Short reports

Interactive logbooks for medical students: are they useful?

N G Patil & Pamela Lee

Objectives The use of logbooks in the education of selected logbooks were reviewed at the end of every
medical undergraduate students is not well-established. rotation and compared with course outlines in order to
Traditionally, logbooks are used simply as a means for evaluate if, according to the students’ notes, the
students to document their activities. This report learning objectives were being met. Throughout each
examines whether logbooks used as an interactive teaching block, the logbook process identified students
vehicle between students and tutors can assist both who could benefit from counselling and/or remediation.
student learning and Faculty teaching. The logbook feedback mechanism was immediate and
Method As part of the New Medical Curriculum therefore, remediation was timely and appropriate.
implemented by the Faculty of Medicine, The University Conclusions The logbooks were effective in 3 ways:
of Hong Kong, all third year students beginning their logbooks were a means of continuous assessment of
formal hospital and community health clerkships were small group learning; logbooks encouraged immediate
given pocket-sized logbooks to document and monitor and ongoing interaction between tutors and students;
their learning activities. The logbooks were specially and they provided a feedback loop for the evaluation of
designed to mirror the activities of the teaching blocks, learning activities.
including bedside teaching, tutorials, teaching clinics, Keywords Education, medical, undergraduate/*methods;
health care projects, and whole class sessions, etc. curriculum; educational measurement/*methods; Hong
Results At the end of each teaching block, effort, Kong; knowledge of results.
accuracy of the notes, appropriateness of the notes and Medical Education 2002;36:672–677
the assessor’s overall impression of logbook entries
formed the basis of 20-point assessment. Randomly-

At the Faculty of Medicine in The University of

Introduction
Hong Kong, logbooks formed part of the progressive
The Faculty of Medicine of The University of Hong and continuous interaction of students with tutors;
Kong introduced a New Medical Curriculum (NMC) student assessment – evaluation and monitoring of
in 1997 which emphasized integration, problem-based teaching and learning activities, and the process of
learning, small group teaching and early clinical con- evaluating the extent and appropriateness of student
tact. In 1999, 164 third year students began their learning vis á vis the New Medical Curriculum.
formal hospital and community health clerkships
(Table 1). They were given pocket-sized logbooks to
Implementation
document their learning activities. The use of logbooks
among medical students is not widely studied in the The logbooks were specifically designed to mirror the
medical education literature. However, studies of activities of the teaching blocks, including bedside
properly constructed logbooks can provide structure teaching, tutorials, teaching clinics, health care pro-
and focus during the experiential learning cycle.1-3 jects, and class sessions. Tutors and students were
briefed and instructed not to view this form of assess-
ment as ‘continuous examination’, rather as a process
Medical Education Unit, Faculty of Medicine, The University of for monitoring learning. A video was produced and
Hong Kong shown to tutors and students to illustrate the relevant
Correspondence: N G Patil, Deputy Director, Medical Education Unit, steps in this process.
Faculty of Medicine, The University of Hong Kong, Sassoon Road,
Pok Fu Lam, Hong Kong. Tel.: 00 852 2819 9212/9476 4706; Fax: At the end of each session students were given time
00 852 2818 1186; E-mail: [email protected] to write down relevant points in their logbooks to

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Table 1 Year 3 Rotations (One logbook for each block)

Key learning points
Integrated block 8 weeks
Logbooks can provide structure and focus during
the experiential learning cycle.
Junior clerkship
Course-specific logbooks provide a means for Block A (Medicine-related) 8 weeks
monitoring student learning, both for the student Block B (Surgery-related) 8 weeks
Block C (Multidisciplinary) 8 weeks
and for the instructor.
Continuous assessment allows for early identifi-
cation of learning problems so that remediation
can take place. Excellence can also be readily
identified and rewarded. Outcomes
Grading of logbooks by tutors is problematic if The logbooks were part of the students’ continuous
tutors must assign a grade immediately following assessment. At the end of the third year course, 4 of
an activity. 164 students (2Æ4%) had poor evaluations on their
continuous assessment in more than 2 teaching blocks
Feedback mechanisms provide opportunities for
and had the opportunity to sit a remedial clinical test.
course co-ordinators to reflect on the effectiveness
Eight students (4Æ9%) were judged to be excellent and
of the curriculum.
received recognition for their achievements. All 164
students went on to the remainder of their fourth year
highlight what they had learned. Tutors reviewed Bachelor of Medicine/Bachelor of Surgery course.
these entries with the students, making comments and
suggesting changes if there seemed to be any errors in
Discussion
understanding what had been discussed in the session.
Tutors then assigned a grade of 1 to 5 for the students Throughout each teaching block, the logbook process
who had been involved in a presentation or demon- identified students who could benefit from counselling
stration, making an assessment of the students’ and/or remediation. The feedback mechanism provided
performance (Fig. 1). The remaining students who by the logbooks was immediate and, therefore,
had not participated to the same extent on that day remediation was timely and appropriate. This aspect of
were given the remark ‘cannot be assessed’. Once a the use of logbooks provides convincing evidence that
teaching session concluded, tutors completed attend- they are a useful component of medical education.
ance and assessment procedures by transferring the The use of logbooks also encourages interaction
grades from the logbook to forms which were then between tutors and students. In the past, tutors had
sent on to Faculty. Logbooks remained with students no consistent means of assessing how much students
for future revision. There were detachable forms in the understood during sessions. Furthermore, if there
logbooks for student evaluation of the teaching was a misunderstanding by the students, logbooks
programme. These evaluation forms were forwarded provided an opportunity to deal with it. Students
to Faculty every week. and tutors were briefed more than once throughout
At the end of each teaching block, effort, accuracy of the year to reinforce that this form of assessment was
notes, appropriateness of notes and the assessor’s to assist the students’ learning, and to catch prob-
overall impression of the logbook entries formed the lems before it was too late. The students saw some
basis of a 20-point assessment. Faculty Medical Edu- subjectivity in the process of continuous assessment but
cation Unit personnel also reviewed randomly-selected were assured that the global assessment of the logbooks
logbooks at the end of every rotation and compared at the end of the blocks would also be taken into ac-
them with the course outlines in order to evaluate if, count with their multi-tutor assessment.
according to the students’ notes, learning objectives A random selection of logbooks was assessed by an
were being met. external examiner. The purpose of this exercise was to
In addition to the logbooks, the students’ overall provide some outside evaluation of the fairness of the
performance throughout the academic year was continuous assessment process. The examiner also met
assessed by two end-of-block clinical tests for surgery with a student focus group in order to get their views on
and medicine, plus an end-of-year written test. the process.

