A skills programme for preclinical medical students L . T A Y L O R , D. V E R G I D I S , A . L O V A S I K & P. C R O C K F O R D Edrrcatiori Departmerit, C‘riiverrity ofAlberta Horpitalr arid Faculty qfMedicirie, University c$Albeuta, Edmorrroti, Alberta, C a n a d a
Summary. An education programme in which preclinical medical students are introduced to c o m m o n procedural skills is described. This programme is presented by a multidiscipliriary health care team using short lectures, demonstrations, mannequin practice, and, in selected instances, practice 0 1 7 class-niatc volunteers. T h e programme was evaluated by the students immediately followiiig the presentation and for one class during their clinical activities one year later. T h e students’ support for this prograninie was gcncrdlly enthusiastic and remained undiminished upon reflection 12 months later. Key words: *educ, med, undergrad: *clinical competence: teaching/*methods; program evaluation; attitude ofhealth personnel; students, mcd/psychol; feedback
Introduction I t is well recognized that the transition from the class-room t o the clinical setting is difficult for medical students. While many students have sharpened their communication and assessment skills by carrying out repeated histories and physical examinations under supervision, few have received adequate instruction and supervision in performing routine medical procedures prior to o r during their clinical rotations. D u e to inadequate instruction, medical students may suffcr from lack o f confidence, anxiety and, through exposure t o contaminated body fluids,
Correspondence. Dr P. Crockford, Division of Endocrinology, 362 Heritage Research Building, University of Alberta, Edmonton, Alberta, Canada T h G 2s3.
risk t o their personal health. Also, the quality o f care the patient receives m a y be affected. I n 1988, concerned with the effects of the lack of formalized training in the performance of procedural skills, the Faculty o f Medicine at the University o f Alberta developed and introduced a procedural skills programme t o their undcrgraduatc nicdical education curriculuni. The niandatory programme was schcdulcd to begin 6 weeks before the medical students’ first clinical rotation. T h e main purpose o f the programme was to provide basic instruction, hands-on practice, and supervision in routine medical procedures which the medical students would be expected to perform once they started their clerkship rotations.
Methods I n 1988, the procedural skills programme was scheduled for 9 hours over 3 half-day periods during 3 consecutive weeks. At this time, the immediately preclinical medical students were introduced to 11 procedural skills. In 1989, the programme was lcrigthened to 16 hours over four half-day periods during 4 consccutivc weeks. This change allowed for the addition of three procedural skills and 4 hours further practice time. Due to the fact there were approximately 120 medical students in the class each year, it was necessary to divide the class into tn-o groups of nearly 60 students per group. Each week, three one-hour sessions ran concurrently with approximately 20 students attending each session. T h e 1988 and 1989 schedules for the programme arc presented in Table 1. A multidisciplinary group consisting of nurses, respiratory
Medical students’ procedural skills trainin‘?
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Table 1. Procedural skills programme schedule 1988
Week 1
Week 2
1989
Oxygen therapy and arterial blood gases Venipuncture Injections
Week ;I
Central venous lines Isolation and infection control Lumbar puncture
Week i?
Electrocardiography and blood pressure monitoring Peripheral venous lines Bladder Catheterization and gloving
Week 3;
Bladder catheterization and gloving Injections Peripheral venous lines PRACTICE
Oxygen therapy and arterial blood gases Venipuncture Central venous lines PRACTICE
Week 3
Isolation and infection control Lumbar puncture Electrocardiography and blood pressure monitoring PRACTICE
Week 4:
Pelvic examination Nasogastric intubation Breast examination PRACTICE
technologists, residents, and medical staff provided instruction and supervision for the programme. The methodologies used by the instructors included lecturettes, videos, films, slides, demonstrations, and supervised hands-on practice on mannequins and/or class-mate volunteers. The various methodologies used and instructors who provided the sessions are summarized in Table 2. Students were required to provide a witnessed waiver of responsibility before entering the programme. The Faculty of Medicine required that the programme include information o n thc proper handling of blood and body fluids in the session o n isolation and any session where applicable. Handling and disposal of needles and syringes, hand-washing, gloving, and gowning were stressed. The mannequins and videost purchased a t the time of the initiation of the programme in 1988 and its expansion in 1989 had a total cost of $16270 (Canadian) with funds mainly obtained by soliciting the clinical dcpartmcnts having tSources ofaudiovisualniaterial and mannequins are available from the authors on request.
