Exploring the use of Rasch modelling in "common content" items for multi-site and multi-year assessment.

Rasch modelling is a powerful tool for evaluating item performance, measuring drift in difficulty over time, and comparing students who sat assessments at different times or at different sites. Here, we use data from thirty UK medical schools to describe the benefits of Rasch modelling in quality assurance and the barriers to using it. Sixty "common content" multiple choice items were offered to all UK medical schools in 2016-17, and a further sixty in 2017-18, with five available in both years. Thirty medical schools participated, for sixty total datasets across two sessions, and 14,342 individual sittings. Schools selected items to embed in written assessment near the end of their programmes. We applied Rasch modelling to evaluate unidimensionality, model fit statistics and item quality, horizontal equating to compare performance across schools, and vertical equating to compare item performance across time. Of the sixty sittings, three provided non-unidimensional data, and eight violated goodness of fit measures. Item-level statistics identified potential improvements in item construction and provided quality assurance. Horizontal equating demonstrated large differences in scores across schools, while vertical equating showed item characteristics were stable across sessions. Rasch modelling provides significant advantages in model- and item- level reporting compared to classical approaches. However, the complexity of the analysis and the smaller number of educators familiar with Rasch must be addressed locally for a programme to benefit. Furthermore, due to the comparative novelty of Rasch modelling, there is greater ambiguity on how to proceed when a Rasch model identifies misfitting or problematic data.

Medical students' perception of e-learning approach (MeSPeLA) - a mixed method research.

There is a discrepancy between the research exploring e-learning at medical universities in Central/Eastern and Western European countries. The aim of the MeSPeLA study was to explore the understanding, experience and expectations of Polish medical students in terms of e-learning. Questionnaire containing open-ended and closed questions supplemented by focus group discussion was validated and performed among 204 medical students in Poland before COVID-19 pandemia. Several domains: understanding of e-learning definitions; students' experience, preferences, expectations and perceptions of e-learning usefulness, advantages and disadvantages were addressed. The qualitative data were analyzed using an inductive approach. 46.0% of students chose a communication-oriented definition as the most appropriate. 7.4% claimed not to have any experience with e-learning. 76.8% of respondents indicated they had contact with e-learning. The main reported e-learning advantages were time saving and easier time management. The most common drawback was limited social interactions. The acceptance of the usage of e-learning was high. Medical undergraduates in Poland regardless of the year of studies, gender or choice of future specialization showed positive attitudes towards e-learning. Students with advanced IT skills showed a better understanding of the e-learning definition and perceived e-learning to be a more useful approach. The expectations and perceptions about e-learning in Polish medical schools seems similar to some extent to that in Western European and the United States so we can be more confident about applying some lessons from these research to Poland or other post-communist countries. Such application has been accelerated due to COVID-19 pandemia.

Predicting failure before it happens: A 5-year, 1042 participant prospective study.

PURPOSE OF THE ARTICLE: Students who fail assessments are at risk of negative consequences, including emotional distress and cessation of studies. Identifying students at risk of failure before they experience difficulties may considerably improve their outcomes. METHODS: Using a prospective design, we collected simple measures of engagement (formative assessment scores, compliance with routine administrative tasks, and attendance) over the first 6 weeks of Year 1. These measures were combined to form an engagement score which was used to predict a summative examination sat 14 weeks after the start of medical school. The project was repeated for five cohorts, giving a total sample size of 1042. RESULTS: Simple linear regression showed engagement predicted performance (R2adj = 0.03, F(1,1040) = 90.09, p < 0.001) with a small effect size. More than half of failing students had an engagement score in the lowest two deciles. CONCLUSIONS: At-risk medical students can be identified with some accuracy immediately after starting medical school using routinely collected, easily analysed data, allowing for tailored interventions to support students. The toolkit provided here can reproduce the predictive model in any equivalent educational context. Medical educationalists must evaluate how the advantages of early detection are balanced against the potential invasiveness of using student data.

Variation in performance on common content items at UK medical schools.

