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.     

Perceptions of dissection by students in one medical school: beyond learning about anatomy. A qualitative study

INTRODUCTION: The practice of dissection, as part of undergraduate medical education, has recently resurfaced in the public eye. This paper focuses on a number of important learning outcomes that were reported by Year 1-5 medical students in a British medical school, during the dissection sessions in the first 2 years of their training, as part of a wider qualitative research project into undergraduate medical education. METHODS: A group of 29 students was selected by quota sampling, using the whole student population of the medical school as the sampling frame. Qualitative data were collected by 1 : 1 interviews with students and from formal non-participatory observations of dissection sessions. RESULTS: Apart from learning to cope with the overt 'emotional confrontation' with the cadavers which assists anatomical learning, 7 additional covert learning outcomes were identified by the students: teamwork, respect for the body, familiarisation of the body, application of practical skills, integration of theory and practice, preparation for clinical work, and appreciation of the status of dissection within the history of medicine. DISCUSSION: A number of medical schools have either removed the practical, hands-on aspect of dissection in the medical undergraduate curriculum or are seriously considering such a measure, on financial and/or human resource grounds. This study highlights the fact that dissection can impart anatomical knowledge as well as offer other relevant, positive learning opportunities to enhance the skills and attitudes of future doctors.     

Approaches to medical student remediation after a comprehensive clinical skills examination

OBJECTIVE: Most US medical schools conduct comprehensive clinical skills assessments during Years 3 and 4. This study explores strategies used to identify and remediate students who perform poorly on these assessments. METHODS: In the academic year 2005-06, we conducted 33 semi-structured interviews with individuals responsible for standard setting in and remediation after their schools' comprehensive clinical skills assessments. We coded interviews to identify major themes. RESULTS: Prior to remediation, some schools employed a 'verification' step to ensure the accuracy of the failing score or need for remediation. Participants described a remediation process that included some or all of 3 steps. Firstly, students' specific learning deficits were diagnosed. Next, students participated in remedial activities such as performance review sessions or practice with standardised or actual patients. Lastly, students were re-tested, usually with a shorter, more formative examination. All participants reported using a diagnostic step, most offered or required remedial activities and many re-tested, although schools varied in the emphasis placed on each step. Many participants cited the individualised attention students received from remediation faculty staff as a strength of their approach, although they raised concerns about the substantial time demands placed on remediation faculty. Most respondents reported some dissatisfaction with their school's remediation process, particularly uncertainty about efficacy or rigour. CONCLUSIONS: Schools vary in the intensity and scope of remediation offered to students who perform poorly on clinical skills assessments. Although many schools invest significant resources in remediation, the effect of these efforts on students' subsequent clinical performance is unknown.     

How comfortable do first-year medical students expect to be when taking sexual histories?

The authors assessed the expected degree of comfort among first-year students at two California medical schools in taking a sexual history from four types of patients: heterosexual men; heterosexual women; homosexual (men and women combined); and an AIDS patient. Data were from questionnaires administered at two California medical schools (response rate = 87%). Students expected to be significantly more comfortable with heterosexual patients who were the same sex as the student. Students who had previously taken a sexual history anticipated relatively more comfort with heterosexual patients. The lowest expected comfort was for the AIDS patient. Older students expected to be more comfortable with the AIDS patient, independent of the student's personal sexual experience. Students with a homosexual friend anticipated more comfort with both the AIDS patient and the homosexual patients.     

Variation by medical school in career choices of UK graduates of 1999 and 2000

OBJECTIVE: To report on how newly qualified doctors' specialty choices, and factors that influenced them, varied by medical school. DESIGN: Postal questionnaires. SETTING: United Kingdom. SUBJECTS: All doctors who graduated in the UK in 1999 and 2000. MAIN OUTCOME MEASURES: Choices of eventual career expressed 1 year after graduating, and factors influencing their choices. RESULTS: There were some significant differences between medical schools in the career choices made by their graduates. For example, the percentage of respondents who expressed the choice of general practice was significantly low among graduates of Oxford and Cambridge and high among graduates of Birmingham and Leicester. There was also significant variation between medical schools in choices for hospital medical and surgical specialties. There were significant differences, too, between medical schools in the extent to which career choices had been strongly influenced by graduates' inclinations before starting medical school and by their experience of their chosen specialty, particular teachers and departments at medical school. As well as the differences, however, there were also many similarities between the schools in graduates' career choices. DISCUSSION: Medical schools currently provide students with a broad training suited to any subsequent choice of specialty. We suggest that the similarities between schools in the career choices made by graduates are generally more striking than the differences. We raise the question of whether there should be any specialisation by individual schools to train students for careers in particular branches of medical practice.     

