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Twitter Weekly Updates for 2011-07-04

  • U.N. Report Declares Internet Access a Human Right | Threat Level | Wired.com http://bit.ly/ivNke2 #
  • #saahe2011 officially over. It was a wonderful conference made possible by the participation of health educators from all over the country #
  • Papert http://bit.ly/mggi6R. Being a revolutionary means seeing far enough ahead to know that there is going to be a fundamental change #
  • Papert http://bit.ly/le70h7. The impact of paper in education has led to the exclusion of those who don’t think in certain ways #
  • @dkeats When people are “experts” in a domain they can be blinded to great ideas in other fields and so miss opportunities to drive change #
  • @dkeats Agreed. I’ve had to work really hard to convince people in my dept that I’m not the “computer guy”, I’m the “education guy” #
  • Innovation is about linking concepts from different fields to solve problems, its not about doing the same thing with more efficiency #
  • “How do you learn enough of the words to make sense of the discipline?” #saahe2011 #
  • Presentation by David Taylor on the use of adult learning theories #saahe2011 #
  • Jack Boulet speaking about the challenges and opportunities in simulation-based assessment #saahe2011 #
  • Mendeley Desktop 1.0 Development Preview Released http://ow.ly/1ueXSs #
  • Social media is inherently a system of peer evaluation and is changing the way scholars disseminate their research http://ow.ly/1ueXMA #
  • @dkeats Wonder if the problem has to do with the fact that much “ed tech” is designed by Comp Scientists, rather than Social Sci? #
  • @dkeats Also, people have the idea that LMSs have something to do with T&L, & then struggle when it can’t do what they need it to #
  • @dkeats To qualify, the problem isn’t resistance, its misunderstanding. The conversation always ends up being about technology #
  • There’s a huge difference between “learning” & “studying”, not in terms of the process but ito motivation & objectives #
  • @thesiswhisperer conf is for health educators, mostly clinicians, many of whom are amazing teachers but for whom tech is misunderstood #
  • In a workshop with David Taylor, looking at using adult learning theories #saahe2011 #
  • Blackboard is a course management system, it has little to do with learning. Use it for what its designed for #saahe2011 #
  • Trying to change perception that technology-mediated teaching & learning isn’t about technology. Not going well #saahe2011 #
  • Just gave my presentation on the use of social networks to facilitate clinical & ethical reasoning in practice contexts #saahe2011 #
  • Deborah Murdoch Eaton talks about the role of entrepreneurship to innovate in health education #saahe2011 #
  • Social accountability is relevant for all health professions (healthsocialaccountability.org) #saahe2011 #
  • Charles Boelen talks about social accountability at #saahe2011 keynote, discusses its role in meeting society’s health needs #
  • First day of #saahe2011 over. Lots of interesting discussion and some good research being done in health science education #
  • Concept mapping workshop turned out OK. Got a CD with loads of useful information…a first for any workshop I’ve attended #saahe2011 #
  • Many people still miss the point when it comes to technology-mediated teaching & learning. Your notes on an LMS is not teaching or learning #
  • At a workshop on concept mapping, lots of content being delivered to me, not much practical yet #saahe2011 #
  • Noticed a trend of decreasing satisfaction from 1-4 year, even though overall scores were +. Implications for teaching? #saahe2011 #
  • Banjamin van Nugteren: do medical students’ perceptions of their educational environment predict academic performance? #saahe2011 #
  • Selective assignment as an applied education & research tool -> gain research exp, improve knowledge & groupwork #saahe2011 #
  • Reflective journaling: “as we write conscious thoughts, useful associations & new ideas begin to emerge” #saahe2011 #
  • Change paradigm from “just-in-case” learning to “just-in-time” learning #saahe2011 #
  • Benefits of EBP are enhanced when principles are modelled by clinicians #saahe2011 #
  • EBP less effective when taught as a discrete module. Integration with clinical practice shows improvements across all components #saahe2011 #
  • Students have difficulty conducting appraisals of online sources <- an enormous challenge when much content is accessed online #saahe2011 #
  • Looking around venue at #saahe2011 10 open laptops, 2 visible iPads (lying on desk, not being used), about 350 participants…disappointing #
  • EBP isn’t a recipe (or a religion), although that is a common misconception #saahe2011 #
  • Prof. Robin Watts discusses EBP and facilitating student learning. EBP isn’t synonymous with research #saahe2011 #
  • “A lecture without a story is like an operation without an anaesthetic” Athol Kent, #saahe2001 #
  • Kent drawing heavily on Freni et al, 2010, Health professionals for a new century, Lancet. #
  • #saahe2001 has begun. Prof. Athol Kent: the future of health science education #
  • Portfolios and Competency http://bit.ly/jfFpfU. Really interesting comments section. Poorly implemented portfolios aren’t worth much #
  • @amcunningham I think that portfolios can demonstrate competence and be assessed but it needs a change in mindset to evaluate them #
  • @amcunningham will comment on the post when I’m off the road #
  • @amcunningham Can’t b objective as I haven’t used NHS eportfolio. Also, its hard 2 structure what should be personally meaningful experience #
  • @amcunningham Portfolios must include reflection, not just documentation. Reflection = relating past experience to future performance #
  • @amcunningham Your delusion question in the link: practitioners / students not shown how to develop a portfolio with objectives #
  • @amcunningham Also spoke a lot about competency-based education and strengths / limitations compared to apprentice-based model #
  • @amcunningham Very much. Just finished a 4 day workshop that included the use of portfolios as reflective tools in developing competence #
  • Final day of #safri 2011 finished. Busy with a few evaluations now. Spent some time developing the next phase of my project. Tired… #
  • Last day of #safri today, short session this morning, then leaving for #saahe2011 conference in Potchefstroom. It’s been an intense 5 days #
  • Papert: Calling yourself some1 who uses computers in education will be as ridiculous as calling yourself some1 who uses pencils in education #
  • Daily Papert http://bit.ly/jKlVmn. 10 years ago, Papert warned against the “computers in education” specialist. How have we responded? #
  • Daily Papert http://bit.ly/m7rfYY. Defining yourself as someone who uses computers in education, is to subordinate yourself #
  • YouTube – Augmented Reality Brain http://bit.ly/kcZWXy. When this is common in health education, things are going to get crazy #
  • @rochellesa Everyone needs some downtime, especially at 10 at night when you’re out with your wife 🙂 Seems like a nice guy, very quiet #
  • @rochellesa The large policeman he’s with isn’t keen tho. Mr Nzimande has asked 2 not b disturbed. Understandable when u want to chill out #
  • I’m sitting in a hotel in Jo’burg & Minister of Higher Education Blade Nzimande walks in and sits down next to me. Any1 have any questions? #
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conference education health learning students teaching workshop

