Defining an anaesthetic curriculum for medical undergraduates. A Delphi study

Abstract

Background and Objectives: Anaesthesia is commonly taught to medical students. The duration and content of such teaching varies however and no consensus exists as to what constitutes an optimal curriculum. Anaesthetists possess the necessary knowledge and skills and operate in clinical settings suitable to provide training for medical undergraduates, especially in areas where deficiencies have been identified. This Delphi study was directed towards developing a consensus on an optimal anaesthesia, intensive care and pain medicine curriculum for medical undergraduates.

Methods: This Delphi survey consisted of three iterative rounds with feedback given at the start of each successive round in the form of the results of the previous round. The participants consisted of 27 consultant anaesthetists, choosen by the three Professors of anaesthesia in Ireland to be experts in undergraduate medical education.

Results: Thirty one consultant anaesthetists were chosen to participate in the study. Two consultants declined to participate. Two consultants were omitted from the first round in error and were not included in the remainder of the study. The response rate to the first round was 100%. Two hundred and nine individual items were included in the second questionnaire. 67% consultants responded to the second questionnaire and 59% to the third questionnaire. 74 Items achieved consensus level on completion of the study.

Conclusion: This study demonstrated support amongst respondents for an expanded role for anaesthetists in teaching medical students. An expanded teaching role for anaesthetists would take advantage of the large number of anaesthetists in Irish teaching hospitals, their enthusiasm for teaching, the frequency of patient-consultant proximity and the likely value of their teaching to student learning outcomes. The consensus reached by this study does not recommend a comprehensive anaesthesia curriculum. Rather, more emphasis has been placed on anaesthetists teaching a broader range of knowledge, skills and attitudes relevant to every newly qualified doctor.

Introduction

Anaesthesia, critical care and pain medicine are commonly taught to undergraduate medical students (Cheung et al. 1999; Brull & Bradley 2001). Duration and content of teaching varies and there is little consensus as to what represents the optimum undergraduate curriculum (Prys-Roberts et al. 1988; Cooper & Hutton 1995; Cheung et al. 1999). Specialists in anaesthesia, intensive care medicine and pain medicine possess the knowledge and skills and operate in clinical settings suitable to providing training in such areas as cardiopulmonary resuscitation, care of the critically ill, preoperative assessment, perioperative medicine, acute and chronic pain management and applied physiology and pharmacology (Prys-Roberts et al. 1988; Harmer 1994). Despite the availability of such resources, deficiencies in both knowledge and skills in these areas are evident at both undergraduate and early postgraduate level (Gould et al. 1994).

Currently, anaesthesia, intensive care and pain medicine are taught in all of the five medical schools in the Republic of Ireland. However no agreed uniform curriculum exists between the universities. Similarly, there is no agreement between the universities as to the length, timing or scope of the anaesthetic rotation (personal communication).

Table

Practice points

Little guidance exists in the medical literature as to what exactly anaesthetists should teach. Studies have suggested that areas where anaesthetists should be particularly proficient in teaching are often inadequately taught at undergraduate level. This Delphi study suggests a possible anaesthesia curriculum for medical undergraduates. There was support amongst respondents for an expanded role for anaesthetists in teaching medical ungergraduates.

A Delphi questionnaire is a qualitative research technique designed to obtain consensus opinion amongst a group of experts (Stewart 2001). It consists of a series of iterative questionnaires completed by a panel of experts with controlled feedback to the panel during each round in the form of the results from the previous round (Larach et al. 1994). The method typically involves a series of information gathering rounds in which panel members independently offer, refine and finally gain consensus on their opinions regarding a number of defined statements (Keeney et al. 2006). Unlike some group decision making processes, the Delphi technique utilizes anonymity, iteration and controlled feedback, statistical group response and expert input (Keeney et al. 2006). There are numerous examples of the use of the Delphi technique in medical research (Broomfield & Humphris 2001; Turner & Weiner 2002; Alahlafi & Burge 2005).

