Training experiences immediately after medical school

Interactional skills training in undergraduate medical education: ten principles for guiding future research

BACKGROUND

High-quality healthcare requires practitioners who have technical competence and communication skills. Medical practitioners need interpersonal skills for gathering and transferring information to their patients, in addition to general consultation skills. Appropriate information gathering increases the likelihood of an accurate diagnosis. Transferring information should be performed in a way that promotes patient understanding and increases the probability of adherence to physician recommendations. This applies to: (i) primary prevention such as smoking cessation; (ii) secondary prevention including preparation for potentially threatening interventions; and (iii) tertiary care, including breaking bad news regarding treatment and prognosis.

DISCUSSION

This debate paper delineates factors associated with undergraduate medical communication skills training where robust research is needed. Ten key principles are presented and discussed, which are intended to guide future research in this field and ensure high quality studies with methodological rigour are conducted. The literature on communication skills training for medical school undergraduates continues to grow. A considerable portion of this output is represented by commentaries, descriptive studies or poorly designed interventions. As with any field of healthcare, quality research interventions are required to ensure practice is grounded in high-level evidence.

Preparedness for hospital practice in assuring quality of care

Purpose

The purpose of this paper is to identify the dimensions of preparedness for hospital practice among newly graduated medical officers in Malaysian hospitals who are undergoing their housemanship training; and to compare the level of preparedness among the different curricula and predict the dimensions of preparedness for hospital practice.

Design/methodology/approach

A national study was carried out and data collection was by means of self-administered questionnaire. Data obtained (n=1,213) were subjected to exploratory factor analysis using Statistical Package for Social Sciences version 18 in extracting the dimensions of preparedness for hospital practice.

Findings

Nine dimensions of hospital practice were identified which were access to information and IT skills, interpersonal skills, basic skills, and continuing professional development, holistic skills, coping skills, ethic and legal skills, patient management skills, scientific knowledge, and clinical skills. Overall, the respondents felt their medical schools prepared them for hospital practice. The strongest predictor for preparedness for hospital practice is coping skills. Holistic skill and preparedness for hospital practice was found to be negatively associated. Those who graduated from twining programmes between Malaysian and overseas universities were found to be better prepared for hospital practice.

Social implications

An understanding on preparedness for hospital practice among newly graduated medical officers is a step forward in assuring patient safety and quality of care.

Originality/value

Although of significant importance, however, a study of this nature is rarely researched and the first for Malaysian houseman.

Tutoring Trainees to Suture: An Alternative Method for Learning How to Suture and a Way to Compensate for a Lack of Suturing Cases

INTRODUCTION

Tutoring in suturing was developed to compensate for a shortage of suturing cases. The objective of this study was to compare ideal suturing score (ISS; 9 points), suturing time (min:sec), and suture placement error (mm) between medical students completing the suturing tutoring program and medical students attending ordinary medical school training program.

METHODS

Participants consisted of 2 groups of medical students who had never performed suturing. The study group had the role of suturing tutor to teach interested high school students. The control group consisted of volunteers from the ordinary medical school program. Skills measurement was performed by having students from both the groups perform 3 vertical mattress sutures on a model. The study group was tested at weeks 1, 9, and 10 to assess improvement. Both the groups were tested at week 10 to compare final learning outcome.

RESULTS

There were 41 and 40 participants in the study group and the control group, respectively. ISS was significantly improved in the study group from week 1-week 10 (7.0 ± 1.3 vs. 8.2 ± 0.9, p = 0.01). At week 10, the study group had a higher mean ISS than the control group (8.2 ± 0.9 vs. 7.8 ± 1.1, p = 0.68). Mean suturing time and mean placement error were also lower in the study group at the end of suturing training (5:1 ± 1:0 vs. 5:2 ± 1:2, p = 0.13; 7.4 ± 7.4 vs. 8.0 ± 10.8, p = 0.44).

CONCLUSION

Tutoring trainees to suture can improve a student's ability to learn how to suture.

Opportunity or threat: the ambiguity of the consequences of transitions in medical education

OBJECTIVES

The alleged medical education continuum is interrupted by a number of major transitions. After starting medical school, the first transition students encounter is that from non-clinical to clinical training. The second transition is that of graduated student to junior doctor or specialist trainee, and the third concerns the specialist trainee's transition to medical specialist. As a first step towards a better understanding of the effects of transitions, this paper provides a critical overview of how these transitions have been conceptualised in the medical education domain. The findings are complemented with perspectives from the fields of transitional psychology and organisational socialisation. The transition into medical school is not reviewed.

