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Student exposure to illness-related theatrical performances holds intriguing educational possibilities. This project explored uses of theatrical performance within the context of medical education.Two 1-person shows, dramatically addressing AIDS and ovarian cancer, were presented to audiences totalling approximately 150 medical students, faculty, community doctors, staff and patients.Evaluations for both performances indicated increased understanding of the illness experience and greater empathy for patients. They also showed that respondents obtained additional insights into patient care issues, and developed new ways of thinking about their situations.Presenting illness-related dramatic performances as an adjunct method of enhancing empathy and insight toward patients in a self-selected group of students, doctors, staff and patients was successful. Although this approach might not be effective with all learners, those who participated felt they gained important insights into the nature of the patient experience.

Context Maintenance fluid therapy is a protean topic but is clinically often mismanaged. Our teaching of medical students led us to suspect that textbooks provide limited information about the topic, so we set out to verify this possibility by reviewing the content of books written in English that covered perioperative care. Methods We reviewed publishers’ lists of textbooks and found 22 suitable books. After compiling a standard list of questions on intravenous therapy, we read each book to find out to what extent it delivered the answers, and listed the information obtained. Results Only 13 books answered more than half of the questions. The information varied considerably. Suggested quantities of daily fluid, sodium and potassium requirements varied hugely. Conclusions Information provided in standard textbooks to guide fluid prescription is scant and variable. This could be a cogent reason why junior doctors prescribe postoperative fluids badly: the information in textbooks is inadequate and varies from book to book. The reasons for the poor coverage are not clear. Perhaps other common topics that are often poorly managed are also badly addressed by standard books. [ABSTRACT FROM AUTHOR]

Context The Chief Medical Officer’s recommendations on medical regulation in the UK suggest that National Health Service (NHS) trusts should assess their doctors and confirm whether they remain fit to practise medicine. Objective We set out to evaluate the utility of hospital trust-based assessment in a ‘best-case scenario’ within existing resources. Methods We carried out a generalisability analysis, and feasibility and validity evaluation, based on an assessment process for 137 career-grade doctors at Chesterfield Royal Hospital, Chesterfield, UK, using validated multi-source feedback (MSF) and patient rating (PR) instruments. Results Uptake and response rates were good for MSF (91% and 85%, respectively). However, only 6% of non-clinical doctors and anaesthetists, and 48% of clinical doctors, obtained sufficient PR ratings. Aggregate scores were acceptably reliable. Nine combined MSF ratings and 15 PR ratings produce standard errors of measurement of 0.19 on a 6-point scale and 0.15 on a 5-point scale, respectively. Overall aggregate scores did not identify any doctor as unsatisfactory, but 6 doctors were scored as unsatisfactory by 2 or more colleagues or patients. These performance concerns appear to merit further investigation. Patients rated female doctors better than male doctors (4.61 versus 4.46; P < 0.05). Colleagues rated UK graduates better than non-UK graduates (5.31 versus 5.15; P < 0.05). Conclusions This study shows that the commissioning of professional services makes the implementation of an assessment process linked to appraisal feasible. However, trust-based assessment requires significant development: developmental appraisal needs protection; new instruments are needed for non-clinical specialties; PR requires specific administrative support, and guidance is required over concern thresholds and demographic effects. Disaggregated assessment data may help identify doctors with potential performance problems. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the reliability and feasibility of assessing the performance of medical specialist registrars (SpRs) using three methods: the mini-clinical evaluation exercise (mini-CEX), directly observed procedural skills (DOPS) and multi-source feedback (MSF) to help inform annual decisions about the outcome of SpR training. Methods We conducted a feasibility study and generalisability analysis based on the application of these assessment methods and the resulting data. A total of 230 SpRs (from 17 specialties) in 58 UK hospitals took part from 2003 to 2004. Main outcome measures included: time taken for each assessment, and variance component analysis of mean scores and derivation of 95% confidence intervals for individual doctors’ scores based on the standard error of measurement. Responses to direct questions on questionnaires were analysed, as were the themes emerging from open-comment responses. Results The methods can provide reliable scores with appropriate sampling. In our sample, all trainees who completed the number of assessments recommended by the Royal Colleges of Physicians had scores that were 95% certain to be better than unsatisfactory. The mean time taken to complete the mini-CEX (including feedback) was 25 minutes. The DOPS required the duration of the procedure being assessed plus an additional third of this time for feedback. The mean time required for each rater to complete his or her MSF form was 6 minutes. Conclusions This is the first attempt to evaluate the use of comprehensive workplace assessment across the medical specialties in the UK. The methods are feasible to conduct and can make reliable distinctions between doctors’ performances. With adaptation, they may be appropriate for assessing the workplace performance of other grades and specialties of doctor. This may be helpful in informing foundation assessment. [ABSTRACT FROM AUTHOR]

