Comparison Between Surgical Trainee Self-Assessment With Supervisor Scores in Technical and Nontechnical Skills to Identify Underperforming Trainees.

OBJECTIVE: This study aims to compare trainee self-assessment with supervisor assessment to identify differences in correlations of the demographic data and evaluate whether the instrument can be utilized to identify underperforming trainees. DESIGN: A novel instrument was designed based off the Royal Australasian College of Surgeons original 9 competencies utilizing the JDocs framework and covers 48-items across all surgical competencies. A multiple regression model using age, gender, postgraduate year, IMG status, and level of training as the variables was performed with backwards elimination, and pairwise comparisons made to identify the degree and direction of influence each variable contributed to trainee and supervisor ratings. SETTING: Surgical trainees employed in tertiary centers within the Australian Capital Territory and South-East New South Wales health network in Australia. PARTICIPANTS: A total of 36 of 59 (61%) trainees responded. Two grossly incomplete responses were excluded from further analysis resulting in 34 completed self-assessments for analysis. There was a total of 68 supervisor assessments provided by 25 different nominated supervisors. Of these assessments, 67 were fully completed and one was partially complete. RESULTS: We identified that for both self-ratings and supervisor ratings, the most significant correlation is with the postgraduate year of the trainee, with correlation identified in 7 out of 9 competencies, although in different competency domains. International Medical Graduate status is associated in 2 of 9 self-ratings, and in 3 of 9 supervisor ratings. Underperforming trainees were able to be identified through supervisor assessment but not self-assessment. CONCLUSION: The supervisor assessment form was able to identify underperforming trainees. Our findings resonate with existing literature in other specialty fields, and surgical units that employ assessment forms should feel more confident in the interpretation of the data and provision of feedback to trainees.

A quantitative analysis of the perceived barriers to implementation of multisource feedback in surgical training.

BACKGROUND: The adoption and integration of work-based assessments by surgical units and training programs continues to increase, it is important to identify challenges in their implementation. The authors evaluated the barriers involved in the deployment of a supervisor assessment tool in Australia. METHODS: A questionnaire was created based on existing literature from international, and non-surgical contexts. The questionnaire covered areas known to impact multisource feedback assessments. The questionnaire was delivered in September 2019 to 34 trainees and 25 supervisors. Participants then rated each item within the questionnaire on a Likert scale. RESULTS: During the survey period, 23 of 25 (92%) supervisors and 31 of 34 (91.1%) trainees completed the questionnaire. The results show that an assessment form is well received and there is a difference between trainees and supervisors on perspectives surrounding impact on trainee-supervisor relationships, how a trainee manages negative feedback, consequences of poor scores, the importance of anonymity, and acceptability of input from allied health and nursing staff. CONCLUSION: The results provide reassurance that the perception of supervisors who felt that negative ratings may affect trainee-supervisor relationships is unfounded. A digital distribution format of self-assessment and supervisor assessment forms is well received by participants. This method of assessment should provide trainees an additional source of feedback, and opportunities for self-reflection during their training.

Development of a novel behaviourally anchored instrument for the assessment of surgical trainees.

BACKGROUND: The Royal Australasian College of Surgeons (RACS) created its competency framework in 2003 which initially consisted of nine competencies each regarded as equally important for a practising surgeon. The JDocs Framework is aligned to these competencies and provides guidance for junior doctors working towards the Surgical Education and Training program. METHODS: A novel assessment instrument was designed around the JDocs framework using 48 behaviourally anchored questions. The study was completed in 2020 across five public hospitals in the ACT and NSW. Participants were invited to complete the self-assessment form online. RESULTS: Thirty-six of 59 (61%) trainees participated in the study, with 67 of 68 (98.5%) supervisors having completed the assessment form. Trainee self-rating scores were lower than that of supervisor ratings across all competencies except communication. The self-rating scores were negatively correlated with the seniority of a trainee's level in all nine competencies. The years of post-graduate experience was positively correlated with seven of the nine competencies. For gender and International Medical Graduate status, correlation was only identified for health advocacy and medical expertise. There was no correlation identified with a trainee's age. CONCLUSION: This pilot study has provided an opportunity to explore a new assessment instrument for surgical trainees that is aligned to the RACS competency framework using behaviourally anchored questions. Looking ahead, a better understanding of this instrument will potentially be helpful in early identification of underperforming trainees in order to facilitate early intervention, or its use as a selection tool for formal training programs.