Mentioning race at the beginning of clinical case presentations: a survey of US medical schools

Objectives  Medical students and doctors in the USA frequently mention the patient's race at the beginning of oral or written clinical case presentations. However, this practice is controversial. We aimed to determine whether US medical schools explicitly teach students to mention race at the beginning of case presentations, and to collect additional information on the schools' perspectives on this practice.
Methods  An Internet-based questionnaire was submitted to directors of courses on history taking and physical examination at all US medical schools.
Results  The response rate was 85%. Students are taught to mention race routinely at 11% of schools and selectively at 63% of schools; this practice is discouraged at 9% of schools and not addressed at 18% of schools. Most respondents noted that resident doctors at their institutions routinely mention race at the beginning of case presentations. Even at schools in which mentioning race is discouraged or not addressed, students tend to include race during their clinical rotations. Respondents were divided on whether a standardised approach to inclusion of race should exist at US schools.
Conclusions  Teaching about inclusion or exclusion of race in the opening statement of clinical case presentations varies across US medical schools. This variation presents an opportunity for medical educators to discuss tensions between stereotyping and cultural competence in medical education.     

The teaching of professional attitudes within UK medical schools: Reported difficulties and good practice

INTRODUCTION: The demonstration of appropriate attitudinal behaviour is crucial in the professional development of doctors. This study explores the experiences of UK medical schools in developing and assessing the behaviour associated with the attitudes of undergraduate medical students. METHODS: A qualitative in-depth interview study was based on a questionnaire survey of all UK medical schools. Six heads of medical schools or their nominated representatives were interviewed. Outcome measures were the perceptions and experiences of developing and assessing appropriate attitudes and behaviour in their undergraduate students. RESULTS: Aspects of the hidden curriculum, especially the negative role modelling encountered during clinical practice, were seen to undermine the attitudinal messages of the formal curriculum. Some participants believed that students could still qualify as doctors despite having inappropriate attitudes or behaviour. Others felt certain that this was now unlikely in their school, and this confidence seemed to be backed up with the knowledge that strategies, systems and structures were in place to detect and act upon poor behaviour. DISCUSSION: The conviction that it is right to assess students on their attitudinal behaviour does not yet appear to be held consistently across all schools and we suggest that this may reflect some fundamental tensions arising from differing views about the essential elements of good medical practice, tensions that are also shaping the hidden curriculum.     

Incidence of and sequels to medical problems discovered in medical students during study-related activities

PURPOSE: Students often act as subjects during practical and clinical skills training sessions. This routine seems to be quite acceptable for them but may present side-effects. Disorders, sometimes of a serious nature, have been discovered in medical students during clinical skills training. Because the incidence of and sequels to medical problems discovered in medical students during study-related activities are unknown, we carried out an explorative study. METHODS: An anonymous questionnaire was administered to 1132 students (85%) in our medical school. RESULTS: A total of 740 students (65% response rate) returned the questionnaire. Of them 124 (16.8% of respondents) reported 139 incidents. The estimated incidence was 1.5% per year. In 63 cases (45%) the diagnosis of a consulted doctor was known. Pathology (e.g. a ventricular septal defect) was revealed in 30 students (21%), a normal physiological variation (e.g. a functional cardiac murmur) in 22 (16%) and no abnormality was found in 11 (8%). Most of the incidents (65%) occurred during clinical skills training. The incidents were experienced negatively by 35% of the students. CONCLUSION: Based on these findings, we estimate the incidence of medical problems discovered in medical students during study-related activities to be 1.5%. This and the moral and legal implications emphasise that every medical school should realise the possibility of consequences. In our opinion, this realisation should result, minimally, in the development of a protocol for students and faculty that outlines procedures for handling such incidents. Information should also be provided explaining these possible side-effects of medical education.     

