Frequency and confidence in performing clinical skills among medical interns in Kuwait

Abstract

Background: Several investigations suggest inadequate emphasis of basic clinical procedures during internship training. Many trainees had reported lack of competence, while some expressed confidence to manage conditions although not sufficiently experienced.

Aims: This study aimed at ascertaining the perceptions of new medical graduates regarding the performance of core clinical skills during training and confidence of performing them later. It also aimed at determining any gender variability in the confidence in performing selected clinical skills in Obstetrics & Gynaecology.

Methods: Interns trained during 2005/06 responded anonymously to a questionnaire that listed 48 core clinical skills. The 124 subjects eligible for the study comprised graduates from Kuwait (64), other Gulf Cooperation Council countries (29), Ireland (27) and Egypt. They indicated whether they felt confident to perform the skills in future, and the number of times they had performed them during training. We received 91 completed questionnaires.

Results: The majority felt confident in performing routine skills (basic ECG and X-ray interpretations, insertion of intravenous line, inserting urethral catheter and nasogastric feeding). Approximately two thirds had performed generic skills related to emergency resuscitation, with a half of them confident in performing them in the future. A third felt confident in performing artificial ventilation and endotracheal intubation. The confidence to perform common skills in Obstetrics & Gynaecology varied, with no significant gender variation. Approximately a fifth was confident in performing lumbar puncture, needle aspiration of joints, insertion of thoracic drainage, insertion of central venous catheter, venous cut-down and indirect laryngoscopy. A small proportion reported confidence in performing different clinical procedures although they had not undertaken them during training.

Conclusions: Substantial proportions of trainees lacked confidence in performing emergency resuscitative measures and some routine clinical skills. Training needs to be closely monitored and interns who are not competent identified early for taking remedial measures.

Introduction

The internship (pre-registration) year provides the new medical graduates with the opportunity of gaining experience in a set of core clinical skills under supervision. Furthermore, the internship rotations allow the trainees to function in the professional role of a medical practitioner and develop essential attitudes and values. In addition to acquiring a degree of competence in basic skills, the trainees need to develop adequate confidence to undertake the requisite procedures. These clinical encounters would help in laying the foundation to engage in independent practice later on.

Studies that had been undertaken in the past suggest that the learning of practical skills receives inadequate attention during internship training. Fewer than 15% of interns had performed five or more common practical procedures after their first postings (Clayton et al. 2005), and new doctors had not rated their development of practical skills as high (Hesketh et al. 2003). Other reviews had indicated that newly qualified doctors were not adequately prepared for internship duties (Evans et al. 2004). It is seen that self-reported confidence of interns varied widely from supervisors’ assessments of interns’ competence (Barnsley et al. 2004). A matter that should receive the attention of internship trainers is that many trainees had indicated that they were confident to initiate management of conditions in which they had no or little experience (Turner & Brewster 2000; Clayton et al. 2005).

Table

Practice points
•Though experienced in simple procedures, interns appear inadequately trained in critical skills.
•Some interns feel confident to perform procedures although not adequately trained.
•Many interns have performed common procedures in Obstetrics & Gynaecology, with no evidence of any gender variation in performance.
•Close monitoring of training is needed and internship and undergraduate curricula may warrant review.

The performance of clinical skills by medical interns in the Gulf Cooperation Council (GCC) countries has not been reported previously. The GCC countries comprise six nations in the Arabian Gulf region that have high per capita incomes and a sizeable percentage of expatriates, responsible for delivering a variety of services. The health problems that exist are somewhat comparable, with chronic diseases starting to emerge as areas increasingly attracting attention by health policy makers. The number of nationals entering health personnel training programs has increased considerably in the recent past, with the new medical schools that are being established providing them with the opportunity to undergo medical undergraduate training in their own or in one of the member countries.

After successfully completing a seven-year undergraduate training programme, which comprises a three-semester premedical phase, a five-semester preclinical phase and a six-semester clinical phase, new medical graduates in Kuwait enter internship training. The Kuwait Institute for Medical Specialization (KIMS) administers all postgraduate training in the country including internship training. KIMS posts the internship trainees for attachments in the specialties of Medicine, Surgery, Obstetrics & Gynaecology, and Paediatrics at the major regional hospitals and for an elective rotation in Primary Care practice. The intern is expected to acquire a level of knowledge, skills and attitudes and behaviours needed to embark on a career as a health care provider, or to pursue further training in a medical specialty (KIMS 2003). The majority of the interns pursue higher training in a selected specialty, guided by the needs of the local health care services. The postgraduate training programmes are of varying duration depending on the specialty concerned. Some of these programmes are conducted abroad at approved institutions while others are offered locally in collaboration with internationally recognized training and examination bodies.