BACKGROUND: Due to differing assessment systems across UK medical schools, making meaningful cross-school comparisons on undergraduate students' performance in knowledge tests is difficult. Ahead of the introduction of a national licensing assessment in the UK, we evaluate schools' performances on a shared pool of "common content" knowledge test items to compare candidates at different schools and evaluate whether they would pass under different standard setting regimes. Such information can then help develop a cross-school consensus on standard setting shared content. METHODS: We undertook a cross-sectional study in the academic sessions 2016-17 and 2017-18. Sixty "best of five" multiple choice 'common content' items were delivered each year, with five used in both years. In 2016-17 30 (of 31 eligible) medical schools undertook a mean of 52.6 items with 7,177 participants. In 2017-18 the same 30 medical schools undertook a mean of 52.8 items with 7,165 participants, creating a full sample of 14,342 medical students sitting common content prior to graduation. Using mean scores, we compared performance across items and carried out a "like-for-like" comparison of schools who used the same set of items then modelled the impact of different passing standards on these schools. RESULTS: Schools varied substantially on candidate total score. Schools differed in their performance with large (Cohen's d around 1) effects. A passing standard that would see 5 % of candidates at high scoring schools fail left low-scoring schools with fail rates of up to 40 %, whereas a passing standard that would see 5 % of candidates at low scoring schools fail would see virtually no candidates from high scoring schools fail. CONCLUSIONS: Candidates at different schools exhibited significant differences in scores in two separate sittings. Performance varied by enough that standards that produce realistic fail rates in one medical school may produce substantially different pass rates in other medical schools - despite identical content and the candidates being governed by the same regulator. Regardless of which hypothetical standards are "correct" as judged by experts, large institutional differences in pass rates must be explored and understood by medical educators before shared standards are applied. The study results can assist cross-school groups in developing a consensus on standard setting future licensing assessment.

Student perspective on outcomes and process - Recommendations for implementing competency-based medical education.

PURPOSE: Competency-based medical education (CBME) seeks to prepare undergraduate and postgraduate trainees for clinical practice. Its major emphasis is on outcomes, but questions about how best to reach these remain. One key issue is the need to integrate what matters most to students when setting educational goals: this is crucial if we are to design curricula that trainees understand and engage with, and that promote successful achievement of competencies. METHOD: We interviewed medical students in years 4 and 6 of a 6-year medical degree and used thematic analysis to understand their main educational priorities and how these fit with the aims of CBME. RESULTS: Two major themes emerged: features of content and process. For content, students wanted clear guidance on what constitutes competence, finding broad outcome statements abstract and difficult to understand as novices. They also attach critical importance to features of process such as being welcomed, included in clinical teams and being known personally - these promote motivation, understanding, and professional development. CONCLUSIONS: We present recommendations for those designing CBME curricula to emphasize the student perspective: what kind of guidance on outcomes is required, and features of process that must not be neglected if competence is to be achieved.

Medical graduate views on statistical learning needs for clinical practice: a comprehensive survey.

BACKGROUND: This paper seeks to contribute to a reputable evidence base for required competencies across different topics in statistics and probability (statistical topics) in preparing medical graduates for clinical practice. This is in order to inform the prioritization of statistical topics within future undergraduate medical curricula, while exploring the need for preparing tomorrow's doctors to be producers, and not merely consumers, of statistics. METHODS: We conducted a comprehensive online survey from July 2013 to August 2014 for a target group of 462 medical graduates with current or prior experience of teaching undergraduate medical students of the University of Edinburgh of whom 278 (60.2%) responded. Statistical topics were ranked by proportion of respondents who identified the practice of statistics, performing statistical procedures or calculations using appropriate data, as a required competency for medical schools to provide in preparing undergraduate medical students for clinical practice. Mixed effects analyses were used to identify potential predictors for selection of the above competency and to compare the likelihood of this selection for a range of statistical topics versus critical appraisal. RESULTS: Evidence was gleaned from medical graduates' experiences of clinical practice for the need for, not only a theoretical understanding of statistics and probability but also, the ability to practice statistics. Nature of employment and statistical topic were highly significant predictors of choice of the practice of statistics as a required competency ((F = 3.777, p < 0.0005) and (F = 45.834, p < 0.0005), respectively). The most popular topic for this competency was graphical presentation of data (84.3% of respondents) in contrast to cross-over trials for the competency understanding the theory only (70.5% of respondents). Several topics were found to be more popular than critical appraisal for competency in the practice of statistics. CONCLUSIONS: The model of medical graduates as mere consumers of statistics is oversimplified. Contrary to what has been suggested elsewhere, statistical learning opportunities in undergraduate medicine should not be restricted to development of critical appraisal skills. Indeed, our findings support development of learning opportunities for undergraduate medical students as producers of statistics across a wide range of statistical topics.

