The art of basic wound suturing

Lyndon Mason, Sheetal Rao, David Baker

This article outlines a comprehensive overview of basic wound suturing – a vital clinical skill required of almost all practicing physicians and surgeons. In this article we cover subjects such as types of suture material and needles, sutures sizes, suture techniques, nail bed sutures, instrument handling, postoperative care and suture alternatives.

The mental state examination

Neel Burton, Tom Stockmann, Chris Chopdar, Akshay Nair, Toby Pillinger

This article details a practical routine for examining the mental state that is appropriate both for day-to-day clinical practice and for sitting Objective Structured Clinical Examination (OSCE) type exams. The emphasis is on the steps involved in examining the mental state, rather than on specific signs and symptoms. For a full description of the signs and symptoms of mental disorders, please refer to the other articles and references cited in this paper.

A technique for removing rings from swollen fingers

David Bosanquet, Gareth Roberts, Lucy Haydock, Alun Yewlett

The removal of a ring from a swollen finger can prove difficult, for example, following trauma. We present a simple technique for removing a ring from a swollen finger using a length of suture material, which in our experience is a simple and effective procedure.

Assessing the prescribing skills of trainee medical staff: implementation of a routine assessment and remedial training strategy

Deborah Mayne, Anthony Hildreth, Janice O’Connell, Leslie Boobis, Christopher Gray

Introduction: There is increasing recognition that newly qualified doctors often feel unprepared for employment, particularly with regards to prescribing. This lack of preparedness undoubtedly contributes to clinical error and decreases patient safety.

Methods: Trainees attending induction in a large NHS foundation hospital participated in a compulsory clinical assessment of prescribing skills. Trainees were presented with a clinical scenario from which they were required to prescribe specified drugs on a hospital prescription chart. A consensus panel marked the station according to pre-specified ‘critical’ errors or omissions. Candidates who made critical errors or omissions were invited to remedial training and reassessment.

Results: In total 120 trainees were assessed, of whom 72.5% (87/120) made critical errors or omissions. Subsequently, 79.3% (69/87) of trainees were reassessed; 79.7% (55/69) of whom passed on 2nd attempt, and 78.6% (11/14) passed on 3rd attempt; 3 doctors did not attend further reassessment. The most common critical errors were: prescription of the wrong dose of warfarin (59.2%); failure to stop aspirin (44.6%); and inappropriate abbreviation of ‘units’ when prescribing insulin (39.8%). 47 candidates (38.8%) prescribed amoxicillin in a penicillin allergic patient. Foundation Year 1 doctors performed worse than Senior House Officer (SHO) and Specialist Registrar (SPR) doctors (Mann-Whitney test, p<0.001, p=0.12 respectively) and made more critical errors (p=0.003 and p=0.32).

Discussion: It cannot be assumed that newly appointed doctors prescribe safely. Critical errors or omissions were made by all grades of medical staff, but particularly Foundation Year 1 doctors. Steps to improve exposure to prescribing practice in the undergraduate curriculum should be encouraged and linked to ongoing development of skills throughout practice.

myPaediatrics: a website for learning paediatric clinical skills

Ralph Pinnock, Fiona Spence, Craig Housely, Wen-Chen Hol, Richard Smith

Increased student numbers across five teaching sites, without a significant increase in teaching resources, motivated us to develop a website for our undergraduate paediatric curriculum that supports the development of physical examination and clinical reasoning skills.

The website reflects our department’s philosophy that in order to be clinically competent our students must also be culturally competent. The website concentrates on providing learning opportunities not readily available elsewhere and helps students focus their learning by providing clear goals for study and direction to resources. As our students rotate through paediatrics they provide feedback using a questionnaire on the website which automatically summarises data as it is entered. This ensures that the website is responsive to student learning needs. The students find the website easy to access and negotiate and it helps to focus their study.