interests in the development of this programme. The purchases included eight each of arterial sampling arms and venipunture arms and lesser numbers of other mannequins (example: t w o lumbar puncture simulators). The number and type of mannequins purchased were influenced by the prevalence of the procedure and skills deemed immediately essential to the ncw student intern. Renewable supplies now cost approximately $2200 annually. In 1990, volunteered teaching hours totalled 184 hours while paid teaching hours totalled 96 hours at a cost of $4230. As the course has now been absorbed into the undergraduate medical education programme, recurring annual costs are now picked up by the faculty. Class-room space for the programme was providcd by the University of Alberta Hospitals. A clos’zd hospital ward was transformed into lecture and practice rooms. By having all sessions in one area, it was possible to limit the transit time bctween the sessions. In both ycars, the procedural skills programme was evaluated by the students at the end of each half-day. The students were asked to ratc ‘content’ and ‘presentation’ using a 5-point scale where 1 = poor, 2 = fair, 3 = good, 4 = very
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good, and 5 = excellent. Students were able to include written comments for each session. As well, the students w h o attcnded the 1988 programme were surveyed by written questionnaire one year later, during the middle o f their clinical clerkship, regarding the ‘presentation’ and ‘usefulness’ of having received this instruction. All evaluations were voluntary. Comparisons wcrc made within classes over time by a Wilcoxon Signed Rank test and between classes by a Mann-Whitncy test. Relationships between ‘prcscntation’ and ‘content’ categories were
made using a Spearman Correlation test. All tests were evaluated at the 0.05 significance level.
Results Attendance was niairitaiiicd at near 100% throughout the programme despite thc absencc of a concluding examination. The voluntary evaluation results for the end of each session for the classes of 1988 and 1989, as well as the one-year post-course evaluation o f t h c 1988 programme, are reported in Table 3. T h e
Table 2. Instructors and nicthodologics ( * ) used for scssions
Scsslon
Instructor
Irijections
N ursiri g
Vcnipunrurc
N ursiri g
Pcriphcral vcIlolIs I1ncs
Nursing
Central vciioiis lines
Nursing and medicine
Bladder catheterization a n d gloving
Nursing and medicine
Isolation and ~nfcction control
Nursing
Lumbar puncturc
Medicine
O ~ y g c ntherapy
Respiratory technology
a n d artcri‘il blood
Vldeo/Film/ Lccturette Slide
*
Manncquin demonstration
Mannequin practice
Practice on class-mate volunrccrs
* * Suhcutancous (Intramuscular) (Iritraniuscular) a n d intradcrnial N o t intraniuscular
*
*
Y c5
*
Ye5
*
*
NO
*
*
N0
Nor applicable
*
l’atlcnt positioning. l o c a t l o l l of vertebral space
Arterial blood gases
gases
Electrocardiog r a p h y and blood pressure monitoring
Nursing and medicine
Pel\ ic c x ~ ~ i i i i i r ( t iMcdicinc ~i~
B r c m cxaniii~atio~iMedicine
N0
*
*
*
A xill~rlyc x a n i i i a t ~ o no n l y
Nasogastric intubation
Medicinc
4
Ycs
Medical students’ procedural skills training
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Table 3. Evaluation results for ‘presentation’,‘content’,and ‘usefulness’ within topics (median;number of respondents in brackets). See text for details. First year (1988) End-of-session evaluations Topic (s) Injections Venipuncture Peripheral venous lines Central venous lines Bladder catheterization and gloving Isolation and infection control
Lumbar puncture Oxygen therapy and arterial blood gases Electrocardiography and blood pressure monitoring Pelvic examination
Presentation
Content
Second year (1989) End-of-session
One year later Presentation
Usefulness
evaluations
Presentation
Content
4.70 (78) 4.30 (97) 4.22 (67) 3.38 (74) 4.53 (66) 3.83 (77) 4.1 1 (76) 4.08 (97) 3.84 (65)
Breast examination Nasogastric intubation
generally slightly lesser number of responses in the one-year follow-up resulted from students bcing located in various hospitals, many in rural sites and in other countries. A comparison of responders and non-responders showed n o apparent differences between them in age, scx and previous training. Within each topic, there were n o significant differences ( P > 0.05) among the ratings of ‘presentation’ of material at the end of the 1988 session, its rcviewcd evaluation one year later, and the end of session assessment in 1989. Similarly, the initial satisfaction with the ‘content’ of each topic in 1988 was matched with statistically equivalent satisfaction one year later, during the clinical clerkship, that the time spent was ‘useful’. While there were no statistical differences within topics between the 1988 and 1989 end-of-session evaluations regarding ‘content’, the topic of insertion and maintenance of
