Implications of aligning full registration of doctors with medical school graduation:a qualitative study of stakeholder perspectives

OBJECTIVES: The Shape of Training report recommended that full registration is aligned with medical school graduation. As part of a General Medical Council-funded study about the preparedness for practice of UK medical graduates, we explored UK stakeholders' views about this proposal using qualitative interviews (30 group and 87 individual interviews) and Framework Analysis.

SETTING: Four UK study sites, one in each country.Save

PARTICIPANTS: 185 individuals from eight stakeholder groups: (1) foundation year 1 (F1) doctors (n=34); (2) fully registered trainee doctors (n=33); (3) clinical educators (n=32); (4) undergraduate/postgraduate Deans, and Foundation Programme Directors (n=30); (5) other healthcare professionals (n=13); (6) employers (n=7); (7) policy and government (n=11); (8) patient and public representatives (n=25).

RESULTS: We identified four main themes: (1) The F1 year as a safety net: patients were protected by close trainee supervision and 'sign off' to prevent errors; trainees were provided with a safe environment for learning on the job; (2) Implications for undergraduate medical education: if the proposal was accepted, a 'radical review' of undergraduate curricula would be needed; undergraduate education might need to be longer; (3) Implications for F1 work practice: steps to protect healthcare team integration and ensure that F1 doctors stay within competency limits would be required; (4) Financial, structural and political implications: there would be cost implications for trainees; clarification of responsibilities between undergraduate and postgraduate medical education would be needed. Typically, each theme comprised arguments for and against the proposal.

CONCLUSIONS: A policy change to align the timing of full registration with graduation would require considerable planning and preliminary work. These findings will inform policymakers' decision-making. Regardless of the decision, medical students should take on greater responsibility for patient care as undergraduates, assessment methods in clinical practice and professionalism domains need development, and good practice in postgraduate supervision and support must be shared.

Peer tutoring in a medical school: perceptions of tutors and tutees

Background: Peer tutoring has been described as “people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching”. Peer tutoring is well accepted as a source of support in many medical curricula, where participation and learning involve a process of socialisation.
Peer tutoring can ease the transition of the junior students from the university class environment to the hospital workplace. In this paper, we apply the Experienced Based Learning (ExBL) model to explore medical students’ perceptions of their experience of taking part in a newly established peer tutoring program at a hospital based
clinical school.
Methods: In 2014, all students at Sydney Medical School – Central, located at Royal Prince Alfred Hospital were invited to voluntarily participate in the peer tutoring program. Year 3 students (n = 46) were invited to act as tutors for Year 1 students (n = 50), and Year 4 students (n = 60) were invited to act as tutors for Year 2 students (n = 51). Similarly, the ‘tutees’ were invited to take part on a voluntary basis. Students were invited to attend focus groups, which were held at the end of the program. Framework analysis was used to code and categorise data into themes.
Results: In total, 108/207 (52 %) students participated in the program. A total of 42/106 (40 %) of Year 3 and 4 students took part as tutors; and of 66/101 (65 %) of Year 1 and 2 students took part as tutees. Five focus groups were held, with 50/108 (46 %) of students voluntarily participating. Senior students (tutors) valued the opportunity to practice and improve their medical knowledge and teaching skills. Junior students (tutees) valued the opportunity for additional practice and patient interaction, within a relaxed, small group learning environment.
Conclusion: Students perceived the peer tutoring program as affording opportunities not otherwise available within the curriculum. The peer teaching program provided a framework within the medical curriculum for senior students to practice and improve their medical knowledge and teaching skills. Concurrently, junior students were provided with a valuable learning experience that they reported as being qualitatively different to traditional teaching by faculty.

Right-left discrimination among medical students: Getting it right all of the time?