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674 Interactive logbooks for students • N G Patil & P Lee

Figure 1 Sample extracts from the logbook.

Some students were not exposed to certain core who needed help, recognize excellent performers and
clinical problems during their small group teaching encourage students to do better. Students were assured
sessions due to a lack of patients with these conditions, that the global assessment of the logbooks at the end of
however, this is a common logistical problem in medi- the blocks would also be taken into account with their
cal education and is not a result of the implementation multi-tutor assessment to balance out any perceived
of logbooks. subjectivity in the process of continuous assessment. In
In some instances, the logbooks identified students addition, the bedside sessions in the surgical and
who seemed to be relying too much on the course work. medical blocks were graded as a clinical test and marks
There was obvious reluctance on the part of some were sent to faculty without entry into the logbooks.
tutors to grade the students face-to-face, leading to a Students’ performances in these tests were taken into
majority in their group getting average or above average consideration with the overall grading derived from the
grading. Some students also felt that they deserved continuous assessment and its documentation in the
better grades in comparison to others. There was also logbooks.
unavoidable comparison of tutors considered to be too Each block identified a small number of students
soft or too tough in awarding grades. who were interviewed and counselled to help their
Students and tutors were briefed again to remind learning in subsequent rotations. At the end of the third
them that the purpose of this interaction was to facili- year, 4 students (out of 164) whose continuous
tate learning, and that the grades were to identify those assessment in more than 2 out of 4 third year blocks

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Figure 2 Guidelines to tutors regarding use of attendance/assessment forms and logbooks at small group sessions.

were considered to be poor had the opportunity to sit a All other students were not required to undergo
remedial clinical test. Eight students who were judged third year summative clinical examinations and had
to be excellent were offered a distinction viva. to appear only for the class written test. The external

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676 Interactive logbooks for students • N G Patil & P Lee

Table 2 Usefulness of logbooks for medical students selection who did not require the summative clinical
test.
Useful but could Not The Medical Education Unit at the Faculty re-
Useful be improved useful viewed a random selection of logbooks at the end of
every rotation and compared them with handbooks
Student’s diary/portfolio  given to students at the beginning of the course which
Evaluation of the course  outlined the learning objectives of the each block. A
Evaluation of teachers  copy of a logbook was also printed for the information
Interaction with students 
Continuous assessment 
of block co-ordinators and respective departmental
A document for faculty to  heads.
review the curriculum It was obvious that some students did not get
exposure to certain core clinical problems documen-
ted in the handbook mostly due to non-availability of
patients with these conditions during their small
examiner also reviewed a random selection of log- group teaching session. Some students had just cop-
books in addition to those of the poor and excellent ied the learning objectives and had failed to record
performers. He was satisfied with the fairness of the ‘what they had learned’. We had anticipated that as
continuous assessment process, and made construct- our students had undergone problem-based tutorials
ive suggestions to further improve the students’ log- during the previous 2 years they would be familiar
book entries. It was also agreed that the external with identifying and summarising learning issues. A
examiner would meet a group of students by random briefing session highlighting examples of well-written

Figure 3 Guidelines for global assessment of logbooks by individual block co-ordinators.

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Interactive logbooks for students • N G Patil & P Lee 677

logbooks was arranged, which students found very continued to issue them to subsequent rotations in
helpful, resulting in subsequent improvement in their year 4 and 5.
entries.
An additional observation was that of the near-per-
Acknowledgements
fect attendance of students during the small group
sessions, believed to be due to the emphasis on con- We wish to thank the Dean of the Faculty of Medicine,
tinuous assessment. Tutor punctuality and attendance, Professor Grace Tang, and the block co-ordinators for
a concern for ‘busy’ clinicians, also improved as shown their active role in the implementation of logbooks and
by the feedback obtained from the evaluation forms their constructive suggestions.
enclosed in the logbooks.
Contributors
Conclusions
NGP was actively involved in the design and
Interactive logbooks are a useful method for evaluating implementation of the interactive logbooks. PL is a
the achievement of learning objectives. They also give medical student, and provided constructive criticism
students and tutors an opportunity to reflect on the and comments on the logbooks as an interactive tool.
progress of the medical curriculum, in our case a New
Medical Curriculum. Logbooks also encourage better
Funding
interaction between tutors and students, particularly in
small group settings such as bedside teaching, tutorials, There was no external funding for this study.
etc. The inclusion of evaluation forms in the logbooks
allows students to provide short-loop feedback to
References
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encouraged by the initial benefits in terms of stu- Received 9 January 2001; editorial comments to authors 1 March
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logbooks for third year students in 1999, we have

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