METHODS

Using the term 'transition', six leading medical education journals were searched for relevant articles. A snowballing technique on the reference lists of the 44 relevant articles yielded 29 additional publications. Studies were reviewed and categorised as representing objectifying, clarifying, or descriptive and/or justifying research.

RESULTS

When students enter clinical training, they need to relearn what they thought they knew and they must learn new things in a more self-directed way. As junior doctors or specialist trainees, their main challenges involve handling the many responsibilities that accompany the delivery of patient care while simultaneously learning from the process of providing that care. As medical specialists, new non-medical tasks and decisions on how to delegate responsibilities become issues.

CONCLUSIONS

Research on transitions has objectified the challenges students and doctors face. Clarifying studies often lack conceptual frameworks that could help us to gain deeper insight into the observed phenomena. Psychology offers valuable theoretical perspectives that are applicable to medical education transitions. To transform a transition from a threat to a learning opportunity, medical education should assist students and doctors in developing the coping skills they need to effectively deal with the challenges presented by new environments.

Using the clinical challenges encountered by junior residents to inform curriculum for paediatric pre-intern students

AIM

To develop and evaluate a novel skills-based education programme for medical students completing a paediatric pre-internship (PrInt) at the Children's Hospital at Westmead (CHW), Sydney which incorporated a mini-clinical evaluation exercise style formative assessment component and was based upon a local needs assessment of junior staff.

METHODS

We designed a teaching programme which included four interactive tutorials and formative assessment tasks using observed clinical exercises (OCE). The final programme was informed by a local need-based assessment of out-of-hours junior doctors' tasks. Students rated their level of confidence prior to and after the tutorial and following the OCE. Students provided structured and free text feedback on the programme.

RESULTS

Of 29 PrInt students (2007-2008), with collectively 85 tutorial attendances, 84% rated the programme excellent (39%) or very good (45%). For each topic students' confidence increased after the tutorial and again after the OCE (P < 0.001). Improvement was most marked for skills for which students rated themselves pre-teaching as having poor confidence (pain management and calculation of rehydration fluids). Overall, the proportion with 'high' confidence increased from 8.2% pre-tutorial to 38.8% post-tutorial and 72.9% post-OCE (P < 0.001). Competence in skills was assessed by OCE and all students achieved scores of >90%. Diaries from junior doctors during 20 shifts at the CHW recorded 398 out-of-hours activities, the most common of which are ordering intravenous fluids (19.6%), reviewing asthmatics (16.6%) and recharting medications (16.3%).

CONCLUSION

PrInt students value structured teaching incorporating OCE, which allows assessment of clinical skills and direct formative feedback and promotes gains in confidence, knowledge and skills. Addition of OCE to the teaching programme significantly increased the confidence of PrInt students in performing specific tasks compared with an educational session alone. Local needs assessment of junior doctors by out-of-hours survey both confirmed selection of appropriate topics (pain, fluids) and informed additional topics (asthma management and bronchodilator weaning regime) for future PrInt student programmes.

An international review of tobacco smoking among dental students in 19 countries

This study was conducted as a systematic review of all modern literature describing the prevalence of tobacco smoking among dental students. An electronic keyword search of appropriate terms was initially undertaken to identify relevant material, after which the reference lists of manuscripts were also examined to locate additional publications. A total of 27 studies from 19 countries were identified. The earliest manuscripts appeared in 1970, with the most recent being published in 2006. From a global perspective, our review suggests that tobacco smoking is relatively uncommon among contemporary dental students in Australia, Brazil, Canada, Great Britain and the United States. This is not surprising however, as it has previously been noted that dentists generally smoke at one of the lowest rates among all health professionals, and much lower than that of the communities in which they live. Somewhat discouragingly, we did find that smoking remains quite common among dental students in countries such as Greece, Serbia, Romania and Hungary. Given the fact that some of the student body continue to smoke tobacco, it is clear that more aggressive tobacco-specific measures should become a mandatory component of global dental education in future years.

General competencies of problem-based learning (PBL) and non-PBL graduates

INTRODUCTION

Junior doctors have reported shortcomings in their general competencies, such as organisational skills and teamwork. We explored graduates' perceptions of how well their training had prepared them for medical practice and in general competencies in particular. We compared the opinions of graduates from problem-based learning (PBL) and non-PBL schools, because PBL is supposed to enhance general competencies.

METHOD

We analysed the responses of 1159 graduates from 1 PBL and 4 non-PBL schools to a questionnaire survey administered 18 months after graduation.