Which non-technical skills do junior doctors require to prescribe safely? A systematic review.

AIMS: Prescribing errors are a major source of avoidable morbidity and mortality. Junior doctors write most in-hospital prescriptions and are the least experienced members of the healthcare team. This puts them at high risk of error and makes them attractive targets for interventions to improve prescription safety. Error analysis has shown a background of complex environments with multiple contributory conditions. Similar conditions in other high risk industries, such as aviation, have led to an increased understanding of so-called human factors and the use of non-technical skills (NTS) training to try to reduce error. To date no research has examined the NTS required for safe prescribing. The aim of this review was to develop a prototype NTS taxonomy for safe prescribing, by junior doctors, in hospital settings. METHODS: A systematic search identified 14 studies analyzing prescribing behaviours and errors by junior doctors. Framework analysis was used to extract data from the studies and identify behaviours related to categories of NTS that might be relevant to safe and effective prescribing performance by junior doctors. Categories were derived from existing literature and inductively from the data. RESULTS: A prototype taxonomy of relevant categories (situational awareness, decision making, communication and team working, and task management) and elements was constructed. CONCLUSIONS: This prototype will form the basis of future work to create a tool that can be used for training and assessment of medical students and junior doctors to reduce prescribing error in the future.

Examiners are most lenient at the start of a two-day OSCE.

BACKGROUND: OSCEs can be both reliable and valid but are subject to sources of error. Examiners become more hawkish as their experience grows, and recent research suggests that in clinical contexts, examiners are influenced by the ability of recently observed candidates. In OSCEs, where examiners test many candidates over a short space of time, this may introduce bias that does not reflect a candidate's true ability. AIMS: Test whether examiners marked more or less stringently as time elapsed in a summative OSCE, and evaluate the practical impact of this bias. METHODS: We measured changes in examiner stringency in a 13 station OSCE sat by 278 third year MBChB students over the course of two days. RESULTS: Examiners were most lenient at the start of the OSCE in the clinical section (ß = -0.14, p = 0.018) but not in the online section where student answers were machine marked (ß = -0.003, p = 0.965). CONCLUSIONS: The change in marks was likely caused by increased examiner stringency over time derived from a combination of growing experience and exposure to an increasing number of successful candidates. The need for better training and for reviewing standards during the OSCE is discussed.

Exploring patterns of error in acute care using framework analysis.

BACKGROUND: Junior doctors are often the first responders to deteriorating patients in hospital. In the high-stakes and time-pressured context of acute care, the propensity for error is high. This study aimed to identify the main subject areas in which junior doctors' acute care errors occur, and cross-reference the errors with Reason's Generic Error Modelling System (GEMS). GEMS categorises errors according to the underlying cognitive processes, and thus provides insight into the causative factors. The overall aim of this study was to identify patterns in junior doctors' acute care errors in order to enhance understanding and guide the development of educational strategies. METHODS: This observational study utilised simulated acute care scenarios involving junior doctors dealing with a range of emergencies. Scenarios and the subsequent debriefs were video-recorded. Framework analysis was used to categorise the errors according to eight inductively-developed key subject areas. Subsequently, a multi-dimensional analysis was performed which cross-referenced the key subject areas with an earlier categorisation of the same errors using GEMS. The numbers of errors in each category were used to identify patterns of error. RESULTS: Eight key subject areas were identified; hospital systems, prioritisation, treatment, ethical principles, procedural skills, communication, situation awareness and infection control. There was a predominance of rule-based mistakes in relation to the key subject areas of hospital systems, prioritisation, treatment and ethical principles. In contrast, procedural skills, communication and situation awareness were more closely associated with skill-based slips and lapses. Knowledge-based mistakes were less frequent but occurred in relation to hospital systems and procedural skills. CONCLUSIONS: In order to improve the management of acutely unwell patients by junior doctors, medical educators must understand the causes of common errors. Adequate knowledge alone does not ensure prompt and appropriate management and referral. The teaching of acute care skills may be enhanced by encouraging medical educators to consider the range of potential error types, and their relationships to particular tasks and subjects. Rule-based mistakes may be amenable to simulation-based training, whereas skill-based slips and lapses may be reduced using strategies designed to raise awareness of the interplay between emotion, cognition and behaviour.

