Dason Evans

Support for students with academic difficulties

Context  The human and financial costs of academic failure amongst medical students are extremely high. Often, remedial support is infrequently available or is available only for students failing their final examinations. We describe the design, implementation and preliminary evaluation of a remedial programme (RP) for students who experience academic difficulties.

The effect of an extended hospital induction on perceived confidence and assessed clinical skills of newly qualified pre‐registration house officers

Background  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.

What is a clinical skill? Searching for order in chaos through a modified Delphi process

Background: Everybody seems to know what a clinical skill (CS) is but closer consideration shows that the concept of a CS is not as clear as might be assumed. Some seem to use “CSs” when just referring to physical examination skills, whereas others use the term to also include diagnostic, communication and practical skills. CSs are more than a simple performance, but clinicians are often not consciously aware of the complex interplay of different components of a CS that they are practicing and accordingly do not teach all these aspects to students. Methods: A modified Delphi research was designed to explore concepts around the definition of a CS and its components for learning and teaching. The panel consisted of a group of British doctors, all involved in teaching CSs. Results: One hundred and twenty-two items were identified and ranked through two rounds of a Delphi process, coded into thirty-seven codes and clustered into six principle themes: professional roles; components of CSs; performance; psychomotor aspects; educational environment; and teacher versus student centeredness. Conclusions: A CS may contain one or several different domains such as: physical examination skills, practical procedure, communication skills, and management. Acquiring CSs includes three components: learning how to perform certain movements (procedural knowledge), why one should do so (underlying basic science knowledge), and what the findings might mean (clinical reasoning). If we are to teach CSs for clinical practice, we must take these three different components into account in our instructional design.

Applying your clinical skills to students and trainees in academic difficulty.

Background:  When students and trainees in difficulty present late, there are often signs in their history that suggest that earlier identification and intervention might have been possible. Clinical supervisors may have been reluctant to explore issues with them, perhaps because they felt that it was not their role to do so, or that they may not have the necessary skills or perhaps because of the concern of ‘opening a can of worms’ that they would not be able to address.

Preparation for practice: how can medical schools better prepare PRHOs?

There is growing evidence that new PRHOs feel unprepared for their first post. This study compared three cohorts of graduates, the first from a traditional systems-based curriculum, the second from the same systems-based curriculum, who had also taken an intercalated degree, and the third from a PBL curriculum who had not intercalated. Subjective reports of confidence in clinical skills, anxiety and feelings of preparedness for practice were assessed using a previously published instrument. Graduates from the PBL curriculum who had not intercalated felt significantly better prepared, less anxious and more confident than equivalent graduates from the systems-based curriculum. Systems-based curriculum graduates who had taken an additional intercalated degree scored as highly in these criteria as the PBL graduates who had not intercalated. Despite these improvements, absolute levels of anxiety remained high and feelings of preparedness and confidence in clinical skills remained poor.

How do UK medical graduates rate their knowledge and skills in sexual health and HIV medicine? A national survey

The objectives of this study are to determine self-assessed knowledge and skills in sexual health and HIV medicine in preregistration house officers and to explore undergraduate experiences of teaching and assessment in these subjects prior to the launch of National Core Learning Outcomes in Sexual and Reproductive Health and HIV. The study was designed as a postal questionnaire survey. The participants were all UK medical graduates of August 2004. The response rate 1737/4746 (36%). The main outcome measures were Doctors’ views on their preparedness to manage patients with sexual health and HIV-related problems. Since graduation, 90% of respondents had seen at least one patient with a sexually transmitted infection or HIV-related issue. Seventy-six percent felt confident to take a sexual history. In all, 63% and 53% felt competent in male and female genital examination, respectively. Forty-three percent felt they could conduct an appropriate HIV pretest discussion and 59% felt they could recognize clinical indicators suggestive of HIV. Seventy-eight percent had been formally assessed in sexual health and 55% in HIV medicine. Increased confidence in sexual history taking, HIV pretest discussion and recognition of HIV indicators was associated with a longer duration of teaching and formal examination. In conclusion, although the proportion of recent graduates confident in sexual history taking is encouraging, their lack of skill in discussing HIV testing, risk assessment and recognition of possible HIV presentations must be addressed. Integration of National Core Learning Outcomes into all undergraduate curricula is a key step in reducing inconsistencies in undergraduate training.

