Evaluation of a programme of workshops for promoting the teaching of critical appraisal skills

The aim of this study was to assess the effectiveness of four training workshops at the inception of a programme to cascade critical appraisal skills training throughout Scotland. Data were collected from all participants and organizers at four commissioned critical appraisal skills training workshops in Scotland. The collection of data involved three components: a survey of workshop participants before and after each workshop to determine knowledge of the principles of clinical effectiveness; semi-structured interviews with organizers before, during and after the programme of commissioned workshops to assess views on the workshops; and a postal survey to determine involvement in critical appraisal activities following the initial workshops. The main outcome measures were 'change in knowledge' and subsequent involvement in teaching. An average of 41 people attended each workshop. Participants improved their scores on understanding of clinical effectiveness. Not all of the improvement can be ascribed to the workshops, however, because control item scores also improved, albeit to a lesser extent. The workshops were perceived as an acceptable way of acquiring critical appraisal skills, but doubts were expressed about whether participants would be able to roll out the programme on their own. Of the 32 (42%) attendees who were involved in CASP-style workshops after the initial workshops, 26 (34%) providing aspects of teaching, and a further six (8%) were participants. The evaluation of the CASP workshop technique suggests that it does improve knowledge of clinical effectiveness, but concerns remain about the viability and reliability of this approach as it rolls out training within Scotland.     

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.     

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.     

A skills programme for preclinical medical students

An education programme in which preclinical medical students are introduced to common procedural skills is described. This programme is presented by a multidisciplinary health care team using short lectures, demonstrations, mannequin practice, and, in selected instances, practice on class-mate volunteers. The programme was evaluated by the students immediately following the presentation and for one class during their clinical activities one year later. The students' support for this programme was generally enthusiastic and remained undiminished upon reflection 12 months later.     

Trialling a new way to learn clinical skills: systematic clinical appraisal and learning

AIM: To describe and evaluate the effectiveness of a new method of teaching clinical skills designed to increase students' active and self-directed learning as well as tutor feedback. METHODS: A total of 22 consenting Year 4 medical students undertaking general practice and general surgery clinical experience were involved in a pre- and post-test research design. In the initial period of the study, students were taught clinical skills in a traditional manner. In the second phase a clinical teaching strategy called systematic clinical appraisal and learning (SCAL) was utilised. This learning strategy involved active and self-directed learning, holistic care and immediate feedback. Students independently saw a patient and were asked to make judgements about the patient's potential diagnosis, tests required, management, psychosocial needs, preventive health requirements, and any ethical problems. These judgements were then compared with those of the clinical supervisor, who saw the same patient independently. Students recorded details for each consultation. Comparisons were made of the two study periods to examine whether the use of SCAL increased the number of students' independent judgements, perceived student learning, tutor feedback and self-directed learning. RESULTS: During the SCAL learning period, students reported making a greater number of statistically significant independent judgements, and receiving significantly increased tutor feedback in both general practice and general surgery. The number of learning goals set by students was not found to differ between the two periods in surgery but significantly increased in general practice in the SCAL period. Students' perceptions of their learning significantly increased in the SCAL period in surgery but not in general practice. During the traditional learning period in both settings, there was limited student decision-making about most aspects of care, but particularly those relating to prevention, psychosocial issues and ethics. CONCLUSIONS: The SCAL approach appears to offer some advantages over traditional clinical skills teaching. It appears to encourage active and independent decision-making, and to increase tutor feedback. Further exploration of the approach appears warranted.     

Surgical skills training: simulation and multimedia combined

CONTEXT: Basic surgical skills are needed throughout the medical profession, but current training is haphazard and unpredictable. There is increasing pressure to provide transparency about training and performance standards. There is a clear need for inexperienced learners to build a framework of basic skills before carrying out surgical procedures on patients. Effective learning of a skill requires sustained deliberate practice within a cognitive framework, and simulation offers an opportunity for safe preparation. OBJECTIVES: This paper presents a new approach to basic surgical skills training, where tuition using a specially designed computer program is combined with structured practice using simulated tissue models. This approach to teaching has evolved from practical experience with surgical skills training in workshops. METHODS: Pilot studies with 72 first-year medical students highlighted the need for separate programs for teaching and for self-directed learning. The authors developed a training approach in the light of this experience. Subsequent in-depth observational and interview studies examined (a) individual teaching sessions between surgical teachers and learners (five consultant surgeons and five senior house officers) and (b) group teaching sessions with general practitioners (14 participants in three group interviews). Further work has resulted in a self-directed learning program. CONCLUSIONS: Qualitative analysis of observational and interview data provides strong preliminary support for the effectiveness of this approach. The response of teachers and learners was extremely positive. The combination of information (presented by computer) and practice of psychomotor skill (using simulated tissue models) could be extended to other surgical and practical skills.     

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.     