The students value the videos demonstrating the physical examination of children because such visual medium complements the learning of these skills in their small group bedside teaching sessions. The ‘presenting complaints’ format encourages our students to store their knowledge in the same form that they will retrieve it when they encounter clinical problems. Practising with the presentations and case examples gets them used to using their knowledge as they acquire it. This is likely to assist them in developing the skills of clinical reasoning.

The design of our website could be used as a framework to develop websites for other undergraduate clinical courses.

E-learning in clinical education: a questionnaire study of clinical teachers’ experiences and attitudes

Gerard Gormley, Catherine Coyle, Jenny Johnston, Clare Thomson

Objective: To sample clinical teachers’ experiences and attitudes towards the effectiveness of e-learning and how it should be utilised in medical student clinical teaching.

Methods: A self administered postal questionnaire was developed to capture clinical teachers’ (1) demographic details, (2) main location and frequency of clinical teaching, (3) usage of e-learning in clinical teaching, (4) perceived IT ability, (5) attitudes and perceived impact of e-learning in clinical education, (6) perceived effectiveness of various e-learning mediums in clinical teaching, and (7) perceived impact of e-learning on specific learning domains. The questionnaire was distributed to all clinical teachers affiliated to Queen’s University Belfast, UK (n=319). Responses were rated on five-point Likert scales.

Results: The response rate was 71% (227/319). Respondents reported using e-learning to various degrees in their clinical teaching. Generally they felt comfortable using computers, but were not as confident using e-learning. Overall, they felt that e-learning had made a positive impact on their ability to deliver clinical teaching, particularly in terms of standardisation of teaching and transparency of the curriculum. However, they were concerned that e-learning may encourage learner isolation and not promote learning with real patients. In terms of different e-learning mediums, teachers felt that more visually intense mediums such as clinical demonstration videos and images were more beneficial to students’ clinical learning. They also felt that e-learning had a greater impact on more knowledge based domains than communication, clinical examination and procedural domains of learning.

Conclusion: Clinical teachers value e-learning in its ability to deliver clinical teaching and promote students’ clinical learning. Despite being confident using computers they are less confident in using e-learning, but expressed a desire to improve these skills. They consider e-learning to be best utilised in a blended learning strategy particularly in more theoretical based learning domains, such as clinical reasoning and knowledge acquisition. However, there is still a role for e-learning in clinical skills training, particularly using visually intense mediums. Learning with real patients should always underpin clinical teaching and only ever be supplemented by e-learning – never replaced.

A needs based simulation curriculum to bridge the Trainee Intern and Postgraduate Year One House Officer Years

Dale Sheehan, John Thwaites, Sarah Abbott

Aims: (1) To identify common acutely unwell patient scenarios faced by trainees ‘after hours’. (2) To prioritise the needs of a cohort group of postgraduate year one (PGY1) doctors (3) To utilise PGY1 input into developing a simulation curriculum spanning the undergraduate and postgraduate training years.

Methods: A focus group of PGY1 doctors generated acutely unwell patient scenarios likely to be encountered after hours. These were collated into a questionnaire and then ranked by the total PGY1 cohort as to perceived usefulness within a proposed curriculum bridging the transition from senior medical student to first year house officer. From the questionnaire data, a suggested curriculum was designed and refined, then circulated electronically to a random sample of PGY1 house officers to achieve consensus.

Results: The outcome is a ranked list of clinical conditions that could form the basis for a series of scenarios to be taught across the trainee years and as part of any bridging curriculum.

Conclusion: This paper discusses the results of the study and shares the curriculum of simulation scenarios designed with input from PGY1 doctors. While the proposed curriculum is one of a number of possible models, the process used is applicable to other trainee programmes.

Insight as a measure of educational efficacy – the implications of social learning theory

Paul Jones, Aidan Byrne

Medical education has progressed from students learning isolated facts towards an emphasis on learning as a more complex, interactive process supported by early clinical contact and the presentation of material within a clinical context. This process has used a wide variety of educational theories to explain and justify these changes.

