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Anaesthesia, 1999, 54, pages 4–12 ................................................................................................................................................................................................................................................

A survey of undergraduate teaching in anaesthesia V. Cheung,1 L. A. H. Critchley,1 C. Hazlett,2 E. L. Y. Wong1 and T. E. Oh1 1 Department of Anaesthesia & Intensive Care and 2 Department of Educational Services, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, PRC Summary

Currently, no well accepted and clearly defined ‘core’ curriculum for undergraduate anaesthesia teaching exists. To address this deficiency, we surveyed 73 university departments of anaesthesia and intensive care. Sixty-five replied from South-east Asia (12), Australasia (13), the UK and Ireland (28) and Canada (12). A questionnaire containing 37 items ranging from departmental structure to curriculum content was used. We found significant regional differences. Overall, most departments taught pharmacology of anaesthetic drugs (83%), pre-operative assessment (92%) and care of the unconscious patient (77%). Ninety-seven per cent taught airway management and intubation and 80% taught intravenous cannulation. Basic life support was taught by 92% and advanced life support by 71%. Fewer than half taught advanced trauma life support principles (44%). Critical care teaching was less well defined, but a consensus of schools taught respiratory failure and ventilation, management of circulatory shock and principles of sepsis and multi-organ system failure. Practical clinical skills were taught mainly using patients and simulators, 46% had a skills laboratory and six employed a resuscitation officer. However, it should be noted that we did not assess the quality and outcome of teaching. Keywords Anaesthesia. Education; undergraduate curriculum. ...................................................................................... Correspondence to: Dr L. A. H. Critchley Accepted: 9 June 1998

In recent years many medical schools throughout the world have undergone major revisions to their teaching methods [1]. Traditional instruction characterised by an emphasis on factual learning is being replaced by the teaching of professional competencies such as communication and problem-solving skills [1, 2]. Unfortunately, many medical schools are now facing significant financial restraints with resulting restrictions in their staffing quotas and this has resulted in a greater emphasis being placed on the quality of undergraduate teaching. Thus, many departments within the faculty of medicine are looking to redefine their courses and roles within the medical curriculum. Anaesthesia has only recently been included in the medical curriculum and this reflects important changes in the role of anaesthesia within the hospital [3]. The specialty of anaesthesia now embraces disciplines such as resuscitation, intensive care and pain management, in addition to its original limited role of providing general anaesthesia. Thus, today’s anaesthetists are experts in many important areas of patient care, as well as having a sound knowledge of many aspects of basic physiology and pharmacology 4

[4, 5] and therefore have a great deal to offer in the training of undergraduates. However, the role of anaesthesia within the undergraduate curriculum has not yet been clearly defined and little guidance exists in the medical literature as to what topics should be included and taught. To help address this matter and to help in the continuing development of our own course at the Chinese University of Hong Kong, we undertook a survey of undergraduate anaesthesia and intensive care courses. Data from university departments of anaesthesia and intensive care from South-east Asia, Australasia, UK and Ireland, and Canada were collected to highlight topics taught, with the objective of formulating an undergraduate curriculum in anaesthesia. Methods

A postal survey of anaesthesia departments from Englishspeaking medical schools in South-east Asia, Australia and New Zealand, UK and Ireland, and Canada was performed (Appendix 1). Heads of anaesthesia departments Q 1999 Blackwell Science Ltd

Anaesthesia, 1999, 54, pages 4–12 V. Cheung et al. • Undergraduate teaching in anaesthesia ................................................................................................................................................................................................................................................

