Reflection in professional practice and education

Reflection is a crucial process in the transforming of experience into knowledge, skills and attitudes. As such it is at the core of both learning and continually evolving professional practice. This article draws on literature from adult learning and medical education fields to present a theoretical framework for reflection and practical techniques for its application in general practice. It is directed toward the training of medical students and registrars on clinical rotations, but also for the established general practitioner.     

Cultural and communication awareness for general practice registrars who are international medical graduates: a project of CoastCityCountry Training

OBJECTIVE: (1) To generate discussion about Australian culture and language with GP registrars using the medium of poetry; and (2) to introduce discussion about language and communication skills in a role-play format that GP registrars would embrace as part of their clinical training. DESIGN: (1) A variety of Australian poems was selected to reflect six themes: men, women, the Bush, ANZACS, Aboriginal Australia and migrants, which would provide a basis for discussion on a range of cultural issues to aid a medical professional trained overseas in developing further understanding of aspects of Australian culture. (2) A series of role plays was developed to reflect the clinical themes of each Day Release education program. These were enacted in a small group setting by preselected GP registrars with feedback from a medical educator and an English as a Second Language teacher. SETTING: The Riverina/Murrumbidgee area of New South Wales, one of the three local training groups of CoastCityCountryTraining. PARTICIPANTS: GP registrars attached to the Riverina/Murrumbidgee Local Training Group. MAIN OUTCOME MEASURES: To show that discussion of poetry and participation in role plays are active language- and cultural-learning environments capable of enhancing understanding of a range of issues about Australia that are relevant to a GP registrar. RESULTS: There was increased participation by GP registrars in accessing the set material prior to each session. It was noted that there was also increased active involvement of all registrars in discussion within the group throughout the year. Discussion allowed clarification of aspects of Australian culture to participants with different international medical backgrounds, as well as providing an opportunity for GP registrars to share their own experiences.     

Impact of patient feedback on the interpersonal skills of general practice registrars: results of a longitudinal study

CONTEXT: A general practice vocational training program. OBJECTIVES: To examine the impacts and implications of different models of systematic patient feedback on the development of general practice (GP) registrars' interpersonal skills as they progressed through a GP vocational training program. DESIGN: A longitudinal study in which GP registrars were randomly assigned to three models of patient feedback: a control group and two intervention groups. The major source of data gathering was through the Doctors' Interpersonal Skills Questionnaire (DISQ) which was administered to patients immediately after their consultation. SUBJECTS: 210 GP registrars, 104 GP supervisors and 28 156 patients. RESULTS: Multivariate analysis techniques (including repeated-measures analysis) tested the effectiveness of the interventions. Findings showed that systematic patient feedback at regular intervals throughout GP training resulted in sustained levels of interpersonal skills. The most significant gains in interpersonal skills for both intervention groups occurred in the earlier stages of general practice training. Most registrars found the experience of patient feedback useful for gaining a better understanding of their interpersonal skills and for identifying areas in which they needed to improve. GP supervisors valued the opportunity to receive patient feedback themselves and found the activity a useful adjunct to their preceptor role. CONCLUSIONS: Patients, by providing feedback on doctors' interpersonal skills, have been able to contribute to improving the quality of the patient-doctor interaction. GP registrars and their supervisors value highly the role of patient feedback in interpersonal skill development.     

Evaluating the spoken English proficiency of graduates of foreign medical schools