SAAHE conference, 2011 – day 2

Social accountability: the mark of excellence in health professional education by Charles Boelen

Moved from interrogation → an assertion

What is a health professional?

Flexner’s report changed the scope of medical education by introducing a scientific background, especially in education

Medical education should be patriotic (Flexner)

Educating → health professionals → for a strategy → to meet people’s needs (must begin with identifying people’s needs); the 4 layers are not necessarily closely correlated

There are many influences on the process, besides the input we provide in our HEIs

What are people’s needs and values today? What will they be in 20 years time? We’re training professionals for today and tomorrow

Not teaching for health professionals, but change agents

Social accountability: the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and / or nation they have the mandate to serve. The priority health concerns are to be identified jointly by governments, health care organisations, health professionals and the public”

Priority health concerns:

  • quality (ideally, we provide the best to everyone)
  • equity (who are the most vulnerable?)
  • cost-benefit (resources are fixed and we have to work within them)
  • relevance (what are the most relevant problems to address?)

As educators, we can’t achieve the values above on our own, we need to work with others

Functions of a school:

  • Education
  • Research
  • Service

Stakeholders (Boelen, 2000, Towards unity for health, WHO):

  • Policy makers
  • Health professions
  • Academic institutions
  • Health managers
  • Communities

Social accountability (evaluate impact of commitments)

Social responsiveness (more explicitly aware, use data to drive action)

Social responsibility (awareness)

We should accompany our graduates when they leave our schools

Be critical of the health system

Conceptualisation of professional (role of the school) → production of professional (educational interventions) → usability of professional (society’s satisfaction). Using a commercial model to explore ideas

Pay more attention before beginning training, as well as afterwards

Boelen & Woollard, 2009. The CPU model: conceptualisation-production-usability. Medical Education, 43: 887-894

The concept of social accountability helps us to answer the question: “Why are we doing all of this?”

