Medical graduates' preparedness to practice: a comparison of undergraduate medical school training.

BACKGROUND: There is evidence that newly qualified doctors do not feel prepared to start work. This study examined views of first year Foundation doctors (F1s) regarding how prepared they felt by their undergraduate medical education for skills required during the first Foundation training year in relation to their type of training. METHOD: One-hundred and eighty two F1s completed a questionnaire during their first rotation of Foundation training. Analysis was conducted by type of medical school training: Problem-Based Learning (PBL), Traditional or Reformed. RESULTS: F1s from medical schools with a PBL curriculum felt better prepared for tasks associated with communication and team working, and paperwork than graduates from the other medical school types; but the majority of F1s from all three groups felt well prepared for most areas of practice. Less than half of graduates in all three groups felt well prepared to deal with a patient with neurological/visual problems; write referral letters; understand drug interactions; manage pain; and cope with uncertainty. F1s also indicated that lack of induction or support on starting work was affecting their ability to work in some areas. CONCLUSIONS: Whilst F1s from medical schools with a PBL curriculum did feel better prepared in multiple areas compared to graduates from the other medical school types, specific areas of unpreparedness related to undergraduate and postgraduate medical training were identified across all F1s. These areas need attention to ensure F1s are optimally prepared for starting work.

Foundation doctors' induction experiences.

BACKGROUND: It is well established that trainee doctors struggle with the transition from medical school to starting work and feel unprepared for many aspects of their new role. There is evidence that suitable induction experiences improve competence and confidence, but available data indicate that trainee doctors on the UK Foundation Programme are commonly not experiencing useful inductions. The aim of the reported research was to explore trainee doctors' experiences with induction during their first year of the Foundation Programme to identify the most useful characteristics. METHODS: A questionnaire was designed to explore trainee doctors' experiences with induction at two points during their first Foundation year, during the first and third of three rotations, to enable all induction experiences on offer during the year to be surveyed. Data were collected using an anonymous questionnaire distributed during a teaching session, with an online version available for those trainees not present. Questions gathered information about characteristics of the inductions, usefulness of components of the inductions and what gaps exist. RESULTS: 192 Foundation trainee doctors completed the questionnaire during Rotation 1 and 165 during Rotation 3. The findings indicated that induction experiences at the beginning of the year, including the local Preparation for Professional Practice week, were more useful than those received for later rotations. Longer inductions were more useful than shorter. Departmental inductions were generally only moderately helpful and they missed many important characteristics. Gaps in their inductions identified by many trainees matched those aspects judged to be most useful by those trainees who had experienced these characteristics. CONCLUSIONS: Many Foundation trainee doctors are experiencing inadequate inductions, notably at the department level. Trainees are starting rotations in new departments without rudimentary knowledge about their role and responsibilities in that department, where to find equipment and documentation, who to contact and how to contact them, local preferences, policies and procedures. Unsurprisingly, trainees who do receive such information in their inductions regard it as highly useful. Action is urgently needed to improve departmental inductions so that all trainees have the information they require to work confidently and competently in each new department they rotate into.

The preparedness of newly qualified doctors - Views of Foundation doctors and supervisors.

BACKGROUND: There is evidence that newly qualified doctors do not feel prepared to start work. AIM: This study examined the views of first year Foundation doctors (F1) and supervisors regarding how prepared they felt newly qualified doctors were for the early weeks of work. METHODS: Fifty-two F1s took part in a focus group or individual interview during their first year of Foundation training. Twenty-two supervisors took part in an individual interview. RESULTS: The F1s struggled with new responsibilities, decision-making, time management, prioritizing tasks and the large administrative component to their role. They felt unprepared for making diagnoses, prescribing and acting in an emergency. Supervisors felt F1s were generally well prepared to start work, with skills improving through experience. However, F1s needed more practical experience with real patients and more opportunities to take responsibility, make decisions and perform some clinical skills. Supervisors did not feel that F1s accessed senior support appropriately. F1s indicated they preferred to go to peers for assistance in the first instance, and felt unsupported by seniors, particularly at weekends and on night shifts. CONCLUSIONS: Specific areas of unpreparedness were identified by both F1s and supervisors; leading to recommendations to enhance effective transition from medical student to F1.

The Dundee Ready Education Environment Measure (DREEM): a review of its adoption and use.