PURPOSE: The purpose of this study was to gather additional evidence for the validity and reliability of spoken English proficiency ratings provided by trained standardized patients (SPs) in high-stakes clinical skills examination. METHOD: Over 2500 candidates who took the Educational Commission for Foreign Medical Graduates' (ECFMG) Clinical Skills Assessment (CSA) were studied. The CSA consists of 10 or 11 timed clinical encounters. Standardized patients evaluate spoken English proficiency and interpersonal skills in every encounter. Generalizability theory was used to estimate the consistency of spoken English ratings. Validity coefficients were calculated by correlating summary English ratings with CSA scores and other external criterion measures. Mean spoken English ratings were also compared by various candidate background variables. RESULTS: The reliability of the spoken English ratings, based on 10 independent evaluations, was high. The magnitudes of the associated variance components indicated that the evaluation of a candidate's spoken English proficiency is unlikely to be affected by the choice of cases or SPs used in a given assessment. Proficiency in spoken English was related to native language (English versus other) and scores from the Test of English as a Foreign Language (TOEFL). DISCUSSION: The pattern of the relationships, both within assessment components and with external criterion measures, suggests that valid measures of spoken English proficiency are obtained. This result, combined with the high reproducibility of the ratings over encounters and SPs, supports the use of trained SPs to measure spoken English skills in a simulated medical environment.     

Feedback for general practice trainers: developing and testing a standardised instrument using the importance-quality-score method

INTRODUCTION: Although general practice vocational training has been mandatory in Germany since 1993, a service philosophy still prevails. To help general practice trainers develop their identity and skills as trainers we developed and tested a standardised instrument. The questionnaire is to be filled in by registrars after their attachment to a given practice and handed to the trainer as personal feedback on the training provided. METHODS: Items were collected by asking experts in the field to name content that should be covered. The resulting items were reduced using the importance-quality method derived from health-related quality of life research. Reliability was tested by registrars rating their training twice 3 weeks apart. They also provided free text comments that were coded and analysed to establish criterion validity. RESULTS: A total of 121 items were collected. Eighty registrars provided importance and quality ratings to reduce these to 43 items. Test-re-test reliability and criterion validity were also established. CONCLUSION: The importance-quality method proved to be useful for item reduction according to the objective of the questionnaire. Instruments evaluating the quality of vocational training must be context-sensitive.     

Assessing communication skills of GP registrars: a comparison of patient and GP examiner ratings

CONTEXT: General practice. OBJECTIVES: To compare ratings of GP registrars' communication skills by patients and GP examiners. DESIGN: A comparative study where the communication skills of GP registrars were assessed both by patients, using a validated tool called the Doctors' Interpersonal Skills Questionnaire (DISQ), and by GP examiners as part of the Fellowship examination of the Royal Australian College of General Practitioners (RACGP). PARTICIPANTS: These included 138 GP registrars, 6075 patients, and more than 70 GP examiners. RESULTS: Spearman rank correlations were used to test the strength of the relationship between Fellowship examination and DISQ scores. Findings showed that there were several communication skills areas with mild (but significant) correlations between patient and GP examiner ratings. These areas included warmth of greeting, listening skills, respect, and concern for the patient as a person. No significant correlations were detected for explanation skills. Interestingly, the correlations between GP examiner and patient ratings were stronger for female GP registrars. CONCLUSION: There is some evidence that patients' ratings of GP registrars' communication skills is aligned to ratings made by GP examiners as part of the summative RACGP Fellowship examination. However, further work is required to assess the strength of this alignment, given that patient-doctor communication is assessed more widely through new components of the examination.     

Orientation for general practice in remote Aboriginal communities: a program for registrars in the Northern Territory

BACKGROUND: Remote general practice can be a highly rewarding career, but poses many personal and professional challenges. It is characterised by significant geographical, professional and social isolation and a requirement for practitioners with public health, emergency and extended clinical skills. The remote practitioner faces further challenges in the remote Aboriginal community setting, including language and cultural barriers. OBJECTIVES: This paper discusses the specific components of a remote Aboriginal community general practice registrar orientation program in the Northern Territory, and their particular importance and relevance to remote training and practice in this context. DISCUSSION: Northern Territory General Practice Education, the regional general practice training provider in the Northern Territory, has developed a model for a comprehensive orientation program for general practice registrars planning to work in remote Aboriginal community locations. This comprises a number of core components, including communication and cultural safety training; clinical and procedural skill development; population health; self-care and personal/professional role delineation; and organisational issues. We believe it is a program that is applicable to other disciplines undertaking work in remote Aboriginal communities.     