Global consensus for social accountability of medical schools (www.healthsocialaccountability.org)

A socaily accountable medical shool should:

  • respond to current and future health needs
  • reorient education, research and service accordingly
  • strengthen governance and partnership with other stakeholders
  • use evaluation and accreditation to determine impact

Preparing for the future:

  • ethics → impact
  • democracy → transparency
  • globalisation → competition
  • public support → synergy

What is our common purpose?”

 

Developing enterprising health care professionals. How should we meet the challenge? By Prof. Deborah Murdoch-Eaton

Enterprise:

  • making the most of opportunities
  • identifying areas for improvement
  • developing innovative solutions
  • implementing and refining strategies

Health professionals will always work in a business, whether private or public. A business is only as good as it’s employees

Need confidence to implement changes

Reference to “Health professionals for a new century. Frenk et al, The Lancet”

Provoke” global reforms in all health professions

Core role of universities as social institutions

Need to be effective in an ever-changing environment and knowledge-base

Change in accordance with local needs

Graduate attributes = set of core skills that are not discipline-specific, “meta-skils”

  • Communication
  • Higher order reasoning
  • Critical thinking
  • Ability to use technology

Students should not all fit into the “same box”, need to develop those who can lead and innovate

Structured (and repeated) opportunities to practice skills

Incorporate self-reflection and appraisal of own abilities, provide evidence of own learning / experiences

Soft skills:

  • teamwork
  • creativity
  • project planning
  • presentation skills
  • IT skills
  • time management
  • networking
  • negotiating
  • leadership

Be enterprising in teaching style and assessment

Embedding of enterprise:

  • strands
  • blocks / modules
  • extra-curricular

How do we colleagues to collaborate?

What are the persuasive arguments?

Fit for (whose) purpose?

Empower students to help retain them in the country

Need to give guidance and time to think and reflect deeply, not related to “competence-driven outcomes”

Values, cultures and ethics are hard to measure

new knowledge is regulated by measuring it against exising scholarship through the process of peer review, rather than the extent to which it meets the needs of those external to the field”

Teach students to ask relevant questions, empower them to become change agents

 

Blackboard training initiative by A Botha

Staff training using Blackboard within institution

(People think that) Blackboard can:

  • support good teaching practice
  • support learning styles
  • encourage collaboration
  • keep abreast of learning technologies

Staff were overwhelmed and reported needing extra time for training

Trying to improve quality of people trained, rather than getting numbers through the system

The problem with LMSs is that they don’t take the student into account, the focus is on the lecturer, the content and the course

What is the relationship between activity on the LMS and the throughput?

 

E-learning: student’s perspective by G Sinombe

Used to increase access to course materials and information, increase contact and participation in courses and enhance variety of learning styles ← blended approach

Courses (reading material, notes, assignments, etc.) uploaded ← not e-learning (by whatever definition you choose to use for “e-learning”)

Student responses differed, some attempted to use, some didn’t try at all

Why do some students not try? Study aimed to determine student perceptions and challenges that impacted on their use

Student responses:

  • good tool
  • good for slow learners
  • enhances communication between lecturer and student
  • flexibility in time and place
  • easy access to courses
  • hard to find unoccupied computer
  • network slow, when available
  • hard to access off-campus
  • helps me to share ideas outside of the classroom
  • enhances sharing of ideas

Is “e-learning” necessary? How does it improve performance? This has to be taken in context…what is the context in which you want to use it?

 

Students’ approaches to learning disciplines in an integrated curriculum by D Manning

How many students achieve pass marks while scoring below the minimum in individual subjects?

In how many disciplines are passing students scoring below the pass mark

Students going into clinical years with substantial gaps in their knowledge

What is going to be done about this?

Is there a need for discipline based subminimums and consideration of logistical solutions

 

Ready for the catwalk? By what criteria should a new model be judged? By F Cilliers

How does assessment influence learning? Cilliers et al, AHSE, 2010, December

One or more sources of impact, through one or more mechanisms, leading to one or more learning effects

Test the model in a different context to what it was designed for i.e. model developed in theory, then evaluated in clinical practice

Quality of learning” ← how was this defined?