Objective To determine whether graduate and non-graduate entrants to medical school differ in their views on the first year spent in medical practice as a pre-registration house officer. Methods We carried out postal questionnaire surveys of medical qualifiers of 1999, 2000 and 2002 from all UK medical schools, 1 year after qualification. The timing of the study slightly pre-dates the recent major expansion in graduate entry fast-track courses. Results Differences between graduate and non-graduate entrants were few and, even when statistically significant, were small in scale. Graduate entrants viewed their working hours, pay and living conditions at work, such as hospital accommodation and food, a little less favourably than did non-graduate entrants. Graduate entrants were also less satisfied than non-graduates with time available for family, social and recreational activities. However, graduate entrants were more likely than non-graduate entrants to feel positive about their future career prospects. There were no differences between graduate and non-graduate entrants in whether they felt they had been well prepared by their medical schools for the jobs they undertook as house officers. Levels of job satisfaction expressed by graduate and non-graduate entrants were similar, as were their responses to most other statements about attitudes to clinical work. Conclusions ‘Quality of life’ issues, a sense of being fairly rewarded, and expectations about one’s physical working environment seem a little more important to graduate than to non-graduate entrants. Apart from these, the findings suggest that graduate status, at entry to medical school, has no appreciable influence on attitudes to the work of a junior hospital doctor. [ABSTRACT FROM AUTHOR]

Context Undergraduate medical education in the UK has changed considerably over the last decade. One development has involved the creation of teaching-specific posts for junior doctors by medical schools. These posts are generally termed ‘clinical teaching fellowships’, but it is not known how many of them exist, or whether they are similar in terms of educational activities, professional development, and research and clinical experience opportunities. Methods Teaching deans in all UK medical schools were sent a questionnaire relating to clinical teaching fellowships, and were asked to distribute a second set of different questionnaires to their clinical teaching fellows, which were to be returned to the authors separately. Results A total of 28 deans and 46 fellows responded. Fifteen medical schools had clinical teaching fellows and there appeared to be a total of 77 such posts in the UK. There was little uniformity in the activities undertaken within the posts. Deans who employed clinical teaching fellows were unanimously positive regarding the posts. Fellows were generally positive but expressed reservations relating to approval for postgraduate training, career development, deterioration in clinical skills, financial disincentives, credibility within one’s own specialty, and provision of training and support. Conclusions Clinical teaching fellow posts are generally enjoyed by fellows and valued by deans. Fellows carry out differing duties and their training in medical education is variable. The posts can be unstructured and may lack credibility to doctors outside medical education. Providing specific structured training in medical education, recognised at a national level, would help deal with these concerns. [ABSTRACT FROM AUTHOR]

Objectives To assess candidates’ and interviewers’ perceptions of the use of a multiple mini-interview (MMI) for selection of senior house officers (SHOs) to a UK regional paediatric training programme. Methods Both candidates and interviewers completed anonymous questionnaires (comprising 16 and 25 questions, respectively). Demographic data were recorded for both groups. Data were analysed by frequencies; using Mann–Whitney and Kruskall–Wallis tests for comparisons; and Cronbach’s alpha for internal consistency within the data. Results Both candidates and interviewers were positive about the fairness of the MMI (mean scores of 4.0 and 4.4, respectively). The majority of candidates (83%) had not been to this type of interview before. Gender, age and previous experience of MMIs did not account for differences in candidate responses ( P > 0.05). A total of 86% of candidates were international medical graduates who preferred the format more than UK graduates did ( P = 0.01). Interviewers were mainly experienced consultants who agreed that the multi-station format was better than the traditional interview (mean score 4.8) and represented a reliable process (mean score 4.4). Interviewers were concerned about the range of competencies covered and the subsequent performance of candidates in post (mean scores 3.6 and 3.2, respectively). Conclusions Both candidates and interviewers agreed that the MMI format was reliable, fair and asked appropriate, easy-to-understand questions. In high-stakes interviews such as for specialty training in Modernising Medical Careers programmes, it is vital that all concerned have confidence in the selection process. [ABSTRACT FROM AUTHOR]