Use of critical incidents to develop a rating form for resident evaluation of faculty teaching

CONTEXT: Monitoring the teaching effectiveness of attending physicians is important to enhancing the quality of graduate medical education. METHODS: We used a critical incident technique with 35 residents representing a cross-section of programmes in a teaching hospital to develop a 23-item rating form. We obtained ratings of 11 attending physicians in internal medicine and general surgery from 54 residents. We performed linear and logistic regression analysis to relate the items on the form to the residents' overall ratings of the attending physicians and the programme directors' ratings of the attending physicians. RESULTS: The residents rated the attending physicians highly in most areas, but lower in provision of feedback, clarity of written communication and cost-effectiveness in making clinical decisions. When we used the residents' overall ratings as the criterion, the most important aspects of attending physicians' teaching were clarity of written communication, cost-effectiveness, commitment of time and energy and whether the resident would refer a family member or friend to the physician. When we used the programme directors' ratings as the criterion, the additional important aspects of performance were concern for the residents' professional well-being, knowledge of the literature and the delivery of clear verbal and written communication. CONCLUSIONS: The critical incident technique can be used to develop an instrument that demonstrates content and construct validity. We found that residents consider commitment of time to teaching and clinical effectiveness to be the most important dimensions of faculty teaching. Other important dimensions include written and verbal communication, cost-effectiveness and concern for residents' professional development.     

Language background,English language proficiency and medical communication skills of medical students

Associations between language background, English language proficiency and medical communication skills were investigated in a group of 149 third year undergraduate medical students studying at an Australian university. Written and aural English proficiency were assessed with the Screening Test for Adolescent Language (STAL). Medical communication skills and the fluency of spoken language were scored during an Observed Structured Clinical Interview (OSCI), rated by a standardized patient and a clinician. An association was found between language background, performance on the STAL and spoken language proficiency. Satisfactory performance in medical communication skills was not associated with language background or overall performance on the STAL. In this study it was the global rating of unsatisfactory spoken language fluency that was associated with poorer performance in medical communication skills under examination conditions.     

Demystifying the FRACGP exam

In the initial stages of examination preparation, many candidates for the Fellowship of The Royal Australian College of General Practitioners (FRACGP) feel overwhelmed by the perceived complexity and magnitude of the impending exam. This article describes an exam workshop for general practice registrars in Western Australia that provides case based and context based (ie. as if in your practice) learning experiences to address this anxiety. It aims to provide FRACGP candidates with a practical approach to exam preparation. One general practice patient case is worked through in stages, and the information obtained is related to the six question types as found in the FRACGP exam. This article will be useful for anyone contemplating sitting the FRACGP exam, general practitioner supervisors, and others involved in the education of general practice registrars.     

Evaluating the spoken English proficiency of international medical graduates: detecting threats to the validity of standardised patient ratings

PURPOSE: To investigate potential threats to the validity of the spoken English proficiency ratings provided by standardised patients (SPs) in high-stakes clinical skills examinations. METHOD: Spoken English ratings from 43 327 patient encounters were studied. These involved over 5000 candidates, 40% of whom were female and 33% of whom self-reported English to be their native language. Over 100 SPs were involved in the study, 51% of whom were female and 90% of whom were native English speakers. Possible performance differences in English ratings were studied as a function of candidate and SP gender, and as a function of candidate and SP native language (English versus all other languages). RESULTS: No significant candidate by SP gender effect was detected. There were no meaningful differences in mean English ratings as a function of SP or candidate gender. Likewise, English ratings did not vary as a function of either candidate or SP native language. While candidate mean English ratings were not associated with the native language of the SP, native English-speaking candidates did achieve significantly higher ratings. DISCUSSION: The lack of significant interaction between candidate and SP gender, and candidate and SP native language, suggests that the SPs provided unbiased English ratings. These results, combined with the expected higher English ratings given to candidates with English-speaking backgrounds, provides additional evidence to support the validity and fairness of spoken English proficiency ratings provided by standardised patients.     

