Views of junior doctors on the specialist registrar (SpR) training scheme: qualitative study of UK medical graduates

OBJECTIVE: To report junior doctors' views on specialist registrar (SpR) training. DESIGN: In 1999, as part of ongoing studies of doctors' careers, we surveyed all doctors who had qualified from UK medical schools in 1993. Structured questions about recipients' careers were accompanied by a form inviting free text comments. Comments about the SpR scheme were extracted for analysis. RESULTS: Doctors commented that there were insufficient national training numbers (NTNs) for those who wanted them, and that more than the minimum entry requirements seemed necessary for shortlisting. Strengthening curricula vitae through research and published work could prolong the duration of training and did not guarantee success. Specialist registrar training was considered by some respondents to be narrow and inflexible, with service work taking priority over training needs. As a result, some respondents feared they would not be competent to practise as consultants. There was a perceived shortage of consultant vacancies and 6 months was considered insufficient time for obtaining a suitable post. DISCUSSION: It is inevitable that doctors may not necessarily be able to pursue their initially chosen career paths. Trainers need to provide realistic advice about career opportunities. Provision of information about NTN availability and formal career counselling could help to prevent delays in career progression. The shortened and more structured programme of training has reduced its flexibility in some doctors' experience. Improvements in educational content will need greater input from consultants, which may require an increase in consultant posts. Time will tell whether concerns about competence to practise as consultants and consultant post availability will be justified.     

CPD for GPs using the THOR-GP website

BACKGROUND: An estimated 3200 UK general practitioners (GPs) practise occupational medicine on a sessional basis. AIM: To assess the educational needs of GPs practising occupational medicine and participating in The Health and Occupational Reporting (THOR) network. METHODS: A questionnaire survey of GPs participating in a national reporting scheme, recording occupational ill-health from general practice (THOR-GP). The questionnaire used scales derived from the syllabus for the Diploma of the Faculty of Occupational Medicine to assess the use of the THOR-GP website for continuing professional development (CPD). Questions were also asked concerning the attitudes and experience of these doctors to CPD in occupational medicine. RESULTS: The response rate was 73% (213/291). Only 22% of responders used the THOR-GP website for CPD. Lack of time was the most frequently cited reason for not using the site. The topics provided on the website which were rated least interesting also appeared as requests for further information in questionnaire returns. CONCLUSION: Online learning has the potential to fulfil the needs of GPs practising occupational medicine. The designers of material for online learning should actively manage and modify the material available in response to educational needs. Further research is required into the clinical and business outcomes of online learning for these doctors.     

Case mix presenting to paediatricians in a UK district (1998)

This observational study analysed paediatric outpatient referrals to a district service in the UK in 1998 and compared results with studies conducted 10 y previously.Data was collected prospectively from the written correspondence on all new outpatient referrals offered appointments by paediatricians at Northampton General Hospital over a 3-month period.Two hundred and ninety-seven (66%) referrals were to general paediatricians, 108 (24%) to 'patch' community paediatricians and 47 (10%) to community paediatrician consultant clinics. The referral rate to general outpatients was 20/1000 per annum, similar to referral rates in 1988. Urogenital and cardiac problems have overtaken asthma as the most commonly referred conditions. Referrals to consultant community paediatricians were predominantly development and behaviour difficulties and were more complex than those referred to other groups. 'Patch' community paediatricians received 87% of their referrals from practitioners other than doctors and played a significant role in co-ordinating care in the community. They referred less than 3% for consultant assessment.The referral rate to general paediatric outpatients has remained stable over the last decade although the case mix has changed. For the first time, we provide population-based case mix and referral rates to community paediatricians. We highlight the important role of non-consultant career grade paediatricians in supporting clinical services in the community. Open access to some investigations for general practitioners (GPs) could be explored as a way of managing demand for general paediatric outpatient appointments.     