RESULTS

Compared with their non-PBL colleagues, the PBL graduates gave higher ratings for the connection between school and work, their medical training and preparation for practice. According to the graduates, the most frequently used competencies with sufficient coverage during medical training were expert knowledge, profession-specific skills and communication skills. The majority of the PBL graduates, but less than half of the non-PBL graduates, indicated that communication skills had been covered sufficiently. All the graduates called for more curriculum attention on working with computers, planning and organisation, and leadership skills. More PBL graduates than non-PBL graduates indicated that they had learned profession-specific methods, communication skills and teamwork in medical school.

DISCUSSION

Overall, the graduates appeared to be satisfied with their knowledge and skills. The results suggest that the PBL school provided better preparation with respect to several of the competencies. However, both PBL and non-PBL graduates identified deficits in their general competencies, such as working with computers and planning and organising work. These competencies should feature more prominently in undergraduate medical education.

Country report: Australia

The last 10 years has been an interesting time for Australian medical education despite reduced funding.

WORKFORCE

There are five main workforce trends: a rural/urban maldistribution, a need for more specialists, public hospital staffing difficulties, increasing female practitioners and under-representation of indigenous practitioners.

ISSUES FACING THE DEANS

Lack of resources is a problem facing Deans, with pressure for clinical service in teaching hospitals. Entrepreneurial activities have been undertaken including the enrollment of overseas students. Medical schools have also responded to important government initiatives.

DEVELOPMENTS IN MEDICAL EDUCATION

Australia's 11 medical schools have undergone significant reform in the last decade. There is a mix of four (graduate), five and six year courses. AUSTRALIA'S NEW MEDICAL SCHOOL: James Cook University opened the first medical school in northern Australia in 2000. The School admits students from rural, northern Australian and indigenous backgrounds. It has a strong regional mission. RURAL AND COMMUNITY-BASED EDUCATION: Government funding to address the maldistribution of the workforce has led to the establishment of rural clubs, Departments of Rural Health and community-based programs.

THE FIRST TWO POSTGRADUATE YEARS

There have been recent moves to improve education in the two years following graduation. This includes the initiation of national projects in curriculum and assessment.

POSTGRADUATE AND CONTINUING MEDICAL EDUCATION

Postgraduate programs in Australia are being reformed to build on the changes in undergraduate education. CME is also under review.

CONCLUSION

Australian medical educators should build on the recent reforms and take on some of the new directions in medical education.

Interactional skills of students from traditional and non-traditional medical schools before and after alcohol education

OBJECTIVE

To compare alcohol-related intervention and general interactional skills performance of medical students from a traditional (Sydney) and a non-traditional (Newcastle) medical school, before and after participation in an alcohol education programme about brief intervention.

DESIGN

In two controlled trials, students received either a didactic alcohol education programme or didactic input plus skills-based training. Prior to and after training, all students completed videotaped interviews with simulated patients.

SETTING

The Faculties of Medicine at the University of Newcastle and the University of Sydney, Australia.

SUBJECTS

Fifth-year medical students (n=154).

RESULTS

Both alcohol-related intervention and general interactional skills scores of the Newcastle students were significantly higher than those of the Sydney students at pre-test but not after training. Although alcohol-related interactional skills scores improved after training at both universities, they did not reach a satisfactory level. The educational approach used had no effect on post-test scores at either university.

CONCLUSIONS

Significant baseline differences in interactional skills scores favouring non-traditional over traditional students were no longer evident after both groups had been involved in an alcohol education programme. Further research is required to develop more effective alcohol intervention training methods.

Preventive and other interactional skills of general practitioners, surgeons, and physicians: perceived competence and endorsement of postgraduate training

BACKGROUND

Perceived competencies and support for formal postgraduate training across a range of preventive and other interactional skills were examined in three medical groups.

METHODS

All eligible final year students and recent graduates of the three major Australian medical colleges (n = 767) were mailed a questionnaire examining communication skills in four domains: preventive, educational, therapeutic, and general.

RESULTS

Overall consent rate was 45%. For most items, at least one-third of each group reported low competence. On preventive items, low competence ratings ranged from 5 to 39% in general practice, 38 to 67% in surgery, and 33 to 51% in the speciality physician group. Significant intergroup differences occurred on eight competence items. Agreement with training on preventive topics ranged from 80 to 91% in general practice, 48 to 69% in surgery, and 72 to 82% in the specialty physician group. On all 11 training items where significant differences occurred, the general practice group reported the highest level and the surgeon group the lowest level of endorsement for formal training and assessment.

CONCLUSIONS

Substantial proportions in the general practice, surgery, and the physician specialty report lack of competence in common interactional skills. There were high levels of support for formal training in preventive and other interactional skills. The strong endorsement supports the development of effective, tailored interactional skills training programs.