Objective To determine medical students’ self awareness and ability to discriminate right from left; to identify characteristics associated with this ability; and to identify any techniques used to aid discrimination. Design Questionnaire and psychometric study. Setting Undergraduate medical school, Northern Ireland. Participants 290 first year undergraduate students. Main outcome measure Medical students’ ability to discriminate right from left using the Bergen right-left discrimination test. Results Test scores ranged from 31 to 143 on a scale of 0- 144 (mean 112 (standard deviation 22.2)). Male students significantly outperformed female students (117.18 (26.96) v 110.80 (28.94)). Students who wanted to be surgeons performed significantly better than those who wanted to be general practitioners or medical doctors (119.87 (25.15) v 110.55 (27.36) v 112.50 (26.88)). The interaction effect for sex and career wishes was not significant (P=0.370). Students who used learnt techniques to help them discriminate scored significantly less than those who did not (P

Does first aid have a place in the medical curriculum? A survey of medical students

Introduction: When a medical emergency occurs in the prehospital environment, there is an expectation from the general public for medical students to offer assistance with a similar level of competence as qualified doctors. However, the question is raised; do medical students have sufficient training in first aid skills to fulfil the role expected of them?

Prior to the publication of the latest version of Tomorrow’s Doctors by the UK General Medical Council, a student selected component (SSC) in first aid was delivered at the medical school in Queen’s University Belfast (QUB), Northern Ireland. The overwhelming popularity of this SSC prompted a desire to investigate and understand students’ experiences of first aid.

Aim: To identify first and second year medical students’ knowledge of, and attitudes towards, first aid and their expectations of the medical curriculum.

Methods: A questionnaire was delivered using TurningPoint Audience Response System® during the second semester of the 2008 - 2009 academic year to all first and second year medical students at QUB.

Results: Less than half of the students felt that they had a good level of first aid knowledge, a third would feel confident helping in an emergency and only 10% would be confident leading an emergency situation. The vast majority of students believed first aid is beneficial, that the general public expect medical students to have the knowledge to handle an emergency situation, and that a full first aid course should be included in the core medical curriculum at an early stage. They did not believe it should be a pre-requisite for medical school.

Conclusion: Only a small proportion believed their first aid knowledge adequate. An overwhelming proportion believed that first aid training is beneficial and that the public expect competency in managing emergencies. This study clearly demonstrates students’ need and desire for first aid training in the core medical curriculum at an early stage and to the highest training level possible.

A study of the relational aspects of the culture of academic medicine

PURPOSE: The impact of medical school culture on medical students has been well studied, but little documentation exists regarding how medical faculty experience the culture in which they work. In an ongoing project, the National Initiative on Gender, Culture and Leadership in Medicine, the authors are investigating how the existing culture of academic medical institutions supports all faculty members' ability to function at their highest potential. METHOD: The authors conducted a qualitative study of faculty in five disparate U.S. medical schools. Faculty in different career stages and diverse specialties were interviewed regarding their perceptions and experiences in academic medicine. Analysis was inductive and data driven. RESULTS: Relational aspects of the culture emerged as a central theme for both genders across all career categories. Positive relationships were most evident with patients and learners. Negative relational attributes among faculty and leadership included disconnection, competitive individualism, undervaluing of humanistic qualities, deprecation, disrespect, and the erosion of trust. CONCLUSIONS: The data suggest that serious problems exist in the relational culture and that such problems may affect medical faculty vitality, professionalism, and general productivity and are linked to retention. Efforts to create and support trusting relationships in medical schools might enhance all faculty members' efforts to optimally contribute to the clinical, education, and research missions of academic medicine. Future work will document the outcomes of a five-school collaboration to facilitate change in the culture to support the productivity of all medical faculty. © 2009 Association of American Medical Colleges.

Assisstantship improves medical student preparedness for starting work

Background: The GMC has recommended introducing student assistantships during which final year students, under supervision, undertake most of the responsibilities of a FY1 doctor. The Medical School at Queen’s University Belfast in 2011/12 introduced an assistantship programme. We have evaluated the impact of the assistantship on students’ perception of their preparedness for starting work.
Methods: Students were asked to complete a questionnaire at the beginning of the assistantship. It assessed the students’ perception of their preparedness in five areas: clinical and practical skills, communications skills, teaching and learning, understanding the work environment and team working. After the assistantship they again completed the questionnaire. Comparison of the results allowed an assessment of the impact of the assistantship.
Results: There was a statistically significant improvement in the students' perception of their preparation for 49 of 56 tasks contained within the questionnaire. After the assistantship 81.2% of students felt well prepared for starting work compared with 38.9% before the assistantship. 93.9% agreed that the assistantship had improved their preparedness for starting work.
Conclusions: The assistantship at Queen’s University improves medical students’ perception of their preparedness for starting work. The majority of medical students feel well prepared for starting work after completing the assistantship.