Methods

In this study, the performance of new medical graduates who completed internship training was surveyed with respect to:

1. number of times specific core clinical skills were performed during training;

2. confidence in performing the specified set of clinical skills;

3. any gender variability in the confidence in performing selected clinical skills in the field of Obstetrics & Gynecology.

In consultation with clinical trainers and program directors responsible for internship training in Kuwait, and considering the skills that had been listed in previous investigations (Bax & Godfrey 1997), 48 clinical skills that all interns should have performed by the time they completed internship training were identified. The skills were grouped under Medicine, Surgery, Obstetrics & Gynaecology and Investigative Procedures, with those that came under more than one specialty being categorized under Generic Skills. Interns who undertook rotations in Surgery, Medicine, Obstetrics & Gynaecology, and Paediatrics during the 2005 to 2006 period were invited to participate in the study.

Interns who completed their rotations were handed each a copy of the questionnaire when they reported at the administration office at KIMS and were requested to respond to it anonymously. All trainees were included in the investigation, with the total number to be surveyed not being based on calculations specifically related to statistical significance. The study group consisted of graduates from Kuwait (64), other Gulf Cooperation Council countries (29), Ireland (27) and Egypt. The respondents indicated the number of times the skills had been performed during training and their confidence to perform the skills in future. The completed questionnaires were collected by the office personnel. Out of the 124 eligible for the study, responses were received from 91 (response rate: 73.8%). The subjects who did not submit the questionnaires were not contacted again: it is unlikely that the non-respondents differed substantially from those who responded, and it may be assumed that the non-compliance was due to procedural factors.

The data obtained were analysed based on the counts and percentages of responses in each category, and the results were correlated with the perceptions of confidence for performing each of the skills listed. We used Z test for proportions to evaluate the statistical association between the concordant pairs, i.e., those confident but never performed and those performed but not confident, as well as to see any gender variability of this relationship.

Results

The frequency of performance of selected clinical skills is summarised in Table 1. Among the skills that were categorized as generic, nearly half the trainees had not performed cardiac defibrillation or endotracheal intubation (50.5%), while a considerable proportion had not performed artificial ventilation (42.9%) or securing airway (30.8%). A fifth of the trainees had never performed cardiopulmonary resuscitation. A little over half the trainees had performed insertion of intravenous line or insertion of urethral catheter more than three times. Over three quarters (81.3%) of the trainees had not done needle aspiration of joints, while over half of the trainees had not performed insertion of central venous catheter (59.3%), treatment of tension pneumothorax (58.2%), or insertion of thoracic drainage (58.2%). Of the procedures related to Surgery, the skills such as venous cut-down or operative intubation had never been performed by nearly 40% or a higher proportion of trainees. However, when analysing the skills that had been performed over three times, over half the trainees had undertaken incision and drainage of abscesses (50.5%), and over two thirds catheterization (65.9%) and insertion of Foley's catheter (74.7%).

Table 1.  Frequency of performance of selected core clinical skills by internship trainees (n = 91)