A study of pre-registration house officers' clinical skills

BACKGROUND: Little is known about the ability of pre-registration house officers (PRHOs) to perform basic clinical skills just prior to entering the medical register. OBJECTIVES: To find out whether PRHOs have deficiencies in basic clinical skills and to determine if the PRHOs themselves or their consultants are aware of them. METHOD: All 40 PRHOs at the Chelsea and Westminster and Whittington Hospitals were invited to undertake a 17 station OSCE of basic clinical skills. Each station was marked by one examiner completing an overall global score after completing an itemised checklist. An adequate station performance was the acquisition of a pass/borderline pass grade. Prior to the OSCE, a questionnaire was given to each PRHO asking them to rate their own abilities (on a 5-point scale) in the skills tested. A similar questionnaire was sent to the educational supervisors of each PRHO asking them to rate their house officer's ability in each of the same skills. RESULTS: Twenty-two PRHOs participated. Each PRHO failed to perform adequately a mean of 2.4 OSCE stations (SD 1.8, range 1-8). There were no significant correlations between OSCE performance and either self- or educational supervisor ratings. The supervisor felt unable to give an opinion on PRHO abilities in 18% of the skills assessed. DISCUSSION: This study suggests that PRHOs may have deficiencies in basic clinical skills at the time they enter the medical register. Neither the PRHOs themselves nor their consultants identified these deficiencies. A large regional study with sufficient power is required to explore the generalizability of these concerns in more detail.     

Clinical skills training: developing objective assessment instruments

The purpose of this study was to develop objective assessment instruments for use in psychomotor skill training and to test the instruments for interobserver reliability. Two checklist style instruments, one for suturing and one for endotracheal intubation, were developed through a process of review of standard texts, consultation with local experts and field testing. Following development they were used by paired examiners in an Objective Structured Clinical Examination (OSCE) setting to test the instruments for interobserver reliability. A total of 88 final year medical students were recruited from the five Ontario medical schools to participate as examinees. The checklists worked well within the practical constraints of a 10 minute OSCE station and demonstrated a high level of interobserver reliability with Kappa scores of 0·65 for the suturing checklist and 0·71 for the intubation checklist. Furthermore, the Kappa scores for individual checklist items served to identify items which demonstrated poor interobserver reliability and thus highlighted them for review.     

Skills and attributes of directors of educational programmes

OBJECTIVES: The purpose of this study was to obtain a list of desirable skills and attributes of prospective educational programme directors as judged by potential employers of future directors. DESIGN: An international mail survey was conducted worldwide, using a one-page, open-ended questionnaire. SETTING: University of Illinois at Chicago, USA. SUBJECTS: Deans, department heads and chief executive officers from the various health professions. RESULTS: A total of 139 respondents completed the questionnaire (22. 3% response rate). Responses were remarkably similar across health professions. The nine leading skills were: oral communication skills, interpersonal skills, competent practitioner, educational goal-definition skills, educational design skills, problem-solving and decision-making skills, team worker and building skills, written communication skills and fiscal manager and budgeting skills. The three leading personal attributes were: visionary, flexible and open-minded and trustworthy and value-driven individual. CONCLUSIONS: The complete list of skills and attributes can be used by employers or administrators to build checklist items when hiring or reviewing programme directors or to plan and evaluate training programmes. The importance of leadership compared to managerial responsibilities is discussed as well as the need to train future educational programme directors.     

Factors influencing the communication skills of first-year clinical medical students

The aim of this study was to examine the factors influencing medical students' communication skills. The sample comprised all first-year clinical students. Thirty-two received teaching in communication skills during the year; the remaining 56 did not. Students' career preferences, attitudes towards communication skills and confidence in their ability to communicate with patients were assessed by questionnaire at the beginning and end of the year. At the end of the year each student was videotaped interviewing a simulated patient. Students' communication skills were assessed on the basis of this interview by raters using a standardized rating scale, and by patient questionnaires. While there was some evidence that brief communication skills training improved skills, sex of student was a more significant predictor of level of skill. Students who perceived communication skills as less relevant to medicine and those who were more confident about their own communication skills were more likely to prefer a career in hospital medicine. Students' judgements of their ability to communicate effectively were poor. In the main there was no relationship between confidence and level of skill: where they were related, the association was negative. The benefits from communication skills training might be enhanced by involving hospital doctors in the teaching, and providing students with detailed video feedback on their skills at the outset.     

The effectiveness of immediate feedback during the Objective Structured Clinical Examination

Using eight different physical examination or technical stations, 400 examinations were conducted to evaluate the effectiveness of immediate feedback during the Objective Structured Clinical Examination (OSCE). The test group comprised 50 medical students who underwent a standard 4-minute examination followed by 2 minutes of feedback. Immediately following feedback the students repeated an identical 4-minute examination scored by the same examiners. The control group consisted of 50 students from the same class who underwent an identical testing sequence, but instead of receiving feedback, they were instructed to continue their examinations for an additional 2 minutes before repeating the stations. Simple repetition of the task did not significantly improve score (mean increase 2.0%, NS). Extending the testing period from 4 to 6 minutes resulted in a small but significant increase in score (mean 6.7%, P less than 0.001). However, there was a much larger increase in the scores obtained following 2 minutes of immediate feedback compared to pre-feedback performance (mean 26.3%, P less than 0.0001). The majority of students and examiners felt that feedback, as administered in this study, was valuable both as a learning and teaching experience. Short periods of immediate feedback during an OSCE are practical and can improve competency in the performance of criterion-based tasks, at least over the short term. In addition, such feedback provides students with valuable self-assessment that may stimulate further learning.     

