Residents' training goals in respiratory knowledge and skills: perspective of three parties

Medical residents, full-time respiratory teaching staff, and community-based doctors rated the importance of fifty-five respiratory training goals involving knowledge and skills necessary for the future practices of all medical residents. Residents also rated their perceived preparedness in these training areas. Intra-and inter-group analyses indicated that residents agreed more often, and consistently assigned more importance (94% of goals) to the training goals than did the teachers and doctors. Although the residents considered themselves prepared for 69% of the training goals, they also had moderate intra-group disagreement. These results may reflect variable training experiences and/or institutional practices, but areas of less than adequate preparation were identified and can be corrected. The other two groups were in general agreement except regarding some clinical skills. This study offers possible explanations for the group responses and indicates the potential benefit for groups to discuss, identify, and survey training goals.     

Educational needs of internal medicine residency graduates: general internist versus subspecialists

Residency training is inadequate with respect to the needs of general internal medicine doctors in several areas. We undertook this study to determine the practice habits and educational requirements of general versus subspecialty internists. A survey was mailed to 138 doctors who had completed at least a three-year university-based internal medicine post-graduate training. Sixty-three (46%) responded, of whom 32 completed additional training in a subspecialty of internal medicine. Many (14 of 32) subspecialists described their practice as general internal medicine (GIM) with a subspecialty emphasis. GIM was as important to their practice as it was to the general internists. General internists saw non-internal medicine disciplines as important but subspecialists did not. General internists frequently performed procedures that were not formally taught during training, while subspecialists rarely if ever performed a procedure outside the scope of their fellowship training. Internal medicine training programmes should be able to individualize training based on the career choices of trainees such that training will more fully prepare trainees for practice.     

Consulting skills training and medical students' interviewing efficiency

In more traditional medical education, medical students took a patient's medical history by asking a series of sequenced, routine questions, covering presenting medical problem(s); medical history; social and personal history; systems review; and physical examination. Following this process, the student then attempted to derive the patient's medical problems. This inductive problem-solving paradigm may not assist students to prepare for their future interviewing needs, given doctors use a hypothetico-deductive, problem-solving approach when interviewing patients and numerous researchers have developed specialized communication skills training programmes designed to enhance students' interviewing skills. Students given specific consulting skills training have tended to show significantly greater interpersonal effectiveness and improved interview behaviours compared with students who experience traditional patient clerking training. These improvements in interviewing tend to persist over the period of students' medical training. The aim of the present study was to determine whether specialized communication skills training helped students elicit greater quantity and quality of information from patients and if so, whether such information assisted students in improving their diagnostic skills. Videotaped history-taking interviews conducted by students trained in communication skills and untrained (control) students were rated for their interview efficiency. A comparison of ratings given by experimentally naive, independent observers revealed that trained students were more efficient, but took no longer than their control group counterparts to elicit fuller, more relevant information. However, the student groups did not differ in the accuracy or scope of their medical diagnoses. It is argued that students' lack of medical knowledge in this early phase of their clinical training militated against their being able to use their interviewing competence to derive more potentially accurate medical diagnoses.     

Self-assessment in the measurement of public health workforce preparedness for bioterrorism or other public health disasters

OBJECTIVE: The purpose of this study was to examine effective ways to evaluate public health workers' competence for preparedness. METHODS: The Public Health Ready project, developed by the National Association of County and City Public Health Officials and the Centers for Disease Control and Prevention, is a pilot program designed to prepare local public health agencies to respond to emergency events. Workers at a Public Health Ready site (N=265) rated their need for training and their competence in meeting generic emergency response goals. Cluster analysis of cases was conducted on the self-assessed need for training. RESULTS: Three groups of workers emerged, differing in their overall ratings of need for training. A given worker tended to report similar needs for training across all training goals. CONCLUSIONS: In this study, workers' ratings of need for training may reflect an overall interest in training rather than need for training in a particular area. Caution should be exercised in interpretation when generic goals and self-assessment are used to measure need for training. Future assessments of training needs may be more effective if they use objective measures of specific local plans.     

Specialists Understanding of the Health Care Preferences of Chronically Ill Adolescents

PurposeDoctors must understand patients’ priorities to create an effective treatment partnership. Little is known about whether subspecialist pediatricians understand chronically ill adolescents’ preferences.MethodsA survey was conducted of 155 adolescents with chronic illnesses and 52 subspecialty physicians recruited from the same clinics of a children’s hospital. Adolescents and physicians rated the importance that adolescents place on items relating to quality of care and physician-patient communication styles using a previously validated measure.ResultsFor quality of care items, rank order correlation between physicians and patient responses was high (r = .63, p < .001) and both rated pain management items as most important. Physicians underestimated the importance adolescents placed on communicating with the physician as a friend and medical-technical aspects of care. For communication items, physicians’ responses were significantly different than adolescents for 13 of 17 items. Except for three items pertaining to autonomy, physician and patient responses were in the same direction, but adolescent responses were less extreme.ConclusionsPhysicians understood the importance of pain management to adolescents with chronic illnesses, but overestimated their desired level of autonomy. Asking adolescents for their preferences may be the first step in improving adolescents’ experience of care.     