	Performed
	Never		One/two times		Over 3 times
Skills	N*	%	n	%	n	%
Generic Clinical Skills
Cardiac defibrillation	51	56.0	28	30.8	9	9.9
Endotracheal intubation	46	50.5	26	28.6	13	14.3
Artificial ventilation	39	42.9	33	36.3	16	17.6
Securing airway	28	30.8	38	41.8	24	26.4
Administering cardio-pulmonary  resuscitation	22	24.2	38	41.8	30	33.0
Insertion of intravenous line	14	15.4	22	24.2	51	56.0
Inserting urethral catheter	12	13.2	23	25.3	54	59.3
Medicine
Pericardiocentesis	74	81.3	10	11.0	4	4.4
Needle aspiration of joints	67	73.6	14	15.4	6	6.6
Insertion of central  venous catheter	54	59.3	17	18.7	14	15.4
Treatment of tension  pneumothorax	53	58.2	25	27.5	12	13.2
Insertion of thoracic drainage	53	58.2	25	27.5	9	9.9
Surgery
Venous cut-down	65	71.4	12	13.2	5	5.5
Operative intubation	39	42.9	25	27.5	24	26.4
Anorectoscopy,  proctoscopy/sigmoidoscopy	31	34.1	34	37.6	23	25.3
Incision and drainage of abscesses	16	17.6	26	28.6	46	50.5
Catheterization	8	8.8	20	22.0	60	65.9
Insertion of Foley's catheter	6	6.6	13	14.3	68	74.7
Investigative procedures
Microscopic examination of  microbiological specimens	52	57.1	17	18.7	18	19.8
Examination of blood film	43	47.3	22	24.2	20	22.0
Urine examination (microscopic/dipstick)	20	22.0	25	27.5	41	45.1
Blood sampling (venepuncture)	10	11.0	31	34.1	47	51.6

*The totals under each category may not add up to 91 as the number of subjects who did not respond is not shown in the table.

With respect to the investigative procedures that the trainees had been expected to perform, nearly half the trainees had never undertaken microscopic examination of microbiological specimens (57.1%) or examination of blood films (47.3%). While about 20% of the trainees had not performed urine examination (microscopic/dip stick) and 11% blood sampling (venepuncture), these investigative procedures had been undertaken three or more times by nearly half the trainees.

The majority of the interns felt confident with routine skills such as inserting intravenous line (71.4%), inserting urethral catheter (69.2%), and nasogastric feeding (63.7%). Moreover, approximately half the trainees felt confident with emergency resuscitation skills such as securing airway (54.9%), administering cardiopulmonary resuscitation (46.2%), and pleural tap (41.8%), with a third confident in performing artificial ventilation (38.5%) and endotracheal intubation (29.7%). Considerably lower percentages of the trainees were confident in performing lumbar puncture (25.3%), and needle aspiration of joints (20.9%) (Table 2). Some trainees indicated that they had confidence to undertake cardiac defibrillation (17.4%) and lumbar puncture (13.0%), as well as needle aspiration of joints (20.9%) in future, although they had not performed these procedures during training.

Table 2.  Interns’ self-perceived confidence in performing selected clinical skills (n = 91)

	Confident		Concordant Pairs (%)
Clinical skill	N*	%	Confident but never performed n (%)	Performed but not confident n (%)	P value
Inserting intravenous line	65	71.4	1 (1.5)	6 (54.5)	<0.001
Inserting urethral catheter	63	69.2	1 (1.6)	6 (50.0)	<0.001
Nasogastric feeding	58	63.7	3 (5.2)	9 (60.0)	<0.001
Securing airway	50	54.9	1 (2.0)	8 (38.1)	<0.001
Administering CPR	42	46.2	3 (7.1)	20 (60.6)	<0.001
Pleural tap	38	41.8	3 (7.9)	11 (40.7)	<0.001
Artificial ventillation	35	38.5	3 (8.6)	12 (35.3)	<0.001
Entrotracheal intubation	27	29.7	2 (7.4)	13 (32.5)	<0.001
Cardiac defibrillation	23	25.3	4 (17.4)	14 (32.6)	<0.001
Lumbar puncture	23	25.3	3 (13.0)	18 (40.0)	<0.001
Needle aspiration of joints	19	20.9	5 (26.3)	5 (11.1)	<0.001

*The totals under each category may not add up to 91 as the number of subjects who did not respond is not shown in the table.

In the field of Obstetrics & Gynaecology, while approximately three quarters of the respondents reported confidence in performing skills such as repair of episiotomy (85.6%) and conducting normal deliveries (70.4%), a half felt confident in performing high vaginal swab (52.8%) and collection of cervical smear (44%), and a third in undertaking artificial rupture of membranes (38.5%) and application of foetal electrodes (28.6%). The reported confidence showed no significant gender variation (Table 3).