from all medical schools within each region were targeted. One follow-up postal reminder was sent to all nonrespondents after 2 months. A number of departments returned detailed reports of their curricula rather than completing the questionnaire. In such cases the questionnaire was completed using the information provided. The questionnaire contained 37 items (Appendix 2) and inevitably the focus of these reflected our experience in running a 4-week undergraduate course in anaesthesia and intensive care [6]. Included items related to the organisation of anaesthesia within the medical faculty; the medical school curriculum in general; which topics were covered by the anaesthesia department; the teaching of practical clinical skills, resuscitation, critical care medicine and pain management; the assessment of student performance; and postgraduate teaching. Although the majority of questions involved fixed response answers (e.g. yes/no), open-ended questions were also included for which written responses were required. The Statistical Package for the Social Sciences (SPSS; version 7.5) was use to analyse all fixed response answers. Free text responses were grouped into major categories and the content analysed separately. The following results of the survey are presented mainly as descriptive statistics. Continuous data were presented using median and 25% and 75% quartiles to help reduce potential bias due to extreme results. Comparative analyses were made by geographical region. Medical schools were grouped into four major regions; (1) South-east Asia, (2) Australia and New Zealand, (3) UK and Ireland and (4) Canada (Appendix 1). Results

We received 65 replies from 73 schools to which our questionnaire was sent (89%). Over 95% of these returned questionnaires were fully completed. Replies included 12 from South-east Asia, 13 from Australia and New Zealand, 28 from UK and Ireland and 12 from Canada. Organisation Eighty per cent of medical schools had an independent teaching department of anaesthesia and intensive care, although this figure was significantly lower in Australasia (40%). Eighty-four per cent of schools had a Chair of Anaesthesia. In 45% of schools, the hospital and university departments of anaesthesia were organisationally separate, whereas in 47% they were integrated. The average department employed [median (quartiles)]: 25 (16–40) consultants (staff specialists) and 1.5 (0–4) university staff. Funding from the universities accounted for an average of 10% (1–50%) of the total departmental budget. Departments employed 20.5 (12–37) postgraduate residents (trainees) of whom Q 1999 Blackwell Science Ltd

6 (2–18) were actively involved with the medical undergraduate teaching programme. The duration of the undergraduate medical programme ranged from 3 to 6 years. In Canada, in which a previous baccalaureate degree is normally required, most schools (82%) required 3–4 years of medical training. In Australia, most schools (92%) required 6 years of medical training. Overall 17% of schools still ran a traditional style course of preclinical and clinical modules and 18% of schools ran an exclusively problem-based learning (PBL) course. The majority of schools incorporated a mixed curriculum that included at least 25% PBL. However, in Canada where PBL began, 64% of the courses were exclusively PBL. Anaesthesia staff taught mainly in the third (33% of schools), fourth (57%) and fifth (33%) years of training. Time spent teaching each student was estimated to be 16 (0–50) contact hours with 68% of this time being spent on compulsory subjects. In 57% of schools, house officers (interns) received little or no further teaching from the anaesthesia department. Curriculum content Anaesthesia Lectures and tutorials in anaesthesia covered a variety of topics (Table 1). Pre-operative assessment (92% of schools), pharmacology of anaesthetic drugs (83%) and care of the unconscious patient (77%) were most commonly taught. Practical clinical skills were taught by nearly all departments with airway management and intubation (97%) being almost universal and intravenous cannulation being taught by 80% (Table 2). Practical skills were taught using patients (93%), simulators or mannequins (71%) and tutorials (93%). In Australasia, 33% of the schools reported using computer-aided teaching. A dedicated area for the teaching of practical skills was provided by 46% of schools. Acute pain management Acute pain management was taught by most schools (94%), although this was less frequently the case in Canada (73%). Methods used for teaching pain management included lectures (79%), ward rounds with the acute pain service (50%) and supervised patient pain management in the recovery room (48%). Some schools (23%) used PBL case studies to teach acute pain management. Emergency medicine and resuscitation Resuscitation skills were taught by anaesthetists in 86% of schools, by accident and emergency staff in 59% of schools and by intensivists in 38% of schools. Six schools reported employing paramedics or resuscitation officers. Most schools taught basic life support (BLS) (92%) and advanced life support (ALS) (71%) by the use of mannequins (92%), 5

V. Cheung et al. • Undergraduate teaching in anaesthesia Anaesthesia, 1999, 54, pages 4–12 ................................................................................................................................................................................................................................................