central venous lines deserves attention and will bc alluded to in the Discussion. Writlen comments provided valuablc information o n the students’ rating of the programme. Several students reported that they felt the programme had helped relieve some anxiety with regard to performing some procedural skills. Practice o n class-mate volunteers was well received.
Discussion Several previous reports have identified clinical skills arid procedures that students should be able to perform upon graduation from an undergraduate rnedical programme (Hunskarr & Seim 1983; Martin et al. 1985; Kowlowitz et a / . 1990). Additional endorsement for including training in procedural skills at the undergraduate level
conics from a survey by Kaisen e t a / . (1984), in which t w o out of three interns, in evaluating for preparation for general practice, felt that proccdural skills should be learned in medical school. T h e procedural skills programme generally received an overall rating o f 4 (very good) to 5 (excellent). O f the sessions presented in both years of the programme, the greatest difference in the ratings, although not statistically significant, was noted in the ‘presentation’ and ‘content’ o f the session o n central venous lines. T h e improved end-of-session evaluation during the second year may have occurred because o f the change in the presentation as, in 1988, the session emphasized insertion technique, whereas, in the subsequent year, emphasis was placed upon the purpose, maintenance and complications o f central venous lines with considerably less emphasis on insertion. This finding was in keeping with the report o f Kowlowitz et a / . (lYYO), w h o concluded that it was important for students to be exposed t o this technique but it was not important for them t o perform it confidently. These authors also noted in their survey that bladder catheterization received a lower rating than did some procedures (e.g. venipuncture). We recognized that it would be quite probable that our trainees would have catheterization performed b y other competent paramedical personnel but, nonetheless, felt that it was important for them to k n o w indications for the procedure, the catheters employed, and complications of the technique. Furthermore, b y combining it with their first opportunity t o learn sterile gloving, the benefit o f the dedicated time was enhanced. I n sonic‘ o f the sessions it was possible for the student to practisc a skill on a mannequin and then practise 0 1 1 a fellow class-mate. Table 2 lists the various methodologies used and the varying degrees of student participation. All students practised intradcrmal and subcutaneous injections on each other. venipuncture, inscrtion o f peripheral vein lines, and arterial sampling were pcrfi,rnicd by all students on class-mate voluntcers. Similarly, masking, hand-washing, gowning atid gloving and blood pressure monitoring were performed by everyone. M o s t experienced, and all witnessed, the procedure for obtaining a n electrocardiogram. Approximately one-tenth o f the students performed nasogastric intubation on
their colleagues, while the remainder witnessed the procedure. These experiences were reported to be highly useful for they not only allowed for actual performance of the skill. but thcy also allowed the participant to experience the anxieties and discomforts associated with the procedures from a patient’s perspective. T h e written comments were related primarily to the mannequins used in the demonstrations and practice, the volunteer class-mate practice, and the time available for practice. Even though the mannequins did not ideally simulate a real patient due t o the artificial nature o f the skin and underlying structures, the students noncthcless reported thcy were able to review the gross anatomy and develop their manual dexterity in performing the various procedures. For sonic sessions, such as pelvic examination, only mannequin practice was possible. Social limitations, funding, and time constraints did not make it feasible t o use professional ‘patients’. Even though it has been reported in the literature that the training procedure for pelvic examination can be stressful, and adequate satisfaction with one’s performance can only come from performance o f the procedure on a real patient (Vontvcr et u l . 