Objectives The purpose of this study was to develop a better understanding of how medical trainees define medical errors and what factors influence medical trainees' perceptions of medical errors. Methods We surveyed 423 medical students and house staff at an urban academic medical centre to learn about how they defined medical errors, their experiences with medical errors, their beliefs about when a patient should be informed of an error, and their attitudes towards medical errors with differing severity of outcomes. Results Trainees stated that an event could be considered an error regardless of outcome, negligence, intention or consent. Definitions did not vary according to gender or level of training. Trainees had increasing feelings of guilt and fear as the outcomes related to errors worsened. Respondents were more likely to feel guilty and angry at themselves, and be afraid of accusations of malpractice, losing their licence, damaging their reputation, or losing confidence when errors were made while working individually versus in a team setting. Female trainees were more likely than male trainees to feel guilty and angry at themselves, and were afraid of losing confidence if they made an error. Conclusions Trainees' perceptions and attitudes towards errors vary depending on whether they are in their clinical years, the severity of outcome, and whether the error is attributable to an individual or a team. These factors will have to be explored in greater depth if we are adequately to prepare young doctors for the errors they will inevitably make. [ABSTRACT FROM AUTHOR]

Objective The purpose of this study is to define the most relevant topics for inclusion in an undergraduate psychiatric curriculum by asking non-psychiatrists what knowledge, skills and attitudes related to psychiatry they need in their day-to-day practice. Methods A questionnaire study involving non-psychiatric doctors (based both in hospitals and general practice) was carried out using Delphi methodology in 2 waves. In the first wave, 408 doctors described the psychiatric competencies they required in their current posts. From this, a list of 101 psychiatric topics was generated. In the second wave, 867 doctors rated these topics according to the relevance of each topic to their practice. Results Depression, alcohol misuse and drug misuse were rated as most relevant. General practitioners found more topics relevant to their practice than did hospital doctors, and there were disparities in the relative importance that the 2 groups gave to topics. Conclusions This study demonstrates a systematic method for developing core curricular undergraduate learning objectives in a specialty area by asking doctors outside that specialty to identify topics that are relevant to their practice. Similar methods could be used for a range of specialties other than psychiatry and could provide a rational and transparent means of developing a core curriculum for medical students, when combined with perspectives from other sources. [ABSTRACT FROM AUTHOR]

Objectives To determine whether doctors in their first year after qualification wanted career advice, and, if so, whether they thought they had been able to obtain useful advice, and whether older doctors thought that adequate career advice had been available to them. Methods We carried out a postal questionnaire survey of all UK medical graduates of 1988, 1993, 1996, 1999 and 2002, and a 25% random sample of the graduates of 2000. Results The response rate was 67.4% (24 261/35 976 mailed questionnaires). Of doctors in the first postgraduate year, 95% agreed that: ‘It is important to be given career advice at this stage of training.’ A total of 38% disagreed with the statement: ‘I have been able to obtain useful career advice since graduation.’ Of more experienced doctors surveyed between 3 and 11 years after graduation, 34% agreed that: ‘Making career choices has been made more difficult by inadequate career advice.’ Conclusions The great majority of junior doctors want career advice after qualification. It cannot be assumed that they are able to seek it out for themselves satisfactorily. Career advice needs to be planned into postgraduate work and training. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to provide better understanding of how pre-registration junior medical officers (PJMOs) make their career choices by investigating when decisions are made, what factors impact on choices, and the role of experience in this process. Methods A third ( n = 54) of PJMOs from the 2003 cohort at South Australian teaching hospitals participated in the current research. Inductive content analysis was used to discover themes in data gathered from semistructured interviews. Results Interviews revealed that although 26% (14/54) of participants had made their career decisions in their pre-registration year, 50% (27/54) had still to decide on a career choice. The factors identified as impacting on career choice were grouped into 5 main categories: job satisfaction; lifestyle; career path; training programme, and the wider environment. Depending on the demographic profile of the PJMO, different relative importance was assigned to these factors. The most important elements used to confirm or disconfirm PJMOs' potential career choices were the experiences they had of different specialty areas. Discussion This study allowed an in-depth exploration of the factors that affect the decision-making process of PJMOs. It also found that defined groups of PJMOs place different degrees of importance on these factors, which may have implications for medical workforce planning. It is clear that experience and role models are a crucial component of the career decision-making process. This has importance for specialties that are not incorporated into junior medical training. [ABSTRACT FROM AUTHOR]