The work environment of junior doctors: their perspectives and coping strategies.

OBJECTIVE: This study explores the associations between psychological distress in junior doctors and their work environment and how they cope with work stressors. METHODS: A cross-sectional survey designed by Health Education and Training Institute was delivered in 2014 to over 1900 junior doctors across 15 hospital networks through Australian Capital Territory and New South Wales. Psychological distress was evaluated using the Kessler Psychological Distress Scale-10 (K10). Numerous variables were assessed for associations with psychological distress to identify the strongest relationships and the coping strategies used. Potential associations between work demands, coping strategies and psychological distress were explored. RESULTS: 540 responses were analysed. 414 (81%) thought their workload was reasonable, 376 (75%) were enjoying their current job and 446 (82.6%) were content with their work life. However, 85 (15.7%) reported that they would not study medicine if given their time again, and 146 (27%) reported workplace bullying. The mean K10 score was 17.2 (σ=6.3) and the prevalence of elevated psychological distress was between 63% and 80% higher than the general community. Variables most strongly associated with distress were: being discontented with workload, lack of enjoyment from current job, taking time off work and having experienced workplace bullying. There was a preference to use social activities as a method of coping but at higher levels of psychological distress there is a greater proportion who took time off work. CONCLUSIONS: Psychologically distressed junior doctors need recognition, support and treatment. Future interventions should focus on improving work environment, job satisfaction, provision of supports, use of healthy coping strategies and improving work-related relationships. This could potentially reduce levels of psychological distress in junior doctors, optimise delivery of healthcare to patients and maximise workforce potential.

Learning trajectories in longitudinal rural medical school placements.

BACKGROUND: Rural longitudinal placements are now a key part of clinical medical education, and are part of workforce strategies to enhance the rural medical workforce. Learning trajectories (a map to guide student learning) have been recommended as a means of maximising student learning on placements, and have the potential to assist long-term rural students and supervisors in adapting to a longitudinal clerkship. CONTEXT: This study focuses on year-3 medical students in rural longitudinal clinical placements at an Australian graduate-entry medical school. INNOVATION: This article reports the outcomes of working with current rural supervisors and students to develop a learning trajectory across the rural stream year, for implementation in future years. IMPLICATIONS: Students and supervisors identified incremental learning goals in keeping with Dreyfus's model of progressive skill development. Students offered tips to future students to adjust to variations in learning experiences across rural sites. Some supervisors were reluctant to have a learning trajectory, fearing it would be seen as proscriptive and reduce student ambition for varied rich experiences. Future research will focus on the impact of the rural learning trajectory.

Quality of life impairment associated with body dissatisfaction in a general population sample of women.

BACKGROUND: In order to elucidate the individual and community health burden of body dissatisfaction (BD), we examined impairment in quality of life associated with BD in a large, general population sample of women. METHODS: Self-report measures of BD, health-related quality of life (SF-12 Physical and Mental Component Summary scales) and subjective quality of life (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by 5,255 Australian women aged 18 to 42 years. RESULTS: Most participants (86.9%) reported some level of dissatisfaction with their weight or shape and more than one third (39.4%) reported moderate to marked dissatisfaction. Higher levels of BD were associated with poorer quality of life for all items of both quality of life measures, the degree of impairment being proportional to the degree of BD. Associations were strongest for items tapping mental health and psychosocial functioning, although greater BD was associated with substantially increased risk of impairment in certain aspects of physical health even when controlling for body weight. Post-hoc analysis indicated that the observed associations between BD and quality of life impairment were not accounted for by an association between BD and eating disorder symptoms. CONCLUSIONS: In women, BD is associated with marked impairment in aspects of quality of life relating to mental health and psycho-social functioning and at least some aspects of physical health, independent of its association with body weight and eating disorder symptoms. Greater attention may need to be given to BD as a public health problem. The fact that BD is "normative" should not be taken to infer that it is benign.

Role of personality in medical students' initial intention to become rural doctors.

