Early clinical skills training аt the University of Liverpool, United Kingdom

INTRODUCTION

Undergraduate medical education in the United Kingdom, like many other countries, is undergoing significant reform. These changes arise as a result of a number of different influences, including reduced inpatient stays, increased primary healthcare based management of an increasing number of conditions, increasing patient consumerism and concern about factual overload in the undergraduate curriculum. The General Medical Council (1993) has published on these issues and has indicated the need to change and provided the blueprint for the current revision taking place. At the University of Liverpool, in north west England, a new undergraduate medical curriculum (NMC) was implemented in October 1996. This NMC has adopted problem based learning (PBL) as the main vehicle for learning, these tutorials are themed and modular, each module usually lasting 2 weeks. The course includes parallel courses in clinical and communication skills.

CURRICULUM STRUCTURE

The structure of the NMC is significantly different from that of the traditional course. The traditional divide between pre-clinical and clinical studies has been replaced by a model that requires the integration of the learning of basic science alongside learning clinical medicine. Clinical encounters take place from the second year onwards. Clinical skills training is incorporated into the first year of the curriculum from the first week onwards (Fig. 1). This training takes place on a weekly basis with students attending a purpose designed renovated ward in the previously disused Liverpool Royal Infirmary. Each student attends one session (lasting approximately 1,5 hours) per week. Eight sessions are run per week to accommodate the number of students (approximately 210). This part of the course is one of the few compulsory elements in the 1^st year of the NMC (the others being the PBL tutorials and communication skills tutorials).

CLINICAL SKILLS RESOURCE CENTRE

The imaginative restoration of the ward has included retention of some interesting architectural features, such as, the fireplace in the middle of the ward. Large windows face east and west so as to make the most of natural daylight. The entrance to the ward is dominated by a reception, designed to mimic a nurses station, to set the clinical scene. One side of the ward has a workbench along most of the length. The workbench gas been provided with a number of electrical points, telephone sockets and computer network points allowing a whole range of facilities to be available to support learning. Stations can be created at any point along the length of the workbench. The opposite side of the ward has space for beds and couches to permit clinical bedside activity. A fully equipped resuscitation bay is incorporated into this side of the ward, along with an area that includes hand washing facilities, a surgical scrub trough and sluice. The central part of the ward provides a large floor space that can be utilised for a whole range of activities. Additional rooms are available off the main ward for tutorial and personal study, as well as a room equipped by Keeler for ophthalmoscopic and otoscopic examination.

STAFFING

The Clinical Skills Resource Centre is staffed by a three full-time staff, a clinician (Director) and two Nurse Tutors. The Nurse Tutors are both experienced, and have worked as Nurse Specialists, both have a degree and have additional educational qualifications and extensive teaching experience. These staff have been supplemented from time to time by support from local GPs, hospital based clinicians, faculty members and retired doctors.

CLINICAL SKILLS PLANNING

The clinical skills course in the 1^st year of the NMC covers the domains of history taking, physical examination, practical procedures and some basic clinical data interpretation. The content of the clinical skills sessions reflects the theme of the PBL module whenever possible, so that, for example, during the module entitled «The Wheezy Adolescent», students cover respiratory history, examination of the chest, lung function testing and the use of inhalers. The range of skills to be covered in the first year was derived from a skills matrix in which the domains were matched to the themes of the modules (Table 1), with the underlying objective of covering areas that a student might commonly encounter in general medicine or surgery. The emphasis in the training is always to stress the findings expected in the «normal». The result of this process has been to develop a list of skills (over 80 in number) to be introduced during the course of the 1^st year course (Table 2). Further work is in hand as the course progresses to expand this portfolio of skills and to increase the level of sophistication of skills acquired by students, for example, in advanced cardiac life support during the second and third years of the NMC. The characteristics of the Liverpool approach are summarised in Table 3.

ASSESSMENT AND EVALUATION

The students are assessed throughout the course. Each session in the Clinical Skills Resource Centre involves a number of activities (termed stations) which student undertake. Students are provided with an assessment sheet for each session and are required to self-assess the majority of stations. The assessment is based on a straight forward Likert scale from 1 (very poor) to 5 (very good). Some stations (involving working in pairs) involve peer assessment and a few involve tutor assessment. These assessments are collated to provide students with graphs showing the frequency distribution of scores so that students can compare their own performance against the group as a whole. Formal assessment occurs at the end of the first (formative) and second (summative) semesters. The assessments take the form of Objective Structured Clinical Examinations (OSCEs) (Harder R.M., Gleeson F.A., 1979). Students have a major contribution to make to the course through the process of evaluation. Each session and each station is evaluated by students on the same Likert format. Poorly scoring stations are further scored for what component did not work. These components include time available, tutor support, resources, clearly stated and achievable learning objectives. Students are also encouraged to comment on any aspect of the session. The results of these evaluations are fedback to students at subsequent sessions and any changes made to the course are highlighted to stress the value placed on their contribution.

