Letters to the Editor

Improving clinical examination, diagnosis and management skills in junior doctors managing hand injuries in the emergency department

Dear Sir

With a high turnover of junior staff in emergency departments as a result of MMC changes, the numbers of junior staff are constantly in a state of flux. With time spent in the department, confidence in diagnosis, management and referral improves. Anatomy is normally the first subject taught as a student and probably the first subject forgotten when one commences medical training as pre-registration house officer. Through anecdotal evidence is seems that anatomy of the hand in terms of structure and function is poor amongst juniors. This subsequently impacts on diagnosis, management and referral of the patient. Further this has ramifications for the patient in terms of form and function of the hand and for some, hand injury is a life-changing event. With the cost of hand injury so high, an audit looking into the examination, diagnosis and management of common hand injuries presenting to a busy city hospital Accident and Emergency department was undertaken. From December 2006 to March 2006, junior SHO/FY2 staff in the emergency department were assessed with the use of picture quiz at the start of their rotation, and then 2 months into the rotation after a teaching session on hand injuries. The results overall were encouraging. Despite mandatory training and departmental guidelines, overall knowledge initially ranged from 49% to 73% with a mean of 66%. Interestingly, the same test repeated 2 months later showed that overall knowledge and management of hand injuries improved to a mean group score of 75%. This may be justified by doctors having spent more time at work, greater exposure to clinical cases, the sharing of experiences between colleagues, working in the urgent care centre, continuing education in departmental teaching sessions and other educational courses such as Basic Surgical Skills and Advanced Trauma and Life Support courses.

Retrospective analysis of data from patient records between 01/01/06 and 01/12/06 was also carried out. There were 99 recorded hand injuries. In addition, there were 141 recorded finger injuries. In the same period, a total of 898 referrals were made to the Plastic Surgeons. Given that approximately 150,000 patients are seen in the Emergency Department, the proportion of recorded hand injuries is relatively small. However, management should not be dictated by this and every effort should be made to optimize overall care for patients who present with such injuries.

This small study clearly has limitations. It does however demonstrate that education, periodic reminders (by way of assessments) and time can improve the overall clinical assessment, diagnosis and management of hand injuries by junior staff in the emergency department.

The results thus far show that teaching and formal education improves diagnosis and management of such injuries thereby improving overall outcome. Therefore, should senior Emergency Physicians play a more active role in contributing to education and training?

Zeeshan Ahmad, BSc (Hons), MB BS

Department of Emergency Medicine St. Thomas’ Hospital, Guy's & St. Thomas’ NHS Foundation Trust, London, SE1 UK

[email protected]

The influence of introducing an exam during the basic course in clinical skills on the learning success

Dear Sir

Students’ knowledge on clinical examination procedures often is poor even after passing the basic training course on clinical examination and patient history (Seegal & Wertheim 1962; Wiener & Nathanson 1976). The goal of our investigation was to find out how learning success in clinical examination can be improved.

A total of 206 medical students participated in the investigation. All students completed the basic course with attestations after each completed course-section. At the beginning and end of each respective term, the students took a voluntary written exam on basic clinical skills. For a new group of students we introduced a station of an ‘Objective Structured Clinical Examination’ (OSCE) (the students had to examine a patient) at the end of the term.

Prior to the beginning of the basic course in clinical skills 23% of the written exam's questions were answered correctly. After completion of the course, this result increased to 52%.

The introduction of one station of an OSCE resulted in a significant increase in knowledge compared to students who had not taken this practical exam. We could see an increase in correct answered questions of 22% of all questions and up to 37% in special topics. With the written exam, it was possible to identify individual student's deficits in the various course topics.

Our data show that the mere introduction of a practical exam at the end of a term may lead to a significant increase in student's learning success. As a reason for this better preparation and consolidation of the learning contents may be assumed.

In our approach, testing of course contents at the end of a term is superior to individual examination during the course by attestations as it is performed in more than 75% of all German medical schools.

Stefan Grüne^1,2, Klaus Schlottmann², Harald Lang² Hubertus von Korn¹ & Michael Reng²

¹Department of Internal Medicine II Hospital Hetzelstift, D-67434 Neustadt, Germany

²Department of Internal Medicine I University of Regensburg D-93042 Regensburg, Germany

A multiplayer learning game for medical education

Dear Sir

There are a wide variety of simple ‘learning game templates’ available (Dempsey et al. 2002); although many have uses for teaching some basic recall facts, they usually do not possess the pedagogy that we need for a serious teaching tool. With this in mind, an asynchronous multiplayer learning game was developed, and the students were asked for feedback as it was being developed.