Context Workload pressures may lead pre-registration house officers (PRHOs) to undervalue critical appraisal and thinking skills. This study aimed to explore Mersey Deanery PRHOs' attitudes, experiences and perceived readiness for practising evidence-based medicine with critical appraisal skills. Methods A cross-sectional survey of 157 PRHOs from 5 postgraduate centres in the UK, using a semistructured questionnaire, at the beginning and end of the pre-registration year. Main outcome measures were level of agreement with closed statements exploring experiences and opinions about critical appraisal skills and evidence-based practice. Open questions explored personal experiences. Results Most PRHOs (69%) felt medical school prepared them to use critical appraisal skills and perceived such skills as relevant (63%). Fewer felt that their clinical work was based on best available evidence (57%). The busier the PRHOs, the less likely they were to agree that their practice followed best evidence. The PRHOs were more likely to feel supported and that their practice was evidence-based at the end of the year. Responders identified several reasons for their practice not being evidence-based, including workload, lack of skills, deferring to senior colleagues, and non-conducive hospital culture. Conclusions The nature of PRHO work still mitigates against critical thinking and appraising evidence, with a lack of protected time and perceived inconsistent support from educational supervisors. Many PRHOs rely entirely on evidence-based summaries and guidelines from others. The PRHO year is a period of crucial transition, however, and critical appraisal skills and evidence-based approaches need developing post-qualification, with sufficient protected time for their integration into practice. Foundation year reforms reinforce such requirements. [ABSTRACT FROM AUTHOR]

Objectives The clinical learning environment is an influential factor in work-based learning. Evaluation of this environment gives insight into the educational functioning of clinical departments. The Postgraduate Hospital Educational Environment Measure (PHEEM) is an evaluation tool consisting of a validated questionnaire with 3 subscales. In this paper we further investigate the psychometric properties of the PHEEM. We set out to validate the 3 subscales and test the reliability of the PHEEM for both clerks (clinical medical students) and registrars (specialists in training). Methods Clerks and registrars from different hospitals and specialties filled out the PHEEM. To investigate the construct validity of the 3 subscales, we used an exploratory factor analysis followed by varimax rotation, and a cluster analysis known as Mokken scale analysis. We estimated the reliability of the questionnaire by means of variance components according to generalisability theory. Results A total of 256 clerks and 339 registrars filled out the questionnaire. The exploratory factor analysis plus varimax rotation suggested a 1-dimensional scale. The Mokken scale analysis confirmed this result. The reliability analysis showed a reliable outcome for 1 department with 14 clerks or 11 registrars. For multiple departments 3 respondents combined with 10 departments provide a reliable outcome for both groups. Discussion The PHEEM is a questionnaire measuring 1 dimension instead of the hypothesised 3 dimensions. The sample size required to achieve a reliable outcome is feasible. The instrument can be used to evaluate both single and multiple departments for both clerks and registrars. [ABSTRACT FROM AUTHOR]

Aim To report house officers' views in 2003 of their first postgraduate year, and to compare their responses with those of house officers 2 and 3 years previously. Methods Postal questionnaires to all house officers in 2003 who graduated from UK medical schools in 2002. Results The response rate was 65.3% (2778/4257). The house officers of 2003 enjoyed the year more than those of 2000–1. A total of 78% of respondents in 2003 scored 7–10 in reply to the question ‘How much have you enjoyed the house officer year overall?’, scored from 0 (no enjoyment) to 10 (enjoyed it greatly), compared with 70% of 2000–1 house officers. They were more satisfied with leisure time available to them (51% scoring 6–10 in 2003; 35% in 2000–1). There were significant improvements in almost every aspect of doctors' experience. Hospital medical posts were rated more highly than surgical posts, and general practice posts higher still. Overall, 38% of respondents regarded their training as having been of a high standard, and 37% felt that they received constructive feedback on their performance. Differences between men and women in their views about their jobs were small. Discussion The house officers of 2003 reported more positively on their experiences than did those of 2000–1. Although a substantial percentage were negative about specific aspects of clinical support and training, particularly in surgical posts, almost all the responses covering training and clinical support moved in a favourable direction over time. [ABSTRACT FROM AUTHOR]

Background Analyses of adverse events in surgery reveal that many underlying causes are behavioural, such as communication failure, rather than technical. Non-technical (i.e. cognitive and interpersonal) skills are not addressed explicitly in surgical training. However, surgeons need to demonstrate these skills, which underpin their technical excellence, to maximise patient safety in the operating theatre. This paper describes the method used to identify surgeons' non-technical skills, and the development of a skills taxonomy and behavioural rating system to structure observation and feedback in surgical training. Methods Cognitive task analyses (critical incident interviews) were conducted with 27 consultant surgeons in general, cardiac and orthopaedic surgery. The interviews were coded and a multidisciplinary group of surgeons and psychologists used an iterative process to develop a skills taxonomy. This was supported by data gathered from an attitude survey, literature review, analysis of surgical mortality reports and observations in theatre. Results Five categories of non-technical skills were identified, including situation awareness, decision making, task management, leadership and communication and teamwork. This provided a structure for a prototype skill taxonomy (v1.1), which comprised 14 non-technical skill elements. Observable behaviours (markers) indicative of good and poor performance were developed for each element by 16 consultant surgeons to form a prototype behaviour rating system. Conclusions The prototype skills taxonomy and behaviour rating system are grounded empirically in surgery. The reliability of the system is currently being tested using standardised scenarios. If this evaluation proves successful, the system could be used to structure feedback and guide non-technical skills training. [ABSTRACT FROM AUTHOR]

