Medical graduates' preparedness to practice: a comparison of undergraduate medical school training.

BACKGROUND: There is evidence that newly qualified doctors do not feel prepared to start work. This study examined views of first year Foundation doctors (F1s) regarding how prepared they felt by their undergraduate medical education for skills required during the first Foundation training year in relation to their type of training. METHOD: One-hundred and eighty two F1s completed a questionnaire during their first rotation of Foundation training. Analysis was conducted by type of medical school training: Problem-Based Learning (PBL), Traditional or Reformed. RESULTS: F1s from medical schools with a PBL curriculum felt better prepared for tasks associated with communication and team working, and paperwork than graduates from the other medical school types; but the majority of F1s from all three groups felt well prepared for most areas of practice. Less than half of graduates in all three groups felt well prepared to deal with a patient with neurological/visual problems; write referral letters; understand drug interactions; manage pain; and cope with uncertainty. F1s also indicated that lack of induction or support on starting work was affecting their ability to work in some areas. CONCLUSIONS: Whilst F1s from medical schools with a PBL curriculum did feel better prepared in multiple areas compared to graduates from the other medical school types, specific areas of unpreparedness related to undergraduate and postgraduate medical training were identified across all F1s. These areas need attention to ensure F1s are optimally prepared for starting work.

The preparedness of newly qualified doctors - Views of Foundation doctors and supervisors.

BACKGROUND: There is evidence that newly qualified doctors do not feel prepared to start work. AIM: This study examined the views of first year Foundation doctors (F1) and supervisors regarding how prepared they felt newly qualified doctors were for the early weeks of work. METHODS: Fifty-two F1s took part in a focus group or individual interview during their first year of Foundation training. Twenty-two supervisors took part in an individual interview. RESULTS: The F1s struggled with new responsibilities, decision-making, time management, prioritizing tasks and the large administrative component to their role. They felt unprepared for making diagnoses, prescribing and acting in an emergency. Supervisors felt F1s were generally well prepared to start work, with skills improving through experience. However, F1s needed more practical experience with real patients and more opportunities to take responsibility, make decisions and perform some clinical skills. Supervisors did not feel that F1s accessed senior support appropriately. F1s indicated they preferred to go to peers for assistance in the first instance, and felt unsupported by seniors, particularly at weekends and on night shifts. CONCLUSIONS: Specific areas of unpreparedness were identified by both F1s and supervisors; leading to recommendations to enhance effective transition from medical student to F1.

Foundation doctors' induction experiences.

BACKGROUND: It is well established that trainee doctors struggle with the transition from medical school to starting work and feel unprepared for many aspects of their new role. There is evidence that suitable induction experiences improve competence and confidence, but available data indicate that trainee doctors on the UK Foundation Programme are commonly not experiencing useful inductions. The aim of the reported research was to explore trainee doctors' experiences with induction during their first year of the Foundation Programme to identify the most useful characteristics. METHODS: A questionnaire was designed to explore trainee doctors' experiences with induction at two points during their first Foundation year, during the first and third of three rotations, to enable all induction experiences on offer during the year to be surveyed. Data were collected using an anonymous questionnaire distributed during a teaching session, with an online version available for those trainees not present. Questions gathered information about characteristics of the inductions, usefulness of components of the inductions and what gaps exist. RESULTS: 192 Foundation trainee doctors completed the questionnaire during Rotation 1 and 165 during Rotation 3. The findings indicated that induction experiences at the beginning of the year, including the local Preparation for Professional Practice week, were more useful than those received for later rotations. Longer inductions were more useful than shorter. Departmental inductions were generally only moderately helpful and they missed many important characteristics. Gaps in their inductions identified by many trainees matched those aspects judged to be most useful by those trainees who had experienced these characteristics. CONCLUSIONS: Many Foundation trainee doctors are experiencing inadequate inductions, notably at the department level. Trainees are starting rotations in new departments without rudimentary knowledge about their role and responsibilities in that department, where to find equipment and documentation, who to contact and how to contact them, local preferences, policies and procedures. Unsurprisingly, trainees who do receive such information in their inductions regard it as highly useful. Action is urgently needed to improve departmental inductions so that all trainees have the information they require to work confidently and competently in each new department they rotate into.

