Placement Overlap with Other Students; Effects on Medical Student Learning Experience.

PHENOMENON: In the United Kingdom (UK) the government has increased the number of places at university to study medicine in England to meet workforce demands. In parallel, there have been growing student numbers in other healthcare professions and new professions whose roles overlap with doctors, such as advanced nurse practitioners and physician associates, have been introduced. These increasing numbers of medical students and other healthcare professions training in the same clinical setting have led to questions about the effect on the student experience. We aimed to investigate the impact of student-student encounters on the learning experience during clinical placements before student numbers increase further. APPROACH: In this investigation medical student perceptions were collected retrospectively at Norwich Medical School, University of East Anglia in the UK, during the 2018/19 academic year following two clinical placements in secondary care settings. Through mandatory online course evaluations, all medical students were asked if their learning had been positively or negatively affected by other students, and how frequently they had certain student-student experiences. FINDINGS: Responses from 786 (of 844) medical students (93% response rate) demonstrated that most students felt their learning had been affected in some way by the presence of others while on their secondary care placements. Students experienced both positive and negative impacts of encounters with other students. Final year students tended to report more negative experiences, with first year students reporting more positive. while some students had experienced competition for learning opportunities and lower quality interactions with patients and doctors due to "overcrowding," more students reported benefits from learning from and with other students. However, it also was found that any negative encounters with other students, even if accompanied by positive experiences, detrimentally affected student satisfaction with the placement. INSIGHTS: This investigation indicates that student-student interactions influence the clinical learning experience of medical students both positively and negatively. Given the overriding influence of negative encounters, the findings suggest a need to maximize the beneficial effects of encountering other students on clinical placements; while protecting against missed or poor-quality learning opportunities due to competition between students, particularly for more senior students. Medical educators need to consider where their clinical attachments are at risk from multiple students being present at the same time and work to alleviate the negative impacts of such student-student encounters, while actively encouraging peer learning experiences between the medical students and collaborative activities between students of different healthcare professions. This is likely to become increasingly important as student numbers in medicine and other healthcare professions continue to grow.

Work-related asthma: A position paper from the Thoracic Society of Australia and New Zealand and the National Asthma Council Australia.

Work-related asthma (WRA) is one of the most common occupational respiratory conditions, and includes asthma specifically caused by occupational exposures (OA) and asthma that is worsened by conditions at work (WEA). WRA should be considered in all adults with asthma, but especially those with new-onset or difficult to control asthma. Improvement in asthma symptoms when away from work is suggestive of WRA. Clinical history alone is insufficient to diagnose WRA; therefore, objective investigations are required to confirm the presence of asthma and the association of asthma with work activities. Management of WRA requires pharmacotherapy similar to that of non-WRA, however, also needs to take into account control of the causative workplace exposure. Ongoing exposure will likely lead to decline in lung function and worsening asthma control. WRA is a preventable condition but this does rely on increased awareness of WRA and thorough identification and control of all potential occupational respiratory hazards.

Respiratory surveillance for coal mine dust and artificial stone exposed workers in Australia and New Zealand: A position statement from the Thoracic Society of Australia and New Zealand.

Coal mine lung dust disease (CMDLD) and artificial stone (AS) silicosis are preventable diseases which have occurred in serious outbreaks in Australia recently. This has prompted a TSANZ review of Australia's approach to respiratory periodic health surveillance. While regulating respirable dust exposure remains the foundation of primary and secondary prevention, identification of workers with early disease assists with control of further exposure, and with the aims of preserving lung function and decreasing respiratory morbidity in those affected. Prompt detection of an abnormality also allows for ongoing respiratory specialist clinical management. This review outlines a medical framework for improvements in respiratory surveillance to detect CMDLD and AS silicosis in Australia. This includes appropriate referral, improved data collection and interpretation, enhanced surveillance, the establishment of a nationwide Occupational Lung Disease Registry and an independent advisory group. These measures are designed to improve health outcomes for workers in the coal mining, AS and other dust-exposed and mining industries.

Medical Students' Views About Having Different Types of Problem-Based Learning Tutors.

BACKGROUND: At Norwich Medical School, Year 3 or 4 medical students taking a year out of the 5-year undergraduate MBBS degree to do a master's degree in clinical education worked as near-peer problem-based learning (PBL) tutors for students in Year 2. Peer-assisted learning has been shown to benefit both peer tutors and tutees; in this study, experiences of students with near-peer PBL tutors were compared to students with other types of PBL tutor. METHODS: Using existing student evaluation data, we compared student views about PBL tutor performance, PBL group functioning, and overall satisfaction with PBL learning experience according to whether their PBL tutor/s were (1) a single near-peer tutor (later-year MB BS student), (2) a single staff tutor, (3) multiple staff tutors, or (4) multiple newly qualified doctor tutors. RESULTS: Results indicated that students' evaluation of tutor performance was more positive for near-peer PBL tutors compared to both groups of staff tutors for most areas evaluated. Additionally, students' evaluation of overall satisfaction with PBL was more positive for near-peer PBL tutors compared to multiple staff tutors. Tutor performance for multiple staff tutors was evaluated less positively compared to both single staff and multiple newly qualified doctor groups. But there were no statistically significant differences between the four groups regarding PBL group functioning. CONCLUSION: Near-peer PBL tutors perform comparably or better to staff PBL tutors in salient measures of tutor performance and group functioning. We conclude that medical students find near-peer PBL tutors to be an acceptable addition to the PBL tutor workforce.

Does medical students' empathy change during their 5-year MBBS degree?