Effects of basic clinical skills training on objective structured clinical examination performance

OBJECTIVES: The aim of curriculum reform in medical education is to improve students' clinical and communication skills. However, there are contradicting results regarding the effectiveness of such reforms. METHODS: A study of internal medicine students was carried out using a static group design. The experimental group consisted of 77 students participating in 7 sessions of communication training, 7 sessions of skills-laboratory training and 7 sessions of bedside-teaching, each lasting 1.5 hours. The control group of 66 students from the traditional curriculum participated in equally as many sessions but was offered only bedside teaching. Students' cognitive and practical skills performance was assessed using Multiple Choice Question (MCQ) testing and an objective structured clinical examination (OSCE), delivered by examiners blind to group membership. RESULTS: The experimental group performed significantly better on the OSCE than did the control group (P < 0.01), whereas the groups did not differ on the MCQ test (P < 0.15). This indicates that specific training in communication and basic clinical skills enabled students to perform better in an OSCE, whereas its effects on knowledge did not differ from those of the traditional curriculum. CONCLUSION: Curriculum reform promoting communication and basic clinical skills are effective and lead to an improved performance in history taking and physical examination skills.     

Selection for medical school: just pick the right students and the rest is easy!

BACKGROUND/AIMS: The new Peninsula Medical School (PMS) admitted its first undergraduate cohort in September 2002. Development of a new school has given rise to opportunities for critical appraisal of best practice in selecting students for medical school and development of new ways forward. METHODS: The authors developed a selection strategy and principles grounded in the objectives of the PMS programme and drawing extensively on best practice in assessment. Critical appraisal of custom and practice amongst other UK medical schools led to the rejection of hitherto commonly used instruments and procedures and the development of new ones. Common assumptions about ways to ensure quality were also challenged. RESULTS: A process for development of an evidence-based selection strategy is described. In addition, selection instruments and criteria to be used in a new medical school are discussed. Quality performance policies informed by psychometric and qualitative assessment performance measures are recommended. DISCUSSION AND CONCLUSION: Critical appraisal of custom and practice and the development of new strategies, criteria and selection instruments go only part way to informing best practice. As with other UK medical schools grappling with these issues, the test of these selection processes lies in their product.     

Meeting the challenge of prescribing and administering medicines safely: structured teaching and assessment for final year medical students

OBJECTIVES: To promote safe prescribing and administration of medicines in the pre-registration house officer (PRHO) year through a programme of structured teaching and assessment for final year medical students. DESIGN: Forty final year medical students from two medical schools were randomly allocated either to participate in a pharmacist facilitated teaching session or to receive no additional teaching. Teaching comprised five practical exercises covering seven skills through which students rotated in small groups. One month later, a random sample of 16 taught and 16 non-taught students participated in a nine-station objective structured clinical examination (OSCE) to assess the impact of the teaching. SETTING: Manchester School of Medicine (MSM), and Kings College School of Medicine and Dentistry (KCSMD). PARTICIPANTS: Final year medical student volunteers. MAIN OUTCOME MEASURES: The need for teaching as indicated by student prior experience; questionnaire rating of student acceptability of teaching and assessment; self-rating of student confidence post-assessment, and student performance assessed by OSCE. RESULTS: The study demonstrated that the taught group achieved higher scores in eight OSCE stations. Four of these were statistically significant (P < or= 0.005). Taught students felt more confident performing the skills on five stations. From 0 to 47.5% students had prior experience of the skills taught. The post-teaching questionnaire evaluated exercises positively on several criteria, including provision of new information and relevance to future work. CONCLUSIONS: Structured teaching provided an effective and acceptable method of teaching the medicines management skills needed in the PRHO year. The structured approach complemented variable precourse clinical experience.     

Improving medical student performance in adolescent anti-smoking health promotion

BACKGROUND: We developed a 1-hour teaching seminar for medical students on anti-smoking health promotion for adolescents. We report the development of the programme and a performance-based evaluation. AIM: To develop a seminar for medical students with the objective of improving medical student inquiry into smoking and the delivery of advice accordingly for adolescent patients in routine consultations. METHOD: The seminar was developed using principles of adult learning and delivered to a cohort of medical students (intervention group). Participants were Year 5 medical students in their paediatrics term. A comparison group of 58 medical students who did not receive the seminar was studied in the semester prior to the intervention. The primary outcome measure was a change in anti-smoking health promotion practice within an objective structured clinical examination (OSCE), where taking a smoking history and making links between smoking status and health were indicated in a 15-year-old simulated patient (SP) with poorly controlled asthma. This was part of the summative assessment in the paediatrics term. RESULTS: In the OSCE, 21 of 58 (36%) students in the comparison group asked the asthmatic SP about smoking, compared with 41 of 56 (73%) students in the intervention group (P = 0.0001). In all, 15 (26%) of the comparison group students addressed the patient's smoking, compared with 33 of the 56 (59%) intervention group students (P = 0.0004). CONCLUSION: A carefully designed seminar addressing adolescent smoking can increase the frequency of smoking inquiry and advice by medical students.     

