Identifying core skills for the medical curriculum

A survey was undertaken at the University of Sheffield Medical School to identify clinical and other professional skills which are required on graduation and to assess whether and when these skills have been acquired. The purpose of the survey was to identify core practical skills, defined as skills which the majority of clinical firms require and which, in addition, were used by the majority of Pre-registration house officers (PRHOs). The survey was conducted by questionnaires which were circulated to the following four sample groups (number in sample: % response rate): (1) consultants in clinical firms taking undergraduates and post-graduates from Sheffield Medical School (63: 75%); (2) house officers starting their pre-registration year (118: 52%); (3) house officers ending their pre-registration year (120: 43%); and (4) undergraduates starting their final year (110: 65%). The questionnaire contained a stimulus list of 31 clinical and four personal skills with an opportunity for respondents to list other skills they felt to be important. Of the 35 skills listed on the questionnaire, 26 were identified as core practical skills. Fifteen of the core skills had been acquired by the majority of students by the time they graduated, 13 of which were acquired prior to the final undergraduate year. Core skills not acquired as an undergraduate were acquired as a PRHO. The survey acted as a quality control mechanism for teaching at both undergraduate and post graduate levels and provided the basis of a medical school core of practical skills on the basic medical education continuum.     

Working patterns and the quality of training of medical house officers: evaluating the effect of the `new deal'

The `new deal' on junior doctors' hours of work has led to the widespread introduction of working patterns such as full shifts and partial shifts in the United Kingdom. The impact of these changes on the training of medical staff is unclear. The subjects of the current study were 36 pre-registration medical house officers working shift rotas and on-call rotas at a teaching hospital in the north of England. They were studied over a 12-month period using a self-report questionnaire seeking their views on the quality of their training experience and their satisfaction with the in-service training they received. Nursing staff, consultant and medical student opinion was also sought. Partial-shift and full-shift systems led to reduced hours of work when compared to on-call rotas (mean hours: partial shift 65·0; full shift 59·8; on-call 72·7), but they were associated with significantly lower training experience and training satisfaction scores for the house officers than were on-call systems (P < 0·01). Shift systems were unpopular among consultants and medical students but not nursing staff. Despite reducing excessive hours of work, shifts may be detrimental to the training of medical house officers. The further imposition of shift working should be suspended until such time as the impact of new working patterns on the training of medical staff has been determined.     

The clinical and educational experiences of pre-registration house officers in general practice

AIMS: To describe aspects of the clinical experience and educational supervision gained by pre-registration house officers (PRHOs) in general practice, and to relate these to the current General Medical Council (GMC) aims for general clinical training in general practice. DESIGN: Qualitative evaluation, part of which involved semistructured interviews with 12 PRHOs who were experiencing a general practice rotation. Interviews were conducted at the beginning and the end of the pre-registration year, and following return to hospital work after completion of the general practice placement. SETTINGS: Three teaching hospitals, two district general hospitals and six general practices in south-east England. PARTICIPANTS: 12 PRHOs who were involved in rotations incorporating a general practice placement. RESULTS: To varying degrees, the GMC aims for training in general practice were met for all the participants. All PRHOs recognized the value of the clinical experience and educational supervision they received in general practice. They particularly valued aspects such as having an individual training programme based on their own needs, and the interlinking of theory and practice, which aided learning. Most felt that having responsibility for their own patients acted as an important incentive for learning, and in general, PRHOs appreciated having the time to learn which general practice allowed. CONCLUSIONS: For the majority of PRHOs, the time spent in general practice was seen as a positive clinical and educational experience. In a variety of ways, the general practice placement encouraged PRHOs to develop the self-directed learning skills seen as essential to the lifelong learning advocated by the GMC. A number of recommendations are made to help improve the integration of the hospital and general practice components of these rotations.     

Skills of pre-registration house officers: gender differences reported in Norway

During training pre-registration house officers should acquire skills, practical clinical procedures, and good clinical judgement, in order to be able to practice on their own. This is not always the case ( Flaatten et al. 1987 ). Ten years ago the Norwegian Health Authorities issued a regulation regarding the content of hospital training (6 months internal medicine and surgery, respectively). A number of practical skills to be learned were listed. As part of an assessment of the quality of the internship, a study was carried out into what extent the pre-registration house officers had acquired these clinical skills.     