BACKGROUND: The Dundee Ready Education Environment Measure (DREEM) was published in 1997 as a tool to evaluate educational environments of medical schools and other health training settings and a recent review concluded that it was the most suitable such instrument. AIMS: This study aimed to review the settings and purposes to which the DREEM has been applied and the approaches used to analyse and report it, with a view to guiding future users towards appropriate methodology. METHOD: A systematic literature review was conducted using the Web of Knowledge databases of all articles reporting DREEM data between 1997 and 4 January 2011. RESULTS: The review found 40 publications, using data from 20 countries. DREEM is used in evaluation for diagnostic purposes, comparison between different groups and comparison with ideal/expected scores. A variety of non-parametric and parametric statistical methods have been applied, but their use is inconsistent. CONCLUSIONS: DREEM has been used internationally for different purposes and is regarded as a useful tool by users. However, reporting and analysis differs between publications. This lack of uniformity makes comparison between institutions difficult. Most users of DREEM are not statisticians and there is a need for informed guidelines on its reporting and statistical analysis.

Does a summative portfolio foster the development of capabilities such as reflective practice and understanding ethics? An evaluation from two medical schools.

Portfolios need to be evaluated to determine whether they encourage students to develop in capabilities such as reflective practice and ethical judgment. The aims of this study were (i) to determine whether preparing a portfolio helps promote students' development in a range of capabilities including understanding ethical and legal principles, reflective practice and effective communication, and (ii) to determine to what extent the format of the portfolio affected the outcome by comparing the experiences of students at two different medical schools. A questionnaire was designed to evaluate undergraduate medical students' experiences of completing a portfolio at two medical schools. A total of 526 (45% response rate) students answered the on-line questionnaire. Students from both medical schools gave the highest ranking for the portfolio as a trigger for reflective practice. 63% of students agreed their portfolio helped them develop reflective practice skills (p < 0.001), whereas only 22% disagreed. 48% of students agreed portfolios helped them understand ethical and legal principles whereas 29% disagreed (p < 0.001). In contrast, only 34% of students thought the portfolio helped them to develop effective communication. Students perceive portfolio preparation as an effective learning tool for the development of capabilities such as understanding ethical and legal principles and reflective practice, whereas other capabilities such as effective communication require complementary techniques and other modes of assessment.

Cross-sectional evaluation of a longitudinal consultation skills course at a new UK medical school.

BACKGROUND: Good communication is a crucial element of good clinical care, and it is important to provide appropriate consultation skills teaching in undergraduate medical training to ensure that doctors have the necessary skills to communicate effectively with patients and other key stakeholders. This article aims to provide research evidence of the acceptability of a longitudinal consultation skills strand in an undergraduate medical course, as assessed by a cross-sectional evaluation of students' perceptions of their teaching and learning experiences. METHODS: A structured questionnaire was used to collect student views. The questionnaire comprised two parts: 16 closed questions to evaluate content and process of teaching and 5 open-ended questions. Questionnaires were completed at the end of each consultation skills session across all year groups during the 2006-7 academic year (5 sessions in Year 1, 3 in Year 2, 3 in Year 3, 10 in Year 4 and 10 in Year 5). 2519 questionnaires were returned in total. RESULTS: Students rated Tutor Facilitation most favourably, followed by Teaching, then Practice & Feedback, with suitability of the Rooms being most poorly rated. All years listed the following as important aspects they had learnt during the session: • how to structure the consultation • importance of patient-centredness • aspects of professionalism (including recognising own limits, being prepared, generally acting professionally). All years also noted that the sessions had increased their confidence, particularly through practice. CONCLUSIONS: Our results suggest that a longitudinal and integrated approach to teaching consultation skills using a well structured model such as Calgary-Cambridge, facilitates and consolidates learning of desired process skills, increases student confidence, encourages integration of process and content, and reinforces appreciation of patient-centredness and professionalism.

Statistics teaching in medical school: opinions of practising doctors.

