Does performance at the intercollegiate Membership of the Royal Colleges of Surgeons (MRCS) examination vary according to UK medical school and course type? A retrospective cohort study.

OBJECTIVES: The knowledge, skills and behaviours required of new UK medical graduates are the same but how these are achieved differs given medical schools vary in their mission, curricula and pedagogy. Medical school differences seem to influence performance on postgraduate assessments. To date, the relationship between medical schools, course types and performance at the Membership of the Royal Colleges of Surgeons examination (MRCS) has not been investigated. Understanding this relationship is vital to achieving alignment across undergraduate and postgraduate training, learning and assessment values. DESIGN AND PARTICIPANTS: A retrospective longitudinal cohort study of UK medical graduates who attempted MRCS Part A (n=9730) and MRCS Part B (n=4645) between 2007 and 2017, using individual-level linked sociodemographic and prior academic attainment data from the UK Medical Education Database. METHODS: We studied MRCS performance across all UK medical schools and examined relationships between potential predictors and MRCS performance using χ2 analysis. Multivariate logistic regression models identified independent predictors of MRCS success at first attempt. RESULTS: MRCS pass rates differed significantly between individual medical schools (p<0.001) but not after adjusting for prior A-Level performance. Candidates from courses other than those described as problem-based learning (PBL) were 53% more likely to pass MRCS Part A (OR 1.53 (95% CI 1.25 to 1.87) and 54% more likely to pass Part B (OR 1.54 (1.05 to 2.25)) at first attempt after adjusting for prior academic performance. Attending a Standard-Entry 5-year medicine programme, having no prior degree and attending a Russell Group university were independent predictors of MRCS success in regression models (p<0.05). CONCLUSIONS: There are significant differences in MRCS performance between medical schools. However, this variation is largely due to individual factors such as academic ability, rather than medical school factors. This study also highlights group level attainment differences that warrant further investigation to ensure equity within medical training.

A cross-sectional study examining MRCS performance by core surgical training location.

BACKGROUND: In the UK, core surgical training (CST) is the first specialty experience that early-career surgeons receive but training differs significantly across CST deaneries. To identify the impact these differences have on trainee performance, we assessed whether success at the Membership of the Royal College of Surgeons (MRCS) examinations is associated with CST deanery. METHODS: A retrospective cohort study of UK trainees in CST who attempted MRCS between 2014 and 2020 (n = 1104). Chi-squared tests examined associations between locality and first-attempt MRCS performance. Multivariate logistic regression models identified the likelihood of MRCS success depending on CST deanery. RESULTS: MRCS Part A and Part B pass rates were associated with CST deanery (p < 0.001 and p = 0.013, respectively). Candidates that trained in Thames Valley (Odds Ratio [OR] 2.52 (95% Confidence Interval [CI] 1.00-6.42), North Central and East London (OR 2.37 [95% CI 1.04-5.40]) or South London (OR 2.36 [95% CI 1.09-5.10]) were each more than twice as likely to pass MRCS Part A at first attempt. Trainees from North Central and East London were more than ten times more likely to pass MRCS Part B at first attempt (OR 10.59 [95% CI 1.23-51.00]). However, 68% of candidates attempted Part A prior to CST and 48% attempted Part B before or during the first year of CST. CONCLUSION: MRCS performance is associated with CST deanery; however, many candidates passed the exam with little or any CST experience suggesting that some deaneries attract high academic performers. MRCS performance is therefore not a suitable marker of CST training quality.

Does performance at medical school predict success at the Intercollegiate Membership of the Royal College of Surgeons (MRCS) examination? A retrospective cohort study.

BACKGROUND: Identifying predictors of success in postgraduate examinations can help guide the career choices of medical students and may aid early identification of trainees requiring extra support to progress in specialty training. We assessed whether performance on the educational performance measurement (EPM) and situational judgement test (SJT) used for selection into foundation training predicted success at the Membership of the Royal College of Surgeons (MRCS) examination. METHODS: This was a longitudinal, cohort study using data from the UK Medical Education Database (https://www.ukmed.ac.uk). UK medical graduates who had attempted Part A (n=2585) and Part B (n=755) of the MRCS between 2014 and 2017 were included. χ2 and independent t-tests were used to examine the relationship between medical school performance and sociodemographic factors with first-attempt success at MRCS Part A and B. Multivariate logistic regression was employed to identify independent predictors of MRCS performance. RESULTS: The odds of passing MRCS increased by 55% for Part A (OR 1.55 (95% CI 1.48 to 1.61)) and 23% for Part B (1.23 (1.14 to 1.32)) for every additional EPM decile point gained. For every point awarded for additional degrees in the EPM, candidates were 20% more likely to pass MRCS Part A (1.20 (1.13 to 1.29)) and 17% more likely to pass Part B (1.17 (1.04 to 1.33)). For every point awarded for publications in the EPM, candidates were 14% more likely to pass MRCS Part A (1.14 (1.01 to 1.28)). SJT score was not a statistically significant independent predictor of MRCS success. CONCLUSION: This study has demonstrated the EPM's independent predictive power and found that medical school performance deciles are the most significant measure of predicting later success in the MRCS. These findings can be used by medical schools, training boards and workforce planners to inform evidence-based and contemporary selection and assessment strategies.

