Disorganized junior doctors fail the MRCP (UK)

Abstract

Career progression during undergraduate and early postgraduate years is currently determined by successfully passing examinations. Both academic factors (secondary school examination results, learning style and training opportunities) and non-academic factors (maturity, ethnic origin, gender and motivation) have been identified as predicting examination outcome. Few studies have examined organization skills. Disorganized medical students are more likely to perform poorly in end-of-year examinations but this observation has not been examined in junior doctors. This study asked whether organization skills relate to examination outcome amongst junior doctors taking the clinical Part II examination for the Membership of the Royal College of Physicians (Practical Assessment of Clinical Examination Skills). The study was conducted prospectively at four consecutive clinical courses that provided clinical teaching and practice to prepare trainees for the examination. Arrival time at registration for the course was the chosen surrogate for organization skills. Trainees were advised that they should arrive promptly at 8.00 a.m. for registration and it was explained that the course would start at 8.30 a.m. Recorded arrival times were compared with the pass lists published by the Royal College of Physicians. The mean arrival time was 8.17 a.m. A total of 81 doctors (53.3%) passed the examination with a mean arrival time of 8.14 a.m. However, 71 doctors failed the exam and arrived, on average, six minutes later than doctors who passed (p = 0.006). Better-prepared junior doctors were more likely to pass the final examination. Arriving on time represents a composite of several skills involved in the planning of appropriate travel arrangements and is therefore a valid marker of organization skills and preparation. This novel study has shown that good time-keeping skills are positively associated with examination outcome.

Introduction

Progress in medicine during undergraduate and early postgraduate years is currently determined by successfully passing examinations. Secondary school examination results (James et al., 2001), learning style (Newble & Entwistle, 1986) and training opportunities (Holland et al., 2002) are the fundamental academic factors that have been identified as influential in predicting examination grades. Important non-academic factors include maturity, ethnic origin, gender (James et al., 2001) and motivation (Webb et al., 1997).

Few studies have examined whether organization skills influence the outcome of examinations. Two studies of dental students compared self-reported measures of organizational skills to examination results. The first identified that students who scored higher grades in their end-of-quarter examinations had started their preparation at the beginning of the quarter (Lindemann & Cabret, 1995). In contrast, organization skills (incorporating setting goals and priorities, mechanics of time management and preference for organization) reported at entry to dental school did not correlate with high school examination results (Mace & Tira, 1999).

However, one study using a simple, but objective, administrative task as a surrogate for organization skills and attitude in a cohort of medical students revealed a significant correlation between failing to complete the task and poor performance in end-of-year examinations (Wright & Tanner, 2002). This observation has not been reported in postgraduate trainees. Therefore, this raises the question as to whether this relationship of poor organization to examination failure extends to junior doctors. Based on an earlier chance observation, we investigated this phenomenon in postgraduate students about to sit their exit exam from general medical training.

Methods

The study was conducted prospectively at four consecutive clinical courses in Leicester. These courses provide clinical teaching and practice to prepare trainees (three to five years post-qualification) for the clinical Part II examination for Membership of the Royal College of Physicians (Practical Assessment of Clinical Examination Skills—PACES) and takes place 10 to 14 days before the examination. Trainees apply several months in advance and are accepted onto the course on a first-come, first-served basis. The most recent documented UK pass rate for PACES is 47.1% (Chairman of the Clinical Examining Board, 2004).

Arrival time at registration for the course was the chosen surrogate for organization skills. A letter, sent to trainees confirming their acceptance onto the course, advised that they should arrive promptly at 8.00 a.m. for registration and explained that the course would start at 8.30 a.m. Written directions were provided with the letter and signs were posted in the hospital on the day. Recorded arrival times were compared with the pass lists published by the Royal College of Physicians.

Results

Of the 155 doctors attending the course, 152 informed us that they were taking the PACES examination at the next sitting. The mean arrival time was 8.17 a.m. A total of 81 doctors (53.3%) passed the examination with a mean arrival time of 8.14 a.m. However, 71 doctors failed the exam and arrived, on average, six minutes later than doctors who passed (Mann–Whitney p = 0.006).