A decision was made in our medical school to incorporate games into most of the courses in the preclinical years. The new game resource was built and jointly funded by the Teaching and Learning Enhancement Fund and the Faculty of Medicine and Dentistry, University of Alberta. The learning resource that has emerged is called 'Brainspan’. The goal was to develop a game generator that would produce games, allow for instructor/student feedback and function as a tool for educational research.

Students use an alias when playing, which allows them to be anonymous to other players. They answer the multiple choice questions and earn points for correct answers. With a correct answer, the student can also challenge another player and send the question to him/her. If the other player accepts the challenge and can answer it correctly, the challenger loses the points he/she wagered; if the other player answers it incorrectly, the challenger gets the extra points wagered. A multipurpose messaging system is built into the game; it relays challenges, provides a conduit for feedback to the instructor and allows student-to-student communication.

A recent addition to the game system is the ability to validate questions and evaluate their quality by doing an item analysis on the data files from the games. This will enable us to ensure that not only the questions in our games are linked to course objectives but also they are standardized.

Instructor reports are available and can be used to obtain just-in-time feedback about teaching, allowing teachers rethink and address content areas which have obviously not been understood thoroughly by the students.

This is a unique and important student centred learning tool that we hope to continue developing as a resource for our students.

Judy Gnarpe, DrMedSci, RM(CCM)

Department of Medical Microbiology and Immunology

University of Alberta, Edmonton, AB Canada T6G 2H7

[email protected]

Rate of publication based on required student research for a 4-week clerkship

Dear Sir

At medical school's end, matching with a residency is students’ highest priority. Residency program directors select on many factors, including research. The Association of American Medical Colleges (AAMC) recommends students undertake research projects to promote independent learning and develop analytic, problem-solving skills Interestingly, AAMC also reported that neither research experience nor number of publications predict successful match for United States seniors (AAMC 2007).

Most US medical schools are shifting to require research before graduation. Our Midwestern regional medical school offers a 4-week, required course entitled Health of the Public (HoP) to enhance medical student's research skills for population-based studies. However, projects have never been tracked for outcomes.

We examined HoP manuscript publication as one measure of the current program structure. At our institution, 20% (3/15) published following presentation at the local Annual Research Forum from 1999 to 2006, which most likely represents a subset of projects from the HoP rotations (Ahlers-Schmidt, Chesser, Maher and Vernon 2008). A retrospective cohort study was performed on HoP course records. Records from 2003 to 2007 produced a list of senior poster presentations. Data were collected from three manuscript databases; identifiers included poster title, keywords, student name and mentor name. Publications were compared against abstracts for confirmation.

Between 2003 and 2007, 69 HoP posters were presented. Four (5.8%) were published; however, one (20%) never included the student as an author. Fifteen mentors supervised the remaining 65 presentations. Eight mentors (53.3%) reported five (7.7%) projects had been submitted or were currently submitted to peer-reviewed journals; seven mentors (46.7%) did not respond. For a course emphasizing research, the number of projects eventually found in peer-reviewed journals seems strikingly low and is possibly due to the fact that projects occur over a 4-week period. This is arguably a short span to obtain publishable data considering most projects must obtain expedited IRB approval before data collection begins.

Mentors’ interest in publishing has a role, and student motivation following course completion is a factor. Most students’ HoP rotation is the spring semester of fourth year, and nearly a third match with a residency program by then. Thus, publication has little application to their immediate goals. While a brief HoP rotation does introduce research, findings dissemination through peer-reviewed journal publication is infrequent.

Introducing research earlier to produce a manuscript of publishable quality could improve publication rates. This institution's faculty hopes to revise the structure for student research to allow an earlier introduction for student research which may improve these outcomes.

Carolyn R. Ahlers-Schmidt, Amy Chesser, Chad Ammar, Maha Assi, S. Edwards Dismuke

University of Kansas School of Medicine, Wichita, KS, USA

[email protected]

Philip Hansen

Department of Anesthesiology, Albany Medical Center Hospital, Albany, NY, USA

Notes

*Email: [email protected]