Table 1 Topics covered by lectures and

Pharmacology Pre-operative assessment Obstetric anaesthesia Medical ethics Patient sedation Local anaesthetic agents Care of the unconscious patient Miscellaneous topics

S.E. Asia

A & NZ

UK & I

Canada

Overall

92 100 67 50 75 83 83 75

85 100 75 8 62 85 92 23

78 100 52 7 41 74 89 33

83 58 58 0 0 33 25 70

83 92 60 14 44 70 77 45

tutorials in the four regions (%).

A & NZ: Australia and New Zealand; UK & I: UK and Ireland. Miscellaneous topics included pain management (14 references), resuscitation (10), airway management (5), cardiovascular monitoring and support (4), fluid balance (4), postoperative care (3), local blocks (2) and 17 other topics mentioned only once.

Table 2 Practical skills taught in the four

Airway management Intubation Venepuncture Intravenous cannulation Administration of drugs intravenously Lumbar puncture Administration of blood products Arterial blood sampling and analysis CVP measurement Central venous cannulation Chest drain insertion Miscellaneous skills Dedicated skills laboratory

S.E. Asia

A & NZ

UK & I

Canada

Overall

100 100 80 100

100 100 36 64

93 96 69 74

100 92 42 92

97 97 59 80

80 60 80

55 36 27

37 7 26

17 25 17

43 25 33

80 90 70 20 30 70

18 36 36 9 27 23

33 33 33 0 7 59

0 25 17 0 8 18

32 42 37 5 15 46

regions (%).

Miscellaneous skills included laryngeal mask airway insertion (1), writing postoperative orders and treating postoperative complications (4). Presence of a dedicated area for practical skills teaching also shown.

clinical demonstrations (72%) and lectures (80%). PBL case studies were used in 30% of schools overall and 55% of Canadian schools. In Australasia (70% of schools) and Canada (73%) students were required to pass a certified first aid course. Initial assessment of the trauma patient was taught in 53% of schools and principles of advanced trauma life support (ATLS) were taught in 44% of schools. Three schools also conducted a formal ATLS course. These skills were taught by lectures in 68% of schools, practical demonstrations in 55% of schools, practice on mannequins in 49% of schools

and PBL case studies in 40% of schools. The teaching of resuscitation skills and emergency medicine topics is summarised in Table 3. Three schools also reported teaching the management of anaphylaxis, three on acute poisoning and two on environmental emergencies. Critical care medicine Critical care medicine was taught by 74% of schools, but less frequently so in Canadian schools (36%). Only 10% (0–20%) of anaesthesia teaching time was allocated to critical care medicine teaching. This time was divided Table 3 Teaching of resuscitation and

First-aid course Basic life support Advanced life support Initial assessment ATLS principles

6

S.E. Asia

A & NZ

UK & I

Canada

Overall

40 100 73 64 46

70 85 77 62 54

22 96 63 44 33

73 82 83 55 55

44 92 71 53 44

emergency topics in the four regions (%).

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Table 4 Free text responses (n ¼ 149) from 32 respondents (44%) showing the critical care medicine main topics taught in the undergraduate curriculum. Number of responses for each shown in parentheses.

General intensive care

Respiratory system

Cardiovascular system

General principles (4) Admission criteria (5) Triage (1) Ethics (2) Councelling relatives (3) Audit (1)

Respiratory failure (8) Ventilation (17) ARDS (4) ABG analysis (2) Oxygen therapy (3) Tracheostomy (1)

Management of shock (4) Invasive monitoring (10) Circulatory support (15) Fluid and blood component (4) Massive blood transfusion (1)

Neuro-intensive care

Acute injury

Other systems

Head injury (2) Confusion (1) Unconscious patient (3) Brain death (5) Organ donation and transplant (4) Sedation (1)

Trauma (3) Sepsis SIRS (9) MOSF (8) Scoring systems (1) Patient transport (3)

