Letters to the Editor

Medical students describe their patterns of practising clinical examination skills outside timetabled sessions

Dear Sir

There is a body of research showing how deliberate practice (defined as “a regimen of effortful activities designed to optimize improvement”) relates to the acquisition and maintenance of expert performance in various domains of expertise including medicine (Ericsson 1993).

There is little information in the literature about the practice habits of medical students for learning clinical examination skills. A study by Mavis (2000) showed that for students who practised for more than three hours before an objective structured clinical examination (OSCE), only 20% of their time was spent practising clinical skills.

Our aim was to identify the clinical skills practice habits of medical students outside of their timetabled clinical skills sessions; understand what factors influence these practice behaviours; and explore how practice opportunities could be improved.

An anonymous, self-completed survey tool was designed and distributed to all second and third year undergraduate medical students at the University of Auckland at the end of 2004. Data were coded and analysed using univariate statistics.

The response from Year 3 was moderate (79/118 = 67%) with a lower rate from Year 2 (67/141 = 48%). Year 2 students were more likely to have never practised examination skills outside of timetabled clinical skills sessions as compared with year 3 students (28.8% versus 5.1%). Most year 3 students (46/53 = 86.8%) specifically practised before the end-of-year clinical exam. Year 3 students were more likely to use the skills centre compared with year 2 students who tended to practise at home. Students practised complex skills (blood pressure, neurology) more often. Analysis of open questions on how opportunities for practice could be improved identified two main themes: (i) access to skills centre and (ii) supervision.

In conclusion, formal clinical assessment has an influence on the how, when, and what students practice. A dedicated clinical skills centre provides a suitable location for practice that students use in proportion to their exposure and familiarity with the resource. Increasing access to the centre would improve the number and type of opportunities to practise clinical skills. We hope to further explore the opportunities for senior peer supervision and study the transition from early skills learning to learning in the health service environment.

Harsh Bhoopatkar and Andy Wearn

The University of Auckland

Clinical Skills Resource Centre

Faculty of Medical and Health Sciences

Private Bag 92019

Auckland

New Zealand

Tel: [phone]

Fax: [phone]

Email: [email protected]

Can medical students’ pre-curriculum performance on the Ethics in Health Care Instrument (EHCI) be used as a predictor of future academic performance? A pilot study

Dear Sir

As part of the evaluation of ethics learning in Glasgow's new learner centred, problem based, integrated medical curriculum the Ethics in Health Care Instrument (EHCI) was administered to the first intake of students at the start of their course. The EHCI incorporates 12 case vignettes, each of which includes an ethical dimension. 165 (70%) students completed an EHCI. Subjects are asked to select one of the pre-set answers to each vignette and then justify their chosen response. We hypothesised that high scorers on the EHCI pre-curriculum not only have greater pre-existing ethical knowledge than low scorers, but that this knowledge is contextualised to the clinical setting. Contextualising this knowledge to the clinical context suggests prior consideration of, and interest in the clinical context. Given that interest is a stable and long lasting attribute in adults (Schefele 1991), students’ interest would be expected to continue. We hypothesised that high scoring students will be more likely to outperform low scoring students in applying knowledge in the clinical context in the future. Follow-up data were obtained from the medical faculty on students' exam results. These included the results of students who left the course to undertake an intercalated BSc and who joined a different year on their return to the medical curriculum.

While differences in exam performance between high and lower scorers on the EHCI pre-curriculum were found, the study was underpowered to detect important differences in outcome. It would have required 750 students to have 80% power to be able to detect these differences.

In following students through the medical curriculum an unexpected observation was that students undertaking an intercalated degree were found to be less likely to drop out of the medical course. As the only association found to be significant at the 5% level, amongst a number of factors tested, it cannot be treated as conclusive. However, previous studies have suggested that intercalated students have higher A-level grades and higher deep and strategic learning scores than students not taking an intercalated degree (McManus et al. 1999). This effect is diluted as the proportion of students taking an intercalated degree increases. In this study, 42% of the cohort undertook an intercalated degree, comparable to the average in UK medical schools of one-third of students (McManus et al. 1999).

