Lloyd, S.,* Tan, Z.E.,† Taube, M.-A.† & Doshi, J.‡ *Department of ENT, Manchester Royal Infirmary, †University of Manchester, Manchester, ‡Salford Royal Hospital, Birmingham, UK, Clin. Otolaryngol. 2014, 39, 281–288
Objective: To determine an ENT undergraduate syllabus. Design: Two round Delphi survey. Setting: Email questionnaire. Participants: Stakeholders with a vested interest in ENT undergraduate education. Main outcomes measured: Mode and median scores for 232 learning outcomes. Results: The individual learning objectives that scored most highly were related to history taking and examination, red flag symptoms, common ENT conditions including all
forms of otitis, acute and chronic rhinosinusitis, thyroid disease, pharyngeal infection and airway compromise and formulation of differential diagnoses. Conclusions: Using a Delphi technique, a structured, evidence-based curriculum has been developed. This should assist those medical schools who do not currently have ENT in their curriculum but wish to reinstate it to produce a high quality teaching programme. It may also assist those medical schools who do have ENT in their curriculum to continue to develop their curriculum.
ENT conditions have been shown to account for up to a quarter of primary care consultations.1,2 This Figure rises to 50% in paediatric consultations.3 Despite this there is a significant body of evidence suggesting that ENT teaching is not adequate in UK medical schools. A survey in 2012 of all UK medical schools demonstrated that 10 of 26 did not offer an ENT attachment.4 A study by Chawdhary et al.5 found that only 28% of a cohort of UK medical students felt that they were adequately prepared to handle common, routine ENT complaints. Another study found that a group of UK medical students felt significantly less confident with ENT history taking, examination and management, compared with their cardiology clinical competencies (P < 0.001).6 Two-thirds of respondents would have liked further undergraduate experience. Another study from a single UK medical school showed that 17% and 42%, respectively did not attend ENT clinic or theatre during their five years at medical school.7 Beyond medical school, a lack of ENT undergraduate teaching is still apparent. 75% of a cohort of accident and emergency staff stated that they had not received enough undergraduate ENT teaching.8 Several studies have also shown that GPs also feel that their undergraduate otolaryngology experience is inadequate.9–11 This lack of exposure to ENT could potentially lead to clinical problems because of a lack of basic ENT knowledge. There is certainly evidence that
a knowledge of ENT is important in certain non-ENT medical specialties including accident and emergency,8 general practice and paediatrics. Furthermore, studies have shown that patients often present to non-ENT specialists (such as their general practitioner) following procedures such as tonsillectomy.3,12 It is important to note that a lack of ENT undergraduate training is not confined to the UK. There is similar evidence of poor exposure to ENT in other countries, for example Canada.13,14 From the perspective of ENT as a specialty, it is also advantageous to be strongly represented in medical school curricula. It allows students to see how ENT surgeons work and gives the surgeons the opportunity to encourage students to consider entering the speciality. As a result, high calibre students and junior doctors may be attracted to the speciality.15,16 There is clearly a demand and need for more otolaryngology undergraduate teaching. There is, however, a lack of evidence regarding what should be included in undergraduate ENT teaching. The Delphi process is an established method of curriculum development. It aims to generate as many ideas as possible from the participants (‘experts’) about the topic under study. It consists of a series of questionnaires (‘rounds’). In each round, the experts are provided with their own individual responses as well as the rest of the group. They are asked to reconsider their response and change it, if they feel it is appropriate. This process is repeated in subsequent rounds until consensus is achieved. The primary aim of this study was to use a Delphi process to determine an ENT undergraduate syllabus that will
Correspondence: S. Lloyd, Manchester Auditory Implant Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Tel.: +44 161 276 8511; Fax: +44 161 276 5003; e-mail: [email protected] © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 39, 281–288
281
ORIGINAL ARTICLE
Development of an ENT undergraduate curriculum using a Delphi survey
282 S. Lloyd et al.
provide a template on which medical schools can base any future development in their undergraduate curriculum. In addition, the literature and the rationale for increasing otolaryngology exposure within undergraduate training will be discussed.
