Barriers to student access to patients in a group of teaching hospitals

Student academic performance in rural clinical schools: The impact of cohort size and competition

OBJECTIVES

The Deakin University School of Medicine commenced in 2008 as a rurally focused medical school in south-eastern Australia. This research was designed to examine the effectiveness of the school's adoption of small regional clinical school settings.

METHODS

A retrospective cohort study of the first two cohorts of students was employed to assess academic performance at each of five geographically dispersed clinical training sites, with varying student cohort sizes. The Dundee Ready Education Environment Measure (DREEM) questionnaire provided quantitative data regarding the students' perception of their educational environment. The data were analyzed using univariate and multivariate analyses.

RESULTS

The highest examination scores, and greatest satisfaction with educational environment, were associated with the clinical school that had a small-sized group of students and was not co-located with another medical school. These differences remained after adjusting for multiple potential confounding factors.

CONCLUSION

The smaller sites appear to have provided superior support for student learning in this new medical school. This advantage diminishes when smaller cohorts are co-located with students from other medical schools. Cohort size and co-location of medical school curricula may be important independent variables for researchers to consider when comparing the results of clinical education innovations in different settings.

How we avoid patient shortage with an integrated analysis of learning objectives and clinical data during development of undergraduate medical curricula

Access to patients is a crucial factor for student-centred medical education. However, increasing numbers of students, teacher shortage, a patient spectrum consisting of rarer diseases, and quicker discharges limit this necessary access, and therefore pose a challenge for curriculum designers. The herein presented algorithm improves access to patients in four steps by using routinely available electronic patient data already during curriculum development. Step I: Learning objectives are mapped to appropriate ICD-10 (International Statistical Classification of Diseases) codes. Step II: It is determined which learning opportunities need to be considered first for patient allocation in order to maximise overall benefit. Step III: Hospital's departments with the highest expertise on respective learning objectives are assessed and selected for teaching. Step IV: Patients of the chosen department that present the best match for a given learning opportunity are assigned to participation. This integrated analysis of learning objectives and existing clinical data during curriculum development is a well-structured method to maximise access to patients. Furthermore, this algorithm identifies learning objectives of a curriculum that do not correspond well to the spectrum of patients of the respective teaching hospital and which should therefore be taught in learning formats without patient contact.

Conducting patient assessments as a medical student: frequency, barriers, and facilitators

BACKGROUND

Opportunities for medical students to engage in deliberate practice through conducting patient assessments may be declining, but data on the numbers of patients assessed by students during training are lacking.

PURPOSES

The study described relationships between the frequency of patient assessments, student confidence, belief they had seen sufficient patients, and their perceptions of barriers and facilitators of seeing patients.

METHODS

We employed survey methodology to estimate the number of patient assessments conducted across 6 rotations in the 1st year of clinical training, gather ratings of confidence and student belief they had conducted sufficient patient assessments, and barriers and facilitators of seeing patients.

RESULTS

Rotations focused on general medicine and surgery provided more opportunities for patient assessments than specialist rotations (all p < .001). Students conducting more than 10 patient assessments rated confidence in conducting patient assessments and belief they had seen enough patients for their clinical learning, higher than students who saw 10 or fewer patients (all p < .001).

CONCLUSIONS

Our study demonstrated variation in the frequency of patient assessments, and weak relationships between numbers of assessments, student confidence, and barriers to seeing patients. Further investigation is warranted of the impact of fewer opportunities for deliberate practice of skills for expertise development.

Can simulation replace part of clinical time? Two parallel randomised controlled trials

CONTEXT

Education in simulated learning environments (SLEs) has grown rapidly across health care professions, yet no substantive randomised controlled trial (RCT) has investigated whether SLEs can, in part, substitute for traditional clinical education.