Doctors' views about their first postgraduate year in UK medical practice: House officers in 2003

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.     

An audit of clinical teaching in paediatric surgery to interns and surgical registrars

OBJECTIVES: The study aimed to assess the knowledge increment in paediatric surgery of interns (pre-registration) after a 1-month period of training and of registrars after a 6-month rotation. A comparison of the knowledge base of interns from different universities was included. DESIGN: A standard questionnaire was completed by all interns and registrars on the first day of their appointment and again at the end of rotation. Knowledge increment was assessed for each student and each question. SETTING: King Edward VIII Hospital, Durban, South Africa. SUBJECTS: Interns (equivalent to pre-registration house officers) and registrars (registered practitioners) undergoing general surgical training. RESULTS: Both registrars and interns improved their test scores after their training period. However, satisfactory exit scores were achieved by interns in only 72% of questions. CONCLUSIONS: This study forms the basis for assessing future educational strategies and has identified areas of teaching weakness which can be remedied. The reduction in exposure of interns to clinical paediatric surgery must be balanced by more efficient use of teaching time.     

The pre-registration house officer year: a critical incident study

To define the major problems faced by pre-registration house officers, 328 critical incidents from 200 house officers and related staff were collected. Each incident was analysed and key words representing the main features were abstracted. These were then aggregated into eight broad categories; personal aspects, clinical skills, communication and relationships, problem-related, organization skills, education, dying patients, and administration. Further analysis of the incidents suggested a series of conclusions which include the need for effective supervision of the house officer with feedback on performance. An induction/orientation period is necessary; there is evidence that a proportion of house officers need additional experience of practical procedures; house officers often have difficulty in setting priorities and they have little experience, prior to qualification, of organizational skills; during the year they are very busy with little time off. Facilities and accommodation may be less than adequate. They perceive a lack of support from senior staff to help with personal problems and career guidance; they are conscious that communication skills are of great importance and would like additional help with this; there is little time for formal education during the year. The range of clinical material presented is enormous, however, and the challenge for medical education is to ensure that the opportunities for learning are not missed.     

A qualitative study of pre-registration house officers in general practice

OBJECTIVES: To evaluate a unique pre-registration house officer (PRHO) rotation involving half a week in general practice over a 4-month period. House officers' and supervisors' views were sought on the value of this type of rotation. DESIGN: Qualitative study using semi-structured interviews. SETTING: A four-partner postgraduate training practice in a deprived urban part of North-east England. SUBJECTS: Pre-registration house officers and supervisors. RESULTS: House officers gained in educational and clinical terms from their period in general practice. They had a high level of individual supervision and teaching and encountered a wider spectrum of illness than in hospital. They found certain aspects of general practice stressful. The supervision required was greater than that needed for a registrar. The supervision of house officers requires support and possibly further education for the supervisor. CONCLUSIONS: General practice can provide valuable supervised experience at this stage of a doctor's career.     

The pre-registration year 1983-1988

The pre-registration year, a mandatory period of general clinical training in the United Kingdom, has been the subject of recent comment and criticism. The literature on the year is analysed, taking as a starting point and framework the 1983 review by the Association for the Study of Medical Education (ASME), and focusing on the 1987 Recommendations of the General Medical Council. It is concluded that the pre-registration programme has been improved, but that attention needs to be given to house officers' hours of duty, to career counselling for them and to training for teachers and supervisors.     

‘Hello,my name is Gabriel,I am the house officer,may I examine you?’ or The Objective Santa Christmas Examination (OSCE)

OBJECTIVE: To design a clinical examination of high content validity suitable for use as a formative assessment tool with pre-registration house officers (PRHO'S) towards the end of their first house officer post. DESIGN: A multicentre collaboration between four UK medical schools who offer undergraduate curricula which are problem-based, systems-based, patient-orientated, student-centred, jargon-laden and utterly staff-bewildering. MAIN OUTCOME: An objective structured clinical examination (OSCE) which is suitable for use with graduates of UK medical schools. It assesses the knowledge, skills and attitudes essential for future careers in a hierarchical system where protecting the senior staff from all forms of irritation is paramount. RESULTS: PRHO'S who excel in this examination get better references. CONCLUSION: The OSCE format can be used to provide 'real-life' scenarios appropriate to the season.     