Midwives benefit from good postnatal care, too.

Appropriate, timely and responsive postnatal care can help women and families negotiate the major life transition that childbirth brings. However, women's experiences of postnatal care are often negative and our increasingly biomedical approach to birth means that greater emphasis is placed on antenatal and intrapartum care at the expense of postnatal care. Good postnatal care is essential not only for women, but for midwives too, and our failure to acknowledge the significance of birth, and our contribution to that event can diminish us as people and midwives.

The effects of contributing to patient care on medical students' workplace learning.

CONTEXT: Previous research has suggested that as medical students become more senior, they should increasingly take on the roles they will enact as newly qualified doctors by contributing to patient care. However, student contribution to patient care carries inherent risks to patient safety. This study aimed to provide students with a new opportunity to contribute to patient care and to use this as a platform from which to explore the influence of contributing to patient care on medical student learning. METHODS: This study took place in the context of final-year medical student prescribing education at the University of Edinburgh, Edinburgh, UK. Students on attachment at a district general hospital were afforded a unique opportunity to learn prescribing by completing in-patient drug charts in a process termed 'pre-prescribing'. All students were invited to participate in focus groups conducted by the principal researcher. Focus group discussions were audio-recorded, transcribed verbatim and thematically analysed. RESULTS: Six focus groups, each lasting 20-50 minutes, were conducted with four to seven participants (33 students in total). The emerging themes took the form of developmental outcomes and learning processes. Developmental outcomes included ability to perform the task, modification of attitudes towards the task, formation of a professional identity, and development of relationships within the team. The central feature of the experience which influenced all developmental outcomes, was making mistakes. The themes interact in complex ways and all contribute towards development as a professional. CONCLUSIONS: This study has demonstrated that contributing to patient care enhances students' development as professionals. Some of these developmental outcomes, such as improvements in knowledge and skills, may be achievable to some extent within the classroom. Other changes, such as developing relationships, forming a sense of professional identity and modifying attitudes, might arguably be achievable only within the context of contributing to patient care.

New South Wales and Australian Capital Territory Researcher Development Program 2005-07: modest investment, considerable outcomes.

This evaluation of the Researcher Development Program (RDP) in NSW and ACT aimed to determine whether the RDP was effective in assisting novice researchers to undertake primary health care research. In mid-2008, 47 participants of the NSW and ACT RDP during 2005-07 were invited to participate in a postal survey. The survey included questions regarding previous research training and experience, outcomes during and after participation in the program, and organisational aspects of the program. Follow-up interviews were conducted with selected participants. Interview questions covered time in the program, supervision, organisational support and placement outcomes. Thirty-seven participants responded to the survey and 23 (62%) participants took part in the semi-structured interviews. Seventy-eight per cent of survey respondents felt that the RDP helped them move from novice to a more experienced researcher with effective supervision identified by participants as a key element in determining the success of the program. Many felt that time allocation was inadequate and 20% thought their capacity to maintain their workload was adversely affected by participating. Outcomes were considerable given the modest nature of the program. Notable outcomes were that most participants published their research and presented their research at a conference. Furthermore, one-fifth of survey respondents had enrolled in higher degrees. Several interviewees reported that their research led to changes in practice. Most respondents found the RDP valuable and considered that undertaking the program increased their research knowledge.

The preparedness of UK graduates in acute care: a systematic literature review.

PURPOSE OF STUDY: The ability to recognise acutely unwell patients and to instigate generic resuscitation is essential for all newly qualified doctors. The aim of this review is to synthesise recent work examining the perceived preparedness of UK medical graduates in acute care, relative to the other outcomes detailed in Tomorrow's Doctors (2009). STUDY DESIGN: A systematic literature search was performed using five databases. It sought literature related to preparedness in acute care and other Tomorrow's Doctors outcomes from the perspectives of the graduates themselves and their professional colleagues. Two researchers undertook data extraction and quality scoring, and preparedness ratings in each outcome were mapped to a generic rating scale to allow comparison between studies. RESULTS: 256 articles were recovered, with 10 included in the final analysis. The 10 articles suggested that graduates perceive themselves to be least well prepared in acute care and prescribing. Their professional colleagues perceive them to be less prepared in acute care than in any of the other outcomes and perceive preparedness in acute care to have declined since the first publication of Tomorrow's Doctors. Furthermore, there is evidence that preparedness in acute care is an area of concern for UK graduates. CONCLUSIONS: The assimilation of evidence in this review suggests that recent changes in UK undergraduate training, while improving preparedness in some areas, may have neglected acute care. While not a good surrogate for actual preparedness, perceived preparedness is important in influencing the behaviour of new graduates and therefore warrants further consideration.