UK consensus statement on the content of communication curricula in undergraduate medical education

Context The teaching and assessment of clinical communication have become central components of undergraduate medical education in the UK. This paper recommends the key content for an undergraduate communication curriculum. Designed by UK educationalists with UK schools in mind, the recommendations are equally applicable to communication curricula throughout the world. Objectives This paper is intended to assist curriculum planners in the design, implementation and review of medical communication curricula. The document will also be useful in the education of other health care professionals. Designed for undergraduate education, the consensus statement also provides a baseline for further professional development. Methods The consensus statement, based on strong theoretical and research evidence, was developed by an iterative process of discussion between communication skills leads from all 33 UK medical schools conducted under the auspices of the UK Council of Clinical Communication Skills Teaching in Undergraduate Medical Education. Discussion How this framework is used will inevitably be at the discretion of each medical school and its implementation will be determined by different course designs. Although we believe students should be exposed to all the areas described, it would be impractical to set inflexible competency levels as these may be attained at different stages which are highly school‐dependent. However, the framework will enable all schools to consider where different elements are addressed, where gaps exist and how to generate novel combinations of domains within the communication curriculum. It is hoped that this consensus statement will support the development and integration of teaching, learning and assessment of clinical communication.     

The impact of case specificity and generalisable skills on clinical performance: a correlated traits-correlated methods approach

Context  The finding of case or content specificity in medical problem solving moved the focus of research away from generalisable skills towards the importance of content knowledge. However, controversy about the content dependency of clinical performance and the generalisability of skills remains.
Objectives  This study aimed to explore the relative impact of both perspectives (case specificity and generalisable skills) on different components (history taking, physical examination, communication) of clinical performance within and across cases.
Methods  Data from a clinical performance examination (CPX) taken by 350 Year 3 students were used in a correlated traits−correlated methods (CTCM) approach using confirmatory factor analysis, whereby 'traits' refers to generalisable skills and 'methods' to individual cases. The baseline CTCM model was analysed and compared with four nested models using structural equation modelling techniques. The CPX consisted of three skills components and five cases.
Results  Comparison of the four different models with the least-restricted baseline CTCM model revealed that a model with uncorrelated generalisable skills factors and correlated case-specific knowledge factors represented the data best. The generalisable processes found in history taking, physical examination and communication were responsible for half the explained variance, in comparison with the variance related to case specificity.
Conclusions  Pure knowledge-based and pure skill-based perspectives on clinical performance both seem too one-dimensional and new evidence supports the idea that a substantial amount of variance contributes to both aspects of performance. It could be concluded that generalisable skills and specialised knowledge go hand in hand: both are essential aspects of clinical performance.     

Can medical schools rely on clerkships to train students in basic clinical skills?

OBJECTIVE: Many medical schools have drawn up lists of basic clinical skills that students are required to have mastered at the end of medical training. To determine whether undergraduate students actually perform these basic clinical skills during clerkships and whether different approaches to skills training led to different results, we surveyed 365 final-year medical students in 1996 and 1997. METHOD: A questionnaire containing items on 265 skills in eight body systems was administered to students from two conventional medical schools (Ghent and Antwerp, Belgium), and one Dutch medical school, Maastricht, which offers a problem-based curriculum and systematic skills training. RESULTS: Although quite a few skills were not performed by Maastricht students, the results of this school compared favourably to those of the Ghent and Antwerp medical schools. Significant differences between Ghent and Antwerp were found for surgery, paediatrics and gynaecology/obstetrics. In the non-obligatory clerkships in dermatology, otorhinolaryngology and ophthalmology a great percentage of skills were not performed. CONCLUSIONS: The main conclusion is that all three medical schools cannot rely on clerkship experiences alone to provide adequate basic skills training. A problem-based learning environment and training in a skills laboratory appear to result in students performing more skills during clerkships. Assessment of clinical skills, obligatory clerkships in specialties and general practice, and continuous monitoring of the quality of clerkships may also be strong determinants of the present findings.     

A survey of medical undergraduate community-based teaching: taking undergraduate teaching into the community

Summary: Summary. This article summarizes the findings of a survey investigating the extent to which medical schools in the United Kingdom have developed community-based undergraduate teaching: the types of courses being run and their content; whether they are being evaluated; and how the students are assessed. Courses have been categorized under four main headings: (1) based in general practice, for teaching about general practice as a clinical specialty or using practice patients for teaching general medicine and basic clinical skills; (2) community-oriented, led by GP or community tutors; (3) specialist teaching led by hospital consultants; and (4) agency-based teaching. Twenty-eight schools responded to a written request for information and details of 83 courses were received.     