Oral examinations in medical education

A questionnaire survey was conducted on the nature of the oral examinations in different disciplines in the medical schools in Sri Lanka. A total of 352 students from Peradeniya and Jaffna medical faculties and pre-registration house officers, including Colombo faculty graduates of the two teaching hospitals, responded to the questionnaire. The results of the survey, which included twelve disciplines, reveal that the time duration of the oral encounter ranged from 10 to 20 minutes. The number of questions asked ranged from five to nine. Detailed analysis of the intellectual level of the questions showed that more than 63% of the questioning was at simple recall level and none at the level of problem-solving. These results show that the oral examination in addition to its inherent weakness of low reliability and objectivity also lacks validity in terms of content sampling. Its predictive validity of professional competence, which requires problem-solving skills, is questionable. Content analysis of the items also revealed that all the abilities tested in the orals could best be tested in a pen-and-paper examination or a structured practical or clinical examination.     

House officers'' attitudes towards terminal care

This study examined the change in doctor's knowledge, attitudes and management of the terminally ill during the pre-registration year. There was a slight improvement in the factual knowledge of most house officers, but some showed a deterioration in their understanding of the problems of the terminally ill. There were marked deficits in knowledge of symptom control. The house officers' own experience of serious illness or bereavement did not alter their measured knowledge or attitudes to the patients.     

Practice preferences of primary medical care and traditional internal medicine house officers

In an academic medical centre between 1980 and 1985, the attitudes, preferences and career goals of house officers in a primary medical care residency training programme were assessed at entry and at the end of each house officer year. Primary care trainees who went on to practise in a general medicine setting were compared to primary care trainees who subsequently received subspecialty training and also to traditional internal medicine trainees. House officers in the primary care programme generally maintained attitudes and preferences central to the practice of primary care, and scored significantly higher than traditional track house officers on attitudes and preferences compatible with the practice of medicine in a primary care setting. However, primary care house officers who later went into subspecialty training received scores similar to those of traditional track house officers on practice preferences relating to specialty care. There were no significant differences between primary care and traditional track house officers on standard measures of knowledge and clinical skill.     

How do clinicians learn to request permission for autopsies?

A postal survey of 434 clinicians at four local hospitals was undertaken in order to identify the methods by which clinicians learn how to request permission for hospital autopsies and to assess the preferred techniques and timing of relevant communication skills training. The majority of 128 responding clinicians had learnt through personal experience with some assistance from senior colleagues and peers. Few clinicians appeared to have learnt through formal training. The preferred methods for the provision of communication skills training were training in small groups (such as seminars or tutorials) and observation of clinicians at work. The most desirable time for the provision of this training was considered to be between the beginning of the final undergraduate year and the end of the pre-registration house officer year. The communication skills training provided within medical education is in need of improvement. More emphasis should be given to clinical-task- or situation-specific applications such as requesting permission for autopsies.     

Education and training in the senior house officer grade: results from a cohort study of United Kingdom medical graduates

INTRODUCTION: This paper shows the findings from a survey of 439 senior house officers undertaken as part of the British Medical Association cohort study of 1995 medical graduates. The aim of the study was to assess the quality of senior house officer training in the United Kingdom. METHOD: In July 1997 a postal questionnaire was sent to a sample of 545 doctors who graduated from medical school in 1995. Responses were received from 515 (95%). Only those doctors who had worked as a senior house officer in the previous 12 months were included in the analysis (n = 439). RESULTS: Encouraging results are that 69% of the senior house officers surveyed had discussed their progress directly with their consultant, and 24% rated their supervision by their consultant as 'excellent'. Of concern are the findings that 47% of respondents did not receive protected teaching time and 16% were unable to take study leave. DISCUSSION: The study revealed wide variability in the quality of training received by senior house officers in the United Kingdom. Whilst some respondents - notably those in general practice, accident and emergency, paediatrics and psychiatry - had enjoyed a high standard of education and training, it was clear that a minority of posts continue to offer little if any educational value to the post holder. The results point to a need for a more systematic approach to maintaining standards in senior house officer training with greater incentives for under-performing trusts.     