Discovery and optimisation of a selective non-steroidal glucocorticoid receptor antagonist.

High-throughput screening of 3.87 million compounds delivered a novel series of non-steroidal GR antagonists. Subsequent rounds of optimisation allowed progression from a non-selective ligand with a poor ADMET profile to an orally bioavailable, selective, stable, glucocorticoid receptor antagonist.

Understanding the behaviour of newly qualified doctors in acute care contexts.

CONTEXT: A particularly onerous aspect of the transition from medical student to practising doctor concerns the necessity to be able to rapidly identify acutely unwell patients and initiate appropriate resuscitation. These are skills in which many graduates feel poorly prepared and are considered by some to be best learned on the job. This constructivist study investigated the factors that influence the behaviour of junior doctors in this context and initiated the development of a framework that promotes understanding of this important area. METHODS: Focus groups involving 36 clinicians with a variety of clinical experience were conducted and analysed using a qualitative, grounded theory approach. The complex relationships between emergent themes guided the development of a framework that was refined and validated by further interviews with participants. RESULTS: Six main themes, grouped under three broad headings, emerged from the data: 'transferring knowledge into practice' and 'decision making and uncertainty' (cognitive challenges); 'acts and omissions' and 'identity and expectations' (roles and responsibilities), and, finally, 'the medical hierarchy' and 'performing under stress' (environmental factors). The framework presented within this paper illustrates the complex relationships between these factors. CONCLUSIONS: Although the potential of metacognitive strategies to reduce medical error is acknowledged, the framework promotes looking beyond the individual to consider the contributions to patient safety of identity issues, role uncertainty and the hierarchical clinical environment. A more distributed approach to situation awareness may help junior doctors to better tolerate complexity and uncertainty. The efficacy of simulation as an educational strategy may be improved by finding ways to recreate the hierarchical and stressful environment in which junior doctors practise. Junior doctors should be aware of the impact of affect and emotion on behaviour, and clinical supervisors should strive to ensure that roles and responsibilities are explicitly discussed.

Are medical graduates ready to face the challenges of Foundation training?

PURPOSE OF STUDY Previous research demonstrates that graduating medical students often feel unprepared for practice and that their perceptions of preparedness correlate only partially with those of their supervising consultants. This study explores the components of preparedness for practice from the perspectives of both newly qualified doctors and their educational supervisors. STUDY DESIGN A questionnaire study was undertaken at the University of Edinburgh, involving feedback on preparedness for practice over three consecutive years from 2007 to 2009, against 13 major programme outcomes, from graduates and their educational supervisors. In addition, free text responses were sought and thematically analysed. RESULTS Graduates consistently felt well prepared in consultation and communication skills but less prepared in acute care and prescribing. Educational supervisors consistently felt that graduates were well prepared in information technology and communication skills but less prepared in acute care and practical procedures. Free text analysis identified four main themes: knowledge; skills; personal attributes; and familiarity with the ward environment. CONCLUSIONS Preparedness for practice data can be enriched by repeated collection over several years, comparison of different perspectives, and incorporation of free text responses. The non-technical skills of decision-making, initiative, prioritisation, and coping with stress are important components of preparing new doctors for practice. Education for Foundation trainees should focus on the areas in which graduates are perceived to be less prepared, such as acute care, prescribing, and procedural skills.

Researcher development program of the primary health care research, evaluation and development strategy.