CLINICAL SKILLS SESSIONS STRUCTURE

Students attend in groups of 21-28 per session. On arrival at the Clinical Skills Resource Centre students receive a Study Guide. Each one is pre-printed with the students name, as are the assessment and evaluation sheets which are always included in the guide. The guide contains a list of stations to be undertake for that session. This list incorporates a description of the task or activity, the approximate time expected to be spent on it, the learning objective(s) associated with it and sometimes some self-assessment question(s) relating to the topic. Resource material, not otherwise readily available in standard textbooks, is included in the guide, this might include background material or a step-by-step guide on how to perform an activity.

Table 1

PLANNING SKILLS MATRIX

A briefing precedes the learning activities. At this stu dents are provided with feedback on evaluations and assessments from the previous module. Any business matters are addressed and the organisation for the coming session is described.

The learning activities are undertaken in the main ward area. The format of the activity varies from one type of station to another. Demonstrations of examinations and procedures usually involve a small group, followed by supervised practice, with students working in pairs. Students often work in pairs on other activities, and this may involve role-play when taking histories. Individual, self directed tasks include audio-visual and computer aided learning based stations.

The learning of a skill is not done in isolation, but commonly involves consideration of underlying basic science. Examples of this include, the demonstration of examination provides opportunity to refer to underlying surface and clinical anatomy; training in injection techniques includes consideration of local anatomy and histology and the physiology of the lungs are incorporated into training involving pulmonary function testing.

Table 2

SKILLS COVERED IN YEAR 1 AT LIVERPOOL

Table 3

THE CHARACTERISTICS OF CLINICAL SKILLS TRAINING AT LIVERPOOL

OUTCOMES

Across a wide range of skills students have performed well in both formal and informal assessment. Self assessments are consistently high and this has been matched by a high level of performance in OSCEs. Student evaluations have been uniformly good or very good for most stations. Students have been highly motivated and absenteeism has not been a problem, indeed students make great effort to make up for any missed sessions.

DISCUSSION

Changes in healthcare delivery and in society have major impact on medical education. Reduced patient encounters alongside information overload may well explain reduced clinical experience (McManus I.C. et al., 1993), and this deficiency may be a source of considerable stress amongst junior medical staff (Williams S. et al., 1997). The General Medical Council has taken steps to rectify some of these deficiencies by specifying a number of skills in which newly qualifying doctors and preregistration house officers would be expected to be competent or to develop competence (General Medical Council, 1993, 1997).

The reform of the NMC at Liverpool has enabled the adoption of a new approach to clinical skills training. The students are provided with a foundation in skills in advance of their clinical encounters so as prepare them for the clinical environment. The clinical encounter is thus not hampered by the obstacle of needing to learn the clinical skill before being able to appreciate the value of the learning experience involved in patient interactions. Students can approach clinical practice with a level of confidence and competence which has been formally assessed. The planning involved in preparing the course has done much to ensure that the range of skills is appropriate and also that all students are exposed to the full set of skills which have been taught in a consistent manner throughout. These skills are learnt alongside the theoretical content of the course. The relationship between theory and skill is stressed by the fact that the skills course is intended to reflect the content of the PBL module, and during skills sessions, underlying basic medical sciences are emphasised, hopefully increasing the understanding and depth of learning of the student.

REFERENCES

• General Medical Council (1993) Tomorrows Doctors. Report of the Education Committee. GMC, London.
• Harden R.M., Gleeson F.A. (1979) Assessment of clinical competence using an objective structured clinical examination (OSCE). Medical Education, 13: 41-54.
• McManus I.C., Richards P., Winder B.C., Sproston K.A., Vincent C.A. ( 1993) The changing clinical experience of British medical students. Lancet, 341: 941-944.
• Williams S., Dale J., Glucksman E., Wellesley A. (1997) Senior house officers work related stressors, psychological distress, and confidence in performing clinical tasks in accident and emergency: a questionnaire study. BMJ, 314: 713-718.
• General Medical Council (1997) The New Doctor. Recommen dations on General Clinical Training. Report of the Education Committee. GMC, London.