How should teaching on whole person medicine, including spiritual issues, be delivered in the undergraduate medical curriculum in the United Kingdom?

Background

Although the General Medical Council recommends that United Kingdom medical students are taught ‘whole person medicine’, spiritual care is variably recognised within the curriculum. Data on teaching delivery and attainment of learning outcomes is lacking. This study ascertained views of Faculty and students about spiritual care and how to teach and assess competence in delivering such care.

A questionnaire comprising 28 questions exploring attitudes to whole person medicine, spirituality and illness, and training of healthcare staff in providing spiritual care was designed using a five-point Likert scale. Free text comments were studied by thematic analysis. The questionnaire was distributed to 1300 students and 106 Faculty at Queen’s University Belfast Medical School.

351 responses (54 staff, 287 students; 25 %) were obtained. >90 % agreed that whole person medicine included physical, psychological and social components; 60 % supported inclusion of a spiritual component within the definition. Most supported availability of spiritual interventions for patients, including access to chaplains (71 %), counsellors (62 %), or members of the patient’s faith community (59 %). 90 % felt that personal faith/spirituality was important to some patients and 60 % agreed that this influenced health. However 80 % felt that doctors should never/rarely share their own spiritual beliefs with patients and 67 % felt they should only do so when specifically invited. Most supported including training on provision of spiritual care within the curriculum; 40-50 % felt this should be optional and 40 % mandatory. Small group teaching was the favoured delivery method. 64 % felt that teaching should not be assessed, but among assessment methods, reflective portfolios were most favoured (30 %). Students tended to hold more polarised viewpoints but generally were more favourably disposed towards spiritual care than Faculty. Respecting patients’ values and beliefs and the need for guidance in provision of spiritual care were identified in the free-text comments.

Students and Faculty generally recognise a spiritual dimension to health and support provision of spiritual care to appropriate patients. There is lack of consensus whether this should be delivered by doctors or left to others. Spiritual issues impacting patient management should be included in the curriculum; agreement is lacking about how to deliver and assess.

Hierarchy as a barrier to advancement for women in academic medicine

Background: Research on barriers to professional advancement for women in academic medicine has not adequately considered the role of environmental factors and how the structure of organizations affects professional advancement and work experiences. This article examines the impact of the hierarchy, including both the organization's hierarchical structure and professionals' perceptions of this structure, in medical school organization on faculty members' experience and advancement in academic medicine. Methods: As part of an inductive qualitative study of faculty in five disparate U.S. medical schools, we interviewed 96 medical faculty at different career stages and in diverse specialties, using in-depth semistructured interviews, about their perceptions about and experiences in academic medicine. Data were coded and analysis was conducted in the grounded theory tradition. Results: Our respondents saw the hierarchy of chairs, based on the indeterminate tenure of department chairs, as a central characteristic of the structure of academic medicine. Many faculty saw this hierarchy as affecting inclusion, reducing transparency in decision making, and impeding advancement. Indeterminate chair terms lessen turnover and may create a bottleneck for advancement. Both men and women faculty perceived this hierarchy, but women saw it as more consequential. Conclusions: The hierarchical structure of academic medicine has a significant impact on faculty work experiences, including advancement, especially for women. We suggest that medical schools consider alternative models of leadership and managerial styles, including fixed terms for chairs with a greater emphasis on inclusion. This is a structural reform that could increase opportunities for advancement especially for women in academic medicine. © 2010 Copyright Mary Ann Liebert, Inc.

