Estimating the effect of selective border relaxation on COVID-19 in New Zealand.

AIMS: We developed a model, updated daily, to estimate undetected COVID-19 infections exiting quarantine following selectively opening New Zealand's borders to travellers from low-risk countries. METHODS: The prevalence of infectious COVID-19 cases by country was multiplied by expected monthly passenger volumes to predict the rate of arrivals. The rate of undetected infections entering the border following screening and quarantine was estimated. Level 1, Level 2 and Level 3 countries were defined as those with an active COVID-19 prevalence of up to 1/105, 10/105 and 100/105, respectively. RESULTS: With 65,272 travellers per month, the number of undetected COVID-19 infections exiting quarantine is 1 every 45, 15 and 31 months for Level 1, Level 2 and Level 3 countries, respectively. The overall rate of undetected active COVID-19 infections exiting quarantine is expected to increase from the current 0.40 to 0.50 per month, or an increase of one extra infection every 10 months. CONCLUSIONS: Loosening border restrictions results in a small increase in the rate of undetected COVID-19 infections exiting quarantine, which increases from the current baseline by one infection every 10 months. This information may be useful in guiding decision-making on selectively opening of borders in the COVID-19 era.

Time to "refine" clinical ward assessments? Or time to retrain?

AIM: To investigate the reliability and intra-professional variation of senior and junior doctors in the assessment of a junior doctor's clinical skills via video simulation. METHODS: Simulation video was created showing 4 clinical scenarios. This video was shown to consultants, registrars and junior doctors in various forms at Auckland City Hospital. Participants evaluated each scenario against a modified version of the current assessment form used by the Medical Council of New Zealand. RESULTS: 103 Respondents completed the survey: 22 Senior Medical Officers, 17 registrars (PGY3+), 43 junior doctors (PGY1-2) and 21 undergraduates (medical students). Statistical significance between groups was reached only for Question 6 in which Senior Medical Officers rated communication skills and respect for patients lower than postgraduate students (p=0.005). Large variability was noted in ratings for 'presentation of history' and 'clinical knowledge'. CONCLUSION: There is marked variation between Senior Medical Officers in the assessment of a junior doctor's clinical practice as demonstrated by the use of a simulation video. This variation is of potential major concern. Quality training methods of assessors may need to be implemented for standardisation of assessment if a summative component exists.

How the trainee intern year can ease the transition from undergraduate education to postgraduate practice.

The trainee intern (TI) year is unique to New Zealand medical education. The TI year occupies a complete calendar year in which the medical student is immersed in clinical care as part of healthcare teams. The TI year is an example of a 'capstone' course; integrating theory into practice, fine tuning workplace skills, and easing the transition from undergraduate medical student to practising clinician. We discuss the TI year within the context of 'transition shock'. Transition shock, related to movement between contexts or levels of responsibility, is not unique to medicine or the healthcare professions. This shock is multifactorial but there are many ways that the structure and activities of the TI year may ease this transition. The TI year is valuable in terms of its potential to improve preparedness, both real and perceived, but further research and ongoing evaluation is still required.

In search of professionalism: implications for medical education.

This is the seventh article in an education series, discussing some of the 'hot topics' in teaching and learning in medicine. Historically, 'professionalism' was defined by the social structures of medicine, but has moved on to represent the expected behaviours and attributes of practitioners. Well publicised cases of professional misconduct, the rise of medical ethics as a discipline, and the move to a more patient-centred approach have driven the profile of professionalism into mainstream medical education. While there are many definitions of medical professionalism, there is a growing degree of consensus around what it encompasses; the way we manage tasks, our interactions with others, and looking after ourselves. The literature indicates that professionalism can be taught, learnt and applied; that attributes and behaviours can be identified; and that assessment is best approached using a range of methods over time. For learners, one of the critical factors in developing professionalism is the modelling by senior members of the profession as students move from peripheral observers to legitimate participants. Medical programmes in New Zealand are engaging with this literature in developing current curricula.

Maximising learning through effective supervision.

This article targets supervisors and their important role in maximising learning of novice practitioners. The article draws on current research to highlight the importance of clinical supervision and the roles and tasks of the supervisor. Some of the challenges of supervision and how the supervisor can be supported are also discussed. The article has a pragmatic and practical focus to assist the supervisor in one of the most important, challenging but rewarding educational roles.

The good apprentice in medical education.

This paper targets both current apprentices and their supervisors drawing on current research to answer the following questions. What is apprenticeship and what are the key elements? What is a good apprentice and what can an intern or registrar do to assist their own learning and development? It takes a pragmatic approach and seeks to assist apprentices and their supervisors by attending closely to what is practicable, realistic, expedient and convenient; articulating this and laying it out as clearly as possible.