How do supervising doctors construe the medical student in clinical training?

Basing the prediction of student performance in medical school on intellective-cognitive abilities alone has proved to be more pertinent to academic achievement than to clinical practice. A major obstacle to the development of adequate measures has been the elusive nature of requirements for successful clinical performance. The present study aimed at defining the relevant variables through an analysis of the concept of the medical student held by supervising doctors. With the aid of a methodology derived from cognitive-social psychology, the components of how training doctors of a large medical school evaluate their students were first explicated in structured interviews. In a second phase of the research, 18 supervisors in five major clinical departments rated their student-supervisees on 15 obtained traits. Findings of trait correlations with an overall evaluation, as well as Guttman's 'Smallest Space Analysis' (1968), indicated a clear priority of cognitive-motivational traits in supervisors' judgements and reduced relevance of personal and interpersonal variables. Certain inconsistencies between avowed ideology of medical training and actual supervising practice could be detected.     

Hospital middle managers' perceptions of their work and competence

Middle managers in acute care hospitals in New England rated the importance of most work roles and skills higher than their competence to perform them. Being male, having a bachelor's or graduate degree, and reporting to a vice president were related to higher competence ratings for some roles and skills while having held a clinical position in the same organization was related to lower ratings. Middle managers rated skills and roles focused on their individual work units as more important than those associated with their organizations or external environments. This framework for categorizing work may be useful in identifying education, institutional support, or work redesign that would assist middle managers in being more effective.     

A programme in undergraduate geriatric education: the Beer Sheva experiment

The Beer Sheva medical school was started in 1974 with the objective of training primary care doctors to meet the health needs of the Negev region of Israel. This paper describes a programme developed at Beer Sheva to prepare students to deal with the health-related problems of the elderly. Students begin their contact with the elderly in their first year (early clinical teaching programme) and continue this exposure in varying degrees during the 6 year curriculum. A preliminary study has shown that there is a trend for students to commence their studies with positive attitudes toward the elderly. The early clinical teaching programme which emphasizes interviewing skills, knowledge about ageing and community services that relate to the aged, reinforces the student's sensitivity to geriatric issues. In order to maintain the student's interest in working with the elderly, it is apparent that it will be necessary to educate both hospital and community-based physicians to provide positive role models for students.     

The approaches to learning of specialist physicians

Recent studies have provided information about the approaches to studying and learning used by medical students. However, no published work is available on the approaches of practising doctors. The Adelaide Diagnostic Learning Inventory for Medical Students (ADLIMS) was modified and administered to a random sample of 308 physicians (internists). Generally speaking, physicians seem to have lower scores on surface approach and higher scores on deep approach than students. Level of clinical experience did not appear to influence this finding. However, marked differences were apparent between the approaches adopted by physicians with additional postgraduate academic training and those without. The former had a much stronger tendency to use the more desirable deep approach. The latter seemed to rely more on the less desirable surface approach. Further longitudinal studies will be required to determine whether this difference is attributable to self-selection of those who have already developed a deep approach or is causally related to a training in research. Although these findings must be interpreted with caution, some implications are clear. Physicians should become more aware of the way they learn and about the way they teach. Inappropriate patterns of learning may be entrenched during the undergraduate and immediate postgraduate years. If validated, these findings may provide support for the inclusion of research projects in medical school and during specialist training.     

Training for terrorism-related conditions in hospitals: United States, 2003-04

OBJECTIVE: This study estimates baseline data to determine which hospital characteristics are associated with providing terrorism preparedness training to clinical staff. METHODS: Information from a Bioterrorism and Mass Casualty Supplement to the 2003 and 2004 National Hospital Ambulatory Medical Care Surveys was used to provide national estimates of variations in terrorism preparedness training by eight hospital characteristics. Of 874 hospitals in scope, 739 (84.6 percent) responded. Estimates are presented with 95 percent confidence intervals. RESULTS: Hospitals with Joint Commission accreditation were more likely to provide terrorism preparedness training to all types of clinical staff (staff physicians, residents, nurse practitioners, physician assistants, and laboratory staff). Teaching hospitals, medical school affiliation, bed capacity, and urban location were also associated with training staff physicians, residents, nurse practitioners, and physician assistants. Hospitals with residency programs were associated with training only staff physicians and residents. There was more parity across hospital characteristics in training nurses and laboratory staff than for physicians, residents, nurse practitioners, and physician assistants. Joint Commission accreditation was the most consistent factor associated with providing training for all nine exposures studied (smallpox, anthrax, chemical and radiological exposures, botulism, plague, tularemia, viral encephalitis, and hemorrhagic fever).     

