MED-NET Conferences 1998, Lille & 1999, Maastricht
Anthology of presentations 3.2.
Priorities in medical education. Medical competencies, communicative and clinical skills.
A. Cumming (Edinburgh, UK)
The traditional approach to undergraduate medical education places emphasis on knowledge-based assessment. Examinations test ability to describe, enumerate, or discuss, but may sometimes lack relevance to the practice of medicine. The acquisition of competency has been based on a random, opportunist approach to skills development, and a reliance on "osmosis" a powerful process, but one which does not discriminate between good and bad. In places there is still resistance to the concept of the doctor as an artisan, as opposed to an intellectual.
Obviously we have moved a long way from this perspective, but it has not wholly disappeared. Traditional medical education places great emphasis on academic development, and much less on personal development. This is despite the fact that after graduation, many of the challenges faced by our students are personal rather than academic in nature.
In the UK, moves to remedy this situation were given a major stimulus by the publication of "Tomorrow's Doctors", a report of the General Medical Council in1993. The report recommended that "essential skills must be acquired under supervision", and "proficiency must be rigorously assessed". There was a specific emphasis placed on communication. It was also recommended that "attitudes of mind and behaviour appropriate to the practice of medicine should be inculcated".
What are the pressures which led to this strong recommendation? Firstly, increased expectations from patients and employers. Patients are less tolerant of doctors who are uncertain and inefficient in performing basic medical tasks. NHS Trust Hospitals who employ our graduates are increasingly vocal and specific about the skills and competencies which they expect from our students when they enter employment. There are medico-legal considerations. These have led to the demise of the "student locum",.during which many students gained useful skills in a highly supervised environment. There is increased medical litigation, with medical schools being held accountable for the undergraduate component of an individual doctors training.
In the UK there are now fewer junior and middle-grade medical staff, working fewer hours, so that recent graduates are in a more exposed situation than before. One can also mention the increasingly technological nature of medical practice, and the pressures which multi-disciplinary practice exerts for doctors to be secure in their own skills and competencies within a team.
Clearly change is necessary. Like many medical schools, we instituted a "Clinical skills course" in 1994. We identified in consultation, 18 core "must do" clinical skills, and used a check-list approach, with "signing-off" by clinicians. We established two clinical skills laboratories with video centres and mannequin suites, and employed nurse practitioners as instructors for several of the skills. Students could acquire the basic skills in a simulated, supervised environment, then be signed off as competent during clinical attachments. This was successful in the sense that students appreciated the increased guidance and help to achieve skills and competency. It was clearly better - but we questioned whether it was enough in itself. It was felt that it over-emphasised the technical aspects of medicine, and that it was not integrated with other learning. Standardised assessment proved difficult with the "decentralised" approach. There was inadequate attention to personal attributes and attitudes, as opposed to practical competence.
It was felt that as the next step, a new approach was required, which was wider in scope than just practical/ communication skills, and which was present in all years of the curriculum in a progressive design. This approach, which is in the first year of delivery, is known in the Edinburgh curriculum as CSPPD - Clinical Skills / Personal and Professional Development. It is a unified, vertically integrated programme over 5 years, which is integrated with concurrent learning. It is assessed and validated within the core assessment framework. There are 8 themes, each with a "theme head". These themes are: communication skills, practical clinical skills and procedures, first aid and resuscitation, consultation skills, computing skills and medical informatics, evidence-based learning and medical practice, medical ethics, legal and professional responsibilities, and personal development.
In curricular terms, the Faculty of Medicine in Edinburgh has agreed to this programme being identified as the central core element around which other parts of the medical course are based. This represents an important shift in thinking about the vocational aspects of an undergraduate medical course.
In teaching and learning, this type of programme involves the teacher in a shift from being primarily an educator, to being also an instructor. Staff development is often required to achieve this. Teachers and students are faced with the need to integrate theory and practice in a new way. They must embrace the widespread use of simulation and role-play. Since many of the skills and competencies are shared with other health-care professionals, multi-disciplinary learning is often a successful approach. Continuity with post-graduate experience is essential, and periods of "house officer shadowing" late in the curriculum are helpful to reinforce these links.
In assessment, OSCEs are a cornerstone, but need to be developed in imaginative and novel ways. New resources are required to deliver this type of teaching. Clinical teaching resource centres (CTRCs), which include areas for skills training and development of communication , are essential. Simulation centres, such as the Scottish Simulator Centre, allow students to use skills in a "virtual" environment, with instant feedback of performance indicators.
Employment of para-medical teachers, either full-time or on a session basis, has proved successful and cost-effective. However, there is an inevitably increased cost associated with this type of teaching, since so much of it can only be delivered in a very small-group environment and in a specialised facility.
Some diversity in the skills and competency of medical graduates is inevitable, and indeed may be desirable. However, the development of common core standards and shared educational approaches between medical schools seems a desirable way forward in this area, which is crucial to the future of medicine in the 21st Century.
ISBN Number 90.805758.1.X
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