A surgical career for New Zealand junior doctors? Factors influencing this choice.

AIMS: To discover the level of interest in a surgical career amongst junior doctors and trainee interns in the Auckland region. Secondary aims are to identify the factors that influence career choice as well as the timing of career choice. METHODS: An anonymous and structured questionnaire was distributed to all trainee interns and junior doctors in their first to fifth postgraduate years in the Auckland region. Questions were based on basic demographics, level of training, career preference and factors from previous experiences in surgery that may have influenced their career choice. RESULTS: Total of 87 replies with 36% expressed interest in surgery whereas 64% were interested in non-surgical specialties. Top three factors influencing career choice were similar in both groups: Lifestyle, career ambitions and family. Personal interest, practical hands-on and positive previous experiences were the top reasons why junior doctors chose surgery. Poor lifestyle, lacking of interest, limited future part-time work and previous negative experiences were the top reasons why junior doctors did not choose surgery. A significantly (p<0.05) larger number of junior doctors in the surgical group had positive previous experiences on their surgical runs, with their consultants and registrars compared with the non-surgical group. Those interested in surgery decided on their careers earlier. CONCLUSION: Career aspirations of New Zealand junior doctors were similar to findings reported overseas. To promote surgery amongst junior doctors and medical students, attention should be paid to the key factors which may influence career choice. By improving working conditions and have better surgical education with good mentoring, team atmosphere and opportunities for early exposure will hopefully allow better recruitment and training of future surgeons.

Doctors as teachers: what do they think?

AIMS: To assess the views of senior medical officers (SMOs) at Auckland City Hospital (Auckland, New Zealand) in the areas of teaching, supervision, and feedback for resident medical officers (RMOs). METHODS: All SMOs at Auckland City Hospital were asked to complete a survey regarding postgraduate medical education. Data was then collected and entered into a Microsoft Excel spreadsheet and was statistically analysed. P values were calculated using Chi-squared testing and Fisher's exact test. RESULTS: 237/730 surveys were received giving a response rate of 32.1%. There was a statistically significant difference between SMOs self-rated competence (SRC) and their perceived required competence (RC) in the domains of 'Teaching' (SRC=3.74; RC=4.36 - p<0.0001), 'Supervision' (SRC=3.78; RC=4.37 - p<0.0001) and 'Feedback' (SRC=3.55; RC=4.36 - p<0.0001). Ratings were done on a 5-point Likert scale where a score of 1 was poor and a score of 5 was excellent. SMOs were then asked whether they required further information around various postgraduate medical education topics. 79.9% requested information on 'managing the poorly performing RMO'. Dual employees (i.e. SMOs employed by both the University of Auckland and Auckland City Hospital) were more likely to have attended a 'Teach the Teacher Course' (66.6%) than those SMOs only employed by Auckland City Hospital (43.3%, p=0.0083). A number of factors were also identified as barriers to conducting effective teaching. These included a lack of time, high clinical workload, poor continuity between trainees and SMOs, and a lack of recognition for teaching roles of SMOs. CONCLUSIONS: Our study showed a gap between the perceived self-rated competence and required competence in SMOs in their role as teachers. There is also a perceived gap in support for SMOs in their role as teachers and the expected educational outcomes for trainees within the New Zealand clinical setting.

Workplace bullying of junior doctors: cross-sectional questionnaire survey.

AIM: Workplace bullying is a growing concern amongst health professionals. Our aim was to explore the frequency, nature, and extent of workplace bullying in an Auckland Hospital (Auckland, New Zealand). METHOD: A cross-sectional questionnaire survey of house officers and registrars at a tertiary hospital was conducted. RESULTS: There was an overall response rate of 33% (123/373). 50% of responders reported experiencing at least one episode of bullying behaviour. The largest source of workplace bullying was consultants and nurses in equal frequency. The most common bullying behaviour was unjustified criticism. Only 18% of respondents had made a formal complaint. CONCLUSION: Workplace bullying is a significant issue with junior doctors. We recommend education about unacceptable behaviours and the development of improved complaint processes.

Training effect of skills courses on confidence of junior doctors performing clinical procedures.