Background Clinical supervision promotes the professional development of specialist registrars (SpRs). Our objective was to investigate and compare the perceived quality of supervision (PQS) in a university teaching hospital (UTH) and a district teaching hospital (DTH) and to identify aspects of supervision that could be improved. Methods The Cleveland Clinic's teaching effectiveness instrument (CCTEI) was used to measure the quality of supervision of attending doctors. Fifteen items reflecting good teaching ability were rated on a 5-point Likert-scale (1–5 = poor–excellent). Results SpRs rated 47 attending doctors using the CCTEI. A total of 416 ratings were obtained. Overall, the mean PQS was 3.85 (SD = 0.29) in the DTH and 3.56 (SD = 0.44) in the UTH ( P = 0.02). A significant difference in PQS was found in 6 items. The supervisors in the DTH scored better on all these items. The best predictor of PQS was the item ‘Organises time to allow for both teaching and care giving’. Conclusions Overall, PQS was better in the DTH compared to the UTH. In both settings, generating a good learning environment and respecting the autonomy of the SpRs scored favourably. Supervisory roles focusing on improving cost-effective practice and communicative skills need more emphasis. [ABSTRACT FROM AUTHOR]

Introduction In 1996 the University of Liverpool introduced an integrated problem-based learning (PBL) medical curriculum incorporating the recommendations of Tomorrow's Doctors. This paper investigates whether the PRHO (pre-registration house officer) educational supervisors who supervise Liverpool graduates believe that the reformed curriculum is producing house officers who have the competencies outlined by the General Medical Council. Methods Forty-one interviews were arranged with a sample of educational supervisors in the Mersey Deanery area to ascertain their views on the competencies of Liverpool PRHOs. The interviews were tape-recorded, transcribed and analysed. Results The supervisors felt that the PRHOs had been well prepared to work as PRHOs, and compared with traditional graduates they were actually better prepared for the job of PRHO. They saw the PRHOs as competent communicators with improved clinical skills, who had good attitudes, were aware of limitations, were team workers, good at history-taking and examination and had different approaches to finding information. There was a very confusing picture regarding basic knowledge, with some consultants expressing concerns, despite saying they had adequate knowledge to work as PRHOs. It emerged that there was little consensus about the knowledge base of the traditional or PBL graduates or what knowledge level was needed at this stage. Discussion Educational supervisors believe that the reformed curriculum in Liverpool is producing competent PRHOs who have been better prepared for the role of PRHO than previous graduates. It could be that uncertainty over knowledge base may be the price paid for reducing the factual burden and improving preparedness for professional practice. [ABSTRACT FROM AUTHOR]

Context In 1996 the University of Liverpool introduced a new curriculum based on the recommendations published in Tomorrow's Doctors. This work examines how graduates of that course view their undergraduate curriculum and whether they consider it prepared them well for the pre-registration year. Methods Five focus groups were arranged with a selection of graduates from the first cohort to graduate from the reformed curriculum in order to ascertain their views on the course and how it had prepared them to work as pre-registration house officers (PRHOs). The focus groups were tape-recorded, transcribed and analysed. Results The PRHOs felt they had been well prepared for the PRHO year, citing the clinical experience of the final year, communication skills classes and the Clinical Skills Resource Centre as having been particularly beneficial. There were concerns about their basic science knowledge base although this had not affected their ability to work as PRHOs. They had criticisms of the way part of their course had been structured but overall they were happy with the content of the course. Discussion A reformed medical curriculum in the UK can prepare graduates well to work as junior doctors and can take away some of the anxiety associated with graduation; therefore, to that extent curriculum reform has worked. However, anxiety about undertaking the role of junior doctor seems to have been replaced by anxiety about knowledge base, despite having adequate knowledge to work as PRHOs. Students undertaking a reformed curriculum are wary about being the first people to use their training in the workplace. This factor may need to be considered when further reforms are introduced. [ABSTRACT FROM AUTHOR]

