An innovative model for final-year students' skills

Medical Teacher, Vol. 28, No. 7, 2006, pp. 648–651

SHORT COMMUNICATIONS

An innovative model for final-year students’ skills training course in internal medicine: ‘essentials from admission to discharge’ ¨ NGER1 C. NIKENDEI1, B. KRAUS1, M. SCHRAUTH2, P. WEYRICH2, S. ZIPFEL2 & J. JU 1 University of Heidelberg Medical Hospital, Germany; 2University of Tu¨bingen Medical Hospital, Germany

ABSTRACT Clerkships are generally seen as a very favourable learning environment for final-year students. However, in recent years the clinical experience of final-year students has been reported to decline progressively. It was decided, therefore, to introduce an innovative skills training model in internal medicine. Sixty final-year students received four consecutive days of training during their first week, consisting of three-hour sessions on each day. The skills training course reflected a patient history from admission to discharge and included all required routine procedures, typical forms/files and computer interactions. Acceptability was measured with self-administered surveys postintervention and again 16 weeks later; self-assessment was measured pre-/post-intervention. The skills training course was well accepted by the students and led to a significant improvement in self-assessment. It was considered to be very helpful for work on the wards in both the immediate and the long-term retrospective evaluation. The final-year skills training course allows students to learn how to handle specific tools and applications for their work on the ward. It possesses face validity and is easy to integrate.

Practice points . Clerkships are seen to be a very favourable learning environment. . However, final-year students’ clinical experience has declined significantly. . A final-year students’ skills training course is easy to integrate, has face validity and is well accepted by finalyear students. . In retrospective evaluation the training is found to help final-year students to become familiar with their work on the ward. . Further research is needed to prove the effectiveness of a final-year students’ skills training course in a group control design.

procedures from patient admission to discharge. The aim of this study was to evaluate (1) feasibility and (2) acceptability of final-year students’ skills training. Introduction This article represents the first description of a skills training course that reflects an entire operational workflow based on a patient history from admission to discharge. Clerkships are widely seen as a very favourable learning environment as they offer students the opportunity to learn in situations that very closely resemble their future professional setting (Regher & Norman, 1996). However, McManus et al. (1993) showed that final-year students’ clinical experience had declined significantly in a five-year cross-sectional study. One explanation is that, although coaching, feedback and supervision are associated with improved general satisfaction of clerkships (Remmen et al., 2000), supervision of students performing clinical competences is rare (Remmen et al., 2000; Van der Vleuten et al., 2000; Van der Hem-Stokroos et al., 2001; Howley & Wilson, 2004; Daelmans et al., 2004) and mainly done by junior doctors (Remmen et al., 1998). In reality, clinical rotations seem to be more like a black box that leads to trial and error (Jolly, 1994). Therefore, we have developed a skills training course for final-year students which ensures that they all become familiar with important routine 648

Methods Design of the skills training The skills training for final-year students takes place during the first week of their four-month study in the Department of Internal Medicine at the University Hospital of Heidelberg. The students are introduced to the medical staff and the hospital’s infrastructure before the training starts. During the training, final year students are familiarized with all important routine procedures, typical forms/files and computer interactions of our hospital. The framework of the training sessions is a simulated case report of 65-year-old Mr Brown, present as standardized patient during the first day of training.

Correspondence: Christoph Nikendei, MD, Department of General Internal and Psychosomatic Medicine, University of Heidelberg Medical Hospital, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. Tel: þ49-6221-56-38663. Fax: þ49-6221-56-5749. Email: christoph_nikendei@med. uni-heidelberg.de

ISSN 0142–159X print/ISSN 1466–187X online/06/070648–14 ß 2006 Informa UK Ltd. DOI: 10.1080/01421590600922917

Skills: structured patient interview, use of a patient history form Knowledge: developing a diagnosis and differential diagnosis Attitudes: adequate interaction with patients at first contact

Skills: completing a laboratory request form, completing an electronic request for technical examination, maintaining a patient file Knowledge: interpretation of laboratory results, significance of technical examination Attitudes: rational use of laboratory and technical examinations entrainment Skills: practice in nasogastric tube insertion, arterial puncture, ECG, Doppler ultrasound Knowledge: indication for nasogatric tube, arterial puncture and Doppler ultrasound; ECG interpretation Attitudes: communication of information to patient during invasive and non-invasive technical procedures Skills: ICD coding of a patient case, preparation of a discharge letter Knowledge: remuneration in the ICD based GR-DRG system, structure of discharge letters Attitudes: understanding of financial aspects of inpatient healthcare, clear description of patient problems in discharge letter