BACKGROUND: Junior doctors face several challenges including how to acquire procedural skills as they embark on their professional careers. There has been a trend away from the less structured opportunistic teaching style of senior doctors towards teaching procedural skills in short courses in skills training centres. AIM: To determine the impact of a procedural skills course and of ongoing experience on the confidence of junior doctors undertaking procedures in clinical practice, and to identify any relationship between confidence level and amount of ongoing experience. METHODS: An intake of junior doctors (n=33) attended a procedural skills course and learnt six procedures, comprising exploration and debridement of a contaminated wound, nasogastric tube insertion, urethral catheterisation, lumbar puncture, pleural aspiration, and intercostal drain insertion and removal. Three questionnaires assessing their experience with the procedures and their confidence were completed before and immediately after the course, and 5 months later. RESULTS: The procedural skills course had a positive impact on the immediate confidence of junior doctors performing all of the clinical procedures as measured by a confidence survey pre- and post-course. Only nasogastric tube insertion, urethral catheterisation, and pleural aspiration demonstrated a maintained increase in confidence when comparing pre-course to five months follow-up confidence levels. Only urethral catheterisation was associated with an overall increase in confidence at 5 months' follow-up. Overall there was a strong positive correlation between changes in experience and changes in confidence. CONCLUSIONS: The procedural skills course produced a significant increase in confidence in the short term, but this decreased unless there was ongoing clinical experience with the procedure. The benefit of short courses is eroded by the lack of reinforcement through continuing experience.

Passing the buck: clinical handovers at a tertiary hospital.

AIMS: To survey house officers and nurses regarding timing, structure and content of clinical handover and compare these results. Secondary aims included the development of an 'on-call' sheet and the development of guidelines for handovers from the results collated. METHODS: 60 house officers (post graduate years 1-3) and 60 nurses working at Auckland City Hospital were asked to complete a survey covering various aspects of clinical handover in their current department. RESULTS: This study showed that nurses have more handovers than house officers in a 24-hour period. Nurses had an average of 3.2 handovers compared with the 1.2 handovers reported by house officers. Nurses rated their handovers as 'good', with a mean score of 7.8/10, while house officers rated the standard of their handovers as only 'average', with a mean score of 5.1/10. This was noted to be a statistically significant difference with a p-value of 0.01. Our study found that 60.9% of house officers reported that they had encountered a problem at least seven times in their most recent clinical rotation that they could directly attribute to a poor handover. However, nurses reported a much lower incidence of problems relating to poor handover standards, with 37.5% of this group indicating that they had experienced a clinical problem with a patient related to a nursing handover. CONCLUSIONS: In this study, we identified that health professionals perceive that clinical problems can be attributed to poor clinical handover. The majority of respondents in the study felt that an effective handover system should include a set location for handover, a standardised 'on-call' sheet and training related to handovers.

How many health professionals does a patient see during an average hospital stay?

AIM: To assess how many health professionals are directly involved in a patient's stay at Auckland City Hospital, Auckland, New Zealand. METHODS: A retrospective review of the records was carried out of all patients admitted through the Admission and Planning Unit and the Emergency Department on a chosen day. Every health professional who wrote in the medical notes was counted and tabulated for each patient. RESULTS: 81 patients were admitted--47 medical and 34 surgical. In medicine, the patients saw an average of 17.8 health professionals during their hospitalisation (95%CI 0.0-36.7) (median 17) (range 5 to 44); an average of 6.0 doctors (0.0-12.6) (5) (2-21); 10.7 nurses (0.0-22.3) (11) (3-24); and 1.0 allied health workers (0.0-4.5) (0) (0-6). In surgery, the patients saw an average of 26.6 health professionals during their hospitalisation (95%CI 0.0-66.7) (median 21.5) (range 2 to 75); an average of 10.0 doctors (0.0-25.8) (8.5) (1-33); 15.9 nurses (0.0-39.2) (13.5) (1-44); and 0.8 allied health workers (0-3.3) (0) (0-4). CONCLUSIONS: Modern hospital healthcare delivery involves many different healthcare professionals. Patients have more nurse contacts than doctors (p<0.0001). Surgical patients see more health professionals than medical patients overall (p=0.01) but the daily rate was not found to be statistically different (p=0.3). Involvement of different health professionals may necessitate good communication/handover processes as well as possible changes to traditional training methods.

Appropriate use of pagers in a New Zealand tertiary hospital.

AIMS: To identify the appropriateness of calls to on-call house officers in a major tertiary teaching hospital. METHODS: A prospective observational study was conducted at Auckland City Hospital over the months of June, July, and August 2004. Fourteen house officers from a range of medical and surgical services categorised calls received while on-call after-hours into one of three groups: 'appropriate and urgent'; 'appropriate but not urgent'; and 'inappropriate'. RESULTS: 844 calls were recorded and categorised, with approximately even distribution between medical services (431 calls) and surgical services (413 calls); 30% of calls were deemed clinically appropriate and required a response within 1 hour; 53% of calls were deemed clinically appropriate but did not require a response within an hour; while 17% of calls were deemed inappropriate. CONCLUSIONS: The most important function an on-call house officer performs is responding to urgent medical situations. Frequent interruptions mean that house officers may become less efficient and more prone to making mistakes. The majority of calls received by on-call house officers did not need immediate responses and would have been better communicated via a less intrusive system such as text-messaging or the keeping of a non-urgent jobs list. If house officers were paged more appropriately then they would be interrupted less frequently and would be able to provide safer, more efficient, and timelier patient care.