Renal failure (7) Nutrition and gut function (3) Miscellaneous (14)

Miscellaneous topics included peri-operative surgical management, burns, poisoning, resuscitation and CPR, infectious diseases, acute medical emergencies, medical tests and embolisms.

into lectures (given by 66% of the schools), bedside teaching (given by 75% of the schools) and PBL case studies (given by 26% of the schools). The critical care curriculum varied greatly between individual schools. A total of 32 respondents (44%) provided 149 free text responses which cover 37 different topics (Table 4). Core topics most frequently reported were general principles of critical care and admission criteria to intensive care (16%), respiratory failure and ventilation (53%), circulatory shock, support and invasive monitoring (47%), renal failure (22%), brain death and organ donation (16%), sepsis, systemic inflammatory response syndrome (SIRS), adult respiratory distress syndrome (ARDS) and multi-organ system failure (MOSF) (28%). Student assessment Passing an anaesthesia module was a mandatory requirement in 61% of the final examinations for the degree of MBChB (or MBBS and MD in Canada). Most schools undertook some form of assessment, the exception being three schools in the UK and Ireland. Methods of assessment ranged from the completion of set tasks (36%), satisfying an attendance record (40%), a tutor’s judgement (48%) (within Canada the latter occurred 91%) and formal examination (61%). Formats of examination included written (23%), multiple choice (47%) and objective structured clinical examination (21%). Discussion

The role of anaesthesia teaching in the undergraduate curriculum has varied greatly over the years [3]. In the Q 1999 Blackwell Science Ltd

UK, the teaching of anaesthesia first became part of the undergraduate curriculum in 1912 because most trainee doctors were required to administer anaesthesia as part of their hospital appointment. This situation has remained the case in many developing countries [7]. In the UK, anaesthesia was removed from the medical curriculum by the General Medical Council in 1947 because general anaesthesia was then being performed mainly by specialist anaesthetists and postgraduate training for anaesthetists had been established. This situation remained in the UK until 1980 when the General Medical Council reintroduced anaesthesia into the curriculum because of the evolution of newer anaesthesia-related skills such as resuscitation [8]. Since the reintroduction of anaesthesia into the curriculum, it has struggled to define its role. In 1981, Newell et al. [9] described a new 2-week anaesthesia course following the establishment of a new clinical school in Cambridge. The aims of their course were to demonstrate the scope of modern anaesthesia, the relevance of basic sciences to anaesthesia, the teaching of observational and decision-making skills and basic technical skill related to resuscitation. Several years later these ideas were further developed by Prys-Roberts et al. [5] to include cardiopulmonary resuscitation, aspects of care of the critically ill patient, pre-operative evaluation and preparation, the pharmacology of anaesthetic drugs including local anaesthetic agents, opioids and sedatives, and pain therapy. PrysRoberts and colleagues’ work has formed the foundation for most present day anaesthesia undergraduate curricula [3, 10]. In Canada, Eagle [11] proposed a similar agenda of resuscitation skills, pain control and medical management 7


