Evaluating interns' performance using simulated patients in a casualty department

Training Medical Students in Behavioural and Cognitive Strategies

It is argued that psychologists have an important role in ensuring appropriate training of medical students in behavioural and cognitive strategies. This paper outlines the innovative medical curriculum at the University of Newcastle and describes the contribution of cognitive psychology to the problem-solving method which underlies the curriculum. It also describes the medical school's approach to training students in interactional skills. One focus of the interactional skills training is to provide practical skills which incorporate behavioural and cognitive strategies to address common, preventable health problems, such as excessive alcohol consumption.

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.

Developing case-specific checklists for standardized-patient-based assessments in internal medicine: A review of the literature

PURPOSE

To review the literature on the methods used in writing case-specific checklists for studies of internal medicine physicians' performances that were assessed by standardized patients.

METHOD

The authors searched Medline, Embase, Psychlit, and ERIC for articles in English published between 1966 and February 1998. The following search string was used: "[(standardi(*) or simulat(*) or programm(*)) near (patient(*) or client(*) or consultati(*))] and internal medicine." The authors then searched the reference lists of papers retrieved from the database searches, as well as those from seven proceedings of the International Ottawa Conference on Medical Education and Assessment.

RESULTS

The procedure yielded 29 relevant articles: database searches yielded 14 published reports dealing with case-specific checklists, 11 articles were culled from the reference lists of these papers, and the Ottawa Conference proceedings yielded four articles. Only 12 articles reported specifically on the development of checklists. In general, there were three sources used for developing checklists: panels of experts, the investigators themselves, and responses from expert physicians to written protocols. No article indicated that researchers had relied exclusively on data from the literature to compose their checklists. Only three articles indicated that literature sources had informed their checklist development. All articles except one relied on explicit criteria for the inclusion of items on the checklists. In 21 of the 29 articles, the checklists had been scored by SPs, but the scoring of specific items on the checklists varied according to the purpose of the SP-physician encounter. Only four of the articles made the checklists available or indicated that the checklists could be obtained from the authors.

CONCLUSION

The development of case-specific checklists for SP examinations of physicians' performance has received little attention. To judge the validity of studies of physicians' performances that use SPs, the development processes for the checklists need to be more fully described to enable readers to evaluate the validity and reliability of the studies.

Teaching medical students alcohol intervention skills: results of a controlled trial

OBJECTIVE

To assess the relative effectiveness of videotape feedback and lecture methods for teaching alcohol brief intervention skills.

DESIGN

In a controlled trial, two student blocks received a manual, lecture and demonstration about the principles and practice of brief alcohol intervention. In addition, experimental students made a 20-min videotape and participated in a 1.5-h small group feedback session. Prior to and after training, all students completed questionnaires and videotaped interviews with simulated patients.

SETTING

Faculty of Medicine and Health Sciences of the University of Newcastle, Australia.

SUBJECTS

Final-year medical students.

RESULTS

Levels of alcohol-related knowledge, attitudes and interactional skills as well as general interactional skills were significantly improved after teaching. Alcohol-related interactional skills that were unsatisfactory at pretest reached satisfactory standards at post-test. An intergroup comparison of the improvement between pre- and post-teaching scores indicated that there was no significant difference in the effectiveness of the two methods.

CONCLUSIONS

Training can improve medical student performance in alcohol intervention. Further research is required to examine the relative effectiveness of different teaching methods.

Improving smoking cessation advice in Australian general practice: what do GPs suggest is needed?

Smoking cessation advice from a general practitioner (GP) significantly increases quit rates among patients who smoke. However, smoking is not discussed during most routine consultations with smokers. This study describes GPs' own views about strategies to support their cessation advice. In 1997, a random sample of 311 GPs in NSW (73% response rate) completed a self-administered questionnaire about smoking cessation. Most respondents were 'very confident' about discussing the health effects of smoking (81.7%). Fewer were as confident about negotiating a quit date (21.5%) or using evidence-based smoking cessation techniques (19.3%). The top three preferred strategies to support smoking cessation advice were all resources for patients: subsidised nicotine replacement therapy (rated as 'quite useful' by 60.5%), pamphlets (55.0%) and free access to smoking cessation clinics (50.8%). Skills training (39.7%) was the preferred resource to improve practitioner effectiveness. Interventions combining skills training with patient resources are likely to be well received by GPs.