Frequency of calls to "on-call" house officer pagers at Auckland City Hospital, New Zealand.

AIMS: To quantify the number of calls made to specified on-call house officer pagers and to comment on possible implications for practice. METHODS: Seven on-call pagers, covering a range of surgical and medical specialties at Auckland City Hospital, were identified. Data for a 4-month period from April to August 2004 was recorded and analysed in two groups: surgical services and medical services. Statistical software was used to calculate mean times between calls in specified time periods, and to compare differences between surgical and medical services. RESULTS: 25,389 pages were recorded. These data are presented as mean frequency of calls to each pager, divided into four time periods. The highest recorded rate was 6.9 minutes (mean) between calls in general surgery (1600-2200 shift), with the lowest recorded rate a mean of one call per 5 hours (2200-0800 shift) in geriatric and general medicine. CONCLUSIONS: Pager frequency is a potentially useful marker of job acuity and consequent junior doctor stress levels. This study demonstrated a high degree of variability in paging frequency both between services and between time periods. We recommend ongoing monitoring of paging frequencies and more even distribution of after-hours workload.

Career choices of New Zealand junior doctors.

AIMS: To report career preferences of New Zealand junior doctors, determine what factors influenced their choice, and determine at what stage of their career that choice was made. METHODS: A structured questionnaire with anonymous replies was sent to final year medical students as well as to junior doctors in their first to fourth postgraduate year. Questions were based around choice of future career, timing, and certainty of this choice and the factors influencing it. RESULTS: Of the 400 questionnaires distributed, 256 (64%; 95%CI: 59-69%) were returned. The most popular career choice was medicine (44%; 95%CI: 38-50%), followed by surgery (34%; 95%CI: 29-40%), general practice (30%; 95%CI: 25-36%), paediatrics (29%; 95%CI: 24-35%), and obstetrics and gynaecology (20%; 95%CI: 16-25%). The choice of a career was mostly based on interest in that specialty. Most (70%; 95%CI: 64-75%) final year medical students; and 52% (95%CI: 41-63%), 45% (95%CI: 33-60), and 17% (95%CI: 9-33%) of doctors in postgraduate year 1, 2, and 2+ respectively; had not made a definite career choice. Sixty-nine percent (95%CI: 63-75%) of respondents stated that they plan to work overseas, mostly to travel (70%; 95%CI: 63-77%) and to further their professional training (58%; 95%CI: 59-73%). CONCLUSIONS: Career aspirations of New Zealand junior doctors were similar to those reported by overseas studies. Adequate guidance throughout medical training and opportunity to gather work-experience over several specialties should be encouraged.

Procedural skills of first-year postgraduate doctors at Auckland District Health Board, New Zealand.

AIMS: To determine whether the current skills list for postgraduate year 1 (PGY1) training in New Zealand is appropriate and an accurate reflection of the experience gained in this year. METHODS: PGY1 doctors at Auckland District Health Board were surveyed about their experience with 86 skills at the beginning and at the end of their first postgraduate year; 28 of these skills were from the Medical Council of New Zealand's (MCNZ) 'Indicative List of Skills' for PGY1. RESULTS: The response rate was 79% for the first survey and 66% for the follow-up. By the end of the PGY1 year, all doctors had performed 21% of the skills listed by the MCNZ, compared to 4% at the beginning of the year. Thirty-nine percent of the skills defined as important to achieve during PGY1 by the MCNZ had been performed by less than half our sample at the end of their PGY1 training. CONCLUSIONS: There is a significant discrepancy between the skills expected of graduates at the end of PGY1 (as indicated by the MCNZ) and those attained.

Resident Medical Officer working conditions in New Zealand: results of a recent survey.

AIMS: To survey Resident Medical Officers (RMOs) and Senior Medical Officers (SMOs) working at Auckland District Health Board (ADHB) on various aspects of RMO-working conditions and to trial the use of electronic keypad responders for this purpose. METHODS: In April 2004, the Physicians Grand Round at ADHB was used as a forum to conduct a survey on RMO working conditions in New Zealand. Results were collected anonymously using electronic keypad responders and recorded in a spreadsheet to allow analysis and comparison of the two professional groups. RESULTS: 27 RMOs and 32 SMOs attended and participated in the survey, answering 11 questions. Responses showed significant differences between the two groups in 7 of the 11 questions asked. In addition, both groups favoured changes to the status quo on a significant number of issues. CONCLUSIONS: RMOs and SMOs in New Zealand have differing opinions regarding the working conditions of RMOs. This study supports the need for wider scale, national discussion of these issues and the development of appropriate strategies to address these differences and their implications.