Interaction with preceptors:

  • regular accountability
  • personal consequences
  • emotional valence

Preparing out of a fear of humiliation, rather than a desire for understanding. Just wanted to “survive” the ward round

“You will learn because you don’t want to continue to live in fear”

Tyrants” and “teddy bears” ← categories of supervisors

You don’t want to disappoint the “teddy bears”, go out of your way to participate, gather more information

But they are still motivated by others, rather than for themselves. Did any students report a desire for understanding based on what it would mean for their own clinical practice?

Teddy bears” = scope and safety to ask questions and explore areas of personal interest

 

Reviewing assessment to promote medical student engagement in basic sciences to cure and care better by C Brand

Curricula are living, self-organising organic systems

De-load” some of the course content

Threshold concepts = conceptual gateway that opens up previously inaccessible domains

All change begins with conversation

 

Introduction of a new clinical assessment: did it achieve it’s aim? by L Green-Thompson

Students arrive in the clinical environment unprepared

Introduced an observed examination (mini-CEX) and then evaluated student perceptions of the exam

Landscape of assessment”

Students reported that the clinical exam was a valuable experience: “a good opportunity to see how far I had come”

Assessments are theoretical events, rather than clinical events”

 

Workshop: Making use of adult learning theories by Dr. David Taylor

Theories not mutually exclusive, each have something to recommend them

Instrumental learning theories:

  • Behaviourist → stimulus – response (e.g. Skinner)
  • Cognitive → mental process not behaviour (e.g. Piaget, constructivism)
  • Experiential → behaviour in practice (e.g. Kolb)

Humanistic theories:

  • Andragogy → need, readiness, motivation (e.g. Knowles)
  • Self-directed learning → what about the social context?
  • Transformative learning → disorienting dilemma that drives learning, context, critical reflection (e.g. Mezirow)

Situated cognition (e.g. communities of practice):

  • Learning and thinking are social
  • Structured by tools available
  • Dependant on situation
  • Knowing is supported by doing (e.g. Wenger)

How difficult it is to “get into” a new discipline. Need to acquire an understanding of the profession before you can “be in it”

The challenge for a learner is to find out enough about the subject to enable learning

Expectancy valence theory: low expectation of success results in poor motivation for learn, unless rewards are overwhelming → can’t give students tasks that they can’t achieve

  • You need to recognise what you already know
  • You need to know how the new knowledge fits in
  • Dialogue makes it easier

Feedback will drive future learning

What are the responsibilities of the learner and teacher respectively in each phase of a learning cycle?

Dissonance (putting the cat among the pigeons):

  • Teacher’s responsibility to challenge student to move outside of their comfort zone
  • Learner needs to be open to being challenged, need to identify their own gaps, pre-conceived perspectives impact on worldview

Critical friendship”

Teachers don’t need to be responsible for the answers, but they need to enable the discovery

Hypotheses that can’t be tested are useless (Poppper)

It’s possible to be critically reflective on your own but feedback is important for error correction → create your own dissonance

Laurillard: feedback is a continuous process that occurs as part of a 2-way dialogue (“conversation”)

Feedback sandwich” 🙂

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assignments conference education personal physiotherapy research social media

Social networks and clinical education: presentation at SAAHE

My presentation at the SAAHE conference is a more in-depth look at the same project that I presented at the conference in 2010. The key points I wanted to make were that:

  • Students struggle to develop practice knowledge because it is hidden from them i.e. they can’t “see” our thinking process as we reason our way through clinical issues
  • One way to externalise practice knowledge is by sharing experiences and outcomes as colleagues or peers
  • Social networks facilitate that sharing
  • Reflection needs to be facilitated and structured, otherwise students feel lost
  • Pedagogically sound teaching principles must be integrated no matter what tools you’re using

Here is the presentation that I gave earlier today:

Categories
assessment assignments conference education ethics health research teaching

SAAHE conference, 2011 – day 1

Introduction by Dr. Lionel Green-Thompson

A country whose health is fragile

The future of health science education: 2020 vision by Prof. Athol Kent

“After an introduction like that I can’t wait to hear myself speak”

It’s not the strongest or fittest who survive but the ones who are most adaptable to change

  • Who will our students be?
  • How many of them will we need?
  • Who will their teachers be?
  • What will we teach them?
  • How will we teach them?