Objectives This study aimed to explore patterns of attendance at classroom-based, taught education programmes for pre-registration house officers (PRHOs) and to identify reasons for non-attendance, and to consider implications for Foundation Programme curriculum delivery and suggest strategies for improving delivery. Method We analysed registers of attendance for education sessions for 3 local teaching hospitals in the Leicestershire, Northamptonshire and Rutland (LNR) Healthcare Workforce Deanery, along with PRHO exit questionnaire returns (from 2001 to 2005). Results Despite a trend for attendance to fall slightly over the course of a rotation, attendance rates have, in general, remained relatively stable at around two-thirds. However, during most 4-month posts, a fifth or more of PRHOs missed half or more of all sessions. Two types of barrier to attendance were identified: ‘routine barriers’, which relate to hospital working patterns, and ‘contextual barriers’, which refer to the particularities of each hospital post. There was no evidence that doctors' motivation and commitment towards the education programme is a main determinant of attendance. Conclusions Contextual barriers to attendance, such as pressure being placed on PRHOs to remain on the ward, can be addressed. However, routine barriers to attendance, including on-call working patterns and annual leave, render it impossible to avoid significant numbers of education sessions being missed by PRHOs in each post during a rotation. En bloc teaching of basic generic skills prior to the start of the rotation plus greater use of online learning resources are examples of ways in which reliance on in-post, classroom-based programmes can be reduced. [ABSTRACT FROM AUTHOR]

Objective Communication skills have gained increasing attention in medical education. Much of the existing literature and medical curricula addresses issues of doctor−patient communication. The critical importance of communication between health professionals, however, is now coming under the spotlight. The interdoctor telephone consultation is a common health care setting in which health professional communication skills are exercised. Breakdowns in this communication commonly occur and, surprisingly, this skill is not formally addressed in medical training. This study sought to clarify the communication issues that can occur during interdoctor telephone consultations in order to inform future educational initiatives in this domain. Methods Data were collected and triangulated among 3 sources: documentation of 129 telephone consults received; 51 hours of field observations of consultants, and semi-structured interviews of 12 callers and 12 consultants. Analysis was performed using grounded theory methodology. Results Overwhelmingly, participants described tensions with telephone consultation communication. Recurrent theme analysis revealed 5 key sources of tension: discursive features; context; fragmented clinical process; reason for call, and responsibility. Often, callers and consultants viewed similar instances in different and opposite manners, contributing to difficulties in the exchange. Further, a vicious cycle in which a participant's strategies to mitigate tension actually increased tension for the other participant was identified. Conclusions Interdoctor telephone consultation has become an integral part of medical practice; however, tensions within this exchange can undermine its effectiveness. The results of this study provide a preliminary theory upon which an educational intervention to improve this communication skill can be based. [ABSTRACT FROM AUTHOR]

Objective To understand core curriculum design and involvement of stakeholders. Methods Twelve homogeneous focus group interviews with a total of 88 students, house officers, senior doctors and nurses concerning an undergraduate emergency medicine curriculum. Following content coding of transcripts, we analysed by condensation, categorisation and qualitative content analyses. Results The focus group participants gave a range of reasons for defining objectives or outcomes. They found their involvement in the process essential. Their argumentation and beliefs differed significantly, revealing 2 opposite perspectives: objectives as context-free theory-based rules versus objectives as personal practice-based guidelines. The students favoured theory-based objectives, which should be defined by experts conclusively as minimum levels and checklists. The senior doctors preferred practice-based objectives, which should be decided in a collaborative, local, continuous process, and should be expressed as ideals and expectations. The house officers held both perspectives. Adding to complexity, participants also interpreted competence inconsistently and mixed concepts such as knowledge, observation, supervision, experience and expertise. Discussion Participating novices' perspectives on objectives differed completely from expertise level participants. These differences in perspectives should not be underestimated, as they can lead easily to misunderstandings among stakeholders, or between stakeholders, educational leaders and curriculum designers. We recommend that concepts are discussed with stakeholders in order to reach a common understanding and point of departure for discussing outcomes. Differences in perspectives, in our opinion, need to be recognised, respected and incorporated into the curriculum design process. [ABSTRACT FROM AUTHOR]

Introduction The need to use outpatient clinics as a major learning environment in hospitals for students and doctors-in-training is clear. However, consultant supervisors perceive major barriers to this and continue to rely heavily on traditional inpatient learning. This quantitative study examines what approaches consultant supervisors employ in outpatient learning, together with what they perceive themselves to use and what they would value in further training. Methods We observed learning episodes for students and doctors-in-training in medical and surgical clinics. A questionnaire on outpatient teaching was also sent to consultant doctors and surgeons. This was based on these observations and focus groups with students and doctors-in-training. Results There was an overall survey response rate of 62% (194/311). The dominant forms of learning we observed were ‘arms-length’ supervision for doctors-in-training and ‘modelling’ for students. Only 7% of learning episodes involved a doctor-in-training doing something under direct supervision. In contrast to the observation results, consultants considered that students and doctors-in-training received a lot of direct supervision and interaction. For example, 45% considered that doctors-in-training ‘may see patients with me in a joint consultation’. Only 30% of respondents would be interested in staff development in learning in outpatient clinics. Conclusions Although consultants reported that they frequently used an active approach to learning in outpatient clinics, modelling was used predominantly for students and arms-length supervision was used for doctors-in-training. [ABSTRACT FROM AUTHOR]

