Competency based teaching: the need for a new approach to teaching clinical skills in the undergraduate medical education course.

This paper will argue that undergraduate medical courses are failing to provide students with adequate training in the area of clinical skills. Some of the reasons for this failure include changes in the health system leading to increasing commitments for clinicians, fewer patients as clinical case examples and limitations in current teaching methods. Current clinical teaching methods measure progress through completion of clinical "blocks" of learning and one-off clinical examinations. This paper offers an alternative approach to clinical teaching in undergraduate medicine. In this approach, each student's progress is measured through the attainment of a predetermined level of competency in dealing with a range of clinical conditions. Some of the benefits of a new approach to clinical teaching in undergraduate medicine include flexibility for both students and clinicians in terms of when and where clinical learning can occur, a significant emphasis on active learning, and increased generalization and integration of learning.

Graduate entry to medical school? Testing some assumptions.

BACKGROUND: Debate abounds regarding the most appropriate candidates to admit to medical school. This paper examines whether there is any advantage to admitting 'graduate' entrants over secondary school leavers on selected medical school and practice outcomes. AIM: To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered 1 medical school in Australia directly from high school (secondary school entry) to those of graduates who entered with tertiary level education (tertiary entry). DESIGN AND METHODS: Cross-sectional study using a mail-out survey to graduates from the first 16 graduating years (1983-98 inclusive) of the University of Newcastle Medical School. RESULTS: Secondary school entrants were, on average, 8 years younger than tertiary entrants and were less likely to have received rural-based schooling. However, there were no differences with respect to gender or type of secondary school attended (public or private). Motivations for studying medicine did not generally differ according to entry type, except that more secondary students were motivated by parental expectations and more tertiary entrants were motivated by the need for professional independence and the desire to prevent disease. A greater proportion of tertiary entrants experienced stress at medical school. However, secondary students experienced more stress due to doubts about being a doctor, while tertiary entrants experienced more stress due to lack of leisure time, finances and balancing commitments. There were no significant differences between the groups in terms of academic performance (as measured by the award of medical school honours) or research outcomes (as measured by completion of a research degree during or after medical school training, publication of scientific papers or holding career posts in the research sciences). There were no differences in career positions held by clinicians, choice of general practice or another specialty as a career, practice location (rural or urban) or employment sector (public or private). CONCLUSION: There is no clear advantage, at least on the outcomes measured in this study, to limiting medical school entry to either those candidates from secondary school or those with tertiary backgrounds. Medical schools could reasonably broaden their selection criteria to include more graduate entry candidates in addition to secondary school leavers without compromising medical school and practice outcomes.

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning.

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.

Which common clinical conditions should medical students be able to manage by graduation? A perspective from Australian interns.

The objectives of the study were to report the development of a core curriculum that details the clinical conditions medical students should be able to manage upon graduation; and to canvass the opinion of interns (first-year postgraduate doctors) regarding their perceptions of the level of skill required to manage each condition. Literature relating to core curriculum development and training of junior medical officers was reviewed and stakeholders in the education and training of medical students and junior doctors in the state of New South Wales, Australia (intern supervisors, academics, registrars, nurses and interns) were consulted. The final curriculum spanned 106 conditions, 77 'differentiated' and 29 'undifferentiated'. Four levels of skill at which conditions should potentially be managed were also identified: 'Theoretical knowledge only'; 'Recognize symptoms and signs without supervision'; Initiate preliminary investigations, management and/or treatment without supervision'; and 'Total investigation, management and/or treatment without supervision'. The list of conditions in the curriculum was converted to a survey format and a one-in-two random sample of interns (n = 193) practising in New South Wales who graduated from the state's three medical schools were surveyed regarding the level of skill required for managing each clinical condition at graduation. A total of 51.3% of interns responded to the survey. Interns felt they should be able to initiate preliminary investigation, management and/or treatment for most conditions in the curriculum, with more than half acknowledging this level of management for 53 of the differentiated and 28 of the undifferentiated conditions. It is concluded that developing core curricula in medical education can involve multiple stakeholders, including junior doctors as the consumers of educational experiences. The data gathered may be useful to medical schools revising their curricula.

Translating learning principles into practice: a new strategy for learning clinical skills.