during the peri-operative period. Unfortunately, no publications pertaining to a curricular content are available in Australasia and South-east Asia. Previously published surveys of undergraduate teaching in anaesthesia have looked at students’ knowledge of anaesthesia [12], pre-operative investigations [13], training in resuscitation [14–17], training in trauma [18, 19], the teaching of practical skills [20], pain management [21, 22] and the teaching of critical care [23]. Our survey differed by looking primarily at the content of curricula. Other than Smith et al.’s survey of resuscitation training in the UK and the USA, and Garcia-Barbero et al.’s survey of critical care teaching in Europe, our survey is the first to compare undergraduate curricula across various regions [14, 23]. However, our survey was deficient in that it did not attempt to determine how extensively these subjects were taught in each surveyed school. Our response rate of 89% compared favourably with those quoted by previous authors. Lauder et al. [15] reported a 73% reply rate from anaesthesia departments in the UK, Gracia-Barbero et al. [23] reported a 47% reply rate from critical care units across Europe, Sanders et al. [19] reported a 96% reply rate from accident and emergency department in the US and Walley et al. [24] reported a 81% reply rate from clinical pharmacology departments in the UK. We suspect that our relatively high response rate reflects a high level of interest by the respondents with a hope that the results could be used to improve their own curricula. The use of free text responses in many of our questions helped us to identify issues which we would otherwise have missed in the original planning of the survey questionnaire. However, one cannot assume that free text responses will necessarily give an accurate measure of the frequency with which topics are taught. Thus comparisons with fixed choice items could only be made with some degree of validity. Our survey did not include medical schools from the US for practical reasons. We anticipated significant difficulties in identifying all university anaesthesia departments within the US. Sanders et al. [19] identified as many as 141 such medical schools. The structuring of medical education within the US is different from that of Hong Kong, Australasia and the UK, but similar to that of Canada. Our survey frequently found that Canadian schools varied from those in the other regions and it can be assumed that if American medical schools had been included, similar variations would have emerged. The principal differences of the North American schools is that a prior baccalaureate degree is required before enrolment in medical school and a corresponding reduced duration of study to a typical 3 or 4 years (rather than 5–6 years elsewhere). In Australia, three medical schools (University of Sydney, University of Queensland and Flinders University) have only just 8

implemented a PBL-based graduate course, with anaesthesia input over all 4 years of the course. Our survey was conducted just before the introduction of these new courses and we did not obtain sufficient data on their anaesthesia curricula. Regional differences were also apparent in the structuring of departments and curricula offered elsewhere. In Australasia, university departments of anaesthesia were particularly poorly represented, being present in only 40% of schools surveyed, although most of these schools had a Chair of Anaesthesia. Departments of anaesthesia also appeared to be poorly funded by the universities, with university budgets accounting for only 10% of income and providing one and half academic staff. In Canada, where undergraduate programmes are limited to 3 or 4 years, the anaesthesia curricula were underrepresented in several key areas which include several ‘core’ anaesthesia topics (such as pharmacology of local anaesthetic drugs and care of the unconscious patient) and critical care medicine. We believe that this underrepresentation reflected the greater emphasis placed on PBL in Canada and the transfer of several subjects to teaching in the internship years. Medical education is increasingly being recognised as a career-long process with medical students being trained to be ‘life-long learners’ and the introduction of ‘formal’ continuing medical education (CME) such as Maintenance of Professional Standards Programmes and recertification by many medical specialities [11]. Basic medical training begins with the preclinical and basic medical sciences, progresses to clinical training and preparation to be junior doctors and ends with internship, a process that on average takes 7 years. For graduate medical schools this will have been preceded by several years of prior degree course work. Formal university education ends after the clinical training year and graduation. In recent years, formal training has extended beyond graduation into the internship years because junior doctors are increasingly being required to perform more demanding and complex tasks. However, our survey showed that 57% of trainee doctors received little or no further anaesthesia-related training during their internship. Norman [25] has recently called for the introduction of a 4 month preregistration house office rotation to anaesthesia to provide a basic grounding in peri-operative care including pain management, resuscitation and managing the critically ill patient. These proposals have been submitted for consideration by the General Medical Council and the Committee of Postgraduate Deans in the UK. Similar calls for postgraduate training in other specialities have also been made [25, 26]. Data from our questionnaire showed a consensus among anaesthetists that pharmacology of anaesthesia drugs, local anaesthetic agents, pre-operative assessment, obstetric Q 1999 Blackwell Science Ltd