Qualitative assessment of the long-term impact of a faculty development programme in teaching skills

CONTEXT: The long-term impact of faculty development programmes (FDPs) is poorly understood, and most assessments of them have been quantitative in nature. OBJECTIVE: This study aimed to use qualitative methods to better understand the long-term impact of an FDP in teaching skills (FDP/TS). METHODS: A survey was carried out in July 2002 of the 242 faculty members and fellows who had participated in a 9-month FDP/TS at any time from 1987 through 2000. The survey included 2 quantitative questions and an open-ended qualitative question about the impact of the programme on the participants' professional and personal lives. RESULTS: A total of 200 past participants (83%) responded to the survey. Participants from early and recent cohorts were similarly represented. In all, 82% of respondents said programme participation had had 'a moderate' or 'a lot' of impact on their professional life, and 49% said their personal life had been affected to this degree. Four major domains, each containing at least 3 subcategories, emerged from qualitative analysis. The domain intrapersonal development included changes participants reported in themselves and in their approach to self-management. Interpersonal development contained subcategories relating to how participants interact with others. Subcategories in the domain development as a teacher related to increased teaching ability and enjoyment. The domain career development included professional growth and career opportunities attributed to programme participation. CONCLUSIONS: Longitudinal FDPs can have broad and sustained positive effects on the professional and personal lives of participants. Qualitative evaluation methods may result in a richer and deeper understanding of the impact of these programmes.     

A survey of clinical teaching fellowships in UK medical schools

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.     

医师职业生涯规划长效管理机制探讨

目的：通过尝试建立医师职业生涯规划长效管理机制,走出驻军医院培养人才的新路,达到为我所用、人尽其才的目的。方法设计规划方案,包括建立规划管理组织、建立医师评价系统、设计职业规划方案、职业规划实施步骤四个环节。结果划分出职业生涯规划时限、制作《医师职业生涯规划实施手册》、《医师职业生涯规划专业资料》、《医院重点学科和核心技术五至十年发展实施方案》。结论将医师个人职业规划与医院发展规划相结合,建立长效管理机制,对驻军医院人才建设具有现实意义。     

Chiropractors' attitudes to, and perceptions of, the impact of continuing professional education on clinical practice

OBJECTIVES: As with other health care professions, there is a need for chiropractors to maintain their clinical competencies through continuing professional education (CPE) and development (CPD). This study set out to evaluate chiropractors' attitudes to, and opinions of, current CPE provision, and their perceived needs for the future. In particular, their perceptions of the impact of CPE on clinical practice were assessed. DESIGN: A survey in which primary quantitative and secondary qualitative data were collected using a self-administered questionnaire. The questionnaire concentrated on four areas: (i) attitudes to CPE; (ii) impact of current CPE on practice; (iii) modes of delivery most likely to change practice; and (iv) future learning needs from continuing education programmes. RESPONDENTS: A random sample of chiropractors registered with the British Chiropractic Association. RESULTS: Overall, chiropractors were positive to CPE and cognisant of the need to keep up to date. However, in spite of several benefits, chiropractors did not perceive current CPE to be instrumental in changing practice. As might be expected, chiropractors perceived clinical updates and hands-on practical workshops to be most effective in changing clinical practice. DISCUSSION: There is currently considerable debate surrounding the ability of CPE and CPD to actually make a difference to the way clinicians practice. This study describes a method of evaluating the impact of CPE/D in changing clinical practice from the viewpoint of the practitioners themselves.     

Development of the student practice evaluation form revised edition package

Background/aim: This paper describes the development of the Student Practice Evaluation Form Revised Edition (SPEF‐R) Package. This assessment tool was based on the Student Placement Evaluation Form (SPEF), which was used nationally to evaluate student performance on professional practice placements. Methods: The SPEF‐R was developed using an action research process through three cycles of action and reflection: (1) national consultation through telephone interviews with participants from three stakeholder groups (10 academics, 28 practice educators and 18 students); (2) development of the SPEF‐R Package; and (3) feedback on draft, piloting and launch. Results: In cycle 1, the most frequently identified strengths of the SPEF included its structure, comprehensiveness and clarity of expectations and utility in planning student placements. Overall, issues/concerns were less frequently identified and included length and the need for more training. In cycle 2, the SPEF‐R package was developed, with key changes made to the SPEF and handbook in response to results and the enhancement of tools for providing feedback on placements and recording practice experience. Cycle 3 involved obtaining feedback on the draft, further revision and launching of the tool. Discussion: Action research is useful for addressing practice issues in higher education. The development of the SPEF‐R was grounded in contemporary views regarding the provision of formative feedback and based on stakeholders’ views. However, further research is required to evaluate its properties as an assessment design. In addition, a training website for professional practice educators was created and an electronic version of the SPEF‐R is in development.     