AIM: There are data to suggest that medical school may not adequately prepare doctors for practice and that there are deficiencies in undergraduate teaching of skills in history taking, physical examination, diagnosis and management (clinical skills). There is a need to re-evaluate methods by which we can teach clinical skills effectively. This aim of this review was to describe the literature concerning the important principles underpinning effective clinical learning. Subsequently a structured learning tool and teaching process was developed in order to support these principles. METHOD: The principles of effective clinical learning were derived after a search of the medical education and relevant behavioural science literature. Consequently, a structured learning tool and teaching process was developed in order to potentiate the translation of these principles into practice for medical school training in clinical skills. RESULTS: Ten principles were derived from the 68 articles referred to in this review. These were: making active decisions, an individual focus to learning, gaining experience, feedback to the learner, reciprocal learning, holistic care, relevant learning, feasibility, cost efficiency and mentoring. A process for history taking, physical examination and management plan was developed for medical students which incorporated these principles. CONCLUSION: Relevant literature can provide the foundations for teaching and learning methods in medical education. We plan to trial this method and evaluate the impact on student learning outcomes.

Identifying medical school learning needs: a survey of Australian interns.

OBJECTIVES: To survey interns regarding their opinion of medical school learning needs for a range of core skills. METHODS: A random sample of interns practising in New South Wales, Australia, who graduated from the state's three medical schools were surveyed two-thirds of the way through their first hospital year. They were asked whether there was a need for further medical school education for each of 226 core skills. Skills were grouped into five themes: management of clinical conditions; clinical investigations; clinical procedures; core practice; and professional development. RESULTS: Frequency distributions weighted for age, gender and medical school background were calculated for each item. The 20 most frequently identified needs related to examinations of the eye and ear, nose and throat; managing uncooperative patients and difficult patient interactions; prescribing; writing not for resuscitation orders and death certificates. Also included were procedural needs related to ear, nose and throat; plastering and wound management; and needs for more education in the management of clinical conditions related predominantly to "acute" cases such as anaphylaxis and diabetic ketoacidosis. CONCLUSION: Interns were able to discriminate between their needs for different skills and identified many core skills for which they perceived there was a need for more medical school education. The implications for medical education are discussed.

The relationship between previous tertiary education and course performance in first year medical students at Newcastle University, Australia.

AIM: The purpose of this study was to identify the relationship between previous tertiary education background and the performance of first year medical students at Newcastle University, Australia. Specifically, we examined degree type (i.e. arts, science, allied health, nursing or other professional backgrounds), level of degree completion (fully or partially completed ), academic achievement ( grade point average) and whether or not students had postgraduate qualifications. The relationship between age and gender was also examined. METHOD: All students admitted to the medical course from 1990 to 1998 with previous tertiary education experience who entered via the "standard" entry pathway and sat the end of year examinations were eligible for the study (N=303). The outcome measures were the results of first assessment ("satisfactory" versus "not satisfactory") and final assessment of the first year ("satisfactory" versus "not satisfactory"). Logistic regression was used to examine the relationship between predictor variables and outcomes. RESULTS: In relation to first assessment results, students with a nursing and arts background were significantly more likely to receive a "not satisfactory" assessment (RR=3.9, 95% CI: 1.6- 7.7; RR=2.9, 95% CI: 1.2-6.8, respectively), as were females (RR=1.8, 95% CI: 1.1-3.5) and students with a grade point average of less than a distinction average (RR=2.8, 95% CI: 1.6-5.2). At final assessment, students with a nursing background and those with a less than distinction average were more likely to receive a "not satisfactory" result (RR=20.7, 95% CI: 3.5-123.9 and RR=4.0, 95% CI: 1.2-13.9, respectively); consequently, they were required to repeat first year. CONCLUSION: Our research suggests that there are some medical student groups who encounter more academic difficulties than others in first year. Identifying these students can assist medical schools to focus academic support appropriately.

How do Australian doctors with different pre-medical school backgrounds perform as interns?