Human factors awareness and recognition during multidisciplinary team meetings.

Multidisciplinary team (MDT) meetings are widely used throughout medicine and dentistry, bringing together expertise and different opinions across many disciplines to benefit patient care. Depending on the cancer site and specialties involved, some MDTs can last for several hours, especially if there are many complex patients to discuss. However, concentration and attention can vary and distraction is almost inevitable with separate conversations between MDT members and the ever-increasing use of smartphones. The role of human factors (HF) in contributing to error is well known in high-risk activities including medicine and surgery. Surprisingly, while there is increasing awareness of their importance by medical and dental professionals to enhance patient safety, to our knowledge nothing to date has been published about the possible effect and role of HF at MDTs. Here we provide a brief HF overview and focus on the factors at an MDT that could lead to distraction, providing suggestions (including some from aviation) for possible ways to enhance and improve discussion during these often-long meetings. It is hoped that this paper will generate some thought and discussion around the current "normal" MDT practice in head and neck and other specialties and challenge colleagues to embrace HF and safety principles in a just and learning culture.

Changing Objective Structured Clinical Examinations Stations at Lunchtime During All Day Postgraduate Surgery Examinations Improves Examiner Morale and Stress.

BACKGROUND: Human factors are important causes of error, but little is known about their possible effect during objective structured clinical examinations (OSCE). We have previously identified stress and pressure in OSCE examiners in the postgraduate intercollegiate Membership of the Royal College of Surgeons (MRCS) examination. After modifying examination delivery by changing OSCE stations at lunchtime with no demonstrable effect on candidate outcome, we resurveyed examiners to ascertain whether examiner experience was improved. METHOD: Examiners (n = 180) from all 4 surgical colleges in the United Kingdom and Ireland were invited to complete the previously validated human factors questionnaire used in 2014. Aggregated scores for each of 4 previously identified factors were compared with the previous data. Unit-weighted z-scores and nonparametric Kruskal-Wallis methods were used to test the hypothesis that there was no difference among the median factor z-scores for each college. Individual Mann-Whitney-Wilcoxon tests (with appropriate Bonferonni corrections) were used to determine any differences between factors and the respective colleges. RESULTS: 141 Completed questionnaires were evaluated (78% response rate) and compared with 108 responses (90%) from the original study. Analysis was based on 26 items common to both studies. In 2014, the college with the highest candidate numbers (England) was significantly different in 1 factor (stress and pressure), compared with Edinburgh (Mann-Whitney-Wilcoxon: W = 1524, p < 0.001) and Glasgow colleges (Mann-Whitney-Wilcoxon: W = 104, p = 0.004). No differences were found among colleges in the same factor in 2016, Kruskall-Wallis: (χ2 (3) = 1.73, p = 0.63). Analysis of responses found inconsistency among examiners regarding mistakes or omissions made when candidates were performing well. CONCLUSION: After making changes to OSCE delivery, factor scores relating to examiner stress and pressure are now improved and consistent across the surgical colleges. Stress and pressure can occur in OSCE examiners and examination delivery should ideally minimize these issues, thereby improving morale is also likely to benefit candidates.

When does ultrasonography influence management in suspected appendicitis?

BACKGROUND: Accurate diagnosis of appendicitis is challenging, particularly in children. Moreover, opinion is divided over the role of ultrasonography (US) in its diagnosis and how US may influence management. This study compares the use of US in two tertiary paediatric hospitals and how it influenced the management of suspected appendicitis. METHODS: Data from acute admissions, radiology, histopathology and theatre were cross-referenced to review all children who underwent an appendicectomy (with or without preoperative US) for suspected appendicitis in Christchurch (CH) in New Zealand and Aberdeen (AB) in Scotland in 2009. RESULTS: Five hundred and ninety-nine patients (442 CH; 157 AB) were included, with similar age and gender distributions. US was performed in 23% of patients with an overall appendix visualization rate of 29%. The overall positive and negative predictive values were 67% and 100%, respectively. Females were more likely to have US than males (P < 0.001, χ(2) ). In females with no appendix seen on US, in the presence or absence of other pathology, a normal appendix was confirmed in 50% and 58%, respectively. Visualizing the appendix resulted in a lower rate of normal appendix at operation (20%, 4/20) compared with when the appendix was not visualized (56%, 14/25). CONCLUSION: Identification of a normal appendix on US seems sufficiently accurate to exclude appendicitis with confidence, while positive US should be interpreted in conjunction with the clinical features in influencing the decision to operate. The incidence of a non-inflamed appendix at operation could be reduced with an increased rate of appendiceal visualization by sonographers.