Education for practice: the role of practical experience in undergraduate and general clinical training

A questionnaire and interview study in two London medical schools reviewed the undergraduate curricula and house year from the perspectives of graduates one year after qualification. Data from 113 house officers (44%), obtained by questionnaire and interview, showed general satisfaction with training. However, they also saw undergraduate preparation as deficient in exposure to some practical procedures and common conditions, and several difficult communication skills were not taught. Graduates reported that they would have liked more experience as undergraduates in resuscitation, lumbar puncture, inserting nasogastric tubes, endotracheal intubation, and in managing diabetic keto-acidosis, asthmatic attacks, myocardial infarcts and respiratory failure. The purposes of the house year and the articulation between it and the undergraduate years require clarification.     

Survey of surgical training in Europe

The Permanent Working Group of European Junior Hospital Doctors (PWG) conducted a survey among surgical trainees in member countries with the aim of describing postgraduate training in surgery throughout Europe. In each country, 10 trainees with surgical training of 2–5 years and 10 trainees with surgical training of 6–9 years answered a questionnaire, completed a diary and kept a log book of operations for 1 week. A total of 165 surgeons from 12 countries completed the survey. A trainee had to care for an average patient load varying from 30 to 80 patients at any one time. The average number of working hours ranged from 52 to 88 h per week, including up to 18 h of unpaid work. The different tasks carried out within these working hours varied considerably, as did the proportion of tasks with educational value. Trainees participated in four to 11 major operations each week, but the number of operations a week did not reflect the number of operations conducted under supervision. In some countries, the majority of the trainees stated that they received their training mainly through unsupervised experience. The average number of days spent on courses and congresses varied from 4 to 15 days per year, with great variation in the percentage of expenses paid. Countries with favourable working conditions, such as fewer working hours, shorter shifts and a day off after being on duty, seemed to have gained these advantages by a reduction in working hours with educational value, rather than by a reduction in routine work.
It is concluded that conditions of surgical training vary greatly between the European countries in relation to duration, working hours, tasks undertaken, and resources used on training. Every country is capable of improving its surgical training.     

Experiences from psychiatric rotation for pre-registration house officers: contributions to subjective learning

SETTING: The clinical experience and the subjective learning of pre-registration house officers who completed 4 months' psychiatric rotation are described. METHOD: The study was cross-sectional and based on self-report. The participants had responded to an anonymous questionnaire at the completion of their 4 months' psychiatric rotation in the period 1999-2001. Of those eligible (n = 137), 85 (61%) completed the questionnaire. The relationships between individual background variables, different factors of the learning environment, and good learning outcome were explored. CONCLUSIONS: The subjective learning benefit and positive learning environment were most related to the amount of practical experience, the degree of tailoring of the tasks to the house officers' competence, and to the formal intramural teaching programme. Supervision, gender, previous experience, and prior interest in psychiatry did not have significant impact on subjective learning. The findings are discussed in terms of the learning model that was developed.     

Students'' attitudes towards psychiatry

Using a reliable measure, a self-administered questionnaire (ATP), and adequate numbers of students, this study demonstrates the negative effects of general medical/surgical training and the positive effect of the psychiatry clerkship on students' reported attitudes towards psychiatry. A negative view of psychiatry at the beginning of the clerkship may make students reluctant to improve their interview skills but is otherwise unimportant in determining their reactions and performance in the clerkship. Medical students' interest in psychiatry as a career increases during the psychiatry clerkship but this merely offsets the decline in interest that occurs at other stages during the clinical training. Much of the attitudinal change that occurs during the psychiatry clerkship is maintained into the pre-registration year but the housemen recorded a significant negative change on the items concerning efficacy of psychiatric treatment and attitudes towards psychiatric patients. Additional training by psychiatrists during the pre-registration year might increase the motivation of young doctors to detect and treat psychiatric illness which they will encounter in all branches of medicine.