METHODS

Participants were physiotherapy students (RCT 1, n = 192; RCT 2, n = 178) from six Australian universities undertaking clinical education in an ambulatory care setting with patients with musculoskeletal disorders. A simulated learning programme was developed as a replica for clinical education in musculoskeletal practice to replace 1 week of a 4-week clinical education placement. Two SLE models were designed. Model 1 provided 1 week in the SLE, followed by 3 weeks in clinical immersion; Model 2 offered training in the SLE in parallel with clinical immersion during the first 2 weeks of the 4-week placement. Two single-blind, multicentre RCTs (RCT 1, Model 1; RCT 2, Model 2) were conducted using a non-inferiority design to determine if the clinical competencies of students part-educated in SLEs would be any worse than those of students educated fully in traditional clinical immersion. The RCTs were conducted simultaneously, but independently. Within each RCT, students were stratified on academic score and randomised to either the SLE group or the control ('Traditional') group, which undertook 4 weeks of traditional clinical immersion. The primary outcome measure was a blinded assessment of student competency conducted over two clinical examinations at week 4 using the Assessment of Physiotherapy Practice (APP) tool.

RESULTS

Students' achievement of clinical competencies was no worse in the SLE groups than in the Traditional groups in either RCT (Margin [Δ] ≥ 0.4 difference on APP score; RCT 1: 95% CI - 0.07 to 0.17; RCT 2: 95% CI - 0.11 to 0.16).

CONCLUSIONS

These RCTs provide evidence that clinical education in an SLE can in part (25%) replace clinical time with real patients without compromising students' attainment of the professional competencies required to practise.

Patient perceptions of medical students' involvement in their obstetrics and gynaecology health care

OBJECTIVE

  To determine perceptions held by patients of the involvement of medical students in their obstetrics and gynaecology health care.

STUDY DESIGN

  This study evaluated patients' perceptions of medical students involved in their care at a tertiary women's hospital. A questionnaire was used to collect patients' perceptions of the student's professional skills, their attitude to and level of comfort in the patient and student interaction.

RESULTS

  Ninety-five percent of patients approached participated in this study. Results demonstrated a high level of patient satisfaction with student involvement in care. Most patients believed students should be part of the hospital team and were prepared to have a student involved in the future. Satisfaction levels were higher for patients for whom English was their first language, women under 40 years of age and those receiving care in assessment and in-patient settings. Patient comfort in student participation was greater for those seen by a female student and those who had previously had a student involved in their care or previously attended the hospital.

CONCLUSION

  Patient perceptions of students' involvement in their obstetrics and gynaecology care are mainly positive. Satisfaction levels differ with the gender of the student, the age of the patient, the location of care and for those for whom English is their first language. Attention must be paid to informing patients of the presence and possible level of interaction of students in their care.

Impact on the dermatology educational experience of medical students with the introduction of online teaching support modules to help address the reduction in clinical teaching

BACKGROUND/OBJECTIVES

With increasing medical student numbers and decreasing clinical teaching opportunities, there has been a need to develop alternative learning resources. The aim of this study was to examine the effectiveness of a new dermatology online teaching resource, from a student perspective.

METHODS

The Australasian College of Dermatologists developed an undergraduate dermatology curriculum and subsequently created online teaching modules in partnership with the University of Sydney. These modules were introduced to final year medical students at the University of Western Australia in 2010. The dermatology learning experiences of these 142 students were compared with the 2009 medical student cohort who did not have access to this resource. A self-administered questionnaire, with a 5-point rating scale, was used.

RESULTS

The 2010 cohort described an improved educational experience using the online modules. Despite a reduction in the number of clinics attended, knowledge and skills gained were scored higher among the 2010 cohort. The student's confidence in their ability to manage common dermatological conditions was also statistically higher in the cohort with the online teaching resource. The learning experience for dermatology compared to other subspecialty teaching in medical school was ranked as a significantly more positive experience in the 2010 cohort.

CONCLUSIONS

Our results suggest that the introduction of the online modules described in this paper to support learning have improved the perceived educational experience of medical students and should be incorporated as a way to improve student teaching in the face of reduced clinic teaching.

Introducing clinical paediatrics to medical students: a novel hospital visitation programme involving Kindergarten children

BACKGROUND

Increasing numbers of medical students in Australia and shorter paediatric hospitalisations require new and creative ways to teach clinical paediatric medicine. At the University of New South Wales, Sydney, we developed a programme involving well Kindergarten children visiting Sydney Children's Hospital to introduce medical students to clinical paediatric medicine.

AIM

The aim was to teach medical students how to engage children and gain their cooperation while performing paediatric examinations.

METHODS

Eight sessions were conducted involving 240 Kindergarten students from seven local primary schools and 217 medical students. School children were escorted by medical students through five activities comprising examination of gross motor skills, testing visual acuity and otoscopy, measuring growth parameters, chest auscultation, pulse counting and blood pressure cuff inflation. Questionnaires were used to gather quantitative and qualitative evaluation data.