Tuesday: admission II (handling laboratory and electronic requests for technical examination and patient files): suspicion of pulmonary embolism because of swollen erythematous left calf after a long bus journey by Mr Brown (pilgrimage tour to Lourdes)

Wednesday: on ward (important skills on ward): gastrointestinal bleeding during Mr Brown’s hospital stay after self-medication with anti-inflammatories, measuring blood gases because of the suspicion of pulmonary embolism; supplementary findings: calf pain induced by exercise for the past six months

Thursday: discharge (introducing DRG system and ICD coding, writing Mr Brown’s discharge letter): Mr Brown is discharged after being treated successfully

Learning goals

Monday: admission I (history taking): 65-year-old Mr Brown has suffered from acute dyspnoea and rightsided chest pain since last night

Topics and patient symptoms

Table 1. Topics, learning goals and methods used in skills training.

Computer-based training in writing discharge letters

Short presentation Computer-based training in ICD coding

Practice in diagnostic and therapeutic interventions by performing role-plays and using manikins

Computer-based training in electronic examination requests Group discussion Short presentation

Short presentation Standardized patient interview Structured feedback Exercise with patient history form Group discussion Short presentation Group work

Methods

Short communications

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The patient’s history and follow-up is updated at the beginning of every session, introducing new therapeutic and/ or diagnostic steps. Table 1 shows the patient’s symptoms, the learning goals and the learning methods used in each individual session. All skills are practised under supervision with feedback given by two experienced communication and technical skills trainers. Evaluation and statistical analysis The evaluation included a questionnaire to grade single elements of training sessions as shown in Table 1 using ratings from 1 (very good) through to 6 (unsatisfactory). Subjective competences pre-/post-training were assessed by self-administered surveys on a Likert scale from 1 (high selfassessed competence) through to 6 (low self-assessed competence). Follow-up evaluation 16 weeks after the training asked about retrospective benefits of the training. The resulting data are presented as mean SD, except where specified otherwise.

(Van Dalen & Bartholomeus, 1990). There have been early attempts to combine these skills by integrating role-plays or standardized patients into technical skills training (Kneebone et al., 2002; Nikendei et al., 2005). The skills training we have developed represents a feasible simulation of a patient history from admission to discharge. As supervision was proved to be rare in clerkships and final years (Remmen et al., 2000; van der Vleuten et al., 2000; Van der Hem-Stokroos et al., 2001; Daelmans et al., 2004; Howley & Wilson, 2004), we ensure with this skills training course that, as a minimum, required routine procedures are practised under supervision. We found the skills training easy to integrate into the clerkship, as the three-hour sessions take place in the late afternoon, enabling final-year students also to fulfil their daily duties on the ward. However, resources are needed in the form of time, teaching materials and personnel. The skills training course for final-year students is well accepted and allows students to learn how to handle the specific tools needed for their work on the ward. Further research is needed to prove the effectiveness of the intervention in a group control design.

Results Sample We observed four cohorts of final-year students at our Department of Internal Medicine (n ¼ 60 final-year students). A total of 31 males and 29 females with a mean age of 27.0 years were trained from December 2004 to June 2005. Survey response rate pre/post skills training was 93.3%. Response rate at the end of the term for long-term evaluation was 71.7%. Evaluation: acceptability, self-assessment and follow-up Evaluation of single teaching elements of the skills training revealed that the hospital tour scored 1.86 (0.89; 1 (very good) through to 6 (unsatisfactory)), completing historytaking files 1.98 (0.95), introduction to filling out lab forms and patient files 1.81 (0.83), training in important diagnostic/therapeutic interventions 1.86 (0.86), and ICD coding/writing of a discharge letter 1.89 (0.82); these were all rated very high. The whole week was rated at 1.59 (0.63). Self-assessment, measured pre-/post-intervention, showed a significant improvement in all assessed skills (11 items: pre 3.32 0.76; post 2.36 0.65; p < 0.001). In the follow-up evaluation after 16 weeks, the skills training was rated as being very helpful for work on the ward (1.88 1.14). Discussion The final-year students’ skills training course is a new and innovative teaching model. It is well received by students and leads to improved self-assessment. Students find it very helpful to become familiar with all essential routine procedures from admission to discharge of a patient. In general, clinical technical and communication skills are predominantly taught separately (Kneebone et al., 2002; Ju¨nger et al., 2005). Role-play and standardized patients are used for communication skills training (Barrows, 1998), whereas single clinical technical skills are taught in skills labs 650

Notes on contributors C. NIKENDEI, MD, is at the University of Heidelberg Medical Hospital, and is responsible for skills-lab training and education of final-year students at the Medical Hospital. B. KRAUS, MD, is at the University of Heidelberg Medical Hospital, and is responsible for the medical education of final-year students. M. SCHRAUTH, MD, is at the University of Tu¨bingen Medical Hospital, and is responsible for the standardized patient programme at the Faculty of Medicine and for the medical education of final-year students. P. WEYRICH, MD, is at the University of Tu¨bingen Medical Hospital, and is responsible for the medical education of final-year students. S. ZIPFEL, MD, is professor and chairman, University of Tu¨bingen Medical Hospital, Department of Psychosomatic Medicine and Psychotherapy. J. JU¨NGER, MD, is at the University of Heidelberg Medical Hospital, and is responsible for the medical education programme at the Medical Hospital.