Arrival times were grouped into five exclusive cohorts: those arriving by 8.00 a.m. and then in 10-minute groups until 8.10 a.m., 8.20 a.m., 8.30 a.m. and finally those arriving after 8.30 a.m. (late). Figure 1 represents the pass rate based on the arrival time, revealing a significant trend towards greater examination success with an earlier arrival time (ANOVA p = 0.035). Seventeen Leicester trainees (11.2% of delegates), who were familiar with the hospital, did not bias the analysis: 64.7% of the Leicester trainees passed with a mean attendance time of 8.10 a.m. compared with 8.17 a.m. for those who failed. Although female doctors (n = 53) had a higher pass rate (pass rates: female 58.5%, male 50.5%) and arrived earlier (mean attendance time: female 8.14 a.m., male 8.19 a.m.), these results did not reach statistical significance.

Figure 1. Percentage of course delegates who pass the MRCP based on their arrival time at a preparatory course. Notes: A total of 152 doctors are included in the analysis, numbers above the bars representing the number of doctors in each cohort. Error bars represent ±SEM. ANOVA p = 0.0354

Discussion

This is the first report to demonstrate that better-prepared doctors arriving on time for a clinical training course for a postgraduate examination were significantly more likely to pass than those arriving late.

We propose that arriving on time represents a composite of several skills involved in the planning of appropriate travel arrangements and is therefore a valid marker of organization skills and preparation, rather than a measure of time-management alone. This marker also equates well with other published surrogates for organization skills, namely a simple administrative task (Wright & Tanner, 2002) or a combination of negative attitudes to study, excessive socializing and poor appraisal of evidence (Newble et al., 1988). However, whereas those studies reported a significant correlation between objective measures of disorganization and poor performance in medical students, this study suggests that this finding extends to postgraduate students.

The association of course arrival time with subsequent passing of PACES was consistent over four separate courses. Though the statistical significance supports the strength of this relationship, this study does not prove causality. In addition, the study was not designed to investigate whether extraneous factors, such as financial constraints preventing the delegates from staying locally the night before the course, biased the results. However, the study findings were almost identical in Leicester-based trainees, who had short distances to travel and were familiar with the hospital.

Interestingly, punctuality of supervisors is a quality highly regarded by trainees (Clarke, 1999). Contrarily, time-management skills of trainees in the organization and prioritization of their clinical on-call work is not rated highly by supervisors (Ringsted et al., 2002). Therefore, further research is required to determine whether doctors with organization skills are better able to prepare for and/or pass exams or whether they are better clinicians per se. Nonetheless, time-management skills are important: the proposed Foundation programme for newly qualified UK graduates includes time-management skills as part of its generic curriculum and will be assessed as a key competence.

Conclusion

These findings support the view that it is not only at medical school that organization skills and attitude influence exam outcome (Wright & Tanner, 2002); the same is true in more experienced junior doctors. As many who have sat postgraduate examinations will testify, these are expensive and important hurdles to cross. So our advice to prospective candidates is clear—lateness is a warning sign of failure: Get organized!

Practice points

Table

• Undergraduate examination success in medicine can be predicted by prior examination results, learning style, training opportunities and non-academic factors such as maturity, gender and ethnic origin.

• This report shows that better-prepared doctors arriving on time for a clinical training course in preparation for a postgraduate examination were significantly more likely to pass than those arriving late.

• Poor time-keeping skills, as an example of organization skills, negatively influence examination outcome in junior doctors.

Competing interests

AGS, KMK, WH and MT have received payment to teach on the course.

Funding and ethical approval

There was no additional funding, and ethical approval was not required.

Acknowledgements

The authors would like to thank the University of Leicester and the University Hospitals of Leicester NHS Trust for their support of the teaching programme.

Additional information

Notes on contributors

Adrian G. Stanley

ADRIAN STANLEY is a Consultant Physician at the University Hospitals of Leicester NHS Trust and Honorary Senior Lecturer (Medical Education) at the University of Leicester. He teaches undergraduates and postgraduates (medical and nursing), with research interests in both. His clinical interests include hypertension, which forms the basis of his clinical research.

Khalid M. Khan

KHALID KHAN is a Consultant Cardiologist and General Physician in North East Wales NHS Trust. His clinical interests include primary prevention, atrial fibrillation and heart failure. His extensive teaching commitment at both undergraduate and postgraduate levels underlines his particular interest in effective communication and training methods.

Walayat Hussain

WALAYAT HUSSAIN is a Specialist Registrar at the Dermatology Centre, Hope Hospital, Manchester. He qualified from the University of Leicester and trained in general medicine in Nottingham. His research interests include undergraduate and postgraduate medical education.

Michael Tweed

MIKE TWEED is Associate Dean for Medical Education in the Department of Medicine at Wellington School of Medicine, New Zealand. His academic interests include aspects of Healthcare Education, in particular the assessment of medical undergraduates.