RESULTS

The programme achieved its main objective, with 94% of students rating highly their learning about interacting with children and appreciating the challenges in examining them. Medical students (94%), tutors (100%) and participating schools (100%) thought the programme should be continued.

CONCLUSION

This new, innovative programme involving well children introduces medical students to clinical paediatric medicine.

Establishing an integrated multiprofessional skills training programme

BACKGROUND

Opportunities to learn and practice skills are becoming less with changes in the health care environment. Responses to this have included curriculum change and the development of skills programmes. Although the skills programmes, often taught in simulated settings in skills Centres have been frequently described, such a model may not be appropriate for all Universities or have the best outcomes. Firstly access to a centre may not be available and secondly, the training may not alter students' behaviour in the workplace in terms of applying and practicing these skills.

AIM

This paper offers tips for developing a centrally coordinated, integrated, multidisciplinary skills training programme.

METHODS

These 12 tips are based upon current literature, discussion with other skills training providers and reflection on local experiences of establishing and maintaining a skills training programme.

RESULTS

The programme, outlined here, used a multidisciplinary, multiprofessional group to design and run a skills programme, which was clearly linked back to clinical attachments, emphasising ongoing practice with feedback.

CONCLUSIONS

The twelve tips highlight the importance of broad ownership of the programme; separate funding and good evaluation are essential if the programme is to be continued in the absence of a specific Centre or a School to run it.

Aligning clinical resources to curriculum needs: the utility of a group of teaching hospitals

This article describes a study in two acute NHS Trusts of the availability and curriculum relevance of inpatients for undergraduate medical student learning. The study was conducted to assist a new medical school plan on how best to utilise the clinical learning resources of adjacent hospitals, at a time when basic medical education is expanding, large academic hospitals are becoming more specialised and medical care provision is shifting to smaller hospital and ambulatory settings. We found that all three hospitals showed similar proportions, mean ages and gender ratios of available patients, and provided a wide range of clinical learning opportunities. The larger academic hospital appeared to offer a narrower, more specialised, range of patient problems that were necessary to meet curriculum objectives, while the smaller hospitals provided a broader range of common problems. Opportunities to participate in clinical skills were limited in all three hospitals. None of the hospitals appeared to provide sufficient clinical material to meet all curriculum learning objectives. As acute health care delivery models change, medical schools may have to be quite deliberate in their utilisation of academic hospitals, community hospitals and primary care, matching student allocations carefully to sources of relevant learning opportunities.

Perceptions by medical students of their educational environment for obstetrics and gynaecology in metropolitan and rural teaching sites

BACKGROUND

Medical student education in Western Australia is expanding to secondary level metropolitan hospitals and rural sites to accommodate workforce demands and increasing medical student numbers.

AIMS

To determine if students' perceptions of the teaching environment for obstetrics and gynaecology differ between tertiary, secondary level metropolitan hospitals and rural sites, and to determine if students' perceptions of their learning environment are associated with improved academic performance.

METHOD

An evaluation was conducted of medical students' perceptions of their learning environment during an obstetrics and gynaecology program at a variety of sites across metropolitan and rural Western Australia. The evaluation was based on the Dundee Ready Education Environmental Measure (DREEM) questionnaire.

RESULTS

There were no significant differences in students' perceptions of their learning environment between the tertiary hospital, combined programs involving a tertiary and secondary metropolitan hospital, rural sites with a population of more than 25,000 and rural sites with a population less than 25,000 people. Perceptions were similar in male and female students. The overall mean score for all perceptions of the learning environment in obstetrics and gynaecology were in the range considered to be favorable. Higher scores of perceptions of the learning environment were associated positively with the measures of academic achievement in the clinical, but not written, examination.

CONCLUSION

Medical students' perceptions of their learning environment in obstetrics and gynaecology were not influenced by the geographical site of delivery or their gender but were positively related to higher academic achievement. Providing appropriate academic and clinical support systems have been put in place the education of medical students can be extended outside major hospitals and into outer metropolitan and rural communities without any apparent reduction in perceptions of the quality of their learning environment.