OBJECTIVE: Recent efforts to redress the deficit of rural medical practitioners have considered the problem of recruitment and retention of rural doctors as one of influencing individuals' career choices. Exposure to rural medical environments during basic medical training is one long-standing example of an initiative aimed in this direction and there is some evidence that it is effective. This study sought to determine whether or not various domains of personality are related to medical students' attitude to practising as rural doctors after graduation. DESIGN: The sample comprised 914 students commencing medical studies in Australian universities. They were recruited as part of the Medical Schools Outcomes Database project and indicated intended location of future medical practice. SETTING: Seven Australian basic medical training programs. MAIN OUTCOME MEASURES: All students completed the NEO five-factor index (NEO-FFI) and Adjective Checklist (ACL) personality instruments. RESULTS: A preference for a rural practice location was associated with a combination of six domains of personality. The probability of rural preference was greater with higher scores on openness to experience, agreeableness and self-confidence but lower with higher scores on extraversion, autonomy and intraception. Taken together these six domains of personality provide useful although imperfect discrimination between students with a rural versus urban location preference. After controlling for student age the associations with extraversion and agreeableness failed to reach statistical significance. CONCLUSIONS: While personality does not fully explain medical students' attitude towards practicing as a rural doctor, the data suggest it is an important factor and that some individuals may be better suited to a rural medical career than others. Considering personality along with other characteristics of the individual might allow targeted 'marketing' of rural practice.

A student-centred feedback model for educators.

BACKGROUND: Effective feedback is instrumental to effective learning. Current feedback models tend to be educator driven rather than learner-centred, with the focus on how the supervisor should give feedback rather than on the role of the learner in requesting and responding to feedback. CONTEXT: An alternative approach emphasising the theoretical principles of student-centred and self-regulated learning is offered, drawing upon the literature and also upon the experience of the authors. INNOVATION: The proposed feedback model places the student in the centre of the feedback process, and stresses that the attainment of student learning outcomes is influenced by the students themselves. This model emphasises the attributes of the student, particularly responsiveness, receptiveness and reflection, whilst acknowledging the important role that the context and attributes of the supervisor have in influencing the quality of feedback. IMPLICATIONS: Educational institutions should consider strategies to encourage and enable students to maximise the many feedback opportunities available to them. As a minimum, educators should remind students about their central role in the feedback process, and support them to develop confidence in meeting this role. In addition, supervisors may need support to develop the skills to shift the balance of responsibility and support students in precipitating feedback moments. Research is also required to validate the proposed model and to determine how to support students to adopt self-regulatory learning, with feedback as a central platform.

Utilisation of multidisciplinary services for diabetes care in the rural setting.

OBJECTIVE: To quantify utilisation of allied health care services by diabetics in rural NSW and explore reasons for any underutilisation. DESIGN: Self-administered mail survey of 268 patients with diagnosed diabetes identified from practice registers. SETTING: Two rural general practices. PARTICIPANTS: One hundred seventeen respondents with diabetes. MAIN OUTCOME MEASURE: Annual frequency of visits to allied health practitioners. RESULTS: In the last year, 40.2% of patients had seen a diabetes educator (DE), 21.4% a dietitian and 47% a podiatrist. However, 25-40% of patients had never used each of the services. Reasons for nonutilisation were non-referral (35.9-68.0%) and lack of perceived need (40.6-59.0%). One third of patients who had not seen a DE in the last year thought their 'general practitioner (GP) provides a similar service'. However, mean annual GP visits (5.6) were significantly lower than urban and rural comparisons. Patients with formal management plans were, in the last year, twice as likely to have seen a DE and podiatrist, and reported two extra visits to their GP compared to those without. CONCLUSIONS: Rates of allied health service utilisation were not significantly lower than urban rates; however, there is room for increased uptake of multidisciplinary services. Patients who do not access these services may expect their GP to fulfil multiple roles within a limited number of visits and may not understand the role of other practitioners. Where allied health services are available locally, utilisation may be improved by increasing use of management plans and fostering awareness of the role of allied health practitioners in diabetes management.

Quality of life impairment in a community sample of women with eating disorders.

OBJECTIVE: Studies of quality of life among individuals with eating disorders have relied almost exclusively on clinical samples. We examined impairment in quality of life in a community sample of women with eating disorders recruited as part of an epidemiological study. METHODS: Measures of health-related quality of life (Medical Outcomes Study 12-item Short-Form Physical and Mental Component Summary scales) and subjective well-being (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by women with eating disorders (n = 159), primarily variants of bulimia nervosa and binge eating disorder, and a comparison group of healthy women (n = 232). RESULTS: When compared with healthy women, women with eating disorders reported substantial impairment in aspects of quality of life relating to mental health, although item-level analysis indicated considerable variation in the extent to which specific aspects of emotional well-being were affected. Impairment in social relationship and in physical health was less pronounced and due, at least in part, to between-group differences in age, body weight and demographic characteristics. Impairment in certain aspects of perceived physical health was, however, apparent among women with eating disorders, even after controlling for between-group differences in body weight. CONCLUSIONS: Community cases of women with eating disorders experience marked impairment in quality of life as this relates to mental health functioning and at least some impairment in physical health functioning. Personality characteristics and ego-syntonic aspects of eating-disordered behaviour may complicate the interpretation of findings relating to impairment in specific aspects of quality of life.