Medical students' attitudes and behaviour towards sexual health interviewing: short- and long-term evaluation of designated workshops

Workshops aimed at promoting fourth-year medical students’ attitudes towards and subsequent behaviour in talking to patients about sexual health are reported on. Improvements in attitudes are reported following the workshops in 1999–2000 with students being more likely to see the relevance of sexual health enquiry, feeling more confident and competent about broaching the subject and expressing greater intention to do so. One year on, comparison of the intervention and non-intervention group for attendance at the workshop showed no difference in the proportion who had subsequently asked patients questions about sex. The proportion of students asking patients rose from 47% in the fourth year to 92% by the fifth year. Issues of long-term evaluation and the importance of the informal relative to the formal curriculum are discussed.

STIFCompetency: development and evaluation of a new clinical training and assessment programme in sexual health for primary care health professionals

UK sexual health services are shifting from hospital-based clinics into primary care, creating a need for high quality clinical sexual health training for non-specialists. Here we describe development, evaluation and costing of a new competency-based training programme, the Sexually Transmitted Infection (STI) Foundation Competency (STIFCompetency) programme, based on the Department of Healths toolkit for delivering more specialized sexual health in primary care. We used an action research paradigm with two iterative cycles. Evaluation was to Kirkpatricks third level with triangulation of results between trainers and trainees, and different methods, including portfolio evaluation, nominal group technique process, semi-structured interviews, Likert questionnaires and chlamydia testing rates. All 13 primary care clinicians completed the training successfully (median 20 hours) and rated STIFCompetency highly. Trainers needed to reduce their clinical workload to accommodate the training. Average cost per trainee was £1125, reflecting the need for direct observation of competence across a wide range of clinical skills.

Red urine in a returning traveller.

and neither had any history of anxiety or depressive illness. They were both experiencing chronic, stressful situations that had not changed over time. The first patient’s problems were related to immigration and the latter with relationship and monetary problems. Given the lack of a premorbid psychiatric history and the association of efavirenz with psychiatric adverse effects in early treatment, withdrawal of therapy was undertaken in case there was a lateonset adverse drug reaction. There was an immediate improvement in mood and clarity of thought in both patients on instituting this change. They had both returned to their normal psychiatric state two weeks later. In these two patients, there appears to be a direct association between their treatment with efavirenz and late-onset neuropsychiatric complications. It would be interesting to hear if this has been observed elsewhere. It may be that, if a patient is taking efavirenz and does develop neuropsychiatric problems, consideration should be given to changing their therapy even if they have been taking the drug for a prolonged period of time. S Dawson and C Woods The Garden Clinic, Department of Sexual Health, Sexual Health Service, Upton Hospital, Slough, Berkshire SL1 2BJ, UK Correspondence to: Dr S Dawson Email: Stephen.Dawson@berkshire.nhs.uk

Ongoing faculty development for peer tutors: A widely neglected need.

Various advantages associated with PAL have been described. Tutees report being more comfortable clarifying their understanding and practicing new skills with peer instructors than with faculty. Peer tutors also sometimes know the current curriculum better and can incorporate their own contemporary clinical experiences into their teaching. Several studies have shown no significant difference in OSCE results for students taught by peers versus expert tutors. Student tutors report improvement in their own clinical skills and increased self‐confidence, demonstrating a reciprocity of learning. For the institution, PAL can be a cost‐effective method of teaching, particularly important in resource‐poor settings. This growing body of literature provides strong support for the use of PAL within medical education and underlies the trend towards more institutions implementing this teaching method.