The purpose of this study is to carry out a three round Delphi questionnaire to develop consensus as to the optimal curriculum for Irish medical undergraduates.

Methods

This study consisted of three iterative rounds with feedback in the form of the results from the previous round.

The panel of experts chosen consisted of consultant anaesthetists in the Republic of Ireland, known to have shown a sustained interest in undergraduate medical education. This panel was chosen in a two stage process. Firstly, those deemed eligible for inclusion and secondly those who were willing to take part.

In the context of the Delphi survey technique, there is no set criterion as to what defines ‘expert’ status (Jones & Hunter 1995; Hassan et al. 2000). It was decided, therefore, that the panel of experts for this study should be chosen on the advice of the three Professors of Anaesthesia in the Republic of Ireland. Each professor was contacted and asked to provide a list of those consultant anaesthetists, from appoximately 310 consultant anaesthetists in the Republic of Ireland, they felt were experts in undergraduate medical education and would therefore be suitable participants in this study.

Once identified as potential participants in the study, each consultant was contacted by post and their permission was requested for inclusion in the study. The thirty one consultants who agreed to take part in the study were then to receive the first of the three questionnaires.

For each of the three rounds of the study, the participants were asked to return the questionnaire within 10 days. Any participant who had not responded within three weeks was sent a follow up questionnaire and contacted by telephone.

The study was pseudo-anonymous in that although the respondents were known to the authors, they were anonymous to each other.

Round 1. The first questionnaire included six open-ended questions. The purpose of this round was to discover what each panel member broadly considered to be the optimal anaesthetic curriculum.

The questions were as follows:

• Q 1. What do you think the timing (in relation to the overall curriculum), duration and location(s) of an undergraduate anaesthetic curriculum should be?

• Q 2. What number and grade of staff (if any) should have responsibility for the running of the curriculum?

• Q 3. What topics in the areas of anaesthesia, intensive care medicine and pain medicine do you feel should be included in the curriculum? Please cover the areas of knowledge, skills and attitudes when answering this question.

• Q 4. What teaching methods and what teaching tools do you feel should be used?

• Q 5. Should, and if so how, students be assessed at the completion of the curriculum?

• Q 6. Should, and if so how, feedback be sought at the completion of the curriculum?

Round 2. The second questionnaire referred to all the items sent in response to the first questionnaire. When different terms were used for what appeared to be the same item, they were grouped together in an attempt to provide one universal description. The panel members were asked to rank each item using a five point Likert scale.

Round 3. The third questionnaire was prepared so that the participants received feedback regarding each item listed in the second questionnaire in the form of a measure of support (mean) and agreement (standard deviation).

The purpose of this feedback was to allow the participants the opportunity to revise their opinion, now aware of the opinion of the other participants.

All participants were sent the three questionnaires, regardless of whether they had responded to the previous questionnaire.

Literature on the Delphi technique does not stipulate when consensus has been reached. We arbitrarily decided that any item with a mean score of greater or equal to 4.0 and with a standard deviation less than or equal to 1.0 had reached consensus level. Any item reaching consensus level after the second round was not included in the third round.

Results

Thirty one consultant anaesthetists were chosen to participate in the study. Two consultants declined to participate. Two consultants were omitted from the first round in error and were not included in the remainder of the study.

The response rate to the first round was 100%. Two hundred and nine individual items were included in the second questionnaire.

Sixty seven percent of consultants responded to the second questionnaire and 59% to the third questionnaire.

Seventy four items achieved consensus level on completion of the study. One hundred and thirty five items suggested after the first round did not achieve a consensus level.

Discussion

This study demonstrated support amongst respondents for an expanded role for anaesthetists in teaching medical students. This is unsurprising, as such a role has long found support amongst the speciality (Cheung et al. 1999; Power & Norman 1992; Cooper & Hutton 1995; Brull & Bradley 2001).