The use of videorecordings of medical postgraduates in improving clinical skills

The examination for membership of the Royal Colleges of Physicians has a high failure rate despite intensive clinical coaching provided by many postgraduate courses. One of the main difficulties appears to be the failure of candidates to identify specific shortcomings in their clinical behaviour. In this study videorecording was used as a method of self-appraisal enabling the candidate to identify strengths and weaknesses. The evidence from the study suggests that self-appraisal by videorecording should be used as an adjunct to clinical instruction.     

Transition to clinical training: influence of pre-clinical knowledge and skills, and consequences for clinical performance

Context  Many students experience a tough transition from pre-clinical to clinical training and previous studies suggest that this may constrict students' progress. However, clear empirical evidence of this is lacking. The aim of this study was to determine: whether the perceived difficulty of transition influences student performance during the first 2 weeks of clerkships; whether it influences students' overall performance in their first clerkship, and the degree to which the difficulty of transition is influenced by students' pre-clinical knowledge and skills levels.
Methods  Clerks ( n  = 83) from a university hospital and eight affiliated hospitals completed a questionnaire measuring the perceived difficulty of the transition period. Data collected included student scores on pre-clinical knowledge and skills, their performance during the second week of the first clerkship, and their overall performance in the first clerkship. Univariate and multivariate multiple regression analyses were used to analyse the data.
Results  The perceived difficulty of transition was neither predictive of student performance during the transition period (adjusted R ² = 11.8%, P  = NS), nor of their overall clerkship performance (adjusted R ² = 8.6%, P  = NS). Students' pre-clinical knowledge and skills played a minor role in the perceived difficulty of the transition period.
Conclusions  The negative effect of the transition period on student progress suggested in the literature was not found in this study. A possible explanation for the limited influence of students' knowledge and skills on performance during the transition period is that the workload in this period causes a cognitive overload, interfering with students' abilities to apply their pre-clinical knowledge and skills.     

Developing a Korean communication skills attitude scale: comparing attitudes between Korea and the West

Objectives  We aimed to develop a Korean version of the Communication Skills Attitude Scale (CSAS) created by Rees et al . in order to elucidate the positive and negative aspects of Korean pre-medical and medical students' attitudes towards communication skills (CS) learning.
Methods  We performed two surveys. In the first of these, 325 pre-medical and medical students completed a translated version of the CSAS. In the second survey, 257 medical students and doctors-in-training answered five open-ended questions to obtain more qualitative data about their attitudes.
Results  Principal component analysis with direct oblimin rotation performed with the data from the first survey produced the following five factors: facilitation of interpersonal skills; doubts about the importance of CS learning in medicine; motivation; negative attitudes towards assessment, and overconfidence. Results from the second survey indicated that facilitation and importance within a medical context were two core attitudinal factors and suggested some modification to the CSAS to improve its fit for Korean pre-medical and medical students.
Conclusions  Using a Korean version of the CSAS (CSAS-K), we determined five factors that revealed a somewhat complex attitude structure among students towards CS learning. The CSAS required some modification, possibly because CS teaching and learning in Korea are in the development stage. Finally, the educational implications of the results are discussed.     

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.     

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.     

The lessons of deafness: deafness awareness and communication skills training with medical students

This paper describes a 1-day course on deafness awareness and communication skills with fourth-year medical undergraduates and summarizes their evaluation of the course. Deaf people commonly experience major communication difficulties with doctors. This course gives students an awareness of deafness (and of the insights deaf people can give to an understanding of communication)--the lessons of deafness--and challenges some critical assumptions in medical practice. Students are given personal experience of deafness and of the consequent powerlessness and loss of self-confidence, while also learning new communication skills which they then apply in a role-play consultation with a deaf patient. Systematic evaluation has been built into the programme and student opinion has been unanimously enthusiastic.     

Acquisition of basic clinical skills in the general practice setting

Undergraduate medical education in the UK is changing due to both educational pressure (from the General Medical Council) and changes in the hospital service. As a result the role of general practice in providing core clinical experience is under debate. The purpose of this study was to determine the clinical contact available for junior clinical medical clerks (third year) attached to five general practices. We report here on the clinical experience recorded by students during 106 sessions (74% of possible sessions). One hundred and one patients were seen, 54% females; ages ranging from 14 to 92. Four hundred and twenty-six symptoms were recorded; the largest category (36%) was CVS/respiratory followed by neurological (20%). Shortness of breath was the commonest single symptom (46% in the CVS/respiratory category). Three hundred and seventy-one signs were recorded; 48% were in the CVS/respiratory category, 33% in the neurological category. Cardiac murmurs were the commonest single sign (34% of the CVS/respiratory category). Sixty-nine separate comments were made by students about the range of clinical experience available; all were favourable. Forty-eight per cent of comments highlighted the availability of patients with appropriate symptoms and signs. This study has demonstrated that general practices can provide appropriate clinical exposure which complements hospital teaching for junior students.