Health Communication in Multilingual Contexts: A Study of Reading Preferences,Practices, and Proficiencies Among Literate Adults in Zambia

Comprehension of health materials and messages is a necessary, though not sufficient, condition for the development of health literacy; in the case of print materials, reading comprehension is elemental. Assessments of the population's ability to read and comprehend written materials are complex and highly salient in multilingual countries, such as Zambia, particularly when an excolonial language is but one of multiple official languages. Yet no study has contrasted adult Zambians' reading comprehension of health materials in the major Zambian languages with comparable English-language materials. This article reports the results of a survey of 2,009 literate Zambian adults who were tested for reading comprehension of health materials written at fourth- and eighth-grade levels. The analysis found that respondents who had not gone beyond primary school scored significantly higher on Zambian- than on English-language reading comprehension tests. Respondents with at least an eighth-grade education scored equally well or better on English-language compared with Zambian-language tests. Overall, respondents were more likely to pass the grade-four than the grade-eight reading comprehension tests. In the multilingual context of Zambia it is vital to produce health communication print materials written at or near a grade-four readability level in English and, when warranted, in appropriate Zambian languages.     

Consumers as educators: implementation of patient feedback in general practice training

There is growing interest in the adoption of patient-based assessments for the training of general practitioners. Consumers are in a unique position to comment on the quality of the doctor-patient interaction. Involving consumers as partners with general practice (GP) registrars and GP educators in the development of a patient feedback instrument enhances the relevance and acceptability of consumers as educators in GP training. It also demonstrates that social and medical agendas can be harmonized. Two patient feedback instruments on interpersonal skills were trialed in a training program for general practitioners in Australia. It was found that one of the instruments was more discriminating than the other because of its different response scale.     

Clinical tutor evaluation: a 5-year study by students on an in-patient service and residents in an ambulatory care clinic

Summary. Medical students on an in-patient service and residents working in an ambulatory care clinic have regularly evaluated their clinical tutors over the 5 years 1985-1989. Both groups of raters reliably and predictably evaluated their tutors and both emphasize between-tutor comparisons more than actual rating values for individual tutors. Tutors active in both contexts regularly receive higher ratings from the medical students than from the residents. Mid-course feedback to tutors in the medical course had no impact on end-of-course ratings. In neither context did tutor ratings improve from one evaluation to the next. Both groups reliably discriminate between the teaching skills and the personality traits of individual tutors.     

Involving doctors in management. A survey of the management development career needs of selected doctors in NHS Wales

Reports the results of a survey of 209 senior registrars and 269 consultants throughout Wales to identify the management development needs of doctors and ascertain their views of the value and utility of current management development course offerings in Wales. Finds that, currently, management development for doctors in Wales is unstructured and uncoordinated but, despite this, many doctors, especially senior registrars, appeared keen to increase their future involvement in management and held positive views regarding management and management development. The questionnaire also required doctors to rank order six managerial topics and their elements: financial, human resource, strategic, operational, service quality and self-management. Of these, self-management issues were rated highest and there was some congruity in the rankings of the six topics by senior registrars and the other three consultant categories. Overall, managing a budget, medical and clinical audit, negotiating skills and leadership skills were ranked highest for inclusion in management development while project management, quality circles and equal opportunities received the lowest ratings.     

Health communication in multilingual contexts: a study of reading preferences, practices, and proficiencies among literate adults in Zambia

Comprehension of health materials and messages is a necessary, though not sufficient, condition for the development of health literacy; in the case of print materials, reading comprehension is elemental. Assessments of the population's ability to read and comprehend written materials are complex and highly salient in multilingual countries, such as Zambia, particularly when an excolonial language is but one of multiple official languages. Yet no study has contrasted adult Zambians' reading comprehension of health materials in the major Zambian languages with comparable English-language materials. This article reports the results of a survey of 2,009 literate Zambian adults who were tested for reading comprehension of health materials written at fourth- and eighth-grade levels. The analysis found that respondents who had not gone beyond primary school scored significantly higher on Zambian- than on English-language reading comprehension tests. Respondents with at least an eighth-grade education scored equally well or better on English-language compared with Zambian-language tests. Overall, respondents were more likely to pass the grade-four than the grade-eight reading comprehension tests. In the multilingual context of Zambia it is vital to produce health communication print materials written at or near a grade-four readability level in English and, when warranted, in appropriate Zambian languages.     