1980), the medical students rated the session as very good o r excellent. They reported that, even though mannequin practice alone was not sufficient, the session was useful because thcy had an opportunity to review pelvic anatomy, to use a speculum, and t o practise the procedure for obtaining cervical smears and cultures. Social limitations also placed restraints on the sessions on breast examination. This was circumvented by the use of a video demonstration followed by demonstration and practice o n a variety o f mannequins. Axillary assessment practicc was possible o n class-mate volunteers. Many students commented 011 the length of time of the sessions. I n most instances, it was rcported there had been sufficient time for the lecturette and demonstration. However, in 1988, many wanted more opportunity for mannequin and human practice. Consequently, the cxtra hour-long practice sessions were added to the tY8Y schcdule. Mechanic & Aikcn (1983) rcportcd that collaboration between nursing and the nicdical faculty could improve the education o f young doctors. We anticipated that thc medical students
Medical students’ procedural skills training would benefit from the interactions during the programme with a multidisciplinary health care team of instructors. The instructors had an opportunity to teach and socialize with medical students who they would be working with in the near future. It was expected that the medical students themselves would feel more confident and the instructors would feel more a t ease with the medical students’ activities once they started their first clinical rotation. While not formally assessed, the medical students did appear to benefit from their exposure to the health care team. Discussions with nursing staff indicated that they had gained an increased confidence with the students’ performance. Hopefully, this early introduction of medical students to other members ofthe health care team will be mutually beneficial. The programme has been continued to date and additional evaluation is planned. Participant satisfaction with the sessions is only one part of the evaluation process. Clinical evaluation of the medical students’ ability to perform the various procedural skills will need to be developed. In this regard, it is probably not necessary to develop elaborate neuropsychological predictors of manual skills as has been suggested for surgical residents (Schueneman et al. 1984), but a basic skills check-list which would facilitate the evaluation process. A resource centre would provide the medical students with an opportunity to review any ofthe procedures using videos, slides and mannequins.
Acknowledgements The authors wish to thank Dr Charles Harley,
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Associate Dean, and other members of the Faculty of Medicine administration, the Division of Nurijing and the Administration at the University of Alberta Hospitals for their support; D r Michael Grace for performing the statistical analysis; and Chris Scott and Kris Schindel for preparing this manuscript.
References Hunskaar S. & Seim S.H. (1983) Assessment of students’ experiences in technical procedures in a medical clerkship. Medical Educafion 17, 3 0 0 4 . Kaisen A , , Kjetsa F . A . , Lie K . K . , Hjetland R . , Haaland P.T., Moller P., Oulie H.E., Tveit T. & Maeland J.G. (1984) Interns’ evaluation o f their preparation for I p c r a l practice: a comparison between the University of Tromso and the University of Bergen. Medical Education 18, 349-55. Kowlowitz V., Curtis P. & Sloane P.D. (1990) The procedural skills of medical students: expectations and icxperiences. Academic Medicine 65, 655-8. Martin Y.M., Harris D.L. & Karg M.B. (1985) Clinical competencies of graduating medical students. Journal ofMedical Education 60, 91’9-24. Mechanic D. & Aiken L.H. (1982) A cooperative agenda for medicine and nursing. New England Journal of Medicine 307, 747-50. Schuencman A., Pickleman J., Hesslein R. & Freeark R. ( 1984) Neuropsychological predictors of operative skill among general surgery residents. Surgery 96, 288-95. Vontver L., Irby D., Rakestraw P., Haddock M., Prin,ce E. & Stenchever M. (1980) The effects of two methods of pelvic examination instruction o n studcnts performance and anxiety. Journal of Medical Education 55, 77S85.
Received 8 April 1992; editorial comments to authors 27 July 1991; 13 March 1992; acceptedfor publication 2 June 1992