The selection and training of examiners for clinical examinations

The inconsistency of the marking in clinical examinations is a well documented problem. This project identified some of the factors responsible for this inconsistency.
A standardized rating situation was devised. Five students were videotaped as they performed part of a physical examination on simulated patients. Eighteen experienced medical and surgical examiners rated their performances using an objective checklist type of rating form. No differences were evident between physicians and surgeons. The group of examiners was divided into three subgroups, one receiving no training, one limited training and one more extensive training. Examiners re-rated the same students 2 months after the first rating.
Inter-rater reliability was satisfactory for the first ratings and training produced no significant improvement. A substantial improvement was achieved by identifying the most inconsistent raters and removing them from the analysis. Training was shown to be unnecessary for consistent examiners and ineffective for examiners who were less consistent. On the basis of these results, only consistent examiners were selected to take part in the interactive component of the objective structured final year examinations. The ratings in these examinations achieved high levels of inter-rater reliability.
It was concluded that the combination of an objective check-list rating form, a controlled test situation and the selection of inherently consistent examiners could solve the problem of inconsistent marking in clinical examinations.     

Self-assessments of need, relevance and motivation to learn as indicators of participation in continuing medical education

This study examined the validity of using physicians' self-assessed needs, relevance and motivation to learn about clinical topics as a means for setting objectives and priorities for continuing medical education (CME) programmes. In an initial survey family doctors were asked to rate their need, relevance and motivation to learn about 120 different clinical topics. Eight months later, the same population was sent a second mail survey asking respondents to indicate if they had learned about a set of sixteen topics taken from the initial survey and, if so, in what kind of learning activities. Eight of the sixteen topics were highly rated and eight were low rated in the initial survey. In terms of actual participation of family doctors, self-assessed motivation to learn exhibited a strong positive relationship with actual participation. Both self-assessed need and relevance were negative to only moderately positive in their association with actual participation. This evidence contributed to the value of using self-assessed motivation as an indicator of future participation of family doctors in CME and questioned the value of using self-assessed need and relevance as indicators of future patterns of participation.     

Views of junior doctors about their work: survey of qualifiers of 1993 and 1996 from United Kingdom medical schools

OBJECTIVE: To investigate the views of junior doctors about their work. DESIGN: Postal questionnaire surveys. SETTING: United Kingdom. SUBJECTS: Doctors who graduated from medical schools in the United Kingdom in 1996, surveyed at the end of their preregistration year (2926 respondents), and graduates of 1993 surveyed 3 years after qualification (2541 respondents). RESULTS: Almost 70% of the 1996 qualifiers felt that they worked excessive hours and 80% felt that they undertook too many routine non-clinical duties. Only 24% agreed that their postgraduate training was of a high standard and 22% felt they were being asked to perform clinical tasks with inadequate training. A total of 70% were dissatisfied with arrangements for cover for absent doctors. Senior doctors and nurses were regarded as supportive by most respondents, but hospital management was not. Although 65% were satisfied with their future prospects, only 36% had been able to obtain useful careers advice. Job enjoyment was reasonably high, with two-thirds scoring 6 or more on a scale from 1 (not enjoying at all) to 10 (greatly enjoying), but 70% of respondents felt that they had insufficient time for family and social activities. A briefer questionnaire sent to the 1993 qualifiers in 1996 showed similar results. CONCLUSIONS: More needs to be done to ensure that junior doctors are trained appropriately for the tasks they undertake, to ensure that they regard their training highly, to reduce excessive non-clinical work, and to provide reasonable working hours and cover.     

The work of the student doctor: a pilot project

The primary task of the student doctor in the third year of medical school is to inquire into problems of illness, in co-operation with patients, house officers and other staff. This is a new kind of work for most medical students, who have spent the previous two years reading textbooks and listening to lectures. How do students get out of these passive forms of learning into active inquiry? How do they learn to work co-operatively with other people in the technical difficulty and emotional upheaval of illness? We know that most medical students somehow manage to become practicing physicians, but we have known very little about this critical transition. We would expect that this phase of training, like any major transition in the life cycle, leads to great strain and the formation of new patterns of thinking and behaviour that will last through a lifetime of clinical practice. These considerations lead directly to practical matters of medical education and research. How can we best study this critical period? How can we offer the best education to student doctors forming working relationships with patients? This paper describes a working model of training and research to meet these concerns, adapted from the work of Michael Balint and colleagues in the ‘G.P. (General Practitioner) Seminars’( Balint, 1954, 1957 ; Bourne, 1975 ).     