AIM: To assess whether there is any advantage to be gained with respect to performance in the first year of postgraduate medical training (internship) by selecting medical school candidates with different educational backgrounds. Specifically, we were interested in comparing the performance ratings of interns who entered medical school with secondary (directly from high school) or tertiary (at least one year of a university degree) level educational backgrounds. FOCUS: We compared the performance ratings of interns according to the subjects or degree undertaken at a secondary or tertiary level, respectively. The effects of age and gender were also examined to determine their influence on performance ratings. METHOD: All graduates (N=235) from the University of Newcastle Medical School, Australia who commenced their intern year in the state of New South Wales from 1993 to 1996 inclusive were eligible for the study. The outcome measure was a score derived from a valid and reliable clinical supervisor rating scale. Independent variables were level of previous educational experience (secondary or tertiary entry), and subjects studied by secondary level entrants (predominantly science or equal proportions of humanities and science) and degree undertaken by tertiary level entrants (arts or science or allied health or nursing). RESULTS: The records of 173 (73% of eligible sample) were included in the analyses. There were no significant differences between the mean ratings of interns with respect to previous educational background, subjects studied at secondary school or degree undertaken. Age and gender did not significantly affect performance ratings.

Intern Prescribing for Common Clinical Conditions.

To examine the ability of interns to prescribe appropriately for common clinical conditions at the commencement and completion of the intern year. Interns' perceptions of their ability to prescribe and the perceived influences on their practices were also assessed. The study was conducted at a teaching hospital in urban New South Wales, Australia. A self-complete questionnaire was administered to 56 interns at the beginning and end of internship. At the beginning of the year respondents were asked to identify how equipped they felt they were to perform specific functions related to prescribing practice. Interns were also asked to write hospital prescriptions for four common clinical cases scenarios: post-operative pain, urinary tract infection, asthma, and community-acquired pneumonia. At the end of the year interns were asked to prescribe for the same clinical scenarios and also asked to identify the main influences on their practice. At the beginning of the year 54% of interns felt equipped to choose an appropriate drug for common clinical conditions, however, few felt they were able to determine the appropriate dose (23% of respondents) or dose frequency (25%). A previously validated four-point rating scale was used by two assessors to judge appropriateness of prescribing [Kappa = 0.6]. At the beginning of the year at least two-thirds of interns were prescribing 'inappropriately' for all clinical conditions. By the end of the year 75% were prescribing 'appropriately' for all conditions. The main perceived influences on prescribing practices were registrars, consultants, books and pharmacists.The use of hypothetical clinical cases to explore prescribing ability has shown that doctors are ill-equipped to perform various aspects of prescribing on graduating from medical school. Although our findings may not translate into practice directly they highlight the existence of a potential problem that warrants further study, especially in the areas of actual practice and the influences on it in the early postgraduate years.

Impact of written information on knowledge and preferences for cardiopulmonary resuscitation.

AIM: To investigate knowledge about and attitudes to cardiopulmonary resuscitation (CPR), and to determine whether written information about CPR alters knowledge and choices made. DESIGN: Questionnaire-based survey before and immediately after provision of written information describing CPR and its risks and benefits. SUBJECTS AND SETTING: All health professionals (803) and competent inpatients (260) in a tertiary care hospital (John Hunter Hospital, Newcastle, New South Wales, Australia) in June 1994. MAIN OUTCOME MEASURES: CPR knowledge scores and choice scores (number of hypothetical clinical scenarios in which CPR would be chosen) before and after provision of information about CPR. RESULTS: Response rates were 64% (health professionals) and 58% (patients). Patients had limited awareness of procedures involved in CPR, while both patients and health professionals overestimated its success rates. Mean knowledge scores increased after provision of information: for patients, from 6.4 out of 18 (95% confidence interval [CI], 6.0-6.9) to 10.4 (95% CI, 9.9-11.1); and for health professionals, from 11.9 (95% CI, 11.7-12.1) to 13.9 (95% CI, 13.7-14.2). In contrast, mean choice scores decreased after provision of information: for patients, from 5.3 out of 12 (95% CI, 4.7-5.7) to 4.4 (95% CI, 3.9-4.8); and for health professionals, from 4.1 (95% CI, 3.9-4.2) to 3.5 (95% CI, 3.3-3.7). CONCLUSION: Our results imply that people understand and use prognostic information to make decisions about CPR. To make autonomous judgements, patients and health professionals need better education on CPR outcomes.

Attitudes towards community medicine: a comparison of students from traditional and community-oriented medical schools.