Little guidance exists in the medical literature as to what exactly anaesthetists should teach. Cheung et al. (1999) surveyed all English speaking medical schools, outside the USA, on the content of their anaesthetic teaching and devised a curriculum based on their findings. But this was a survey of current practices and not what was felt to be optimal. Similarly, Shen et al. (2003) surveyed current practices in the teaching of intensive care medicine in 122 medical schools and recommended that one week be dedicated to the teaching of critical care medicine. Again, this is a survey of current practice only. However, the International Association for the Study of Pain Ad hoc Subcommittee on Medical School Courses and Curriculum has produced a comprehensive consensus based undergraduate curriculum (International Association for the Study of Pain 2000).

Numerous studies have suggested that areas where anaesthetists should be particularly proficient in teaching are often inadequately taught at undergraduate level. Studies investigating undergraduate medical student and newly qualified doctors knowledge and skills in basic airway management (Morgan et al. 2003), acute and chronic pain management (Gould et al. 1994), basic life support (Moercke & Eika 2002) and simple procedures such as intravenous cannulation (Barnsley et al. 2004) have repeatedly shown both knowledge and skills to be deficient. Furthermore, the clinical experience of medical students seems to be diminishing (McManus et al. 1998). It is encouraging that the respondents to this study are enthusiastic about teaching in these areas.

Currently, there is much emphasis on limiting the amount of knowledge to be memorised and encouraging life long learning skills and an ability to adapt to the rapid changes in medical practice (Cooper & Hutton 1995; General Medical Council 2003). Despite this there continue to be reports in the literature recommending the detailed teaching of narrow specialist or subspecialist areas to undergraduates (Alahlafi & Burge 2005). It is important to note that our study differs in this regard. The consensus reached does not recommend a comprehensive anaesthesia curriculum. Rather, more emphasis has been placed on a broader range of knowledge, skills and attitudes relevant to every newly qualified doctor.

Opinions differ as to why anaesthetists should teach medical students. Increased uptake of students into the speciality, improved student attitudes towards anaesthesia, increased remuneration, better prepared doctors and improved patient care have all been given as possible reasons for anaesthetists to consider teaching medical students (Prys-Roberts et al. 1988; Watts et al. 1998; Yang et al. 2001). The participants in this study were not asked why they thought they should teach medical students. However, given the voluntary nature of most anaesthesia related teaching in Ireland and the emphasis given by respondents too many non anaesthesia related items, it would appear, and is hoped, that they teach to help medical students attain the standards expected of newly qualified doctors.

The Delphi technique has several potential advantages as a research tool. It allows participants to remain anonymous and free of social pressure, personality influence, and individual dominance. It is relatively inexpensive compared to the cost of gathering individuals in a face-to-face setting. It is thought to be conducive to independent thinking and gradual formulation and it can be used to reach consensus even amongst groups hostile to each other.

The weaknesses of this study are weaknesses of the Delphi method in general (Turner & Weiner 2002). It is a time consuming to complete each questionnaire and subsequently requires a greater degree of participant commitment than other surveys. The falling response rate during our study may reflect this.

Criticism has been made of the reliability of the Delphi technique, as there is no evidence that two different panels, given the same initial information, will produce the same results.

There is no agreement as to what constitutes an expert. The participants for this study depended on the professors of anaesthesia recommending individuals who they believed to be well informed and interested in undergraduate medical education as this was thought to be the most appropriate way of identifying the experts. This method of choosing a panel may have caused bias in the results.

For Delphi type research, there is no agreement as to what actually constitutes consensus. In an attempt to prevent curriculum overload quite strict criteria to decide when an item had reached consensus level were chosen for the study. They were nevertheless arbitrary. The existence of consensus does not mean that the correct answer has been found. There is a risk that collective ignorance rather than wisdom may have been displayed. Finally the Delphi technique tends to eliminate extreme positions and can force a middle-of-the-road consensus.

For all these reasons the recommendations below should not be viewed as a total solution, simply as the consensus opinion of this group.

When developing a curriculum for any speciality it is important not to do so in isolation.

Lack of communication with other educators offers real potential for repetition and redundancy. Areas well covered by others should not be included in this curriculum. Similarly, teachers need not be confined to teaching their own speciality. This study suggests a valuable role, and indeed preference, for anaesthetists in teaching topics not strictly related to anaesthesia.