Junior doctors'' views about careers in academic medicine

OBJECTIVE: To investigate junior doctors' views about careers in academic medicine. DESIGN: Postal questionnaire survey. SETTING: National Health Service in England. SUBJECTS: Doctors in university posts at specialist registrar level, Medical Research Council and Wellcome Trust training fellows, and specialist registrars in National Health Service posts. RESULTS: Incentives to pursue an academic career which respondents rated as strong related to the challenge of research and the intellectual environment of research units. The strongest disincentives were perceived difficulties in obtaining research grants and uncertainty regarding pay parity with National Health Service colleagues. Medical Research Council and Wellcome fellows had much more protected research time than other academic doctors but were less satisfied with their clinical training. Academic doctors who were not fellows reported spending less than half their time on research and the great majority agreed that their research suffers when there is pressure on the service side. CONCLUSIONS: The job content of academic posts should be kept under regular review to ensure that clinical service pressures do not inappropriately erode research time while also ensuring that postholders have adequate clinical training. Training programmes need flexibility to accommodate the needs of clinical academics in their progress through higher specialist training.     

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.     

Teaching the teachers — a needs assessment of tutors for a new clinical skills course

There is an increasing trend in undergraduate education towards teaching clinical skills from a community base. A new clinical curriculum was introduced in Newcastle upon Tyne in 1995, beginning with an integrated clinical skills course. Although the attitudes and views of general practitioners (GPs) towards community-based clinical teaching have previously been reported, their perceived training needs have not been formally identified. The aims of this study were to identify the competencies needed by GPs for community-based clinical skills teaching, to compare and contrast these needs with their hospital colleagues, and to use the results to develop a teaching programme for the clinical tutors involved in the new course. In order of priority, the GPs and hospital tutors expressed similar needs: small-group teaching skills, assessing student needs, giving effective feedback and assessment of student performance, with a preference for the teaching to be organized within local teaching units. Most GPs and hospital tutors (73 and 69%, respectively) requested a distance-learning pack to complement the teaching. General practitioners rated resources for improving their individual clinical skills more highly than their hospital colleagues: for example, videotapes demonstrating examination techniques. Forty-six per cent of GP tutors had received some formal training in teaching methods compared to 29% of hospital tutors. The implications of the results for developing a 'Teaching the Teachers' course for clinical tutors are discussed.     

Current practice patterns and training status of selected graduates at the King Abdulaziz University College of Medicine, Saudi Arabia

Graduate doctors are the primary output of medical education programmes. It is important for institutions to identify systematically the types of medical activities in which their former students are involved in order to determine the effectiveness of the curriculum, assessing academic standards and reviewing admissions policies. Information was obtained from a survey of men and women graduates from three of the early graduation classes of King Abdulaziz University College of Medicine in Saudi Arabia about postgraduate medical training, certification, practice patterns, and other curriculum issues. Information collected from 151 graduates (90%) indicated that 96% were practising medicine in a variety of medical specialties and subspecialties. Six were not practising at the time of the study. Significant differences were found in the specialties being practised when men and women were compared. Men tended to practise in medicine, surgery, dermatology, urology, ENT, ophthalmology and orthopaedics, while women concentrated in obstetrics and gynaecology and paediatrics. Certification beyond medical school was earned by 49% with no significant difference being found comparing men to women. Men earned the majority of their postgraduate certifications outside Saudi Arabia while most women earned theirs in Saudi Arabia. Graduates indicated that departments in the basic sciences were least helpful in preparing them as doctors, while selected clinical departments were most helpful. It was concluded from the study that the curriculum goals of the College of Medicine, namely a curriculum of international standards producing graduates to take leadership roles in both teaching and medical practice, were realized in part by the graduates surveyed.     

Attitudes of house-physicians towards self-poisoning patients

Eighty-two house-physicians filled in a questionnaire concerning the care of self-poisoning patients with special emphasis on training and attitudes. These recently qualified doctors dealt with large numbers of such patients and expressed dissatisfaction with their training in this respect. Hostile attitudes towards these patients developed most clearly at those district hospitals where psychiatrists are rarely available. During their 6 months as a house-physician, doctors at the teaching hospital became more interested in making a full assessment of these patients whereas those at other hospitals became less so.
Better training at both undergraduate and pre-registration level is needed to make house-physicians more able and more willing to fully assess these patients.