OBJECTIVE: To compare the attitudes towards community medicine of first and final year students from two Australian medical schools. METHOD: In 1995, medical students from Newcastle University (a problem-based, community-oriented curriculum) and Adelaide University (a more traditional lecture-based curriculum) were asked to complete the Attitudes to Community Medicine questionnaire. This is a valid and reliable 35 item survey assessing six key domains of community medicine. The two medical schools differ in their methods of selection and curriculum delivery, and also in curriculum content. RESULTS: Response rates averaged 95% for first year and 81% for final year students. Students selected into both medical schools were found to have positive attitudes with respect to most aspects of community medicine. However, those entering Newcastle had more positive attitudes toward community medicine overall than their Adelaide counterparts. They also scored more positively on subscales relating to holistic care and evaluation of health care interventions. Students who were older and female scored more positively on some subscales, but correction for age and gender did not change the conclusions about medical school differences. CONCLUSION: This study suggests that selection criteria, and probably curriculum style and emphasis, have an influence on the attitudes that medical students possess and later develop toward community medicine.

Measuring the hospital experiences of junior doctors.

The development of an appraisal questionnaire which measures junior doctors' opinions about their hospital experiences is described. The first section of the questionnaire consists of seven reliable subscales which measure opinions about teaching and learning, registrar teaching, consultant teaching, staff support, workload, administration and overall experiences during a period of attachment or term. The second part of the survey contains 11 reliable questions about the hours spent on service and education during the term. The responses to this measure of 257 randomly selected Australian junior doctors are described. The questionnaire may be used to contrast the experiences of junior doctors in different types of terms, different hospitals or varying levels of training. The data generated from the instrument can provide useful information about hospitals, such as the work practices of junior staff and the effectiveness of educational programs.

A system for maintaining the educational and training standards of junior doctors.

The development of junior doctors' competence is complex because the hospital environment in which doctors work places many demands on them. The need for quality education and training and personal development may be in direct conflict with the service commitments required from hospitals. This paper describes the methods by which the Postgraduate Medical. Council of New South Wales, Australia, addresses the needs of junior doctors in the state in order to improve the quality of their education. Key elements of the Council's function include the provision of hospital clinical supervisors who oversee junior doctor education and training, and central involvement in supplying the junior doctor workforce to all state hospitals who must meet defined accreditation standards. This paper also provides data on evaluation of those methods and some educational outcomes.

Decision making in CPR: attitudes of hospital patients and healthcare professionals.

OBJECTIVE: To examine the opinions of patients and healthcare professionals regarding the process of making decisions about cardiopulmonary resuscitation (CPR). DESIGN AND PARTICIPANTS: A cross-sectional survey of 511 healthcare professionals (doctors, nurses and allied health professionals) (64% response rate) and 152 patients (58% response rate) at the John Hunter Hospital, Newcastle, New South Wales, in June 1994. MAIN OUTCOME MEASURES: Opinions on who should be involved in CPR decision making; what issues are important when making the decision; and how these decisions should be communicated. RESULTS: 80% (95% confidence interval [CI], 72%-86%) of patients and 99% (95% CI, 98%-100%) of healthcare professionals (P<0.001) thought patients' views should be taken into account when making CPR decisions. More patients (29%; 95% CI, 22%-38%) than healthcare professionals (14%; 95% CI, 11%-17%) indicated that doctors should be the main decision makers. Two-thirds of respondents regarded the patient's wishes, diagnosis and quality of life as important factors. Most respondents (82%) felt comfortable discussing CPR, but only 29% (95% CI, 22%-37%) of patients and 57% (95% CI, 52%-61%) of healthcare professionals had actually discussed CPR with others (P<0.001). More than half of all respondents preferred to express their wishes about CPR in writing (47% [95% CI, 39%-55%] of patients, 69% [95% CI, 64%-73%] of healthcare professionals; P<0.01); the others preferred to tell a family member or close friend. Most patients (60%; 95% CI, 52%-68%) and healthcare professionals (85%; 95% CI, 81%-88%) wanted their views in their medical records (P< 0.001). CONCLUSION: Most patients want to be involved in CPR decision making and many want some form of advance directive. Although there are some differences in opinions between patients and healthcare professionals, both perceive decision making at the end of life as a shared process, primarily involving the patient and doctor.

Determining the function of a hospital clinical ethics committee: making ethics work.