Recommendations

The curriculum should be taught in the later clinical years of medical school. It should be of at least two weeks duration, with three to four weeks probably optimal. Clinical teaching should be concentrated in the operating theatre and intensive care unit and non clinical teaching in small group tutorials.

One consultant, ideally with sessional time devoted to teaching, should have overall responsibility for the curriculum. A consultant and at least one specialist registrar should administer the course and all anaesthetists should teach medical students. There should be a published core curriculum making clear the knowledge, skills and attitudes to be learnt. This should emphasise items listed in Table 1 and Table 2.

Table 1.  Items for which curriculum inclusion consensus was reached for the questions ‘What do you think the timing (in relation to the overall curriculum), duration and location(s) of an undergraduate anaesthetic curriculum should be?’ and ‘What number and grade of staff (if any) should have responsibility for the running of the curriculum?’ on completion of the Delphi study

Year in which curriculum should be taught	Mean (SD)
No item
Duration of curriculum
No item
Location of teaching
1. Theatre	4.7 (0.4)
2. Intensive care unit	4.5 (1.0)
3. Small group tutorial room	4.5 (0.6)
Number and grade of staff
1. Consultant with sessional time devoted to curriculum	4.2 (1.0)
2. Two for administration [one consultant and one specialist registrar 4/5] and all staff involved in teaching	4.1 (1.0)

SD = standard deviation.

Table 2.  Items for which curriculum inclusion consensus was reached for the question ‘What topics in the areas of anaesthesia, intensive care medicine and pain medicine do you feel should be included in the curriculum? Please cover the areas of knowledge, skills and attitudes when answering this question’ on completion of the Delphi study

Knowledge	Mean (SD)
1. Management of unconscious patient	4.9 (0.5)
2. Acute postoperative pain management	4.8 (0.3)
3. Postoperative pain relief	4.8 (0.4)
4. Perioperative patient management	4.8 (0.5)
5. Airway management	4.6 (0.7)
6. Shock	4.6 (0.8)
7. Management of emergency patient	4.5 (0.7)
8. Management of perioperative emergencies	4.5 (0.8)
9. Resuscitation	4.5 (1.0)
10. Clinical assessment of dehydration	4.5 (1.0)
11. Critical events	4.4 (0.7)
12. Management of Trauma patient	4.4 (0.7)
13. Basic cardiorespiratory physiology	4.4 (0.9)
14. Intravenous fluid management	4.4 (0.9)
15. Management of respiratory distress	4.4 (1.0)
16. Preoperative history taking and examination	4.4 (1.0)
17. A published core curriculum	4.3 (1.0)
18. Identification and resuscitation of critically ill	4.3 (1.0)
19. Common postoperative complications	4.3 (1.0)
20. Acid/base balance	4.3 (1.0)
21. Perioperative physiological changes	4.2 (0.7)
22. Complications of anaesthesia and surgery	4.2 (0.9)
23. Risk factors for anaesthesia	4.2 (1.0)
24. Acute physiological disturbances	4.2 (1.0)
25. Interpretation of standard blood results	4.2 (1.0)
26. Sepsis	4.1 (1.0)
27. Applied basic sciences [anatomy, physiology, biochemistry, pharmacology]	4.1 (1.0)
28. Care of critically ill intensive care patient	4.0 (1.0)
Skills
1. Bag/mask ventilation	4.8 (0.4)
2. Basic life support	4.7 (0.7)
3. Bag/mask ventilation [two man technique]	4.7 (0.9)
4. Hold an airway	4.7 (0.9)
5. Guedal airway insertion	4.5 (0.9)
6. Aseptic technique for procedures	4.4 (0.8)
7. Intravenous cannulation	4.4 (1.0)
8. Observation endotracheal intubation	4.2 (0.9)
Attitudes
1. Courtesy	4.6 (0.9)
2. Recognition of need to get help	4.6 (0.9)
3. Honesty. 4.5 (0.7)   Communication 4.2 (1.0)	4.2 (1.0)
4. Respect for confidentiality______	4.4 (0.7)
5. Ethical behaviour	4.4 (1.0)
6. Respect for patient	4.4 (1.0)
7. Appropriate approach to preoperative patient visit	4.3 (1.0)
8. Emphasis on patient care	4.2 (0.8)
9. Appropriate levels of cleanliness	4.2 (0.8)
10. Team skills	4.2 (1.0)
11. Understanding patient concerns	4.2 (1.0)
12. Postoperative visit	4.1 (0.6)
13. Punctuality_____	4.1 (0.8)
14. Organization	4.1 (0.9)
15. Caring	4.1 (1.0)
16. Appropriate dress_________	4.0 (0.8)
17. Learning behaviour appropriate to a doctor	4.0 (0.8)
18. Communication with relatives	4.0 (1.0)