A system for maintaining the educational and training standards of junior doctors

The development of junior doctors' competence is complex because the hospital environment in which doctors work places many demands on them. The need for quality education and training and personal development may be in direct conflict with the service commitments required from hospitals. This paper describes the methods by which the Postgraduate Medical. Council of New South Wales, Australia, addresses the needs of junior doctors in the state in order to improve the quality of their education. Key elements of the Council's function include the provision of hospital clinical supervisors who oversee junior doctor education and training, and central involvement in supplying the junior doctor workforce to all state hospitals who must meet defined accreditation standards. This paper also provides data on evaluation of those methods and some educational outcomes.

Training experiences immediately after medical school

Trainees in all teaching hospitals in New South Wales were surveyed using a self-completion, postal questionnaire to assess perceptions of the quality and extent of training received for interactional and technical skills. The response rate was 67.1%. Mean age was 25.4 years and 38.8% were female. Overall, training was found to be generally poor in terms of time and educational strategies used. Interactional skills were found to receive lower levels of training than technical skills both prior to and during the intern year with significantly fewer (P < 0.000) educational strategies reported for training received in interactional skills than for technical skills. Trainees' perceptions of the adequacy of training was significantly more negative for interactional than technical skills (P < 0.001). Assessment of competence was also significantly lower for interactional than technical skills (P < 0.001). On average, fewer than one in three trainees considered themselves to be competent in interactional skills compared to two-thirds who reported themselves as competent for technical skills. The findings of this study highlight the need for improved efforts with regard to both the quality and quantity of training provided during the intern year. Considerable scope exists for improved educational experiences for both interactional and technical skill areas, but particularly for interactional skills. Overall, greater use of a range of basic educational strategies such as the provision of 'observation' and 'critical feedback' is indicated. Efforts also need to be directed toward the training of clinical educators to optimize the potential of the preregistration period.

Increased focus on the teaching of interactional skills to medical practitioners

The interaction which occurs between the doctor and patient has been described as the cornerstone of medial care. Research has shown that interactional skills can have a substantial impact on patient outcomes in a number of areas. However, as practitioners do not necessarily acquire such skills through clinical practice, the introduction of formal training programmes for both under and postgraduate medical practitioners should be more closely examined. This paper outlines a number of issues which need to be considered in the formal instruction of medical practitioners in interactional skills. These issues include the teaching of skills within a clinical context that will reflect actual medical practice, the use of all medical disciplines to teach the skills and the inclusion of formal assessment strategies based on the same rigorous criteria as other components of the medical curriculum.

Preventive care in general practice in Australia: a public health perspective

There is considerable potential in Australia for implementing effective preventive care strategies in the general practice setting, especially in the context of Australia's new health goals and targets towards the year 2000. There is a clear need for the clinical paradigm, which focuses on developing efficacious, intensive, practitioner-delivered lifestyle change interventions, to be integrated within a broader public health approach. However, while there has been considerable growth in the breath and variety of health promotion research and activity being carried out in general practice in Australia, the evidence supportive of the efficacy and effectiveness of physician-based interventions (except in the case of smoking cessation) has been less than compelling, and a number of problems still remain. These include: health promotion still remains a minor component of the great majority of consultations; there are many potential interventions which are possible, but little evidence that they will be used appropriately; there is little evidence that patients who are most in need are receiving appropriate services; there is generally a poor linkage between research and practice; and there are real doubts about the ability of the system to sustain preventive care in general practice.