90 70 60 50 40
Method
There were no ethical considerations regarding this study. A modified two round Delphi study was performed. In the first round, an online questionnaire was designed with a total of 232 learning objectives divided into fourteen broad subcategories of otolaryngology. Recipients were asked to rank these learning objectives using a Likert scale (1 = least important, 5 = most important). This included different groups of clinicians who have a stake in ensuring good quality ENT teaching. The groups were ENT consultants and specialist registrars, accident and emergency consultants and specialist registrars, general practitioners and paediatricians. An electronic invitation to participate in the study was sent to the ENT UK mailing list, Manchester Royal Infirmary Accident and Emergency department, Royal Manchester Children’s Hospital Paediatric department and GP mailing lists. The responses were used to formulate a second online questionnaire. The scores were shown in this questionnaire, and the first round respondents were asked again to rate the importance of each item from 1 to 10 (1 = Not important, 10 = Essential). Throughout the study, it was stressed to the participants that the study was aimed at defining an undergraduate curriculum and not a postgraduate curriculum. The results were then collated, and the mode and median score achieved by each item was calculated. A mode of 7 or below determined which items should be excluded from the curriculum. This Figure was chosen because it was the score below which items were deemed to become less relevant to undergraduate teaching. This approach was felt to be more helpful than removing a certain percentage of items from the bottom of the list. Results
There were 159 respondents in the first round, and the composition of the respondents is shown in Fig. 1. The response rate for the second round was 78/159 (49%). The composition of the respondents for this round is shown in Fig. 2. The mode and median score for each subcategory is summarised in Table 1. These are ranked from highest to lowest mode score, and for those with the same
81
80
30
28
27
20
11
10
9
3
Fig. 1. Chart showing the composition of respondents participating in round one of the ENT undergraduate curriculum development. 40 35
35 30 25 20
16
18
15 10 5
4
5 0
Fig. 2. Chart showing the composition of respondents participating in round two of the ENT undergraduate curriculum development.
mode, the categories were then ranked according to median. The categories that ranked higher included those relating to the use of medications, head and neck cancer, management of ENT emergencies and management of conditions affecting the mouth/throat, ear and neck. The ability to formulate a differential diagnosis also ranked highly. The objectives relating to operations were ranked the lowest. The individual learning objectives within each category are shown in Tables 2–16 ranked according to how important they were judged to be. Those scoring a mode of
Objective: To determine an ENT undergraduate syllabus. Design: Two round Delphi survey. Setting: Email questionnaire. Participants: Stakeholders with a vested interest in ENT undergraduate education. Main outcomes measured: Mode and median scores for 232 learning outcomes. Results: The individual learning objectives that scored most highly were related to history taking and examination, red flag symptoms, common ENT conditions including all
forms of otitis, acute and chronic rhinosinusitis, thyroid disease, pharyngeal infection and airway compromise and formulation of differential diagnoses. Conclusions: Using a Delphi technique, a structured, evidence-based curriculum has been developed. This should assist those medical schools who do not currently have ENT in their curriculum but wish to reinstate it to produce a high quality teaching programme. It may also assist those medical schools who do have ENT in their curriculum to continue to develop their curriculum.
