Assessing the technical skills of surgical trainees.

BACKGROUND: The aims were to determine whether tests of technical skill on simple simulations can predict competence in the operating theatre and whether objective assessment in the operating theatre by direct observation and video recording is feasible and reliable. METHODS: Thirty-three general surgical trainees undertook five simple skill simulations (knotting, skin incision and suturing, tissue dissection, vessel ligation and small bowel anastomosis). The operative competence of each trainee was then assessed during two or three saphenofemoral disconnections (SFDs) by a single surgeon. Video recordings of the operations were also assessed by two surgeons. RESULTS: The inter-rater reliability between direct observation and blinded videotape assessment was high (alpha = 0.96 (95 per cent confidence interval 0.92 to 0.98)). Backward stepwise regression analysis revealed that the best predictors of operative competence were the number of SFDs performed previously plus the simulation scores for dissection and ligation, the key components of SFD (64 per cent of variance explained; P = 0.001). CONCLUSION: Deconstruction of operations into their component parts enables trainees to practise on simple simulations representing each component, and be assessed as competent, before undertaking the actual operation. Assessment of surgical competence by direct observation and video recording is feasible and reliable; such assessments could be used for both formative and summative assessment.

Evaluating assessment: the missing link?

BACKGROUND: Methods chosen for assessment and the manner in which they are applied are so intimately associated with how individuals learn that developing appropriate assessment strategies is a key part of effective curriculum development. THE ASSESSMENT CYCLE: We describe a four-stage assessment cycle identifying important steps in assessment. Each step is described in detail, stressing its key aspects, including: the need for clear assessment policy and strategy, the importance of assessment blueprints in planning assessment, the need for effective feedback when presenting results, and the essential, but often overlooked, need to evaluate the assessment process itself. EVALUATING ASSESSMENT: This final evaluation stage is the most important part of the assessment cycle and can be divided into four levels. The first level includes evaluating each question in the assessment, the second level is concerned with establishing validity and reliability, the third level centres on the assessment process and review of assessments by external examiners and the fourth level involves evaluation over several assessments. RELATING ASSESSMENT TO THE CURRICULUM: This long-term evaluation should examine whether existing assessments are congruent with the curriculum and relate to all facets of the students' learning experiences. This is particularly important in a curriculum where the learning outcomes of student-centred learning are emphasized. Changes in the assessment of postgraduate trainees and increasing emphasis on peer review of clinicians will raise the profile of these outcomes in undergraduate education.

Control of infection in general practice: a survey and recommendations.

Twenty general practices in four areas in Britain were surveyed to establish their needs for and practices of sterilising and disinfecting equipment. Of the 327 items of equipment and instruments examined in the survey, 190 were satisfactorily decontaminated, 100 were treated in a way judged to result in doubtful decontamination, and in 37 cases treatment was considered unsatisfactory. Decontamination apparatuses (autoclaves, hot air ovens, and hot water disinfectors) were generally in good working order, but the use of chemical disinfectants was often inappropriate. Recommendations were made on appropriate methods of decontamination for various items in common use in general practice. By virtue of the large numbers of patients treated by general practitioners there is a substantial possibility of transmitting infection; having appropriate methods for decontaminating instruments and equipment is therefore imperative.

Teaching medical ethics symposium. A student-led approach to teaching.

It is increasingly agreed that ethics has a place in undergraduate medical education. There is, however, debate about how it should be taught, and by whom. We present our experience of teaching ethics in a general practice module over six years. During this period there has been a shift from a teacher-centred to a student-centred approach in which students choose ethical issues to explore within a framework provided. The issues raised are discussed with examples, and the future directions of our ethics teaching outlined.

The doctor, the patient and the relative: an exploratory survey of doctor-relative relationships.

The contacts which doctors have with their patients' relatives are important, and raise interesting and sometimes difficult ethical issues. In order to develop hypotheses about doctor-relative relationships, a sample of 18 general practitioners in east London were interviewed. Their views are summarized in this paper, and from them a number of hypotheses concerning these relationships are proposed. Further research will be needed to test these hypotheses.

Determination of worries and expectations of family practice patients.

One of the cornerstones of family practice is the development of the physician-patient relationship within the context of the consultation. Each consultation is modified both by the prior expectations of the participants and by illness-related worries held by the patient. This paper describes the development of an instrument to record the worries and expectations of patients visiting their family physicians and changes occurring as a result of the consultation. The instrument comprises a card sort composed of 26 cards, on each of which is typed a statement relating to a worry or expectation that a patient might hold. One hundred patients were asked to sort these cards before and after the consultation. The major worries of the group were about discomfort, the effects of illness on the family, the prospect of a physical examination, and about explaining the problem to the physician. Prominent expectations were for an explanation of diagnosis and treatment and a friendly and understanding manner from the physician.