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
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
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
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
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
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
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
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
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
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
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.