Survey of the teaching of disability and rehabilitation to medical undergraduates in the UK

The objective of the following survey was to attempt to establish to what extent the undergraduates in medical schools in the UK were being exposed to structured teaching of disability and rehabilitation (i.e. seminars, lectures, group discussions). A questionnaire and covering letter were sent to 25 medical schools exploring how the teaching was performed and whether it utilized the active involvement of disabled people and/or their carers. It also attempted to ascertain the degree of interdisciplinary teaching occurring. Results showed that rheumatology, general practice and geriatrics were predominantly responsible for this teaching, with little structured teaching in ENT and ophthalmology. Five schools (25%) reported back that no structured teaching was occurring in any department. As expected, there was a larger proportion of positive responses on opportunistic teaching (ward rounds, outpatients). Additional invited comments on the questionnaire revealed a variety of innovative activities taking place in different medical schools. It is recognized that a questionnaire of this nature has limitations; nevertheless, it did reveal gaps in the teaching of disability and rehabilitation, with several responses indicating that excess pressure on the curriculum from other subjects left little or no space at the present time. Our survey suggests that disability and rehabilitation are given insufficient emphasis in undergraduate teaching. In particular, more active involvement of patients and their carers should be encouraged. The small proportion of schools which teach rehabilitation as a defined specialty no doubt reflects the inadequate academic structure at present in this field.     

Target-focused medical emergency team training using a human patient simulator: effects on behaviour and attitude

CONTEXT: Full-scale simulation training is an accepted learning method for gaining behavioural skills in team-centred domains such as aviation, the nuclear power industry and, recently, medicine. In this study we evaluated the effects of a simulator team training method based on targets and known principles in cognitive psychology. METHODS: This method was developed and adapted for a medical emergency team. In particular, we created a trauma team course for novices, and allowed 15 students to practise team skills in 5 full-scale scenarios. Students' team behaviour was video-recorded and students' attitude towards safe teamwork was assessed using a questionnaire before and after team practice. RESULTS: Nine of 10 observed team skills improved significantly in response to practice, in parallel with a global rating of team skills. In contrast, no change in attitude toward safe teamwork was registered. CONCLUSION: The use of team skills in 5 scenarios in a full-scale patient simulator environment implementing a training method based on targets and known principles in cognitive psychology improved individual team skills but had no immediate effect on attitude toward safe patient care.     

Training the clinical eye and mind: using the arts to develop medical students' observational and pattern recognition skills

INTRODUCTION: Observation, including identification of key pieces of data, pattern recognition, and interpretation of significance and meaning, is a key element in medical decision making. Clinical observation is taught primarily through preceptor modelling during the all-important clinical years. No single method exists for communicating these skills, and medical educators have periodically experimented with using arts-based training to hone observational acuity. The purpose of this qualitative study was to better understand the similarities and differences between arts-based and clinical teaching approaches to convey observation and pattern recognition skills. METHOD: A total of 38 Year 3 students participated in either small group training with clinical photographs and paper cases (group 1), or small group training using art plus dance (group 2), both consisting of 3 2-hour sessions over a 6-month period. FINDINGS: Students in both conditions found value in the training they received and, by both self- and instructor-report, appeared to hone observation skills and improve pattern recognition. The clinically based condition appeared to have been particularly successful in conveying pattern recognition concepts to students, probably because patterns presented in this condition had specific correspondence with actual clinical situations, whereas patterns in art could not be generalised so easily to patients. In the arts-based conditions, students also developed skills in emotional recognition, cultivation of empathy, identification of story and narrative, and awareness of multiple perspectives. CONCLUSION: The interventions studied were naturally complementary and, taken together, can bring greater texture to the process of teaching clinical medicine by helping us see a more complete 'picture' of the patient.     

Teaching clinical skills to medical students: the use of simulated patients and videotaping in general practice

This paper describes the use of simulated patients in a problem-based teaching programme designed to develop the clinical skills of medical students during a 5-week course in general practice in the University of Leicester. The logistics of training and the advantages of using simulated patients are discussed. Simulated patients are practicable and acceptable in a United Kingdom medical school, and the reaction of students to their use is favourable.