ENT conditions have been shown to account for up to a quarter of primary care consultations.1,2 This Figure rises to 50% in paediatric consultations.3 Despite this there is a significant body of evidence suggesting that ENT teaching is not adequate in UK medical schools. A survey in 2012 of all UK medical schools demonstrated that 10 of 26 did not offer an ENT attachment.4 A study by Chawdhary et al.5 found that only 28% of a cohort of UK medical students felt that they were adequately prepared to handle common, routine ENT complaints. Another study found that a group of UK medical students felt significantly less confident with ENT history taking, examination and management, compared with their cardiology clinical competencies (P < 0.001).6 Two-thirds of respondents would have liked further undergraduate experience. Another study from a single UK medical school showed that 17% and 42%, respectively did not attend ENT clinic or theatre during their five years at medical school.7 Beyond medical school, a lack of ENT undergraduate teaching is still apparent. 75% of a cohort of accident and emergency staff stated that they had not received enough undergraduate ENT teaching.8 Several studies have also shown that GPs also feel that their undergraduate otolaryngology experience is inadequate.9–11 This lack of exposure to ENT could potentially lead to clinical problems because of a lack of basic ENT knowledge. There is certainly evidence that
a knowledge of ENT is important in certain non-ENT medical specialties including accident and emergency,8 general practice and paediatrics. Furthermore, studies have shown that patients often present to non-ENT specialists (such as their general practitioner) following procedures such as tonsillectomy.3,12 It is important to note that a lack of ENT undergraduate training is not confined to the UK. There is similar evidence of poor exposure to ENT in other countries, for example Canada.13,14 From the perspective of ENT as a specialty, it is also advantageous to be strongly represented in medical school curricula. It allows students to see how ENT surgeons work and gives the surgeons the opportunity to encourage students to consider entering the speciality. As a result, high calibre students and junior doctors may be attracted to the speciality.15,16 There is clearly a demand and need for more otolaryngology undergraduate teaching. There is, however, a lack of evidence regarding what should be included in undergraduate ENT teaching. The Delphi process is an established method of curriculum development. It aims to generate as many ideas as possible from the participants (‘experts’) about the topic under study. It consists of a series of questionnaires (‘rounds’). In each round, the experts are provided with their own individual responses as well as the rest of the group. They are asked to reconsider their response and change it, if they feel it is appropriate. This process is repeated in subsequent rounds until consensus is achieved. The primary aim of this study was to use a Delphi process to determine an ENT undergraduate syllabus that will
Correspondence: S. Lloyd, Manchester Auditory Implant Centre, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. Tel.: +44 161 276 8511; Fax: +44 161 276 5003; e-mail: [email protected] © 2014 John Wiley & Sons Ltd Clinical Otolaryngology 39, 281–288
281
ORIGINAL ARTICLE
Development of an ENT undergraduate curriculum using a Delphi survey
282 S. Lloyd et al.
provide a template on which medical schools can base any future development in their undergraduate curriculum. In addition, the literature and the rationale for increasing otolaryngology exposure within undergraduate training will be discussed.
90 70 60 50 40
Method
There were no ethical considerations regarding this study. A modified two round Delphi study was performed. In the first round, an online questionnaire was designed with a total of 232 learning objectives divided into fourteen broad subcategories of otolaryngology. Recipients were asked to rank these learning objectives using a Likert scale (1 = least important, 5 = most important). This included different groups of clinicians who have a stake in ensuring good quality ENT teaching. The groups were ENT consultants and specialist registrars, accident and emergency consultants and specialist registrars, general practitioners and paediatricians. An electronic invitation to participate in the study was sent to the ENT UK mailing list, Manchester Royal Infirmary Accident and Emergency department, Royal Manchester Children’s Hospital Paediatric department and GP mailing lists. The responses were used to formulate a second online questionnaire. The scores were shown in this questionnaire, and the first round respondents were asked again to rate the importance of each item from 1 to 10 (1 = Not important, 10 = Essential). Throughout the study, it was stressed to the participants that the study was aimed at defining an undergraduate curriculum and not a postgraduate curriculum. The results were then collated, and the mode and median score achieved by each item was calculated. A mode of 7 or below determined which items should be excluded from the curriculum. This Figure was chosen because it was the score below which items were deemed to become less relevant to undergraduate teaching. This approach was felt to be more helpful than removing a certain percentage of items from the bottom of the list. Results
There were 159 respondents in the first round, and the composition of the respondents is shown in Fig. 1. The response rate for the second round was 78/159 (49%). The composition of the respondents for this round is shown in Fig. 2. The mode and median score for each subcategory is summarised in Table 1. These are ranked from highest to lowest mode score, and for those with the same
81
80
30
28
27
20
11
10
9
3
Fig. 1. Chart showing the composition of respondents participating in round one of the ENT undergraduate curriculum development. 40 35
35 30 25 20
16
18
15 10 5
4
5 0
Fig. 2. Chart showing the composition of respondents participating in round two of the ENT undergraduate curriculum development.
mode, the categories were then ranked according to median. The categories that ranked higher included those relating to the use of medications, head and neck cancer, management of ENT emergencies and management of conditions affecting the mouth/throat, ear and neck. The ability to formulate a differential diagnosis also ranked highly. The objectives relating to operations were ranked the lowest. The individual learning objectives within each category are shown in Tables 2–16 ranked according to how important they were judged to be. Those scoring a mode of