Background: Research evidence over the past 20 years has established that doctors' ability to empathize with their patients is a crucial component of effective health care. Consequently, teaching and reinforcing empathy has entered undergraduate medical education curricula; however, there have been mixed results in terms of its effectiveness. While there is evidence that empathy fluctuates during undergraduate medical training, there has been very little longitudinal research looking at medical students' empathy levels over their full course of study. The aim of the current study was to investigate whether medical students' empathy changed during their 5-year MBBS degree. Methods: Students completed the medical student version of the Jefferson Scale of Physician Empathy (JSPE) at the start of Year 1 and then near the end of Years 2, 3, 4, and 5 during 2009-2015. Total empathy score for students who had completed the JSPE in all 5 years of medical training was compared over time using nonparametrical statistical analysis. Results: Results indicated that medical students' empathy varies with empathy being highest at the start of the medical course in Year 1, declining to a low in Year 3 and then rising again in Years 4 and 5. There was a tendency for female students to have higher empathy scores compared to male students in each of the 5 years, with scores significantly different in Years 2, 3, and 4. However, there were no differences in empathy scores according to the students' age. Discussion: The decline in empathy in the early years of undergraduate medical training is a concern. Medical educators should teach and reinforce empathy during early years of undergraduate medical training in a sustainable way to guard against declining empathy levels. Specific interventions targeted at increasing empathy in male students might be warranted in the future.

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.

Coal workers' pneumoconiosis: an Australian perspective.

Coal workers' pneumoconiosis (CWP) is an untreatable but preventable lung disease arising from chronic inhalation of coal dust. Recent reports of CWP in Queensland, along with international data, suggest that there is a resurgence in pneumoconiosis. The prevalence of CWP varies considerably between countries. In Australia, there is no mandatory reporting system and no national data on the prevalence of CWP. The symptoms and manifestations of CWP vary depending on the composition of the inhaled dust, duration of exposure, stage of disease and host-related factors. CWP may develop into progressive massive fibrosis (PMF), which can be fatal. Radiological assessment should be performed according to evidence-based standards using the ILO (International Labour Office) International Classification of Radiographs of Pneumoconioses. As preventing exposure to coal dust prevents CWP, it is important to implement and enforce appropriate standards limiting exposure. In Australia, these standards currently vary between states and are not in keeping with international understanding of the levels of coal dust that cause disease. Longitudinal screening programs are crucial for monitoring the health of coal workers to identify individuals with early-stage disease and prevent progression from mild disease to PMF. We recommend: standardisation of coal dust exposure limits, with harmonisation to international regulations; implementation of a national screening program for at-risk workers, with use of standardised questionnaires, imaging and lung function testing; development of appropriate training materials to assist general practitioners in identifying pneumoconiosis; and a system of mandatory reporting of CWP to a centralised occupational lung disease register.

Sleep-Disordered Breathing in Patients with Pulmonary Valve Incompetence Complicating Congenital Heart Disease.

OBJECTIVE: Long standing pulmonary regurgitation results in deleterious effects on right heart size and function with late consequences of right heart volume overload including ventricular dilatation, propensity to arrhythmia and right heart failure. As sleep disordered breathing may predispose to elevations in pulmonary vascular resistance and associated negative effects on right ventricular function, we sought to assess this in patients with underlying congenital heart disease. DESIGN: We performed a pilot study to evaluate the incidence of sleep-disordered breathing in a patient population with a history of long standing pulmonary valve incompetence in patients with congenital heart disease using overnight oximetry. PATIENTS: Patients with a background of tetralogy of Fallot repair or residual pulmonary incompetence following previous pulmonary valve intervention for congenital pulmonary stenosis were included. RESULTS: Twenty-two patients underwent overnight oximetry. The mean age of the cohort was 34.3 ± 15.2 years with no patients observed to have severe underlying pulmonary hypertension. Abnormal overnight oximetry was seen in 13/22 patients (59.1%) with 2/22 (9.1%) patients considered to have severe abnormalities. CONCLUSIONS: An important proportion of patients with a background of pulmonary incompetence complicating congenital heart disease are prone to the development of sleep-disordered breathing as assessed by overnight oximetry. Further study into the prevalence and mechanisms of sleep-disordered breathing in a larger cohort are warranted.

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.

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.

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.

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.

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.

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.

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.

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.

A comparison of single-photon emission CT lung scintigraphy and CT pulmonary angiography for the diagnosis of pulmonary embolism.

BACKGROUND: This study compared single-photon emission CT (SPECT) ventilation/perfusion (V/Q) scintigraphy with multislice CT pulmonary angiography (CTPA). METHODS: In a prospective, observational study, 100 patients who were >or= 50 years of age were recruited. Seventy-nine patients underwent both diagnostic 16-detector CTPA, and planar and SPECT V/Q scintigraphy. The agreement between the CTPA and the SPECT V/Q scintigraphy for the diagnosis of pulmonary embolism (PE) was calculated. The sensitivity and specificity of blinded SPECT scintigraphy reporting was calculated against a reference diagnosis made by a panel of respiratory physicians that was provided with CTPA and planar V/Q scintigraphy reports, clinical information, and 3-month follow-up data. RESULTS: The observed percentage of agreement between SPECT V/Q scintigraphy and CTPA data for the diagnosis of PE was 95%. When calculated against the respiratory physicians' reference diagnosis, SPECT V/Q scintigraphy had a sensitivity of 83% and a specificity of 98%. CONCLUSIONS: This study indicates that SPECT V/Q scintigraphy is a viable alternative to CTPA for the diagnosis of PE and has potential advantages in that it was feasible in more patients and had fewer contraindications; lower radiation dose; and, arguably, fewer nondiagnostic findings than CTPA. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12609000089235.