anaesthesia and care of the unconscious patient should be included in the undergraduate curriculum (these subjects were taught by over 60% of departments) (Table 1). Similarly, there was also an overwhelming consensus that practical clinical skills such as airway management, intubation and intravenous cannulation should be taught. However, provision for the teaching of such skills seems inadequate, with only 46% of the responding departments providing dedicated areas for teaching and practising these skills. Other skills such as lumbar puncture, central venous pressure measurement and cannulation, and arterial blood gas sampling and analysis featured less highly. Thus their inclusion in the anaesthesia curriculum would seem to be optional and there is no evidence to support their inclusion as ‘core’ skills. However, venepuncture, which must definitely be regarded a ‘core’ skill, could more appropriately be taught by other departments in the faculty. In the early 1980s, it became apparent that the ward management of acute postoperative pain was inadequate with only 20% of junior doctors being able to prescribe satisfactory pain relief [22]. Subsequently, there has been a recognised need for effective undergraduate teaching in acute pain management [5]. Consequently, our survey showed that nearly all schools surveyed (94%) now provided teaching in acute pain management. The lower reported levels in Canada (73%) again reflects the PBLbased graduate system common in North America. Many schools still rely on a lecture-based approach to teaching pain management and only half provided any patientbased instruction (e.g. acute pain ward rounds or supervised patient management in the recovery room). Thus the level of pain management skills in newly qualified doctors may still be inadequate. The inadequacy of cardiopulmonary resuscitation skills among doctors and paramedics has also been a subject of concern since the early 1980s [16, 17]. This concern has lead to the birth of the Resuscitation Council in Britain in 1982 and the development of a series of resuscitation protocols by the American Heart Association in North America [27]. Consequently, BSL was one of the first clinical practical skills to become universally established within the anaesthesia undergraduate curricula. Thus, not surprisingly we found that 92% of anaesthesia departments taught BSL, although fewer (73%) taught advanced cardiac life support. These skills were quite appropriately taught using practical demonstrations and practise on simulators (mannequins) (92%). We did not enquire in this survey whether teaching staff had any specific training in teaching cardiopulmonary resuscitation, although such courses have become more easily accessible. Some schools used other departments to share in the teaching of resuscitation. Trained, resuscitation officers can also be used to teach Q 1999 Blackwell Science Ltd

resuscitation skill and six schools specifically mentioned the employment of such personnel. To what extent resuscitation skills are retained after graduation has also been questioned in the literature [15]. In a recent survey by Smith et al. [14] it was shown that certified courses in cardiopulmonary resuscitation was a prerequisite for graduation and formed part of the US ‘National Curriculum’. This has resulted in better retention of these skills by American graduates compared with those in Britain where no such prerequisite exists. Thus, training in cardiopulmonary resuscitation outside North America would most likely also benefit from the establishment of such courses. We found that ATLS principles were taught by fewer than half of schools at undergraduate level and that only three schools (Barts and The London, Newcastle and Saskatchewan) provided formal ATLS courses. Whether these skills should be included in the undergraduate curriculum is undetermined at present. The complexity of these skills may dictate that they are more appropriately taught during the internship. Our survey showed that there was little consensus of opinion over what critical care medicine departments should be teaching at undergraduate level (Table 4). In fact 26% of schools worldwide and 66% of schools in Canada did not teach any critical care medicine at the undergraduate level. Buchman et al. [4] in a recent review of undergraduate critical care teaching highlighted the importance of teaching applied physiology, airway management, intravenous skills and resuscitation skills – all subjects that are not solely the domain of critical care medicine. In their review, subjects fundamental to critical care were circulatory shock (including the management of massive gastrointestinal haemorrhage), acid–base disturbances and the practicalities of arterial blood gas analysis, aspects of respiratory care, multi-organ system failure and its management, admission criteria and ethical issues; similar recommendations were found in our survey. Beyond these topics critical care medicine would appear to be a postgraduate subject. Rogers et al. [28] showed that to provide medical students with a more in-depth knowledge of the management of a critically ill patient would require a 4-week problem-based attachment with a high level of teacher supervision. This requirement would not be a likely possibility in most undergraduate programmes, but would be very applicable to interns as suggested by Norman [25]. In summary, anaesthesia and related topics are more appropriately taught in the latter years of the medical course, although anaesthetists do have the knowledge also to contribute to the teaching of basic medical sciences. Based on the findings of our survey, we recommend the following anaesthesia curriculum for medical schools (see 9


below). This curriculum should consist of an essential core component and an optional elective component. Students can choose subjects from the optional component to study with the core subjects. Dedicated time should be given to anaesthesia in the medical course. We recommend 4 weeks over the whole course. The subjects should be taught at the level of medical students and not that of a trainee in anaesthesia. Assessment of students and of the teachers and the course by students is highly recommended. A pass in the anaesthesia module should be a necessary requirement for the final medical degree.

