K Logan, E Forbes, R Carachi
Department of Paediatric Surgery Royal Hospital for Sick Children Glasgow
SMJ 2005 50(4): 177-178
Introduction
Early exposure to clinical skills was given high priority by the General Medical Council recommendations in the 1993 publication, Tomorrow’s Doctors.1 However, little is known about the ability of students to perform basic procedural skills prior to commencement as pre-registration house officers (PRHOs).2 There is evidence that senior medical students continue to feel training in this area is inadequate and many feel ill-equipped to carry out a range of procedures including catheterisation and suturing.3 Nursing and medical staff have significantly higher expectations of the performance of basic clinical skills by PRHOs than is justified by the graduates’ previous experience.4 Combined with a lack of confidence in their own skills, this is a recognised source of stress for new interns.4
Previous studies have shown that medical students tend to acquire their basic skills through ward teaching in a random, unpredictable manner, which may account for the considerable variation found between students’ ability.4 As a result many students graduate without receiving formal skills training and many practical skills are then performed in the PRHO year with little or no supervision to ensure correct technique,5 benefiting neither the PRHO involved nor the patient.6
Most UK medical schools have now adopted a problembased learning (PBL) environment with emphasis given to patient communication, history taking and system examination and the need for formal clinical skills training, previously a very neglected area7 has now been addressed.
Our study was designed to determine a group of newer PBL students’ experience in a number of “core” clinical skills and their confidence in performing these skills. We also aimed to grade their ability to perform several of these skills under an OSCE setting and to compare the grades with the degree of previous experience.
Methods
We recruited ten, end-of-year, 4th year Glasgow University medical students who were undertaking a paediatric attachment at the Royal Hospital for Sick Children in Glasgow. The students were asked to complete an anonymous questionnaire detailing their previous experience of 9 ‘core’ clinical skills, consisting of catheterisation, venepuncture, lumbar puncture (LP), pleural aspiration (PA), nasogastric intubation, resuscitation (CPR), defibrillation, intravenous cannulation and suturing.
We used a modified version of the OSCE including manikins (6 stations) to test seven of the nine clinical skills, omitting pleural aspiration and venepuncture and combining CPR with defibrillation. In contrast with a standard OSCE, we provided the students with prompting and teaching when required, but awarded no marks where this occurred.
As the students were attending a paediatric module, the OSCEs were paediatrically-based but all the stations used would also be applicable to adult medicine.
In order to effect a meaningful comparison of previous experience with the OSCE results, we devised an objective (if somewhat arbitary) scoring system for previous experience as shown.
0 - No previous experience of procedure
1 – Observation of procedure
2 – Procedure performed under supervision
3 - Procedure performed without supervision.
Results
Discussion
Much has been written about the introduction of problembased learning to improve core clinical skill acquisition. What has been abundantly clear, however, is that newly qualified doctors have been deficient in areas of practical skill which they will almost certainly require shortly after entering the wards - as newly qualified doctors ourselves we understand the range of skills required. No longer is it acceptable for such procedures to be practised for the first time on real patients following graduation. Although based on only a small number of 4th year students we believe that the present study demonstrates unequivocally that repeated exposure to such core clinical skills results in both improved confidence and ability to perform these procedures by the practitioners involved. Additionally it highlights those areas requiring targeting in the local Glasgow situation.
Other academics have advocated the introduction of exposure to clinical skill training as early as the first year of undergraduate courses thereby forming a firm basis for subsequent progress.8,9 So, too, student responses to such early clinical skill instruction were extremely positive.9 The senior undergraduates and newly qualified doctors both expressed their approval to the recently introduced method of training in a skills laboratory where it was possible to perform any task on numerous occasions without embarrassment to either the practitioner or patient.10
Different centres have adopted novel approaches to ensure that OSCEs using non-biological models closely resemble an actual doctor/patient encounter. A study at St. Mary’s hospital campus involved simulated patients standing behind the manikin with the student being obliged to talk to the “patient” whilst performing the procedure on the model. OSCEs for large numbers of candidates are, however, time-consuming, logistically difficult to organise both with regard to space and staff requirements and to ensure uniformity of student assessment. It would appear, however, that in general the OSCE is currently the most reliable method for monitoring ability in such practical clinical skills,11 and is also of benefit in teaching these skills.12 We felt that we achieved this balance through both instruction during the OSCE and subsequent feedback to each of the candidates.
Conclusion
The present study demonstrates succinctly the positive relationship between repeated exposure to practical clinical skills and the ability to perform these. We recommend that formal teaching in a skills laboratory, on at least the nine clinical skills mentioned, should be given throughout the medical curriculum to all students. We believe that whilst this was a snapshot taken on 4th year medical students a similar OSCE repeated at various stages of the undergraduate training would be of benefit to the aspirant doctors and ultimately to their patients.
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