Dr John Goldie

Senior Clinical Tutor

Section of General Practice and Primary Care

University of Glasgow

Email:[email protected]

Dr Phil Cotton

Senior Lecturer in General Practice

Section of General Practice and Primary Care

University of Glasgow

Dr Alex McConnachie

Robertson Centre for Biostatistics

University of Glasgow

Professor Jillian Morrison

Section of General Practice and Primary Care

University of Glasgow, UK

The shadowing period – “Could do better”

Dear Sir

The undergraduate shadowing period is a mandatory requirement for medical students, aiding transition from the role of student to that of junior doctor and a final opportunity for students to identify and address any remaining gaps in their knowledge or skills before commencing in post. However, despite being a mandatory GMC requirement there are no specific guidelines as to how the Shadowing period should achieve this aim. Furthermore, the lack of guidance means there is considerable variation between UK medical schools as to form, timing and content.

We conducted a questionnaire analysis of the shadowing period within our hospital. The results revealed this to be an underutilised time with defects in organisation, structure and content. Many students did not shadow in the job they would commence in August, as is recommended. Little information was given to the supervising consultant or FY1 doctor whom the student would shadow as to the learning objectives of the period. Students felt that the timing of shadowing (a 4 week period immediately after Finals) was far from ideal as they were tired and de-motivated. Most would have preferred shadowing immediately prior to August commencement, facilitating a smoother handover.

Content was poor, with students not required to complete any specific tasks, and little in the way of formal teaching or even monitoring of attendance. Each student's experience was therefore heavily dependent upon the FY1 doctor to whom they were attached, since the latter provided the majority of guidance for their student – this lead to a great degree of variability. Perceived gaps in knowledge and skills were not effectively addressed.

We have since implemented many changes to our shadowing period including a logbook of procedures and a range of teaching sessions. Much of the programme is designed and delivered by Foundation Year doctors.

As a compulsory part of the curriculum, and the final time that students can address deficits in skills, knowledge and experience prior to qualification, it is crucial that shadowing is carried out effectively. We feel a degree of standardisation across all centres would be beneficial and the shadowing period needs to be critically examined to give purpose and focus to the last placement of the pre-graduation doctor. We will be conducting further work in this area at our centre.

Dr Jenny MacDowall

Dr Bernadette Huggon

Department of Undergraduate Education

Royal Blackburn Hospital

Haslingden Road

Blackburn

Lancashire

BB2 3HH

United Kingdom

Phone: [phone]

Email: [email protected]

Teaching hospitals vs teaching academies: the Bristol experience

Dear Sir

During the past two years, from 2003–2005, the University of Bristol in conjunction with several acute NHS trusts has set up a number of teaching academies in the south west of England. The role of these academies is to enable teaching of larger numbers of students in an inter-discipline environment. The two large teaching hospital trusts continue to teach undergraduates as well. Each of these institutions have the same curriculum to deliver, but have been allowed to deliver the course as they see fit, in accordance with local resources and case mix. There are now six teaching academies affiliated to District General Hospitals in the south west region.

A cohort of one year was examined soon after this devolution of teaching in 2003–2004. The year group consisted of 165 students who studied undergraduate ‘junior’ medicine and ENT and Vascular surgery at one of the two types of institutions. All students sat the same end of year examination together which consisted of MCQ, OSCE and OSLER formats. The end of year examination marks for both groups were similar, and student satisfaction with the academy teaching was higher than the teaching hospitals. This suggests teaching academies may be an effective place for teaching undergraduates.

Richard Hunt

Department of Surgery

Royal Sussex County Hospital

Eastern Road

Brighton

East Sussex

BN2 5BE

Tel: [phone]

Fax: [phone]

E-mail: [email protected]