Setting a standard for performance assessment of doctor-patient communication in general practice

CONTEXT: Continuing professional development (CPD) of general practitioners. OBJECTIVE: Criterion-referenced standards for assessing performance in the real practice of general practitioners (GPs) should be available to identify learning needs or poor performers for CPD. The applicability of common standard setting procedures in authentic assessment has not been investigated. METHODS: To set a standard for assessment of GP-patient communication with video observation of daily practice, we investigated 2 well known examples of 2 different standard setting approaches. An Angoff procedure was applied to 8 written cases. A borderline regression method was applied to videotaped consultations of 88 GPs. The procedures and outcomes were evaluated by the applicability of the procedure, the reliability of the standards and the credibility as perceived by the stakeholders, namely, the GPs. RESULTS: Both methods are applicable and reliable; the obtained standards are credible according to the GPs. CONCLUSIONS: Both modified methods can be used to set a standard for assessment in daily practice. The context in which the standard will be used - i.e. the specific purpose of the standard, the moment the standard must be available or if specific feedback must be given - is important because methods differ in practical aspects.     

The Art of Medicine through the Humanities: an overview of a one-month humanities elective for fourth year students

BACKGROUND: The purpose of incorporating humanities teaching into medical education is to encourage students to develop into more sensitive and caring doctors who communicate well with their patients and colleagues. CONTENT: A unique 4th year student elective at the Medical College of Wisconsin incorporates reflective and writing activities. Small group sessions are facilitated by faculty with specific interest and expertise in the humanities. EVALUATION: Students keep a journal in which they record their reflections on personal issues, career planning and reactions to classroom discussions. Each student writes a poem and an essay or short story. The course is well received and oversubscribed. CONCLUSIONS: Students increase their understanding of the humanities through readings, small group discussions, journal keeping and formal writing. By incorporating humanism into their professional lives, medical students can learn to care for their patients in a more humane and thoughtful manner.     

Students' attitudes and potential behaviour with regard to whistle blowing as they pass through a modern medical curriculum

OBJECTIVE: To examine students' attitudes and potential behaviour with regard to whistle blowing as they progress through a modern undergraduate medical curriculum. DESIGN: Cohort design. SETTING: University of Glasgow Medical School. SUBJECTS: A cohort of students entering Glasgow University's new learner-centred, integrated medical curriculum in October 1996. METHODS: Students' pre- and post-Year 1, post-Year 3 and post-Year 5 responses to the whistle blowing vignette of the Ethics in Health Care Instrument (EHCI) were examined quantitatively and qualitatively. Analysis of students' multichoice answers enabled measurement of movement towards professional consensus opinion. Analysis of written justifications helped determine whether their reasoning was consistent with professional consensus and enabled measurement of change in knowledge content and recognition of the values inherent in the vignette. Themes in students' reasoning behind their decisions of whether or not to whistle blow were also identified. RESULTS: There was little improvement in students' performance as they progressed through the curriculum in terms of their proposed behaviour on meeting the whistle blowing scenario. There was also no improvement in the quality of justifications provided. Students' reasoning on whether or not to whistle blow was found to change as the curriculum progressed. CONCLUSIONS: The EHCI has the potential to elicit students' attitudes towards ethical issues at entry to medical school and to measure change as they progress through the curriculum. Students should be encouraged to contemplate dilemmas from all ethical standpoints and consider relevant legal implications. Whistle blowing should be addressed as part of the wider domain of professionalism.     

The value of small group learning: an evaluation of an innovative CPD programme for primary care medical practitioners

INTRODUCTION: A 'competence' model of CPD using facilitated small groups covering a range of clinical topics is an alternative model to lecture-based CPD. The aim of this study was to evaluate a new small group CPD programme and to determine whether the anticipated improvements in the quality of learning were realised. METHOD: A nominal group technique (NGT) was used to compile two questionnaires for participants and facilitators, respectively, seeking quantitative and qualitative information. The NGT is an effective tool and particularly useful in developing questionnaires to evaluate an educational intervention. RESULTS: The results of the participants' survey indicated broad agreement with the NGT responses. For small group participants personal time constraints was the main reason given for not attending. 91% of the respondents indicated that the small group programme improved their knowledge, 73% indicated improvement in their patient care and 61% that their clinical skills had improved. Learning practical skills and the ability to identify and focus on specific learning needs of participants were strengths of the small groups. Participants valued the ability to deal with one theme in-depth over a number of weeks rather than many topics superficially in didactic lectures. CONCLUSION: The introduction of the small group CPD enabled an important shift from an update to a competence model of CPD, which has been shown to be more likely to lead to useful change in clinical practice. This approach to CPD should be encouraged. The main challenge for future research in this area is to assess the impact on clinical practice and health outcomes.     