Table 3.  Interns’ self-perceived confidence in performing clinical skills in Obstetrics & Gynecology: selected skills presented on the basis of gender (M = male, F = female) of trainee (n = 91)

	Confident		Concordant Pairs (%)
			Confident but never performed					Performed but not confident
	M		F		M		F		P value	M		F
Clinical skill	n*	%	n	%	n	%	n	%		n	%	n	%	P value
Repair of episiotomy	40	44.0	36	39.6	0	0	0	0	1	1	2.4	4	10.0	0.148
Conducting normal deliveries	32	35.2	32	35.2	0	0	0	0	1	4	11.1	6	15.8	0.556
High vaginal swab	20	22.0	28	30.8	2	15.4	2	40.0	1	3	14.3	3	10.3	1
Collection of cervical smear	16	17.6	24	26.4	3	21.4	1	14.3	0.232	3	18.8	5	17.9	0.600
Artificial rupture of membranes	16	17.6	19	20.9	3	21.4	1	9	0.260	15	27.8	6	25.0	0.866
Application of fetal electrodes	12	13.2	14	15.4	2	15.4	0	0	0.131	6	37.5	7	33.3	0.910

*The totals under each category may not add up to 91 as the number of subjects who did not respond is not shown in the table.

Discussion

The core skills that were grouped under Medicine, Surgery, Obstetrics & Gynaecology, Investigative Procedures and Generic Skills had been compiled based on the views of the local trainers and the reported literature. It appears that they are of varying degrees of importance as far as the internship trainee is concerned, and the decision to include them among the essential procedural skills for all trainees to perform should be based on the needs of the health services environment of the setting or the country concerned.

In addition, the identification of the expected competencies needs to be based on a needs analysis. In our study, we used two sources of information: the lists of competencies that had been formulated for training in the individual specialties and findings reported in studies conducted in other settings. The lists of competencies, which had the needs of the local health care services as the basis, were reviewed and then circulated among the directors of training for appropriate amendments. The documentation with the suggested changes was then reviewed at a number of meetings of trainers, directors of training and program administrators (who themselves had expertise in medical specialties or medical education) and consensus reached for the identification of the core skills expected of trainees completing internship training. In a future study that is to be undertaken as a continuation of the investigation, the needs analysis is to be expanded by obtaining data directly related to the basic health problems of Kuwait and the other countries in the region.

Relatively simple and common procedures and a few of the emergency resuscitative measures that all health personnel need to be familiar with and be confident in performing do not appear to have received adequate attention. These included endotracheal intubation, cardiac defibrillation and the administration of cardiopulmonary resuscitation (CPR). It is pertinent here to note that the General Medical Council of UK recommend that all medical graduates must be able to demonstrate competence in performing CPR and advanced life-support skills safely and effectively (General Medical Council 2003). The limited exposure of interns to these important topic areas could be due to the availability of registrars, senior registrars or anaesthetists in institutions in Kuwait, who would perform CPR when the need arises, with interns not being called upon to perform the procedure on a routine basis. As CPR is a skill that all medical graduates should be able to perform effectively, all interns need to be adequately skilled and have confidence to perform CPR, irrespective of whether senior staff is available or not.

The majority of trainees had undertaken common procedures in Obstetrics & Gynaecology, with most of them stating that they had confidence in performing these procedures in the future. The extent to which male trainees had been exposed to these clinical procedures appears to be similar to that experienced by female trainees although one may have suspected the presence of a variation as result of the value systems and the Arabian cultural setting that exist in Kuwait. Some of the midwifery skills listed under Obstetrics & Gynaecology could be considered as those occasionally appropriate, to be determined by the local needs. Additionally, it appears that procedures such as pericardiocentesis need not be included among those required for all trainees at this level.

A proportion of the interns (not large yet notable) had stated that they felt confident in performing some clinical skills, in spite of not having undertaken these during internship and being unlikely to have done so during the period of undergraduate studies. It is advisable that trainees who do not have sufficient experience do not embark on any high-risk procedures unless as life-saving emergency measures in situations where trained personnel are not available.

A number of previous studies in the UK have shown that the preparedness and confidence to perform clinical skills were insufficient among new medical graduates (Barnsley et al. 2003; Hesketh et al. 2003; Evans et al. 2004; Clayton et al. 2005; Evans & Roberts 2006). Our study complements these observations, suggesting that a similar situation exits in many regions.

The utilization of the training opportunities needs to be closely monitored and interns who may not have acquired the requisite skills need to be identified early in training so that appropriate remedial measures could be implemented. The use of instruments such as the diagnostic screening tool designed by Ben-David et al. (2004), and later developed further by Hesketh et al. (2005) would help in keeping track of the performances of junior doctors.