The objective of this study was to identify ethical issues of greatest concern to hospital staff, and to establish perceptions regarding the optimal function of a Clinical Ethics Committee (CEC). The design involved a descriptive, cross-sectional study using a self-report questionnaire, which was sent to a random sample of medical, nursing, allied health, technical and administrative staff working at the John Hunter Hospital (a 650-bed, urban, teaching hospital in New South Wales) in September 1995. The questionnaires were sent to 565 staff and completed by 287: an overall compliance rate of 51%. Although the majority of staff supported the existence of the CEC in principle, approximately two-thirds were actually aware of its existence and less than 10% were aware of policies/guidelines produced by the CEC. Ethical issues of greatest concern to respondents were informed consent and confidentiality. Most believed that the main function of the CEC should be education and policy development; fewer supported a role in case consultation or case review, and even less believed that the CEC should take any role in resource allocation decisions. While there is a strong degree of support for the existence of a CEC, there is considerable variation in opinion regarding what should be its function and how it should be organized. The results of this study provide some insight into the issues associated with the emergence of CECs in an Australian context.

Do junior doctors feel they are prepared for hospital practice? A study of graduates from traditional and non-traditional medical schools.

A valid and reliable questionnaire was developed which assesses eight subscales relating to key areas of medical hospital-based work. This was used to evaluate junior doctors' perceptions of the adequacy of their undergraduate medical training to prepare them for hospital practice. Data from 139 (60%) first-year doctors (interns) showed that graduates from the problem-based medical school rated their undergraduate preparation more highly than traditional medical school graduates in preparing them for practice in the areas of interpersonal skills, confidence, collaboration with other health care workers, preventive care, holistic care and self-directed learning. These findings persisted when ratings were adjusted for the effects of age and gender. There were no differences between the intern groups for patient management and understanding science. This research suggests that educational experiences in different undergraduate medical courses are important in preparing doctors for their early working life.

The relationship between assessment measures at Newcastle Medical School (Australia) and performance ratings during internship.

This study examined the utility of the domain assessment measures used in the final 2 years at Newcastle medical school in predicting performance ratings in the first year of postgraduate training (internship). Performance ratings were obtained from the clinical supervisors of two graduating classes of the University of Newcastle medical students during their five terms of internship. Three or more ratings were obtained from 57% of interns. Univariate analysis indicated that scores for three of the five domains (professional skills; identification, prevention and management of illness; self-directed learning) were significantly positively correlated with intern performance ratings. Multivariate analysis indicated that only the domain assessing identification, prevention and management of illness was predictive of higher intern performance ratings. The results support the notion that there is some value in the domain assessment model used at Newcastle in predicting the performance of junior doctors.

A scale to measure attitudes toward community medicine.

A questionnaire to measure attitudes toward community medicine held by general practitioners was designed, and a 35-item scale with a Likert response formal was constructed. The Attitudes Toward Community Medicine scale consists of six subscales relating to key areas of community medicine. The final scale is valid and reliable for group comparisons, with alpha coefficients ranging from alpha = 0.54 to alpha = 0.84. The instrument may be used to evaluate the effectiveness of community medicine teaching, to describe differences in beliefs of practitioners and to estimate changes in attitudes over time.

Screening recommendations in general practice: a survey of graduates from different medical schools.

OBJECTIVE: To examine the influence of sociodemographic background, medical school background, general practice characteristics and attitudes towards preventive medicine on the screening recommendations of New South Wales (NSW) general practitioners (GPs). METHODS: From the NSW Medical Board Register, a sample was obtained of all GPs who graduated between 1983 and 1987 from the University of Newcastle and a random 1-in-3 sample of GPs from the Universities of Sydney and NSW. Two questionnaires were mailed consecutively. PARTICIPANTS: 363 GPs (56% response rate) who completed questionnaires suitable for analysis. MAIN OUTCOME MEASURE: A composite screening score for assessing agreement with standard screening guidelines. The score was derived by allocating points to the screening intervals that GPs recommended for 13 screening tests. A score of 39 indicated maximum agreement with guidelines. RESULTS: 87% of GPs reported being aware of standard screening guidelines. For most screening tests, there was a discrepancy between GPs' recommendations and those of the guidelines. Composite screening scores ranged from 8-38. There were significantly higher screening scores for graduates of Newcastle versus Sydney and NSW university medical schools combined (adjusted mean, 28.0 versus 25.9; P=0.0436), group versus solo GPs (adjusted mean, 26.3 versus 25.6; P=0.0092) and GPs in rural versus urban locations (adjusted mean, 27.9 versus 25.6; P=0.0049). CONCLUSIONS: GPs' recommendations for screening are not always consistent with standard guidelines, despite an awareness of them. Research is needed into the variation with which different screening tests are ordered.