Growth of analytical thinking skills over time as measured with the MATCH test

Context Ber’s Comprehensive Integrative Puzzle aims to assess analytical clinical thinking in medical students. We developed a paediatric version, the MATCH test, in which we added two irrelevant options to each question in order to reduce guessing behaviour. We tested its construct validity and studied the development of integrative skills over time. Methods We administered a test (MATCH 1) to subjects from two universities, both with a 6‐year medical training course. Subjects included 30 students from university 1 who had completed a paediatric clerkship in Year 4, 23 students from university 2 who had completed a paediatric clerkship in Year 5, 13 students from both universities who had completed an advanced paediatric clerkship in Year 6, 28 paediatric residents and 17 paediatricians. We repeated this procedure using a second test with different domains in a new, comparable group of subjects (MATCH 2). Results Mean MATCH 1 scores for the respective groups were: Year 4 students: 61.2% (standard deviation [SD] 1.3); Year 5 students: 71.3% (SD 1.6); Year 6 students: 76.2% (SD 1.5); paediatric residents: 88.5% (SD 0.7), and paediatricians: 92.2% (SD 1.1) (one‐way anova F = 104.00, P < 0.0001). Students of both universities had comparable scores. MATCH 1 and 2 scores were comparable. Cronbach’s α‐values in MATCH 1 and 2 were 0.92 and 0.91, respectively, for all subjects, and 0.82 and 0.87, respectively, for all students. Conclusions Analytical clinical thinking develops over time, independently of the factual content of the course. This implies that shortened medical training programmes could produce less skilled graduates.     

QUALITY ASSURANCE AND CONTINUING EDUCATION NEEDS OF RURAL AND REMOTE GENERAL PRACTITIONERS: HOW ARE THEY CHANGING?

ABSTRACT: The Royal Australian College of General Practitioners' (RACGP) 1998 Rural Quality Assurance and Continuing Education (QA & CE) Needs Assessment Project was designed to generate sufficient data to inform strategic planning for rural and remote GPs participating in the College's QA & CE Program. Results indicated that the demand for QA & CE activities has changed over the past 12 years. Three distinct streams of continuing education emerged, where once only one was researched. This reflected a move towards continuing professional development (CPD) rather than purely continuing medical education (CME). However, differences between the CME needs identified suggested that national data could not be reduced to the local level. Data on CME in which rural and remote GPs felt underserviced, proved more useful in relation to other workforce variables such as age, length of service and gender. A broad 'rural set' of CPD topics was established, and the survey yielded information on learning format preferences that will be of use to providers of QA & CE activities for rural GPs across Australia.     

First step: report on a pilot course for personal and professional development

OBJECTIVE: To describe a pilot course in personal and professional development, entitled 'Becoming a doctor: the first step' and our suggestions for what might be incorporated into future courses. SETTING AND CONTEXT: Leeds Medical School begins a new curriculum in September 1999 with a proportion of the first 3 years being devoted to a new module on personal and professional development. This module will include courses involving communication skills, ethics, working in groups and early patient contact through community visits. Some of these topics were piloted in a short course for first-year medical students in 1998. LEARNING METHODS: The course ran for 9 weeks and was largely experiential. The group facilitators came from diverse health and social care backgrounds. A variety of learning methods were used, concentrating on self-reflection, discussion, community visits and information gathering. EVIDENCE FOR EFFECTIVENESS: The views of both facilitators and students were analysed. Students particularly appreciated the community visits and group work. The facilitators were positive about the course overall while suggesting improvements, including their own involvement in future development of the course. CONCLUSIONS: The pilot course has helped us to focus on objectives for the new curriculum and to plan the new course. In particular there is a need for more attention to be given to the involvement of facilitators in course development.     

How well do paediatric residency programmes prepare residents for clinical practice and their future careers?