The Research Development Program (RDP) was initiated in 2004 under the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy to increase the number and range of people with knowledge and skills in primary health care research and evaluation. RDP Fellows were invited to participate in an online survey about the effect the program had on their research knowledge, attitudes and practice. The response rate was 42% (105/248). Most were female (88%) with 66% aged between 31 and 50 years. Over two-thirds (72%) were health practitioners. Activities undertaken during the RDP ranged from literature reviews, developing a research question, preparing ethics submissions, attending and presenting at conferences and seminars, preparing papers and reports, and submitting grant applications. Despite the fact that only 52% agreed that the RDP time was adequate, 94% agreed that the RDP was a valuable experience, with 89% expressing interest in undertaking further research. These results indicate that this program has had a positive effect on the RDP Fellows in terms of their knowledge about research, their attitude to research, and the way they use research in their work.

The Impact of ERASMUS Exchanges on the Professional and Personal Development of Medical Students.

The ERASMUS program is one of the most popular student exchange projects, particularly among the students of Central and Eastern European countries. However, limited research is available with regard to its influence on the professional and personal development of its participants. The study aimed at investigating the experiences and impact of the ERASMUS program on different domains of the personal and professional life of medical students. A questionnaire containing closed and open-ended questions was distributed among 269 former participants of the ERASMUS program from the Poznan University of Medical Sciences to collect qualitative and quantitative data regarding the topic. The response rate was 41%. Mastering professional foreign language skills was the most frequently reported benefit of ERASMUS (94%), followed by a change of approach towards learning by exposure to innovative teaching techniques, character, professionalism and cultural competency development, impact on the migration decisions of the students, as well as the opportunity to compare healthcare and educational systems across countries. Additionally, 57% of respondents stated that ERASMUS impacted their career plans, and few indicated that it had affected their specialty choice. Approximately 28% of respondents have worked abroad in healthcare or research since graduating. Participation in the ERASMUS program proved to be a unique opportunity for professional and personal development.

Sources of variation in performance on a shared OSCE station across four UK medical schools.

CONTEXT: High-stakes undergraduate clinical assessments should be based on transparent standards comparable between different medical schools. However, simply sharing questions and pass marks may not ensure comparable standards and judgements. We hypothesised that in multicentre examinations, teaching institutions contribute to systematic variations in students' marks between different medical schools through the behaviour of their markers, standard-setters and simulated patients. METHODS: We embedded a common objective structured clinical examination (OSCE) station in four UK medical schools. All students were examined by a locally trained examiner as well as by a centrally provided examiner. Central and local examiners did not confer. Pass scores were calculated using the borderline groups method. Mean scores awarded by each examiner group were also compared. Systematic variations in scoring between schools and between local and central examiners were analysed. RESULTS: Pass scores varied slightly but significantly between each school, and between local and central examiners. The patterns of variation were usually systematic between local and central examiners (either consistently lower or higher). In some cases scores given by one examiner pair were significantly different from those awarded by other pairs in the same school, implying that other factors (possibly simulated patient behaviour) make a significant difference to student scoring. CONCLUSIONS: Shared undergraduate clinical assessments should not rely on scoring systems and standard setting which fail to take into account other differences between schools. Examiner behaviour and training and other local factors are important contributors to variations in scores between schools. The OSCE scores of students from different medical schools should not be directly compared without taking such systematic variations into consideration.

The Southeast Scotland Foundation Doctor Teaching Programme--is "near-peer" teaching feasible, efficacious and sustainable on a regional scale?

BACKGROUND: Peer-assisted learning has advantages for students and tutors. AIMS: We aimed to establish a novel 'near-peer' teaching scheme delivered by junior doctors for final-year medical students in Southeast Scotland. We report feedback from students regarding the perceived utility of this scheme, the results of a randomized controlled trial (RCT) of its impact, and mechanisms for quality assurance and sustainability. METHODS: The scheme was devised by newly qualified doctors. Following open recruitment and tutor training, junior doctor-led sessions were provided on clinical examination and practical prescribing in 2006-2008. Feedback was sought using anonymized questionnaires. An RCT was performed to assess the effect of attendance at a prescribing tutorial on performance in a mock assessment. RESULTS: Of 271 students in 2006-2007, 234 (86%) completed voluntary feedback and 233 (99%) expressed interest in attending more tutorials. In the RCT, students who received a tutorial made fewer dosing errors (9 vs. 22, p = 0.049). The majority of tutors attending the training symposium felt the experience was useful and helped prepare them for teaching. CONCLUSION: 'Near-peer' teaching is a popular adjunct to the undergraduate programme and may promote junior doctors' professional development. Such schemes can be devised and delivered by juniors in conjunction with university staff.