Validation of the doctor-patient communication component of the Educational Commission for Foreign Medical Graduates Clinical Skills Assessment

BACKGROUND: The pivotal role of doctor-patient communication in effective health care delivery led the Educational Commission for Foreign Medical Graduates (ECFMG) to incorporate the assessment of interpersonal skills and spoken English proficiency into its Clinical Skills Assessment (CSA). Furthermore, it was decided that to pass the CSA, a candidate would need to meet or surpass defined performance standards for doctor-patient communication as a discrete component. This requirement, among others, is designed to ensure the readiness of graduates of foreign medical schools (FMGs) to enter postgraduate medical education programmes in the United States. OBJECTIVE: The primary focus of this study was to determine the extent to which performance in a simulated testing environment is related to performance in the clinical setting. METHOD: Nurses were trained to rate the communication skills of residents from the patient's perspective. A total of 43 first-year residents were evaluated. The survey ratings (n=225) were compared with the residents' CSA communication scores. RESULTS: Corrected correlations between CSA ratings and those obtained from nurses ranged from 0.61 to 0.73. CONCLUSION: This study provides evidence for the validity of the communication ratings provided by standardized patients. The reasonably strong associations between ratings obtained during testing and those obtained through observation of 'real' patient interactions suggest that external observers can provide accurate evaluations of doctor-patient communication.     

What You Don’t Know Can Hurt You: The Risk of Language Deprivation by Impairing Sign Language Development in Deaf Children

A long-standing belief is that sign language interferes with spoken language development in deaf children, despite a chronic lack of evidence supporting this belief. This deserves discussion as poor life outcomes continue to be seen in the deaf population. This commentary synthesizes research outcomes with signing and non-signing children and highlights fully accessible language as a protective factor for healthy development. Brain changes associated with language deprivation may be misrepresented as sign language interfering with spoken language outcomes of cochlear implants. This may lead to professionals and organizations advocating for preventing sign language exposure before implantation and spreading misinformation. The existence of one—time-sensitive—language acquisition window means a strong possibility of permanent brain changes when spoken language is not fully accessible to the deaf child and sign language exposure is delayed, as is often standard practice. There is no empirical evidence for the harm of sign language exposure but there is some evidence for its benefits, and there is growing evidence that lack of language access has negative implications. This includes cognitive delays, mental health difficulties, lower quality of life, higher trauma, and limited health literacy. Claims of cochlear implant- and spoken language-only approaches being more effective than sign language-inclusive approaches are not empirically supported. Cochlear implants are an unreliable standalone first-language intervention for deaf children. Priorities of deaf child development should focus on healthy growth of all developmental domains through a fully-accessible first language foundation such as sign language, rather than auditory deprivation and speech skills.     

The effect of the general practice registrar year on perceived skills in palliative care in the West Midlands

OBJECTIVES: To ascertain the effect of 12 months spent as a GP registrar on perceived skills in palliative care. DESIGN: A previously validated questionnaire for use with medical undergraduates is modified and used to survey perceived skills in five aspects of providing palliative care in five different scenarios at two points during the 12-month period of general practice vocational training where no specific teaching intervention is conducted. SETTING: The West Midlands. PARTICIPANTS: 210 GP registrars. RESULTS: Perceived skill ratings were seen to significantly increase during the 12-month period, but anxiety in caring for the dying did not significantly decrease. Ratings of skills were lowest when caring for a child dying with leukaemia or a young adult dying with AIDS. In addition, other important variables which had a statistically significant influence were gender and age, but interestingly not the number of previous senior house officer (SHO) posts undertaken or whether the respondent had had formal teaching on the subject in the past. CONCLUSION: It might therefore be postulated that training as a GP registrar has an important impact on the development of perceived skills in palliative care.