The development and content of an interpersonal psychotherapy group for postnatal depression.

Postnatal depression (PND) usually causes distressing symptoms for sufferers and significant impairments in relationships. Group Interpersonal Psychotherapy (IPT-G) provides the experienced therapist with a brief, focused, and manualized approach to helping women recover from the debilitating effects of PND. This paper describes the background and development of IPT-G for PND. The evidence for the effectiveness of individual and group IPT formats with this population is summarized. The triad of theories underpinning IPT are discussed with an emphasis on the important role of attachment styles during the transition to parenthood. Its strengths, which include its unique package of targets, tactics, and techniques, are highlighted. The benefits and challenges of IPT-G are also explored, and the results of a randomized controlled trial are summarized. Finally, a case study illustrates how IPT-G specifically addresses the social role transitions, conflicts, losses, and social isolation that mothers commonly experience.

Trajectories of long-term outcomes for postnatally depressed mothers treated with group interpersonal psychotherapy.

There is evidence that psychological treatments for postnatal depression are effective in the short-term; however, whether the effects are enduring over time remains an important empirical question. The aim of this study was to investigate the depressive symptoms and interpersonal functioning of participants in a randomised controlled trial (RCT) of group interpersonal psychotherapy (IPT-G) at 2 years posttreatment. The study also examined long-term trajectories, such as whether participants maintained their recovery status, achieved later recovery, recurrence or persistent symptoms. Approximately 2 years posttreatment, all women in the original RCT (N = 50) were invited to participate in a mailed follow-up. A repeated measures analysis of variance assessed differences between the treatment and control conditions on depression and interpersonal scores across five measurement occasions: baseline, mid-treatment, end of treatment and 3-month and 2-year follow-up. Chi-square tests were used to analyse the percentage of participants in the four recovery categories. Mothers who received IPT-G improved more rapidly in the short-term and were less likely to develop persistent depressive symptoms in the long-term. Fifty seven percent of IPT-G mothers maintained their recovery over the follow-up period. Overall, IPT-G participants were significantly less likely to require follow-up treatment. Limitations include the use of self-report questionnaires to classify recovery. The positive finding that fewer women in the group condition experienced a persistent course of depression highlights its possible enduring effects after treatment discontinuation. Further research is needed to improve our long-term management of postnatal depression for individuals who are vulnerable to a recurrent or chronic trajectory.

Intern culture, internal resistance: uptake of peer review in two Australian hospital internship programs.

OBJECTIVE: To compare the uptake of peer review among interns in mandatory and voluntary peer-review programs. POPULATION: All first and second year graduates (n=105) in two Australian hospitals. MAIN OUTCOME MEASURES: Completion of peer review, and reported responses by doctors to peer review. RESULTS: Eight of sixty interns undertaking the mandated program completed all steps. In the voluntary program, none of 45 interns did so. Resistance to peer review occurred at all stages of the trial, from the initial briefing sessions to the provision of peer-review reports. DISCUSSION; Hospital internship is a critical period for the development of professional identity among doctors. We hypothesise that resistance to peer review among novice doctors reflects a complex tension between the processes underpinning the development of a group professional identity in hospital, and a managerial drive for personal reflection and accountability. Peer review may be found threatening by interns because it appears to run counter to collegiality or 'team culture'. In this study, resistance to peer review represented a low-cost strategy in which the interns' will could be asserted against management. CONCLUSION: To enhance uptake, peer review should be structured as key to clinical development, and modelled as a professional behaviour by higher-status colleagues.

Mental health impairment in underweight women: do body dissatisfaction and eating-disordered behavior play a role?