Background The continued reduction in junior doctors' hours in the UK has made it necessary to re-examine traditional assumptions about the synonymous natures of training and service. This paper researches senior house officers' (SHOs) perceptions of ‘service’ and ‘training’, with reference to where they place activities along the training/service continuum, and the factors that lead them to classify these activities in the way they do. Methods Questionnaires were sent to all identified SHOs at Plymouth Hospitals NHS Trust (40% response rate). Three focus groups were held with 5 SHOs, 3 consultants and 2 clinical tutors. Quantitative data derived from the questionnaires were analysed usingspss. Qualitative data collected in the focus groups was coded with the aid ofn6, which facilitated the thematic analysis of transcripts. Results Analysis of the quantitative data allowed the construction of the training/service continuum diagram. Identified factors affecting the perceived training/service balance of SHO activities included: frequency, time, type and nature of work, number of patients, supervision, interaction, other commitments, purpose and focus of the activity, the individual trainee and trainer, and experience and competence. Discussion It is no longer appropriate to assume that all junior doctor activities represent either training or service individually: activities are perceived differently along the training/service continuum depending on their execution and their relation to the SHOs' learning curves. Within the reduced hours framework, it is necessary to match this balance to experience, in order for both training and service requirements to be satisfied. [ABSTRACT FROM AUTHOR]

In 1997 the Royal College of Paediatrics and Child Health introduced portfolios to guide and monitor the learning of specialist registrars. We studied their value for assessment.Using Bigg's SOLO criteria we devised a marking scheme based on 6 domains of competence: clinical, communication, teaching and learning, ethics and attitudes, management and evaluation, and creation of evidence. We rated portfolios according to quality of evidence presented and expectations by year of training. We similarly assessed trainee performance in the annual record of in-training assessment (RITA) interview. Specific advice based on the results of the first portfolio assessments was circulated to all trainees, instructing them to increase the structure and decrease the bulk of portfolios. A second sample of portfolios was reviewed a year later, using similar evaluations, to determine the effects.A total of 76 portfolios were assessed in year 1 by a single rater; 30 portfolios were assessed in year 2 by 2 independent raters. The quality of documentation improved from year 1 to year 2 but there was no significant increase in portfolio scores. The inter-rater correlation coefficient of the portfolio assessment method was 0.52 (Cohen's kappa 0.35). The inter-rater correlation coefficient of the RITA interview was 0.71 (Cohen's kappa 0.38). There was moderate inter-assessment correlation between portfolios and RITA interviews (kappa 0.26 in year 1 and 0.29 in year 2). Generalisability analysis suggested that 5 successive ratings by a single observer or independent ratings by 4 observers on the same occasion would be needed to yield a generalisability coefficient> 0.8 for overall portfolio rating.This method of portfolio assessment is insufficiently reliable as a sole method for high stakes, single-instance assessment, but has a place as part of a triangulation process. Repeated portfolio assessment by paired observers would increase reliability. Longer term studies are required to establish whether portfolio assessment positively influences learner behaviour. [ABSTRACT FROM AUTHOR]

Recent studies raise concerns over the preparedness of newly qualified doctors for the role of the pre-registration house officer (PRHO). This study aimed to assess self-perception of preparedness, objective assessment of core clinical skills and the effect of an extended clinical induction programme prior to commencing full duties. A group of 26 newly qualified doctors from 1 district general hospital underwent an extended 5-day, ward-based induction programme. The participants completed questionnaires on their own perceptions of their preparedness for PRHO duties and underwent an objective structured clinical examination (OSCE) of 4 core clinical skills prior to induction, on completion of induction and 1 month into working life. At the outset PRHOs had low perceptions of their own capabilities in all clinical scenarios and skills. Most perceptions improved after induction, although in 2 clinical areas they felt even less confident. One month into post there were significant improvements in all areas. Only 1 PRHO passed all 4 clinical skills assessments at the pre-induction assessment. Seven (26%) failed on 1 or more skills at the post-induction assessment. However, all participants were deemed competent in all skills at the 1-month assessment. Newly qualified doctors do not feel prepared for PRHO duties and objectively are not competent in basic clinical skills. An extended induction improves preparedness in some but not all clinical areas and improves performance of objectively assessed clinical skills. [ABSTRACT FROM AUTHOR]