BACKGROUND: The General Medical Council expects UK medical graduates to gain some statistical knowledge during their undergraduate education; but provides no specific guidance as to amount, content or teaching method. Published work on statistics teaching for medical undergraduates has been dominated by medical statisticians, with little input from the doctors who will actually be using this knowledge and these skills after graduation. Furthermore, doctor's statistical training needs may have changed due to advances in information technology and the increasing importance of evidence-based medicine. Thus there exists a need to investigate the views of practising medical doctors as to the statistical training required for undergraduate medical students, based on their own use of these skills in daily practice. METHODS: A questionnaire was designed to investigate doctors' views about undergraduate training in statistics and the need for these skills in daily practice, with a view to informing future teaching. The questionnaire was emailed to all clinicians with a link to the University of East Anglia Medical School. Open ended questions were included to elicit doctors' opinions about both their own undergraduate training in statistics and recommendations for the training of current medical students. Content analysis was performed by two of the authors to systematically categorize and describe all the responses provided by participants. RESULTS: 130 doctors responded, including both hospital consultants and general practitioners. The findings indicated that most had not recognised the value of their undergraduate teaching in statistics and probability at the time, but had subsequently found the skills relevant to their career. Suggestions for improving undergraduate teaching in these areas included referring to actual research and ensuring relevance to, and integration with, clinical practice. CONCLUSIONS: Grounding the teaching of statistics in the context of real research studies and including examples of typical clinical work may better prepare medical students for their subsequent career.

Effects of isoflavones on breast density in pre- and post-menopausal women: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Isoflavones from soy and red clover exert modest hormonal effects in women, but the relevance to risk of breast cancer is unclear. The aim of this meta-analysis was to assess the effects of isoflavone-rich foods or supplements on a biomarker of breast cancer risk, women's mammographic density. METHODS: Electronic searches were performed on The Cochrane Library, Medline and EMBASE (to June 2009), and reference lists and trial investigators were consulted to identify further studies. Randomized controlled trials (RCTs) of isoflavone-rich foods or supplements versus placebo with a duration of at least 6 months were included in our analysis. Inclusion/exclusion, data extraction and validity assessment were carried out independently in duplicate, and meta-analysis used to pool study results. Subgrouping, sensitivity analysis, assessment of heterogeneity and funnel plots were used to interpret the results. RESULTS: Eight RCTs (1287 women) compared isoflavones with placebo for between 6 months and 3 years. Meta-analysis suggested no overall effect of dietary isoflavones on breast density in all women combined [mean difference (MD) 0.69%, 95% confidence interval (CI) -0.78 to 2.17] or post-menopausal women (MD -1.10%, 95% CI -3.22 to 1.03). However, there was a modest increase in mammographic density in premenopausal women (MD 1.83%, 95% CI 0.25-3.40) without heterogeneity but this effect was lost in one of three sensitivity analyses. CONCLUSIONS: Isoflavone intake does not alter breast density in post-menopausal women, but may cause a small increase in breast density in premenopausal women. Larger, long-term trials are required to determine if these small effects are clinically relevant.

Identifying professional characteristics of the ideal medical doctor: the laddering technique.

OBJECTIVE: The aim was to examine the utility of the laddering interview technique to investigate complex issues in medical education, such as professionalism. METHOD: The laddering technique was used to identify examples of professional behaviour associated with the ideal medical doctor, and to explain why participants thought these behaviours were important. Three groups were interviewed: doctors (n = 30), first-year medical students (n = 31) and patients (n = 33). RESULTS: All groups identified characteristics associated with a 'communication and interpersonal skills' theme. Data suggested the essence of the doctor-patient interaction was shared by the groups, with varying later emphases due to their different perspectives. Additionally, Doctors and Students generated characteristics associated with 'team-working' and 'competence' themes; Doctors' conceptualization of each theme was more detailed. Positive and negative impacts of Doctor's professional behaviour on the patient, doctor and the wider medical arena were also identified. CONCLUSION: Use of laddering resulted in data-rich results for each of the three stakeholder groups, illustrating shared and divergent preferences as to the preferred characteristics of a medical doctor and effects of successful and less-successful doctor-patient interactions. The identified characteristics are relevant to the area under investigation and salient to these key stakeholders.

Comparing staff and student perceptions of the student experience at a new medical school.