Genetic diversity of ruminant Pestivirus strains collected in Northern Ireland between 1999 and 2011 and the role of live ruminant imports.

BACKGROUND: The genus pestivirus within the family Flaviviridae includes bovine viral diarrhoea virus (BVDV) types 1 and 2, border disease virus (BDV) and classical swine fever virus. The two recognised genotypes of BVDV are divided into subtypes based on phylogenetic analysis, namely a-p for BVDV-1 and a-c for BVDV-2. METHODS: Three studies were conducted to investigate the phylogenetic diversity of pestiviruses present in Northern Ireland. Firstly, pestiviruses in 152 serum samples that had previously tested positive for BVDV between 1999 and 2008 were genotyped with a RT-PCR assay. Secondly, the genetic heterogeneity of pestiviruses from 91 serum samples collected between 2008 and 2011 was investigated by phylogenetic analysis of a 288 base pair portion of the 5' untranslated region (UTR). Finally, blood samples from 839 bovine and 4,437 ovine animals imported in 2010 and 2011 were tested for pestiviral RNA. Analysis of animal movement data alongside the phylogenetic analysis of the strains was carried out to identify any links between isolates and animal movement. RESULTS: No BVDV-2 strains were detected. All of the 152 samples in the first study were genotyped as BVDV-1. Phylogenetic analysis indicated that the predominant subtype circulating was BVDV-1a (86 samples out of 91). The remaining five samples clustered close to reference strains in subtype BVDV-1b. Out of the imported animals, 18 bovine samples tested positive and 8 inconclusive (Ct ≥36), while all ovine samples were negative. Eight sequences were obtained and were defined as BVDV-1b. Analysis of movement data between herds failed to find links between herds where BVDV-1b was detected. CONCLUSION: Given that only BVDV-1a was detected in samples collected between 1968 and 1999, this study suggests that at least one new subtype has been introduced to Northern Ireland between 1999 and 2011 and highlights the potential for importation of cattle to introduce new strains.

Selecting the right medical student.

Medical student selection is an important but difficult task. Three recent papers by McManus et al. in BMC Medicine have re-examined the role of tests of attainment of learning (A' levels, GCSEs, SQA) and of aptitude (AH5, UKCAT), but on a much larger scale than previously attempted. They conclude that A' levels are still the best predictor of future success at medical school and beyond. However, A' levels account for only 65% of the variance in performance that is found. Therefore, more work is needed to establish relevant assessment of the other 35%. Please see related research articles http://www.biomedcentral.com/1741-7015/11/242, http://www.biomedcentral.com/1741-7015/11/243 and http://www.biomedcentral.com/1741-7015/11/244.

The Dundee Ready Education Environment Measure (DREEM): a review of its adoption and use.

BACKGROUND: The Dundee Ready Education Environment Measure (DREEM) was published in 1997 as a tool to evaluate educational environments of medical schools and other health training settings and a recent review concluded that it was the most suitable such instrument. AIMS: This study aimed to review the settings and purposes to which the DREEM has been applied and the approaches used to analyse and report it, with a view to guiding future users towards appropriate methodology. METHOD: A systematic literature review was conducted using the Web of Knowledge databases of all articles reporting DREEM data between 1997 and 4 January 2011. RESULTS: The review found 40 publications, using data from 20 countries. DREEM is used in evaluation for diagnostic purposes, comparison between different groups and comparison with ideal/expected scores. A variety of non-parametric and parametric statistical methods have been applied, but their use is inconsistent. CONCLUSIONS: DREEM has been used internationally for different purposes and is regarded as a useful tool by users. However, reporting and analysis differs between publications. This lack of uniformity makes comparison between institutions difficult. Most users of DREEM are not statisticians and there is a need for informed guidelines on its reporting and statistical analysis.