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MCMANUS, I.C., RICHARDS, P., WINDER, B.C., SPROSTON, K.A. & VINCENT, C.A. (1993) The changing clinical experience of British medical students, Lancet, 341, pp. 941–944. NIKENDEI, C., ZEUCH, A., DIECKMANN, P., ROTH, C., SCHA¨FER, S., VO¨LKL, M., SCHELLBERG, D., HERZOG, W. & JU¨NGER, J. (2005) Role-playing for a more realistic technical skills training, Medical Teacher, 27, pp. 122–126. REGEHR, G. & NORMAN, G.R. (1996) Issues in cognitive psychology: implications for professional education, Academic Medicine, 71, pp. 988–1001. REMMEN, R., DENEKENS, J., SCHERPBIER, A., HERMANN, I., VAN DER VLEUTEN, C., VAN ROYEN, P. & BOSSAERT, L. (2000) An evaluation study of the didactic quality of clerkships, Medical Education, 34, pp. 460–464.

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Medical Teacher, Vol. 28, No. 7, 2006, pp. 651–653

Linking neuroscience theory to practice to help overcome student fear of neurology J.N. HUDSON University of Adelaide, Australia

ABSTRACT Reports in the literature have attributed medical student fear of neurology to an inability to apply knowledge of the basic science to clinical situations. A teaching and learning initiative called case based teaching (CBT) was designed to help medical undergraduates integrate clinical neurology with the neuroscience that underpins it. In the context of the evaluation of a neurological case, students learned the correct technique for eliciting a large number of signs and symptoms, while applying their understanding of normal structure and function to interpret and understand the history, examination and investigation findings. Students were very positive about the practical, problem-solving, small group-learning environment, reporting that it facilitated the integration of nervous system structure and function with clinical medicine. Some admitted to a fear of neurology, which was helped by the limited initiative, but requested more CBT sessions to reduce their neurophobia. Many eminent groups in neurology education recommend integration of teaching in basic science and clinical neurology, and this report indicates that medical undergraduates value this approach too.

Introduction Charles et al. (1999) have called for improved neurology training in medical schools to prevent neurophobia, defined by Jozefowicz (1994) as ‘a fear of the neural sciences and clinical neurology that is due to the students’ inability to apply their knowledge of basic sciences to clinical situations’. Exciting advances in neuroscience knowledge, treatments for neurological disease and developments in sophisticated imaging techniques have added to the intellectual challenge of evaluating a neurological case. However, for a medical student this challenge may prove daunting. After learning

the correct technique for eliciting a large number of signs and symptoms, the findings must then be interpreted using an understanding of normal structure and function. If the fear of neurology arises from a lack of basic science/clinical integration ( Jozefowicz, 1994), students should be guided in the integrative process at the beginning of their neurology education. This article summarizes an initiative, ‘Case Based Teaching’ (CBT), developed and introduced by the Department of Physiology at Adelaide University, to integrate basic neurosciences and clinical neurology at a time when the undergraduate curriculum was a hybrid of both traditional and problem-based learning (PBL) strategies (Tonkin & Hudson, 2001). Neuroanatomy and neurophysiology teaching, while well planned, was coordinated rather than integrated. CBT tutorials had been successfully used in the second year (Hudson et al., 2001) to integrate theory and practice in the other systems, as a foundation for patient-based training in clinical skills. In the nervous system, the large volume of signs gathered to reveal the underlying structure and function of an individual are better practised on a well colleague than an infirm patient, with the experience of being a ‘patient’ potentially fostering appropriate skills and attitudes. For example, experiencing gag and corneal reflex testing can make students more Correspondence: Nicky Hudson, Associate Professor (J.N.), Director, Division of Clinical Education, Graduate School of Medicine, University of Wollongong, Wollongong, N.S.W. 2522, Australia. Tel: þ61 (0) 8 8222 7358. Fax: þ61 (0) 8 8222 6687. Email: [email protected] The work was carried out at The Department of Physiology, The University of Adelaide, Frome Road, Adelaide 5005, South Australia, Australia.

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