7 8

9

10

Core curriculum Anaesthesia and peri-operative medicine Applied physiology, (e.g. fluid and electrolytes, and cardiovascular, respiratory and renal function in the perioperative period), pre-operative assessment, care of the unconscious patient, pharmacology of anaesthesia drugs including local anaesthetic agents, principles of anaesthesia including monitoring, postoperative care and practical pain management. Practical clinical skills Airway management, tracheal intubation, venous cannulation, basic life support and principles of advanced cardiac and trauma life support. Critical care medicine Principles of managing a critically ill patient, admission criteria for the intensive care, circulatory shock, monitoring and management and respiratory failure, oxygen therapy and ventilation.

11 12

13

14

15 16

17

Optional elective curriculum Anaesthesia topics, e.g. induction agents, obstetric anaesthesia and regional anaesthesia. Critical care medicine topics, e.g. sepsis, SIRS and MOSF. Advanced cardiac and trauma life support.

18

References

20

1 General Medical Council Education Committee. Tomorrows Doctor. London: Kiek & Read Limited, 1993. 2 Lowry S. A model for British medical education. British Medical Journal 1993; 307: 1021–2. 3 Harmer M. Back to basics. Anaesthesia 1994; 49: 749–50. 4 Buchman TG, Dellinger RP, Raphaely RC, Todres ID. Undergraduate education in critical care medicine. Critical Care Medicine 1992; 20: 1595–603. 5 Prys-Roberts C, Cooper GM, Hutton P. Anaesthesia in the undergraduate medical curriculum. British Journal of Anaesthesia 1988; 60: 355–7. 6 Critchley LAH, Short TG, Buckley T, O’Meara ME,

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19

21

22

23

Gin T, Oh TE. An adaptation of the objective structured clinical examination to a final year medical student course in anaesthesia and intensive care. Anaesthesia 1995; 50: 354–8. Ene EE, Akpan SG. Undergraduate teaching: a developing country experience. Anaesthesia 1982; 37: 1022–4. General Medical Council Education Committee. Recommendations on Basic Medical Education. London: General Medical Council, 1980. Newell JP, Ogg TW, Wakeford RE. Teaching anaesthetics to medical students: the design and evaluation of a course in a new clinical school. Anaesthesia 1981; 36: 282–8. Cooper GM, Hutton P. Anaesthesia and the undergraduate medical curriculum. British Journal of Anaesthesia 1995; 74: 3–5. Eagle C. Anaesthesia and education. Canadian Journal of Anaesthesia 1992; 39: 158–65. Carnie J, Johnson RA. Clinical anaesthetic knowledge amongst surgical house staff. Anaesthesia 1985; 40: 1114–17. Power KJ, Norman J. Pre-registration house surgeons. A questionnaire study of anaesthesia related knowledge and approach to pre-operative investigations. Anaesthesia 1992; 47: 518–22. Smith GB, Hill SL. Resuscitation training for medical students in the United Kingdom: a comparison with the United States of America. Intensive Care Medicine 1987; 13: 260–5. Lauder GR, McQuillan PJ, Sear JW. Basic life support training. Anaesthesia 1992; 47: 1000–1. Casey WF. Cardiopulmonary resuscitation: a survey of standards among junior doctors. Journal of the Royal Society of Medicine 1984; 77: 921–4. Skinner DV, Camm AJ, Miles S. Cardiopulmonary resuscitation skills of preregistration house officers. British Medical Journal 1985; 290: 1549–50. Price AJ, Hughes G. Accident and emergency doctors lack proper training in trauma. British Medical Journal 1995; 311: 1644. Sanders AB, Criss E, Witzke D, Levitt MA. Survey of undergraduate emergency medical education in the United States. Annals of Emergency Medicine 1986; 15: 1–5. Mercer M, Board P. A survey of basic practical skills of final year medical students in one United Kingdom medical school. Medical Teacher 1998; in press. Gould TH, Upton PM, Collins P. A survey of the intended management of acute postoperative pain by newly qualified doctors in the south west region of England in August 1992. Anaesthesia 1994; 49: 807–10. Weis OF, Sriwatanakul K, Alloza JL, Weintraub M, Lasagna L. Attitudes of patients, house staff, and nurses toward postoperative analgesic care. Anesthesia and Analgesia 1983; 62: 70–4. Garcia-Barbero M, Such JC. Teaching critical care in Europe: analysis of a survey. Critical Care Medicine 1996; 24: 696–704.