AIM: The aim was to compare staff and student perceptions of student experience with the UEA MB/BS educational environment. METHODS: All MB/BS students were asked to complete a standard course evaluation at the end of the 2005/06 academic year, which included the Dundee Ready Education Environment Measure (DREEM). MB/BS teaching staff were asked to complete a revised version of the DREEM. RESULTS: Data from 403 students and 73 teaching staff were compared. The overall DREEM was 144/200 for staff and 141/200 for students. Initial analysis suggested that staff believed that students' were experiencing more positive learning and teaching environments than students actually were, and they viewed the students' social experience as more negative than it actually was. However, staff were unable to comment on number of aspects of the educational environment and scored these as 'unsure'. This distorted the mean values for the subscales. When this was adjudged for, the differences disappeared. CONCLUSIONS: Staff did not believe that students were experiencing a perfect educational environment; in most cases their views were closely aligned. But staff 's unfamiliarity with aspects of the educational environment suggests a continuing need to provide feedback to staff about students' actual experiences, to enable provision of a better environment for students.

Do doctors need statistics? Doctors' use of and attitudes to probability and statistics.

There is little published evidence on what doctors do in their work that requires probability and statistics, yet the General Medical Council (GMC) requires new doctors to have these skills. This study investigated doctors' use of and attitudes to probability and statistics with a view to informing undergraduate teaching.An email questionnaire was sent to 473 clinicians with an affiliation to the University of East Anglia's Medical School.Of 130 respondents approximately 90 per cent of doctors who performed each of the following activities found probability and statistics useful for that activity: accessing clinical guidelines and evidence summaries, explaining levels of risk to patients, assessing medical marketing and advertising material, interpreting the results of a screening test, reading research publications for general professional interest, and using research publications to explore non-standard treatment and management options.Seventy-nine per cent (103/130, 95 per cent CI 71 per cent, 86 per cent) of participants considered probability and statistics important in their work. Sixty-three per cent (78/124, 95 per cent CI 54 per cent, 71 per cent) said that there were activities that they could do better or start doing if they had an improved understanding of these areas and 74 of these participants elaborated on this. Themes highlighted by participants included: being better able to critically evaluate other people's research; becoming more research-active, having a better understanding of risk; and being better able to explain things to, or teach, other people.Our results can be used to inform how probability and statistics should be taught to medical undergraduates and should encourage today's medical students of the subjects' relevance to their future careers.

Medical students' perceptions of peer feedback on an anatomy student-selected study module.

OBJECTIVE: The study aimed to determine student views of peer feedback on their student-selected study (SSS) module. METHODS: A questionnaire was developed to study perceptions of three groups of medical students (N = 42) towards feedback received from peers about their anatomy SSS presentation. RESULTS: Most students felt comfortable receiving and giving feedback. They also felt that received feedback was fair, adequate and helpful, and that receiving feedback made them reflect. Slightly more students reported inadequate feedback from their peers about the presentations' content, compared to other aspects, due to their peers' relative lack of knowledge about their 'specialized' subject. Students would be reluctant to give feedback if anonymity was removed. CONCLUSION: The attitudes of medical students towards peer feedback were largely positive. We advocate further studies to evaluate quality of feedback, and the role of anonymity in peer feedback, and its effect on group dynamics and cohesion.

Medical students' perceptions of their educational environment: expected versus actual perceptions.

Objective To compare Year 1 medical students' perceptions of their educational environment at the end of Year 1, with their expectations at the beginning of the year using the Dundee Ready Education Environment Measure (DREEM). Methods Year 1 students (n = 130) at the University of East Anglia Medical School were asked to complete the DREEM during their induction week at the beginning of Year 1, thinking about the educational environment they expected to encounter (Expected DREEM), and again as part of a compulsory evaluation at the end of Year 1, thinking about the educational environment they had actually experienced (Actual DREEM). A total of 87 students (66.92% of the starting cohort) completed the DREEM on both occasions and gave permission for their data to be published. Results The Expected DREEM score was 153 out of a maximum of 200, and the Actual DREEM score was 143. Student's expected perceptions of learning and teachers, and their expected academic self- and social self-perceptions were all more positive than their actual perceptions. There was no difference between expected and actual perceptions of atmosphere. Specific aspects of the educational environment showing dissonance were identified. In some areas students' low expectations had been matched by their actual experience. Conclusions Medical students had started Year 1 with expectations about the educational environment that had not been met. However, areas showing dissonance received low item scores on the Actual DREEM and as such would be picked up for remediation, even without information about student expectations.