Under the current administrative arrangement, all interns starting the clinical rotations receive a logbook each at commencement of rotations. It lists the core skills and offers a format for recording the trainee's performances. These logbooks need to be used more effectively than at present, and for undertaking relevant feedback that is based on the actual experiences of the trainees. Other formats of documentation that the interns may be trained in is the use of portfolios, for identifying learning needs (Wilkinson et al. 2002) and for structuring learning around the perceived needs (Snadden & Thomas 1998).

Improved communication between the medical school and the employers of interns (Frankel & English 2004), the introduction of a course on student self-direction in the final year (Whitehouse et al. 2002), a period of induction (Lempp et al. 2004) and appropriate curriculum reforms have been reported to be associated with improving perception and competence levels in clinical skills, history taking and examination and better preparedness of the graduates for their role as interns (Jones et al. 2002; O’Neill et al. 2003; Watmough et al. 2006). Good supervision by educational supervisors, coupled with even informal feedback, helps in the transition of the new PRHO (Foundation Year One doctor) from the environment of the medical school to that of the ward (Brown et al. 2007).

The present system of training of interns in Kuwait, which is specialty-based, tends to reinforce the compartmentalization of subject content. Greater integration, with multidisciplinary learning sessions, would allow the trainee to observe the inter-relations among specialties and enhance the learning experience. The scheme of the Foundation Program that has been introduced recently in the UK (General Medical Council 2007) is also an approach that warrants serious study by the local trainers.

Information on improving the training of interns in Kuwait would have important implications for health planners in Kuwait as well as those in the other GCC countries, especially because of the comparability of the health problems that exist in the region and the relative ease with which financial resources and personnel that are needed for effecting improvements may be accessed. Citizens of the member countries have the option of seeking employment in other countries in the GCC, which, also, makes it desirable to have training programmes that are comparable in the essential aspects. Institutions involved in postgraduate training have already initiated some steps in this direction such as the establishment of the Committee for Training and CME/CPD in the GCC Countries. These measures could be strengthened further with greater consultation and collaboration by health care policy makers and internship trainers.

Conclusions

We conclude that both the frequency and confidence in performing core clinical skills in the study group varied, and for some skills they were not up to a level that could be considered as adequate. Interns who do not acquire competency in the core clinical skills need to be identified early and corrective measures taken. While action geared towards remedying the deficiencies should be implemented during the internship training phase, some of these measures could be introduced during the stage of undergraduate studies. We recommend that the progress of the internship trainees through the training program is closely observed, and feedback offered to ensure that the relevant learning opportunities are effectively utilized. Skills that are currently included under the period of internship training but which are either of a level that is outside what is expected of medical graduates or could more effectively be learned at a later phase of training need to be identified, and objectives related to these skills revised or moved to a subsequent stage, as appropriate.

Acknowledgements

The authors are grateful to Mr. Ashish T. Mathews and Mrs. Abaya Nair for their assistance in data entry and statistical analysis.

Additional information

Notes on contributors

I.G. Premadasa

I. G. PREMADASA is a medical educationalist attached to Kuwait Institute for Medical Specialization, Ministry of Health, Kuwait. He serves as the director of life-long learning program of the CME Center.

Diaa Shehab

DIAA SHEHAB is an associate professor in the Department of Medicine, Faculty of Medicine, Kuwait University, where she participates in teaching and evaluation of postgraduate training and life-long learning. She is a consultant in physical medicine and rehabilitation.

Khaled F. Al-Jarallah

KHALED F. AL-JARALLAH is the Secretary General of Kuwait Institute for Medical Specialization, Ministry of Health, Kuwait, where he directs postgraduate training and oversees life-long learning for health professionals. He is a consultant internist and rheumatologist, and is associate professor in the Department of Medicine, Faculty of Medicine, Kuwait University.

Lukman Thalib

LUKMAN THALIB is an associate professor in biostatistics, Faculty of Medicine, Kuwait University. He also serves as the director of its Centre for Research and Conferences, and with his strong background in medical education, is actively involved in curriculum reform at the Faculty of Medicine. He is an honorary research fellow of Griffith University, Australia.