A new Graduate Entry Programme (GEP) included simulated and real clinical contact as an integral part of the teaching programme from the first week, with an emphasis on challenging the students to attempt clinical skills and make clinical judgements. Students were asked to provide feedback on their experiences which were analysed using a qualitative, grounded approach.

The interactive approach was rated highly and although students often found the sessions challenging and sometimes “terrifying”, they indicated that they were gaining insight into both their own behaviour and that of other health care professionals and of patients. These data support the ‘Social Learning Theory’ advanced by Bandura and indicate that evaluating the insight gained by students may be a valuable method for evaluating the efficacy of teaching interventions.

Simulation education in undergraduate medical education: Implications for development of a rural graduate-entry programme

Robyn Hill, Debra Nestel, Amélie Dinsdale, Brendan Flanagan, Chris Browne

Introduction: Simulation as an adjunct to real clinical experience is growing in importance in undergraduate medical education. In 2007 we investigated current use of simulation for teaching clinical skills to predict future applications in our rural graduate-entry medical programme.

Methods: Our interview-based study investigation focussed on the use of simulation in undergraduate (school-leaver) programmes at the two medical schools existing in the State of Victoria, Australia. The focus of the investigation was on staff, facilities and equipment with emphasis on the procedural skills taught and assessed using simulation. Respondents (faculty and students) were selected purposively. Interviews were conducted using a topic guide. Interviews were transcribed and analysed thematically.

Results: Faculty and students supported the use of simulation and made recommendations for optimal use and increased applications. Simulation was most commonly used for patient interactions (simulated patients) and for technical aspects of procedural skills. However, experiences of faculty and students were highly variable and opportunistic. Examples of excellent practice included the use of simulation for raising awareness of patient safety. Faculty sought professional development to make better use of existing applications and consider new ways of working with simulation.

Conclusion: Simulation as an educational method will expand in medical curricula. This study has identified issues relevant to existing and developing programmes that use simulation. We make recommendations for medical schools developing simulation based education in regional locations.

Testicular examination: an evaluation of a one year trial of working with simulated patients to teach medical students within a UK clinical skills department

Nick Purkis

Recent high profile malpractice cases have challenged the ethical integrity of the medical profession like never before [2, 3] and have resulted in enormous pressure on the medical profession to ensure that unethical practices are challenged and prevented.

In response to this, the ‘bar-has-been-raised’ for medical educators as to the importance of teaching undergraduate medical students how to conduct an intimate examination in the correct and professional way. This may include breast, pelvic, testicular or rectal examination and involves patient examination and communication skills. Although the notion of using real people to teach medical students intimate examinations is not new, working with simulated patients to assist and teach medical students how to conduct testicular examination is considered within a UK clinical skills department [9, 10, 17].

Five male simulated patients were recruited and trained to work along side a clinical facilitator in the delivery of testicular examination for undergraduate medical students within a UK clinical skills department. The students were taught how to conduct a testicular examination with the use of a manikin and then through the use of a given scenario, they conducted a clinical examination of the simulated male patient with subsequent feedback.

Following delivery of sessions over a clinical year, 120 questionnaires were distributed to undergraduate medical students to evaluate the delivered sessions. The findings highlight that working with a simulated patient improved the student’s ability to conduct a testicular examination and to communicate more effectively during the examination.

Evaluation of the paediatric clinical teaching component of a new medical program

Annette Burgess

This study was undertaken to evaluate the paediatric clinical teaching component of a new medical program based on integrated learning within authentic contexts. The study evaluated student perception of understanding, competence and confidence, and active involvement in learning. Rating scales, open ended questions and focus group discussions evaluated participant perceptions. Students thought the clinical setting does increase awareness and understanding of child health issues; and competence and confidence in clinical skills. However, engagement in activities was hindered by student perception of insufficient prior knowledge, lack of clear learning objectives, limited patient numbers, and inconsistency in tutor teaching styles. Focus group discussion cross-validated these findings, highlighting that while early exposure to paediatrics in a clinical setting is highly valued, there is scope for improvement by addressing the issues raised by the students.

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