24 Walley T, Bligh J, Orme M, Breckenridge A. Clinical pharmacology and therapeutics in undergraduate medical education in the UK. Current status. British Journal of Clinical Pharmacology 1994; 37: 129–35. 25 Norman J. Anaesthesia pre-registration house officers. Anaesthesia 1997; 52: 831–2. 26 Lucus CE, Ledgewood AM, Salciccioli G, Darmondy W.

The surgical clerkship and medical student education in trauma. Journal of Trauma 1986; 26: 1024–30. 27 Campbel IT, Swan G. Guidelines and training in cardiopulmonary resuscitation. Lancet 1993; 341: 470–1. 28 Rogers PL, Grenvik A, Willenkin RL. Teaching medical students complex cognitive skills in the intensive care unit. Critical Care Medicine 1995; 23: 575–81.

Appendix 1

Medical schools that replied to our questionnaire, (n) ¼ number of replies from separate colleges within the same university medical school. Country

Medical schools

Country

Medical Schools

Hong Kong

Chinese University Hong Kong University

England

Malaysia

Kebangsaan Malaya Sains

Taiwan

China Medical College National Cheng Kung Chung Shan Chang Gung Kaohsiung National Taiwan

Bristol Cambridge Leeds Liverpool Manchester Newcastle Nottingham Oxford Sheffield Southampton Barts and The London (1) Guys and St Thomas’ (2) Imperial College (3) King College (1) University College (1)

Singapore

National

Australia

Flinders Melbourne Monash Queensland Sydney (2) Tasmania Western Australia (3)

New Zealand Canada


Auckland Otago Alberta British Columbia Calgary Mannitoba McGill McMasters Memorial Ottawa Queens Saskatchewan Toronto Western Ontario

London Colleges

Wales

Cardiff

Scotland

Aberdeen Dundee Edinburgh Glasgow

Northern Ireland

Belfast

Republic of Ireland

Cork Galway RCS in Dublin University College Dublin

11


Appendix 2

Outline of questionnaire. Organisation of department: Independent academic department Has a chair of anaesthesia Hospital department separate Number of staff employed Level of university funding

Resuscitation continued (trauma): Is primary survey taught Are ATLS principles taught How are these trauma skills taught Other emergency medicine topics taught

Medical school curriculum: Duration of medical course Under or postgraduate course Problem based learning course When in the course is anaesthesia taught Internship exposure to anaesthesia How is anaesthesia taught & contact hours

Critical care medicine: Is CCM taught What time is allocated to teaching CCM How is CCM taught What CCM topics are taught (free text) What CCM topics should be taught

Curriculum coverage – Anaesthesia: Anaesthesia topics taught Pracical clinical skills taught How are these practical skills taught

Acute pain management: Is acute pain management taught How is it taught

Resuscitation: Who teaches resuscitation Is first aid taught Is basic life support taught Is advanced life support taught How are these resuscitation skills taught

Student assessment: Is passing a module mandatory How are students assessed Other comments

12

Post graduate courses:
