any patterns of bias over the 6 weeks of the exercise. No single evaluator marked student work consistently higher or lower than other evaluators. All Question of the Week papers received numerical scores based on each of the six criteria specified in the rubric, with varying amounts of additional written feedback provided by each evaluator. Despite the concerted effort to provide meaningful feedback, the second most common category of student concern (13%) was about the feedback received. Students requested a consistent grader (rather than the rotating system of graders that we used), more comments, and more recognition of what they had done well. Discussion Students were apparently highly motivated to complete as many assignments as possible. The response rate (99%) was very high, and students seemed to respond carefully and thoughtfully to the questions, making a genuine effort on all assignments. Each Question of the Week related to the content area of that week’s tutorial case, reflecting new content each week. Some criteria used to evaluate student papers, such as Accuracy and Justification of Assertions, were expected to reflect this case specificity and thus not improve significantly. In fact, these categories did not improve between Weeks 1 and 6. All of the other criteria, however, showed significant improvement between Weeks 1 and 6, with most of the improvement coming between the 1st and 2nd weeks. The latter observation suggested that the bulk of the effect may have been in simply clarifying expectations to students. Indeed, this would have been the first formal opportunity to make the expectations of medical writing explicit to these 1st-year veterinary students. Use of Appropriate Terminology might be expected to be case specific because each body system has a set of unique terms with which it is associated (e.g., respiratory: tachypnea; cardiovascular: cardiomegaly; renal: countercurrent). That scores for this criterion improved at Week 3 and then even further at Week 5 begs additional explanation. It is possible that although students may have been able to use medical terminology during say, Week 1, they felt obligated not to, believing that it was important to assure the faculty that they understand definitions of terms. For example, one student began the essay for Week 4 by defining tachypnea rather than simply using the term in an appropriate way to address the question. Instructions to students clearly stated “Write to a colleague who ‘speaks your language’ but who does not necessarily appreciate the particulars of the case you are working on or the question you’re addressing.” Despite this explicit charge, students wrote as if performing for their teachers rather than writing to a colleague. As teachers, we assumed that if a student could use a term correctly, she or he understood what that term meant and that being able to define a term does not necessarily demonstrate understanding. For students, it is easier to learn and provide definitions and more difficult to incorporate accurate terminology into their understanding of body systems. Generally speaking, teachers are concerned that students not only know definitions but that they are able to use terms correctly and appropriately, reflecting an understanding of the material that goes beyond rote memorization. The fact that students continued to improve at Week 5 on this dimension suggests a more meaningful change in students’ approach to medical writing than merely clarifying these teachers’ expectations. We hypothesized that improved writing skills should be reflected in students’ performance in writing short essays for the examination. Essays written for the final examination were graded based primarily on content, which would be reflected principally in accuracy and justification of assertions. Other indicators of the quality of composition were graded only to the extent that they affected the ability of the grader to judge the quality of the content. Thus, the finding that Question of the Week scores during the 6th week for Accuracy and Justification of Assertions showed the best correlation with outcomes on the examination was not surprising. Mean scores for Comprehensive and Thorough and Justification of Assertions were lowest among scores in any given week, and mean scores for the latter did not improve over time. This suggests that these two skills represent difficult areas for students. Students, as a whole, improved in their ability to be comprehensive and thorough in their writing. That the students who improved the most on the Justification of Assertions criteria during the course tended to perform better on the final exam suggests that the ability to justify or explain statements satisfactorily can be learned and that it is central to medical writing and understanding overall. Justification of Assertions arguably represents a higher order skill, and it is not surprising that, on average, students performed less well in this area and would take longer to improve. Apparently, the Question of the Week exercise did not provide enough practice for most students to develop this skill sufficiently, suggesting an avenue for future emphasis in instruction. Students recognized that the Question of the Week exercises were clear approximations to questions that would appear on the end-of-course exam. Nevertheless, a large number of students reported that the Question of the Week had no effect on their studying. The ability to use factual knowledge to solve problems and 237 Downloaded by [University of California, San Diego] at 17:15 04 April 2014 RAWSON ET AL explain solutions clearly and logically are significant goals of our instruction. It would appear that for some students, learning factual knowledge overshadowed the opportunity to practice using that knowledge in meaningful ways. This apparent disconnect between factual knowledge and use of that knowledge to explain medical problems suggests a potential avenue for further study. We attributed improvement in the quality of student writing to practice and feedback afforded by the Question of the Week. However, observed improvement could have been due to normal course activities such as lecture attendance and note taking, reading textbooks, or practicing using medical terminology during tutorial sessions. This argument seems less likely in light of empirical evidence. One study21 found that about 25% of medical students were deficient in reading and writing skills and that the situation was not improved by the 3rd year of medical training. More recently, a survey of deans of veterinary colleges revealed that students’ writing skills were deficient.15 For a significant number of students, then, writing skills do not improve substantially simply as a result of coursework. Programs aimed explicitly at enhancing writing skills are needed. We concluded that Question of the Week had educational merit but needed improvement. Although scores for most criteria increased, the clearest evidence of improvement came from students’ steadily increasing proficiency in using medical terminology in their pathophysiological explanations. This was a satisfying result because the appropriate use of terminology is a hallmark of medical writing and of communication among medical professionals in general. We were encouraged that a significant number of students reported using the exercises in ways that promoted higher order thinking and learning activities that are associated with improved transfer of learning.22 This report supports the conclusions of others that there is a significant deficiency in writing among cohorts of arguably top students admitted to professional programs.15,21 Although medical and veterinary students may come with writing skills that were satisfactory in their undergraduate classes, it is precisely because writing tends to be domain specific or discipline specific12 that writing skills appropriate for a given profession will only be learned by students engaged in that profession. It is important, therefore, that faculty in professional programs design instructional instruments that will provide ample opportunity for students to learn the scientific and technical aspects of writing in a given profession.23 In this study, students improved along some of our criteria, but most of that gain occurred during the first 2 weeks despite continuation of the writing assignments and explicit feedback. We conclude that they 238 needed more practice and perhaps more explicit instruction and modeling to attain the proficiency described by our rubric.24 References 1. Yanoff KL, Burg FD. Types of medical writing and teaching of writing in U.S. medical schools. Journal of Medical Education 1988;63:30–7. 2. Deloney LA, Carey MJ, Beeman HG. Using electronic journal writing to foster reflection and provide feedback in an introduction to clinical medicine course. Academic Medicine 1998;73:574–5. 3. Edwards R, White M, Gray J, Fischbacher C. 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