Does a summative portfolio foster the development of capabilities such as reflective practice and understanding ethics? An evaluation from two medical schools.

Portfolios need to be evaluated to determine whether they encourage students to develop in capabilities such as reflective practice and ethical judgment. The aims of this study were (i) to determine whether preparing a portfolio helps promote students' development in a range of capabilities including understanding ethical and legal principles, reflective practice and effective communication, and (ii) to determine to what extent the format of the portfolio affected the outcome by comparing the experiences of students at two different medical schools. A questionnaire was designed to evaluate undergraduate medical students' experiences of completing a portfolio at two medical schools. A total of 526 (45% response rate) students answered the on-line questionnaire. Students from both medical schools gave the highest ranking for the portfolio as a trigger for reflective practice. 63% of students agreed their portfolio helped them develop reflective practice skills (p < 0.001), whereas only 22% disagreed. 48% of students agreed portfolios helped them understand ethical and legal principles whereas 29% disagreed (p < 0.001). In contrast, only 34% of students thought the portfolio helped them to develop effective communication. Students perceive portfolio preparation as an effective learning tool for the development of capabilities such as understanding ethical and legal principles and reflective practice, whereas other capabilities such as effective communication require complementary techniques and other modes of assessment.

Evaluation and assessment of social accountability in medical schools.

Social accountability as an outcome must be measured at institutional (evaluation) and individual (assessment) level. The definitions used in the measurement will be dependent on the social setting of the medical school being scrutinised. A formal framework is needed so that comparisons can be made and progress measured. The World Health Organisation suggests that there are four principles that delineate social accountability--relevance, quality, cost-effectiveness and equity. Medical schools are evaluated according to their planning, doing and impact in relation to these principles. Boelen and Woollard have clarified the ideas of planning, doing and impact into Conceptualisation, Production and Usability. THEnet group of medical schools use a shortened version of Boelen and Woollard's framework with 20 criteria to evaluate their programmes. At the individual level, there is considerable overlap between the concepts of 'social accountability' and 'professionalism'. Attempts are being made to define and measure professionalism, however, if the behaviour and attitudes of individual graduates is a significant component in defining social responsibility new methods of assessment need to be developed. Factors such as the available resources and the structure of the health services have a very large effect on doctors' attitudes and behaviour. As a result, the task of evaluating and assessing the extent to which medical schools are socially accountable is complex. Judgments on how well a school is meeting the standards will have to make allowance for the local political and economic environment.

Cross-sectional evaluation of a longitudinal consultation skills course at a new UK medical school.

BACKGROUND: Good communication is a crucial element of good clinical care, and it is important to provide appropriate consultation skills teaching in undergraduate medical training to ensure that doctors have the necessary skills to communicate effectively with patients and other key stakeholders. This article aims to provide research evidence of the acceptability of a longitudinal consultation skills strand in an undergraduate medical course, as assessed by a cross-sectional evaluation of students' perceptions of their teaching and learning experiences. METHODS: A structured questionnaire was used to collect student views. The questionnaire comprised two parts: 16 closed questions to evaluate content and process of teaching and 5 open-ended questions. Questionnaires were completed at the end of each consultation skills session across all year groups during the 2006-7 academic year (5 sessions in Year 1, 3 in Year 2, 3 in Year 3, 10 in Year 4 and 10 in Year 5). 2519 questionnaires were returned in total. RESULTS: Students rated Tutor Facilitation most favourably, followed by Teaching, then Practice & Feedback, with suitability of the Rooms being most poorly rated. All years listed the following as important aspects they had learnt during the session: • how to structure the consultation • importance of patient-centredness • aspects of professionalism (including recognising own limits, being prepared, generally acting professionally). All years also noted that the sessions had increased their confidence, particularly through practice. CONCLUSIONS: Our results suggest that a longitudinal and integrated approach to teaching consultation skills using a well structured model such as Calgary-Cambridge, facilitates and consolidates learning of desired process skills, increases student confidence, encourages integration of process and content, and reinforces appreciation of patient-centredness and professionalism.