Both senior residents and faculty members evaluate family practice interns (PGY-1) on the inpatient family medicine service at the University of Missouri-Columbia. The purpose of this study was to investigate the content and nature of narrative comments on a clinical evaluation sheet. Objective 1. The authors placed the subjective comments made by faculty and senior residents in their evaluations of PGY-1 residents into 12 distinctive categories. Objective 2. Comments were coded with a positive or negative valence. Objective 3. The genders of the evaluator and learner were recorded. All evaluations made between 1996 and 1999 were analysed. A total of 1341 individual comments were reviewed. Objective 1. Categories used most often were generic comments (20.2%), personal attributes (18%), and clinical competence (14.1%). There was no difference in category use based on the experience level of the evaluator ( P = 0.17). Objective 2. The majority of the comments (81.9%) were positive in nature. Senior faculty members were significantly less likely to make negative comments than were junior faculty members or senior residents ( P = 0.004). Objective 3. There were no differences in category use based on the gender of the evaluator ( P = 0.13). Objective 1. Narrative evaluation comments may be placed into 12 distinctive categories. Most comments are generic and do not help to inform learning. Objective 2. A total of 82% of comments were positive. Residents were more likely to make negative comments than senior faculty members. Objective 3. There was no demonstrable gender bias in writing negative comments. [ABSTRACT FROM AUTHOR]

The intern year is a key time for the acquisition of clinical skills, both procedural and cognitive. We have previously described self-reported confidence and experience for a number of clinical skills, finding high levels of confidence among Australian junior doctors. This has never been correlated with an objective measure of competence. We aimed to determine the relationship between self-reported confidence and observed competence for a number of routine, procedural clinical skills. A group of 30 junior medical officers in their first postgraduate year (PGY1) was studied. All subjects completed a questionnaire concerning their confidence and experience in the performance of clinical skills. A competency-based assessment instrument concerning 7 common, practical, clinical skills was developed, piloted and refined. All 30 PGY1s then completed an assessment using this instrument. Comparisons were then made between the PGY1s' self-reported levels of confidence and tutors' assessments of their competence. A broad range of competence levels was revealed by the clinical skills assessments. There was no correlation between the PGY1s' self-ratings of confidence and their measured competencies. Junior medical officers in PGY1 demonstrate a broad range of competence levels for several common, practical, clinical skills, with some performing at an inadequate level. There is no relationship between their self-reported level of confidence and their formally assessed performance. This observation raises important caveats about the use of self-assessment in this group. [ABSTRACT FROM AUTHOR]

Objectives The requirement to align the arrangements for postgraduate training in the United Kingdom with those elsewhere in the European Community provided the opportunity to review and reform our arrangements for higher specialist training. This paper describes the case for change – the strengths and deficiencies of the traditional pattern of postgraduate medical training, demographic influences in the medical workforce and the need for a more structural or planned approach to training. Conclusions Over the past 5 years substantial progress has been made: the introduction of new regulatory arrangements and a new higher specialist training grade; the development of a managed and flexible system for delivering training to standards set by the Royal Colleges and which can accommodate the needs of those pursuing academic and research medicine; and the opportunity for trainees’ progress to be measured against published curricula. The significant programme of change has been underpinned by careful workforce planning and the publication of comprehensive guidance. Significant reform of higher specialist training has been achieved. This paper also makes the case for a more strategic approach to planning and developing␣medical education across the continuum, from entry to medical school until retirement, which can guide medical education and improve patient care into the next millennium. [ABSTRACT FROM AUTHOR]

For several months I and a team of fellow performers were involved, as simulated bereaved relatives, with a research project based in hospitals in the north-west of England. The project, the European Donor Hospital Education Programme, EDHEP (UK), was set up in order to provide a research input into the already established EDHEP in Europe. The programme is designed to develop communication and interpersonal skills among health care workers in Intensive Care/Therapy Units, especially in the breaking of bad news of death to near relatives and in asking consent for the removal of tissues and/or organs for transplantation. The associated research was initiated by an international grouping of clinical psychologists with the purpose of assessing the efficacy of the training schedule. Results are expected soon from the main body of research, some aspects of which provide analytical data drawn from encounters between health care professionals and actors as simulated relatives. Here, however, the experiences and feelings of the `relatives' themselves are described, discussed and reflected upon. [ABSTRACT FROM AUTHOR]