SD = standard deviation.

There should be a clear emphasis on clinical exposure, one to one teaching and small group teaching. Large group didactic teaching is not recommended. Use should be made of simulation where appropriate and affordable Table 3.

Table 3.  Items for which curriculum inclusion consensus was reached for the questions ‘What teaching methods and what teaching tools do you feel should be used?’

Teaching methods	Mean (SD)
1. Clinical exposure in theatre and intensive care	4.6(0.5)
2. Problem based learning	4.4(0.7)
3. Option of additional anaesthesia clerkship	4.4(1.0)
4. Questions and answers	4.4(1.0)
5. Interactive tutorials	4.3(0.9)
6. Case based learning	4.2(1.0)
7. Task based learning	4.1(0.7)
Teaching tools
1. Mannequins for cardiopulmonary resuscitation	4.4(0.7)
2. Mannequins for airway	4.4(0.8)
3. Small group tutorials	4.4(1.0)
4. Operating room simulator	4.2(0.9)
5. Mannequins for intravenous access	4.2(1.0)
6. Daily review tutorial	4.1(0.7)
7. Basic life/advanced cardiac life support workshops	4.0(0.7)
8. One to one bedside/theatre teaching	4.0(1.0)

SD = standard deviation.

Students should be assessed at the end of the course and a record of their attendance kept.

The ideal form of assessment was not agreed upon. Assessment should form a part of the students final examination results.

Finally all students should provide feedback on the course immediately after completion of their anaesthesia rotation. Tick box questionnaires and a two way process between student and teacher are appropriate feedback methods Table 4.

Table 4.  Items for which curriculum inclusion consensus was reached for the questions ‘Should, and if so how, students be assessed at the completion of the curriculum?’ and ‘Should, and if so how, feedback be sought at the completion of the curriculum?’ on completion of the Delphi study

	Mean (SD)
1. Students should be assessed	4.7(0.9)
2. As part of final medical and surgical exam	4.4(0.8)
3. Record of attendance	4.1(1.0)
Feedback
1. From each student	4.7(0.9)
2. Completed immediately after clerkship	4.4(0.6)
3. Two way process between teachers and students	4.4(0.7)
4. Tick box questionnaire	4.3(1.0)

SD = standard deviation.

Conclusion

The primary reason for teaching medical students should be to help improve the competence of newly qualified doctors. Anaesthetists in Ireland are currently under utilised in this area. We believe that the expansion of the anaesthesia curriculum to include the recommendations of this study would make better use of the large number of anaesthetists in Irish teaching hospitals, their enthusiasm for teaching, the frequency of patient-consultant proximity and the likely value of their teaching to student learning outcomes.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Additional information

Notes on contributors

Denise Rohan

DENISE ROHAN, FCARCSI, is a consultant anaesthetist in Beaumont Hospital, Dublin, Ireland.

Sinead Ahern

SINEAD AHERN, FCARCSI, is a year four anaesthesia specialist registrar in Cork University Hospital, Cork, Ireland.

Ken Walsh

KEN WALSH, FCARCSI, is a consultant anaesthetist in Cork University Hospital, Cork, Ireland.