Identifying professional characteristics of the ideal medical doctor: the laddering technique.

OBJECTIVE: The aim was to examine the utility of the laddering interview technique to investigate complex issues in medical education, such as professionalism. METHOD: The laddering technique was used to identify examples of professional behaviour associated with the ideal medical doctor, and to explain why participants thought these behaviours were important. Three groups were interviewed: doctors (n = 30), first-year medical students (n = 31) and patients (n = 33). RESULTS: All groups identified characteristics associated with a 'communication and interpersonal skills' theme. Data suggested the essence of the doctor-patient interaction was shared by the groups, with varying later emphases due to their different perspectives. Additionally, Doctors and Students generated characteristics associated with 'team-working' and 'competence' themes; Doctors' conceptualization of each theme was more detailed. Positive and negative impacts of Doctor's professional behaviour on the patient, doctor and the wider medical arena were also identified. CONCLUSION: Use of laddering resulted in data-rich results for each of the three stakeholder groups, illustrating shared and divergent preferences as to the preferred characteristics of a medical doctor and effects of successful and less-successful doctor-patient interactions. The identified characteristics are relevant to the area under investigation and salient to these key stakeholders.

Putting theory into practice - a case study in one UK medical school of the nature and extent of unprofessional behaviour over a 6-year period.

BACKGROUND: Producing a medical profession which is fit for the demands and expectations of society involves ensuring that practitioners learn what it means to behave in a 'professional' way. Codes of professional conduct have been developed for medical students in the UK, but the literature on how medical schools actually apply these is small. More detail is needed to evaluate approaches to assessing professionalism, or to analyse the extent to which students 'fail' this aspect. AIM: To describe one UK medical school's approach to monitoring and assessing aspects of professional behaviour; quantify the prevalence and severity of behaviours recognised as cause of concern in the first 6 years of the programme; evaluate whether there is evidence of any association between professional and academic underperformance and draw conclusions for further development of fitness to practice procedures. METHODS: Mixed methods utilising exam board and administrative data for statistical and descriptive analysis. RESULTS: Even under detailed scrutiny, only 3% of students received formal warnings for behavioural problems over the course of a 5-year programme, and notifications decreased as students entered the senior years. There was a trend towards association between academic and professional underperformance. CONCLUSION: Creating clear expectations, providing positive role models and monitoring student behaviour makes explicit what is expected of students as 'professionals in the making', and contributes to overall low rates of misdemeanour. The predictive value of recurrent and serious behavioural problems is not yet known as it is too soon for these graduates to have established careers. Students who are struggling academically may also present with unprofessional behaviours but the cause of this is unclear. Further research is needed to benchmark systems across the UK, and to know whether formalising expectations of undergraduates result in less problems in subsequent practice.

Statistics teaching in medical school: opinions of practising doctors.

BACKGROUND: The General Medical Council expects UK medical graduates to gain some statistical knowledge during their undergraduate education; but provides no specific guidance as to amount, content or teaching method. Published work on statistics teaching for medical undergraduates has been dominated by medical statisticians, with little input from the doctors who will actually be using this knowledge and these skills after graduation. Furthermore, doctor's statistical training needs may have changed due to advances in information technology and the increasing importance of evidence-based medicine. Thus there exists a need to investigate the views of practising medical doctors as to the statistical training required for undergraduate medical students, based on their own use of these skills in daily practice. METHODS: A questionnaire was designed to investigate doctors' views about undergraduate training in statistics and the need for these skills in daily practice, with a view to informing future teaching. The questionnaire was emailed to all clinicians with a link to the University of East Anglia Medical School. Open ended questions were included to elicit doctors' opinions about both their own undergraduate training in statistics and recommendations for the training of current medical students. Content analysis was performed by two of the authors to systematically categorize and describe all the responses provided by participants. RESULTS: 130 doctors responded, including both hospital consultants and general practitioners. The findings indicated that most had not recognised the value of their undergraduate teaching in statistics and probability at the time, but had subsequently found the skills relevant to their career. Suggestions for improving undergraduate teaching in these areas included referring to actual research and ensuring relevance to, and integration with, clinical practice. CONCLUSIONS: Grounding the teaching of statistics in the context of real research studies and including examples of typical clinical work may better prepare medical students for their subsequent career.