BACKGROUND: We sought to evaluate the hypothesis that mental health impairment in underweight women, where this occurs, is due to an association between low body weight and elevated levels of body dissatisfaction and/or eating-disordered behaviour. METHODS: Subgroups of underweight and normal-weight women recruited from a large, general population sample were compared on measures of body dissatisfaction, eating-disordered behaviour and mental health. RESULTS: Underweight women had significantly greater impairment in mental health than normal-weight women, even after controlling for between-group differences in demographic characteristics and physical health. However, there was no evidence that higher levels of body dissatisfaction or eating-disordered behaviour accounted for this difference. Rather, underweight women had significantly lower levels of body dissatisfaction and eating-disordered behaviour than normal-weight women. CONCLUSIONS: The findings suggest that mental health impairment in underweight women, where this occurs, is unlikely to be due to higher levels of body dissatisfaction or eating-disordered behaviour. Rather, lower levels of body dissatisfaction and eating-disordered behaviour among underweight women may counterbalance, to some extent, impairment due to other factors.

Maximising student preparation for clinical teaching placements.

BACKGROUND: With the increasing emphasis on ambulatory health care, clinical educators need to ensure that students are sufficiently prepared to maximise learning opportunities during placements in ambulatory settings. CONTEXT: This study focuses on third-year medical students entering urban or rural clinical placements at an Australian graduate entry medical school. INNOVATION: All rural and a subset of urban students received intensive training in taking Papanicolaou (Pap) smears prior to starting the clinical placement. Training involved gynaecological teaching associates, active practice and real-time feedback. Evaluation included workshop feedback, reflection on effectiveness during the placement, and comparison of trained and untrained students' recorded clinical experience of taking Pap smears. IMPLICATIONS: Students given pre-placement training praised their learning experience, and on average took more Pap smears during their placement than did their untrained peers. The difference, however, did not reach statistical significance. The pre-placement teaching workshop on a difficult skill was popular and worthy of further study regarding other challenging clinical skills.

Initial evaluation of rural programs at the Australian National University: understanding the effects of rural programs on intentions for rural and remote medical practice.

INTRODUCTION: Rural health workforce issues are a priority area for the Australian Government and substantial funding has been provided for rural education programs to address health workforce disparities across Australia's rural and remote communities. The Australian Government established a Rural Health Strategy in 2001 and as a result there are now 14 rural clinical schools in Australia. The 2008 Urbis Report highlighted the lack of research on rural programs and workforce outcomes, essential to ensuring that educational efforts, resources and funding are being concentrated appropriately. This study examined the Australian National University (ANU) Medical School's 4 year rural program to identify the impact of elective and compulsory program components on student intentions to practice in a rural and remote location post-graduation. The study also explores factors that affect student decisions to apply for year-long rural placements. METHODS; ANU Medical School's graduating cohort of 2008 fourth year medical students completed an anonymous and voluntary online survey questionnaire. Survey sections included student demographics, compulsory and elective components of the ANU rural program, and an overall evaluation of the ANU rural curriculum. The survey contained a mixture of forced-answer questions and open-ended commentary. Quantitative data were analyzed for descriptive and frequency statistics using EpiInfo V3.5.1 (http://wwwn.cdc.gov/epiinfo/). Qualitative data were reviewed and consistent themes among responses extracted. RESULTS: In total, 40 students from a cohort of 88 (45%) responded, with 26 respondents (65%) indicating that at medical school commencement they considered working in a rural or remote area. At the end of their medical education, 33 respondents (82%) indicated their intention to spend some time in their careers working in a rural or remote area. Students from non-rural backgrounds had greater positive change in their intentions to practice rurally as a direct effect of ANU rural programs when compared with students from rural backgrounds. More than 70% of students believed the amount of rural focus in the curriculum was correct, 75% believed that they will be better medical practitioners because of the program, and 85% found the curriculum was delivered effectively. Students who undertook elective rural programs such as a year-long rural placement were more likely to have future rural career intentions when compared with students undertaking compulsory rural components. Compulsory components, however, had a strong influence on students applying for elective programs. Regarding application for the year-long rural placement, students reported clinical exposure was the most encouraging factor, and time away from family and friends, and lack of spousal and family support were the most discouraging factors. CONCLUSION: Rural programs at the ANU, and medical school exposure to rural health experiences is important in influencing students' perceptions of a career in rural and remote health. This study provides evidence that both compulsory and elective components contribute to a successful holistic rural program which nurtures the rural interest of all students. Overall, students at the ANU medical school were satisfied with the rural curriculum. The results confirm that there is difficulty in recruiting students with family commitments into year-long rural placement programs, despite incentives. Those students who select long-term rural study for reasons other than an interest in a career in rural health end the program with positive rural intentions.