Physical Activity and Cognitive Function in the Elderly: a Systematic Review

Background: Physical activity appears important contributor for healthy aging, including cognitive function. However, it is unclear whether late life physical activity alone is beneficial to cognitive function. We performed a systematic review to examine the effect of late life physical activity in maintaining cognitive function in older persons.
Methods: Search Strategy and Selection criteria: The search sources consisted of PubMed, MEDLINE, CINAHL, Cochrane Controlled Trials Register (CENTRAL), and the University of Washington Medical School Library Database between July 15, 2011 and August 15, 2012 with language restricted to English. Studies that were published in journals on or after January 2000 with participants older than 60 years of age were reviewed. Randomized controlled trials including at least 30 participants and lasting for at least 6 months and all observational studies of at least 100 participants and lasting at least 1 year in duration were eligible for inclusion Two reviewers assessed the applicability and results of these studies.
Results: Twenty-six studies fulfilling the inclusion criteria are included. Twenty-one studies reported that late life physical activity resulted in maintenance or enhancement of cognitive function. Three studies reported a dose-response relationship between physical activity and cognition.
Conclusions: Late life physical activity is beneficial for cognitive function in the elderly. However, the majority of the evidence is of medium quality with moderate risk of bias. Larger, randomized controlled trials are needed to better define the association between late life physical activity and cognitive function. Further research is required to determine which types of exercise have the greatest benefits on specific cognitive domains. Despite these caveats, current data are sufficient to recommend that moderate level, late life physical activity may be an effective method to improve cognitive function and delay the onset and progression of cognitive disease in the elderly.

'Sorry I meant the patient's left side': impact of distraction on right/left discrimination

Context Medical students can have difficulty in distinguishing left from right. Many infamous medical errors have occurred when a procedure has been performed on the wrong side, such as in the removal of the wrong kidney. Clinicians encounter many distractions during their work. There is limited information on how these affect performance. 
Objectives Using a neuropsychological paradigm, we aim to elucidate the impacts of different types of distraction on left–right (LR) discrimination ability. 
Methods Medical students were recruited to a study with four arms: (i) control arm (no distraction); (ii) auditory distraction arm (continuous ambient ward noise); (iii) cognitive distraction arm (interruptions with clinical cognitive tasks), and (iv) auditory and cognitive distraction arm. Participants’ LR discrimination ability was measured using the validated Bergen Left–Right Discrimination Test (BLRDT). Multivariate analysis of variance was used to analyse the impacts of the different forms of distraction on participants’ performance on the BLRDT. Additional analyses looked at effects of demographics on performance and correlated participants’ self-perceived LR discrimination ability and their actual performance. 
Results A total of 234 students were recruited. Cognitive distraction had a greater negative impact on BLRDT performance than auditory distraction. Combined auditory and cognitive distraction had a negative impact on performance, but only in the most difficult LR task was this negative impact found to be significantly greater than that of cognitive distraction alone. There was a significant medium-sized correlation between perceived LR discrimination ability and actual overall BLRDT performance. 
Conclusions
Distraction has a significant impact on performance and multifaceted approaches are required to reduce LR errors. Educationally, greater emphasis on the linking of theory and clinical application is required to support patient safety and human factor training in medical school curricula. Distraction has the potential to impair an individual's ability to make accurate LR decisions and students should be trained from undergraduate level to be mindful of this.

Recovery of Sleep or Recovery of Self? A Grounded Theory Study of Residents’ Decision Making Regarding How to Spend Their Nonclinical Postcall Time

Purpose: As resident work hours policies evolve, residents’ off-duty time remains poorly understood. Despite assumptions about how residents should be using their postcall, off-duty time, there is little research on how residents actually use this time and the reasoning underpinning their activities. This study sought to understand residents’ nonclinical postcall activities when they leave the hospital, their decision-making processes, and their perspectives on the relationship between these activities and their well-being or recovery.

Method: The study took place at a Liaison Committee on Medical Education–accredited Canadian medical school from 2012 to 2014. The authors recruited a purposive and convenience sample of postgraduate year 1–5 residents from six surgical and nonsurgical specialties at three hospitals affiliated with the medical school. Using a constructivist grounded theory approach, semistructured interviews were conducted, audio-taped, transcribed, anonymized, and combined with field notes. The authors analyzed interview transcripts using constant comparative analysis and performed post hoc member checking.

Results: Twenty-four residents participated. Residents characterized their predominant approach to postcall decision making as one of making trade-offs between multiple, competing, seemingly incompatible, but equally valuable, activities. Participants exhibited two different trade-off orientations: being oriented toward maintaining a normal life or toward mitigating fatigue.

Conclusions: The authors’ findings on residents’ trade-off orientations suggest a dual recovery model with postcall trade-offs motivated by the recovery of sleep or of self. This model challenges the dominant viewpoint in the current duty hours literature and suggests that the duty hours discussion must be broadened to include other recovery processes.