Do doctors need statistics? Doctors' use of and attitudes to probability and statistics.

There is little published evidence on what doctors do in their work that requires probability and statistics, yet the General Medical Council (GMC) requires new doctors to have these skills. This study investigated doctors' use of and attitudes to probability and statistics with a view to informing undergraduate teaching.An email questionnaire was sent to 473 clinicians with an affiliation to the University of East Anglia's Medical School.Of 130 respondents approximately 90 per cent of doctors who performed each of the following activities found probability and statistics useful for that activity: accessing clinical guidelines and evidence summaries, explaining levels of risk to patients, assessing medical marketing and advertising material, interpreting the results of a screening test, reading research publications for general professional interest, and using research publications to explore non-standard treatment and management options.Seventy-nine per cent (103/130, 95 per cent CI 71 per cent, 86 per cent) of participants considered probability and statistics important in their work. Sixty-three per cent (78/124, 95 per cent CI 54 per cent, 71 per cent) said that there were activities that they could do better or start doing if they had an improved understanding of these areas and 74 of these participants elaborated on this. Themes highlighted by participants included: being better able to critically evaluate other people's research; becoming more research-active, having a better understanding of risk; and being better able to explain things to, or teach, other people.Our results can be used to inform how probability and statistics should be taught to medical undergraduates and should encourage today's medical students of the subjects' relevance to their future careers.

How medical students demonstrate their professionalism when reflecting on experience.

OBJECTIVES: This paper aims to examine the discourses used by students in a formal assessment of their ability to demonstrate professional values when reflecting on their experiences. METHODS: We carried out a discourse analysis of 50 randomly selected essays from a summative assessment undertaken by all five year groups of students in one UK medical school. RESULTS: Students were able to identify a wealth of relevant examples and to articulate key principles of professional practice. They were also able to critique behaviours and draw appropriate conclusions for their own intended professional development. Detailed textual analysis provided linguistic clues to the depth of apparent reflection: recurrent use of rhetorical language with minimal use of first-person reflections, lack of analysis of underlying factors, and simplistic views of solutions may all indicate students whose ability to learn by reflection on experience needs further development. There were also areas in which cohorts as a whole appeared to have a limited grasp of the important professional issues being addressed. CONCLUSIONS: Assessing written reflections is a useful way of making students link their experiences with professional development. The detailed analysis of language usage may help to refine marking criteria, and to detect students and course components where reflective learning competencies are not being achieved.

Learning in the clinical environment.

Clinical learning is central to medical education. Learning theories suggest that it is most effective when students are actively engaged with patient care and receiving timely feedback. Changes in health care delivery mean that learning must take place in a variety of clinical settings. The 'One Minute Preceptor' approach allows teaching to take place in the course of routine delivery of care.

Comparing staff and student perceptions of the student experience at a new medical school.