The development of undergraduate curricula in surgery: I. General issues

Undergraduate surgical education is evolving in line with societal changes, the growth of information technology, developments in educational processes, and shifts in the health-care industry. The underlying principles include the establishment of a strong linkage between the objectives and content of curricula, the identification of core knowledge and appropriate attitudes, achieving competence in basic skills, the creation of greater integration, and the promotion of study in depth. The aim of the present paper was to provide surgeons with an overview of these developments.

Identifying core obstetric and gynecologic skills required of, and used by, graduates of the Faculty of Medicine and Health Sciences, United Arab Emirates University

BACKGROUND

Acquisition of core practical skills by students assures quality and relevance of medical education.

PURPOSE

To determine whether students and interns are acquiring core obstetric and gynecologic skills.

METHODS

A self-administered questionnaire was sent to obstetric and gynecology clerkship coordinators (n = 3), consultants (n = 14), residents (n = 13); interns (n = 13) and final-year students (n = 29; n = 93, response rate = 77%, N = 72). The questionnaire contained a stimulus list of 21 clinical, 8 communication, and 5 professional skills.

RESULTS

Of 34 listed skills, 24 were identified as core skills. At least 50% of consultants, faculty, and residents expected 28 core skills to be covered in the undergraduate program. At least 50% of interns believed that 21 core skills had been acquired at graduation.

CONCLUSION

Our curriculum is facilitating acquisition of core obstetric and gynecologic skills.

Acquiring surgical skills

BACKGROUND

Technical competence is the bedrock of surgery, yet it has only recently been viewed as a valid area for either critical evaluation or formal teaching.

METHODS

This review examines the teaching of surgical skills. The core is derived from a literature search of the Medline computer database.

RESULTS AND CONCLUSION

The impetus for surgical change has generally related to the introduction of new technology. Advances initially allowed for open operation within the main body cavities; more recently minimal access surgery has appeared. The latter was introduced in an inappropriate manner, which has led to the evolution of teaching of technical skills away from an apprenticeship-based activity towards more formal skill-based training programmes. There is now a need for a solid theoretical base for the teaching of manual skills that accommodates concepts of surgical competence.

Breaking bad news. 3: Encouraging the adoption of best practices

Steps to encourage clinicians to adopt the best practices for communicating bad news to patients are outlined. First, official, credible guidelines endorsed by key organizations or professional bodies, giving a clear message about the components and importance of the best practices, must be produced. Second, the guidelines should be disseminated; publication in journals or mailing to clinicians is unlikely to be sufficient. Third, clinicians should be provided with feedback on whether their performance meets established standards. This requires acceptable systems to collect valid and reliable performance data. Fourth, clinicians need contingencies for providing best practice care. Fifth, barriers to improvement should be explored and strategies to address them, including interactional skills training, implemented. Continuous quality assurance, commitment, and evaluations will help clinicians use the best practices for breaking bad news to patients.

Breaking bad news. 2: What evidence is available to guide clinicians?

Literature related to breaking bad news to medical patients was reviewed. An analysis of citations appearing between 1994 and August 1997 updated earlier work and indicated that a minority (24%) of the studies on the subject were designed to collect original data. Ten randomized controlled trials (RCTs) evaluating communication strategies with cancer patients in the diagnostic phase have been published since 1980. These RCTs were analyzed for methodological adequacy and their clinical implications. The sampling methods of the RCTs presented particular problems. Although patients liked the experimental interventions, there was little evidence of any effect on the patients' psychological adjustment; the effects on patients' knowledge and satisfaction levels were inconsistent. Healthcare consequences of issues concerned with patient selection, cultural factors, medical-legal requirements, and intervention costs are outlined and specific suggestions offered for future research testing the effects of different approaches to breaking bad news.

Working patterns and the quality of training of medical house officers: evaluating the effect of the 'new deal'

The 'new deal' on junior doctors' hours of work has led to the widespread introduction of working patterns such as full shifts and partial shifts in the United Kingdom. The impact of these changes on the training of medical staff is unclear. The subjects of the current study were 36 pre-registration medical house officers working shift rotas and on-call rotas at a teaching hospital in the north of England. They were studied over a 12-month period using a self-report questionnaire seeking their views on the quality of their training experience and their satisfaction with the in-service training they received. Nursing staff, consultant and medical student opinion was also sought. Partial-shift and full-shift systems led to reduced hours of work when compared to on-call rotas (mean hours: partial shift 65.0; full shift 59.8; on-call 72.7), but they were associated with significantly lower training experience and training satisfaction scores for the house officers than were on-call systems (P < 0.01). Shift systems were unpopular among consultants and medical students but not nursing staff. Despite reducing excessive hours of work, shifts may be detrimental to the training of medical house officers. The further imposition of shift working should be suspended until such time as the impact of new working patterns on the training of medical staff has been determined.