They will be smarter, better prepared, more IT literate, more women, more black students

We need far more than are currently graduated, more from rural areas, more mid-level workers, clinical assistants

“Innovation through diversity”

Why do health professionals leave? Political, security, working conditions, financial reasons

Makes reference to Freni, et al, Health Professionals for a new century, The Lancet

30% of all posts are unfilled

Need to increase intake & satellite campuses must evolve

All service posts should have a teaching component

Doctors who want part-time work (e.g. mothers) can be integrated as clinical teachers

Generalists who teach as opposed to specialists

Peer teaching should become a core, significant component of clinical teaching (“the mark you get will be the same mark your students get”)

Syllabus will change from curative to preventative → PHC, lifelong learning, less factual, more core and process orientated (“we can’t possibly teach all the facts”, “teach how to learn”)

“The world is flat” → information is everywhere

Move from university → centres → health/education system-based

Teach students HOW to learn

Move from assessment of learning → assessment for learning

“A lecture without a story is like an operation without an anaesthetic”

800 specialised language forms in O&G alone ← imagine what this must look like to a new clinical student

Is the gap between secondary education and health science education going to increase?

The content we give students today is based on work that was done 5 years ago. In 10 years time that content will be less valuable even than today. For all intents and purposes, the content is irrelevant. We need to give students the tools to identify gaps in their own knowledge, and the skills to find the answers to the questions that will help fill those gaps.


Evidence-based practice: how can we facilitate student learning? by Prof. Robin Watts

Practice = EBP is nothing if concepts are not implemented in clinical practice

Evidence-informed practice? More inclusive in that it implies that evidence isn’t the only factor in clinical decision-making, and that practice knowledge is an important component to take into account

Different language roots have an impact on how EBP is understood by people from different parts of the world

EBP steps:

  • Asking (Population, phenomenon of Interest, Context, Outcome)
  • Acquiring
  • Appraising (levels of evidence – hard for students to conduct appraisals of online sources)
  • Applying
  • Assessing

Is evidence derived from medical research directly generalisable to other health disciplines? Should be be modified? Avoid making assumptions of transferability

Springer, “7 pillars of information literacy”

Discrete subject (EBP separate from other modules), or integrated throughout and within other modules? Standalone courses appear to be less effective than integrated. Discrete modules found improvement in basic knowledge, but no impact on appraisal ability. It integrated into clinical practice, improvements occur throughout. Integration should be well-designed.

Content in EBP module should be sequenced, building on previous content / components

Benefits of EBP enhanced when modelled by clinicians

Integrating EBP into the curriculum requires a culture and mindset change

 

Morning POEMs (Patient Oriented Evidence that Matters) – Teaching Point-of-care, patient centred, evidence-based medicine by Dr. Eamon C. Armstrong

Patient presentation followed by real-time internet search for best available evidence → discussion of patient management using those sources

EBM triad:

  • good clinical expertise
  • best external evidence
  • patient values and expectations

POEM = valid:

  • information that patient will care about i.e. has positive patient outcomes
  • addresses a common problem
  • should require a change in practice

How do you brindge the growing knowledge “chasm”

Change the paradigm from “just-in-case” (learn everything in case it comes up) to “just-in-time” (learn what you need, when you need it)

Negotiate common ground around medical decision-making

Prior to the introduction of POEMs, use of electronic sources was scant (study done in US hospital)

Led to fundamental change in prevailing teaching and learning practice

 

The use of reflective journaling in the training of play therapy students by Isabella Jacobs

Reflection used to raise personal awareness, and integrate theory into practice

Students find that ideas become clearer when they write them down, they have to declare concepts in concrete form

Existential dialogue = ways of being, reflective journal may help to implement

Students must receive guidance regarding expectations for jounnaling i.e. must be structured

Role of the self in patient encounters

Journals not assessed, although a random selection of journals were analysed

Students not informed prior to journaling that the journals would be researched, so as not to influence their responses. Informed consent obtained from students after assignments were completed

Students initially reluctant to participate in journaling, but awareness of self began to emerge over time

“as we write conscious thoughts, useful associations and new ideas begin to emerge” (Miller, in Moon, 2006)

“regain my balance by losing my mind” (student quote)

“I do not want to be in unawareness anymore” (student quote)

Some students referred to the process as “a life changing experience”

 

Selective alignment as an applied education and research tool by Sophia Fourie

Assingment which served as an educational tool and research project

Students gained research experience, improved knowledge, and encountered principles of rational drug prescription

 

Do emergency medical care student’s perceptions of their educational environment predict academic performance? by Benjamin van Nugteren

Role of the academic environment in student success?