Development and implementation of an innovative intern training programme

The quality of medical education during internship is a cause for concern. This paper describes a structured educational programme for interns that was based around learning modules, clinical attachments and bedside teaching. The programme was incorporated into the term rotation of interns within an Area Health Service, and evaluated. Learning modules were timetabled by a Programme Coordinator and interns were reminded to attend. Clinical attachments were organized by the interns from a list of willing supervisors. Attendance at timetabled learning modules averaged 67%, which was greater than the 27% attendance at clinical attachments. Both sessions received high ratings for quality and clinical relevance. This structured education programme was based upon adult learning methods and was both feasible and well received by interns. Intern training programmes need to be programmed into the working week to ensure attendance, and modified following evaluation by interns. Such programmes should be considered by all hospitals to which interns are allocated.

Clinical competence of interns. Programme Evaluation Committee (PEC)

A clinical supervisors rating form addressing 13 competencies was used to assess the clinical competence of graduates one year after qualification in New South Wales (NSW), Australia. Data from 485 interns (97.2%) showed that graduates from the problem-based medical school were rated significantly better than their peers with respect to their interpersonal relationships, 'reliability' and 'self-directed learning'. Interns from one of the two traditional NSW medical schools had significantly higher ratings on 'teaching', 'diagnostic skills' and 'understanding of basic mechanisms'. Graduates from international medical schools performed worse than their peers on all competencies. These results were adjusted for age and gender. Additionally, women graduates and younger interns tended to have better ratings. Junior doctors have differing educational and other background experiences and their performance should be monitored.

Do physicians take into account patients' expectations?

To determine whether patient expectations are fulfilled when they are expressed to physicians, self-administrated questionnaires were given to 360 consecutive ambulatory patients. Information was randomly given or not given to physicians. Diagnosis (94%), information about prognosis (82%) and prevention (76%), and continuing care (80%) were important expectations. There was no agreement between global or individual patient expectation and physician response (kappa < or = 0.3). The physicians prescribed more medications than expected, and almost never discussed prevention or prognosis. Finally, the characteristics of care were not different between the physicians who knew and those who did not know patient expectations. The authors conclude that ambulatory patients visit physicians to receive a diagnosis, continuing care, and information about prognosis and prevention. In this study, physician knowledge of those expectations did not increase their fulfillment.

Behaviour Therapy's Role in Preventing Physical Illness

This paper argues for an expansion of the field of behaviour therapy from a predominant focus on individual and family based treatment of problems into the prevention of physical illness at a population level. It outlines criteria which can be used to make rational decisions about which domains behaviour therapists should focus on, it then provides a rationale for placing more emphasis on population based strategies of prevention. The particular contributions which the discipline of behaviour therapy has to offer to such an expanded role are then delineated and the benefits of an expanded role into primary and secondary prevention of physical disease are discussed in relation to past research.

Interns' performances with simulated patients at the beginning and the end of the intern year

OBJECTIVE

To determine whether interns' performances of technical, preventive, and communication aspects of patient care improve during the intern year.

DESIGN

A descriptive study. At the beginning and end of the intern year, interns' consultations with three simulated (standardized) patients were videotaped and scored according to explicit criteria set by an expert panel. Problems simulated were urinary tract infection, bronchitis, and tension headache.

SETTING

The casualty outpatient department in a general teaching hospital in New South Wales, Australia.

PARTICIPANTS

Twenty-eight interns rotated to the casualty department.

RESULTS

Little improvement over the intern year in technical competence or preventive care was observed, even though initial levels of compliance with criteria were quite low for some items. Greater improvement was apparent in the area of communication skills.

CONCLUSIONS

The results suggest that the internship should be restructured to more adequately teach the skills required for primary care.

Are departments of general practice in medical schools really needed?

Few medical schools appear aware of modern developments in general practice and of its educational potential in helping provide balance to a predominantly teaching hospital approach to the diagnosis and treatment of disease. Contributing to the problem are a lack of clarity about the term "undifferentiated doctor", failure to understand the different purposes of undergraduate and vocational training and the erroneous view that general practice is not a "proper" university discipline because it lacks an intellectual basis.