AIM: The aim was to compare staff and student perceptions of student experience with the UEA MB/BS educational environment. METHODS: All MB/BS students were asked to complete a standard course evaluation at the end of the 2005/06 academic year, which included the Dundee Ready Education Environment Measure (DREEM). MB/BS teaching staff were asked to complete a revised version of the DREEM. RESULTS: Data from 403 students and 73 teaching staff were compared. The overall DREEM was 144/200 for staff and 141/200 for students. Initial analysis suggested that staff believed that students' were experiencing more positive learning and teaching environments than students actually were, and they viewed the students' social experience as more negative than it actually was. However, staff were unable to comment on number of aspects of the educational environment and scored these as 'unsure'. This distorted the mean values for the subscales. When this was adjudged for, the differences disappeared. CONCLUSIONS: Staff did not believe that students were experiencing a perfect educational environment; in most cases their views were closely aligned. But staff 's unfamiliarity with aspects of the educational environment suggests a continuing need to provide feedback to staff about students' actual experiences, to enable provision of a better environment for students.

AMEE Guide no. 34: Teaching in the clinical environment.

Teaching in the clinical environment is a demanding, complex and often frustrating task, a task many clinicians assume without adequate preparation or orientation. Twelve roles have previously been described for medical teachers, grouped into six major tasks: (1) the information provider; (2) the role model; (3) the facilitator; (4) the assessor; (5) the curriculum and course planner; and (6) the resource material creator (Harden & Crosby 2000). It is clear that many of these roles require a teacher to be more than a medical expert. In a pure educational setting, teachers may have limited roles, but the clinical teacher often plays many roles simultaneously, switching from one role to another during the same encounter. The large majority of clinical teachers around the world have received rigorous training in medical knowledge and skills but little to none in teaching. As physicians become ever busier in their own clinical practice, being effective teachers becomes more challenging in the context of expanding clinical responsibilities and shrinking time for teaching (Prideaux et al. 2000). Clinicians on the frontline are often unaware of educational mandates from licensing and accreditation bodies as well as medical schools and postgraduate training programmes and this has major implications for staff training. Institutions need to provide necessary orientation and training for their clinical teachers. This Guide looks at the many challenges for teachers in the clinical environment, application of relevant educational theories to the clinical context and practical teaching tips for clinical teachers. This guide will concentrate on the hospital setting as teaching within the community is the subject of another AMEE guide.

Medical students' perceptions of peer feedback on an anatomy student-selected study module.

OBJECTIVE: The study aimed to determine student views of peer feedback on their student-selected study (SSS) module. METHODS: A questionnaire was developed to study perceptions of three groups of medical students (N = 42) towards feedback received from peers about their anatomy SSS presentation. RESULTS: Most students felt comfortable receiving and giving feedback. They also felt that received feedback was fair, adequate and helpful, and that receiving feedback made them reflect. Slightly more students reported inadequate feedback from their peers about the presentations' content, compared to other aspects, due to their peers' relative lack of knowledge about their 'specialized' subject. Students would be reluctant to give feedback if anonymity was removed. CONCLUSION: The attitudes of medical students towards peer feedback were largely positive. We advocate further studies to evaluate quality of feedback, and the role of anonymity in peer feedback, and its effect on group dynamics and cohesion.

Systematic review of studies of patients' satisfaction with breast reconstruction after mastectomy.

Systematic review of studies of patients' satisfaction with breast reconstruction published in English (1994-2006) using Medline, Embase, Cochrane databases. Twenty-eight studies related to cosmesis and two related to pain management were identified. Study designs were mostly randomised surveys but half of samples were small. Five studies compared surgical techniques and satisfaction, twelve analysed surgical techniques; two studies looked at the effect of radiation therapy. Nine studies assessed satisfaction determinants. All studies reported good levels of satisfaction. Methodological deficiencies (small sample sizes, context and study designs, satisfaction assessment, basic statistical analysis) limit the generalisability of the findings. Overall, studies suggested that patients were satisfied with breast reconstruction whatever the technique used, whereas age or procedure timing did not affect general satisfaction. Breast symmetry, size, shape and scars were reported as influencing the patients' score. Nipple reconstruction positively influenced satisfaction; radiation before/after reconstruction achieved satisfactory cosmesis, and complications predicted dissatisfaction.