Identify areas of student dissatisfaction / satisfaction

Used the DREEM questionnaire: 50 statements based on 5 point Likert scale

Looked at:

  • perceptions of learning
  • perceptions of teachers
  • academic self-perception
  • atmosphere
  • social self-perception

Associated above outcomes with academic performance

Noticed a trend of decreasing satisfaction in all of the above components from 1st – 4th year medical students, even though overall satisfaction was reasonably high. What are the implications considering these students are going straight into clinical practice? Is burnout beginning already?

When the data is connected relative to final exams / other stressors might make a difference to student perceptions

 

Workshop: Concept maps and cognition by Dr. Stephen Walsh

Here’s the basic concept map I made during the short workshop:

 

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conference education learning research students teaching workshop

SAFRI 2011 (session 2) – day 1

A few days ago we began the second SAFRI* session of 2011, which will lead into the SAAHE conference** later in the week. Every day I take notes and will try to put them up as we go along bearing in mind that a lot of what we do is workshop-based. The notes are a combination of points given by presenters, and my own reflections that were sparked by something that someone said. My thoughts are in italics.

Achievement: changed the way I think about the world (word = clinical education)

Challenge: helping others to see the world the way I do

Never give up…or Give up often? Come up with lots of ideas, some will be good, some not so good, some terrible. Test them all (even if only mentally) and throw away the ones that don’t stand up to being tested. Analogy with digital cameras and taking loads of photos because the cost is zero and you can delete the poor ones.

Find the underlying principle that can be generalised to many contexts i.e. details aren’t necessarily important

Why did I miss the diagnosis? (Bordage, 1999) → “Less is better” i.e. foundations are good to build on

We tend to focus on student behaviour, instead of their learning e.g. “students must attend class and pay attention”…but if you’re not interesting, then why should they attend? What is it about their presence that somehow ensures that “learning happens”? If they’re not going to listen to you (and if they can pass the exam without attending), then why do we place so much emphasis on their presence?

Teach an approach to discovery, rather than a list of things

Dual processing theory (a universal model of diagnostic reasoning)

  • How do we reason through clinical problems?
  • Make observations and identify signs / variables
  • Query your existing database i.e. your pre-existing knowledge
  • Identify associations between the observed variables and your own database i.e. pattern recognition
  • If existing knowledge is insufficient, query an external database (e.g. patient / textbook)

If you go through the above process enough times, you “get experience” → add more patterns to your internal database

I’m sure the above process is more eloquently and comprehensively described elsewhere

Dancing naked in the mind field” – title of a book that perfectly describes why I blog…putting my thoughts, reflections and experiences out there and by doing so, exposing myself while sharing.

Having a diagnosis frees you from having to think. This has implications for when you’re tired / stressed / pushed for time, in that in those circumstances you can’t think and so latch onto a diagnosis. Students experience the same thing when they’re looking for answers. Having the answer means they don’t have to think because thinking is hard and places a high demand on system resources.

There’s a strong emotional response / association with diagnoses that are made intuitively i.e. without an analytical reasoning process

Talking out loud externalises a reasoning process that is often obscured and hidden from the student

“Diagnostic error and clinical reasoning” (Norman & Eva, Medical Education, 2010)

“construct referenced” as it relates to feedback?

Black , P. & William, D. (1998). Assessment and classroom learning, Assessment in Education, 5, pp. 7–75

Readings:

  • “Classroom assessment techniques” (Angelo & Cross)
  • Rushton, A. (2005). Formative assessment : a key to deep learning ? Medical Teacher, 27(6), 509-513
  • Nofziger, A. C., Naumburg, E. H., Davis, B. J., Mooney, C. J., & Epstein, R. M. (2010). Impact of Peer Assessment on the Professional Development of Medical Students : A Qualitative Study. Academic Medicine, 85(1), 140-147

*SAFRI (Southern Africa FAIMER Regional Institute); FAIMER (Foundation for Advancement of International Medical Education and Research)

**SAAHE (South African Association of Health Educators)

 

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