CONTEXT: Educators across Canada are presently discussing whether the current 4-year residency programmes adequately prepare paediatricians for their future careers. Studies carried out in the USA have repeatedly shown areas of weakness in residency training, but there are no studies looking at the overall adequacy of training across Canada. OBJECTIVES: To assess practising paediatricians' perceptions of the adequacy of their residency training as preparation for clinical practice and to assess practising paediatricians' opinions about the required mandatory length of training. METHODS: A questionnaire based on previous studies was sent to 434 paediatricians certified between 1999 and 2003, asking for their opinions of their preparedness for practice in the broad areas of paediatrics and in the professional roles of the doctor-specialist. RESULTS: Overall, 239 (55%) paediatricians replied, 96% of whom indicated they were 'adequately' or 'very well' trained. Areas in which opinions on training were positive included emergency medicine, neonatology, endocrinology, haematology/oncology, neurology, infectious diseases and respirology. Areas where preparation was considered to have been less adequate included gynaecology, child psychiatry, behavioural psychology, surgical specialties, orthopaedics and adolescents. With respect to the roles of the doctor-specialist, strengths of training included the areas of medical expert, collaborator, ethics and professionalism, and communicator. Respondents felt they were less adequately prepared for the role of a medical expert dealing with palliative care, for dealing with bereaved parents and as manager of an office practice. Despite these weaknesses, 80% felt that 4 years of training was sufficient. DISCUSSION: The results of the study are comparable with those of previous studies carried out in the USA and reinforce the need for regular programme assessment. This study will hopefully lead to the improvement of current paediatric residency programmes and enhanced education and training of future paediatricians. Although overall satisfaction with training was high, paediatric programmes need to make some changes by providing more appropriate training with less tertiary care, hospital-based training and more community and ambulatory-based experiences.     

Continuing professional development for general practitioners: supporting the development of professionalism

Medical Education 2010: 44 : 412–420 Objectives The profession of medicine has long been characterised by virtues such as authorisation, specialisation, autonomy, self‐regulation and adherence to an ethical code of practice, and its complexity has granted it the privilege of self‐regulation. Studies have shown continuing professional development (CPD) for general practitioners (GPs) to be most effective when it is set up within a multi‐method design. This paper reports a research‐based evaluation of a 2‐year educational CPD project for 21 GPs. Methods The project focused on the issue of ‘children in need’ and was delivered through group supervision, teaching days, an e‐portfolio, literature, newsletters and a desk checklist. A mixed‐methods evaluation design was used. Results The GPs demonstrated an overall preference for supervision as an authentic method for self‐directed professional development because it facilitated the creation of a common platform for relevant and useful knowledge in the context of general practice. Other methods were perceived as less valuable for GPs’ CPD. Conclusions The results suggest that general practitioners need to establish a common platform of shared experiences before engaging in multi‐professional CPD. Participation in the supervision allowed the three groups of GPs to develop their professional skills, but left them with a desire for more training in establishing cooperative practices with their partners in care. The professional challenges discussed during the supervision sessions were important elements of the national GP Curriculum, but not all elements of professionalism were covered.     

Continuing professional development of physicians in Uruguay: lessons from a countrywide experience

This article describes the advancement of continuing professional development (CPD) for physicians in Uruguay and explains the motivations for a CPD system, the role of the faculty of medicine and the other stakeholders, the strategic goals, and current results, including strengths and weaknesses. The work described here had three strategic objectives: (1) initiate a CPD accreditation program, (2) train physician leaders in CPD, and (3) promote the creation of a national system for CPD. By the end of 2006, the accreditation program had 34 accredited institutions. Over a 10-year period, 150 physician leaders from different regions of the country and with different specialties had been trained in the framework and methodological issues of CPD. Legislation is expected to be introduced into parliament during 2007 for coordinating CPD efforts at a national level.     

The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career

OBJECTIVES: This study examined determinants of students' attitudes to psychiatry and intentions to pursue psychiatry as a career, considering: (1) experiences during the clinical attachment; (2) type of curriculum (traditional or problem-based), and (3) student characteristics (age and gender). The relationships between attitudes, career intentions and academic performance were examined. METHOD: Fourth year medical students (n = 379) completed questionnaires at the beginning and end of an 8-week psychiatry attachment to assess their attitudes to psychiatry, career intentions and experiences during the attachment. Students completed two assessments consisting of a multiple choice paper and a clinical viva. Consecutive cohorts of students receiving a traditional curriculum (n = 188) and a problem-based curriculum (n = 191) were compared. RESULTS: Students' attitudes to psychiatry improved and intentions to pursue psychiatry as a career increased during the attachment. These changes were predicted by specific experiences during the attachment, such as receiving encouragement from consultants, seeing patients respond well to treatment and having direct involvement in patient care. There was no difference in change in attitudes or career intentions between the two cohorts. Students with more favourable attitudes or career intentions at the outset did not report more favourable experiences during the attachment. Attitudes and career intentions were unrelated to performance in psychiatry assessments. Improvement in attitudes was related to an increased intention to pursue psychiatry as a career. CONCLUSIONS: Change in attitudes and career intentions was dependent on the actions of the clinical teachers. Undergraduate teachers may have an important influence on the numbers of doctors who choose this specialty as a career.