Designing and implementing a skills program using a clinically integrated, multi-professional approach: using evaluation to drive curriculum change

The essential procedural skills that newly graduated doctors require are rarely defined, do not take into account pre-vocational employer expectations, and differ between Universities. This paper describes how one Faculty used local evaluation data to drive curriculum change and implement a clinically integrated, multi-professional skills program. A curriculum restructure included a review of all undergraduate procedural skills training by academic staff and clinical departments, resulting in a curriculum skills map. Undergraduate training was then linked with postgraduate expectations using the Delphi process to identify the skills requiring structured standardised training. The skills program was designed and implemented without a dedicated simulation center. This paper shows the benefits of an alternate model in which clinical integration of training and multi-professional collaboration encouraged broad ownership of a program and, in turn, impacted the clinical experience obtained.

Designing and implementing a skills program using a clinically integrated, multi-professional approach: using evaluation to drive curriculum change

The essential procedural skills that newly graduated doctors require are rarely defined, do not take into account pre-vocational employer expectations, and differ between Universities. This paper describes how one Faculty used local evaluation data to drive curriculum change and implement a clinically integrated, multi-professional skills program. A curriculum restructure included a review of all undergraduate procedural skills training by academic staff and clinical departments, resulting in a curriculum skills map. Undergraduate training was then linked with postgraduate expectations using the Delphi process to identify the skills requiring structured standardised training. The skills program was designed and implemented without a dedicated simulation center. This paper shows the benefits of an alternate model in which clinical integration of training and multi-professional collaboration encouraged broad ownership of a program and, in turn, impacted the clinical experience obtained.

They just don't get enough! Variable intern experience in bedside procedural skills

BACKGROUND

Medical school and resident training programmes offer different learning opportunities and outcomes. The aim of the study was to assess medical student and intern experience in common clinical procedures.

METHODS

Interns employed in a metropolitan teaching hospital from 2000 to 2004 completed a survey of experience and confidence in clinical procedures at the beginning and end of their intern year. Attendance at and the contribution to procedural confidence of a voluntary procedural skill-training programme were examined.

RESULTS

For the 314 interns, clinical experience before and during internship varied for each procedure and between year cohorts as did training programme attendance (44-84%). Student procedural confidence was predicted by pre-intern experience either on patients or by simulation (beta = 0.17, 95% confidence interval (CI) 0.02-0.21, P = 0.03) and age >30 years on commencing internship (beta = 8.44, 95%CI 3.03-14.06, P = 0.003. Adjusted R(2) = 0.08, P = 0.002). Intern procedural confidence by year's end was predicted by attendance at the training programme (beta = 0.48, 95%CI 0.34-0.62, P < 0.001), intern experience with patient procedures (beta = 0.34, 95%CI 0.21-0.47, P < 0.001) and a clear decision to enter a postgraduate training programme (beta = 0.13, 95%CI 0.04-0.22, P = 0.007, Adjusted R(2) = 0.50, P < 0.001).

CONCLUSION

Interns and students receive variable experience to carry out procedural skills on patients. This makes designing training programmes difficult as training needs vary each year. Both mandatory supervision of key skills and opportunities to supplement limited experience are needed during the intern year to ensure a uniform experience.

Training doctors in general practices: A review of the literature

OBJECTIVE

This study was undertaken to assess the evidence of whether new forms of medical training, where substantial training takes place in general practice, will be acceptable to GPs. In particular, we asked the questions: Are GPs willing to act as trainers and supervisors in their practices? Do GPs have the appropriate skills to be trainers? Do practices have the infrastructure and resources to support placements? And, are patients happy to be seen by medical students and General Practice Registrars?

DESIGN

Key Australian and international databases, key Australian journals and key Australian websites were searched for literature on general practice-based training of medical students and General Practice Registrars.

RESULTS

In the international and Australian literature, we found that many GPs consider training medical students and General Practice Registrars to be intrinsically satisfying. They vary in their skills, and most medical schools have made significant investments in training and support activities. Many practices do not have the necessary infrastructure, and investments need to be made if extended placements are to be successful. Many patients are happy to be seen by students and Registrars, but careful thought needs to be given to implementing appropriate models so that students have good learning opportunities, patients are not disadvantaged and general practices can operate efficiently.

CONCLUSION

The success of this new model of clinical placements is dependent on medical schools having a detailed understanding of the needs and expectations of GPs.