Developing doctors: what are the attitudes and perceptions of year 1 and 2 medical students towards a new integrated formative objective structured clinical examination?

BACKGROUND: Objective Structured Clinical Examination (OSCE) is a core component of undergraduate medical student assessment. With increased emphasis on integrated programmes, more courses include OSCEs in the traditionally 'preclinical' years. The acceptability and impact of such assessment methods at this stage of training is unknown. METHODS: In 2013 and 2014 University College London Medical School piloted a formative, integrated OSCE in years 1 and 2 of the undergraduate medical degree programme. This study with a sequential exploratory design aimed to explore the acceptability and impact of such an OSCE in the early years of medical school. 1280 students completed the OSCE and were invited to complete a questionnaire exploring their views of the OSCE (response rate 96.6 %). Four focus groups, each with five or six participants (22 in total) were subsequently held to further explore themes. Data was independently transcribed and coded using thematic analysis. RESULTS: Students were strongly in favour of the introduction of an OSCE in addition to existing assessments. Six overarching themes were identified: application of knowledge and skills; OSCE as an experience; OSCE as a process; a learning curve; becoming a doctor; and creating an effective OSCE. CONCLUSIONS: Results strongly support the role of OSCE early in the medical course with many benefits reported. An OSCE at this stage aligns with the vision of integrated medical education which includes early patient contact and introduction of clinical and professional skills. It also fosters feelings of responsibility and professional identity amongst students

Paper trials: a qualitative study exploring the place of portfolios in making revalidation recommendations for Responsible Officers

A portfolio of supporting information (SI) reflecting a doctors entire medical practice is now a central aspect of UK appraisal for revalidation. Medical revalidation, introduced in 2012, is an assessment of a doctors competence and passing results in a five yearly license to practice medicine. It assesses of a doctors professional development, workplace performance and reflection and aims to provide assurance that doctors are up-to-date and fit to practice. The dominant assessment mechanism is a portfolio. The content of the revalidation portfolio has been increasingly prescribed and the assessment of the SI is a fundamental aspect of the appraisal process which ultimately allows Responsible Officers (ROs) to make recommendations on revalidation. ROs, themselves doctors, were the first to undergo UK revalidation. This qualitative study explored the perceptions of ROs and their appraisers about the use of this portfolio of evidence in a summative revalidation appraisal.28 purposefully sampled London ROs were interviewed following their revalidation appraisal and 17 of their appraisers participated in focus groups and interviews. Thematic analysis was used to identify commonalities and differences of experience.SI was mostly easy to provide but there were challenges in gathering certain aspects. ROs did not understand in what quantities they should supply SI or what it should look like. Appraisers were concerned about making robust judgements based on the evidence supplied. A lack of reflection from the process of collating SI and preparing for appraisal was noted and learning came more from the appraisal interview itself.More explicit guidance must be available to both appraisee and appraiser about what SI is required, how much, how it should be used and, how it will be assessed. The role of SI in professional learning and revalidation must be clarified and further empirical research is required to examine how best to use this evidence to make judgments as part of this type of appraisal

Quality and impact of appraisal for revalidation: the perceptions of London’s responsible officers and their appraisers

BACKGROUND: To evaluate NHS England London region's approach to the revalidation appraisal of responsible officers in London, exploring perceptions of the quality and impact of the appraisal process. Revalidation is the process which aims to ensure doctors in the UK are up-to-date and fit to practice medicine thus improving the quality of patient care. Revalidation recommendations are largely premised on the documentation included in annual appraisals, which includes the professional development a doctor has undertaken and supporting information about their practice. METHODS: A pan-London qualitative study exploring the views of responsible officers and their appraisers about the revalidation appraisal process. The study aimed to gain an in-depth understanding of the experiences and perceptions of the participants. Responsible officers were purposefully sampled to represent the broadest range of designated bodies. Data analysis generated themes pertaining to quality and impact of appraisal for revalidation with the potential to feed into and shape the evolving system under investigation. RESULTS: The central importance of highly skilled appraisers was highlighted. Both groups reported educational opportunities embedded within the appraisal process. Independent appraisers, not matched by clinical speciality or place of work, were considered to take a more objective view of a responsible officer's practice by providing an 'outsider perspective'. However, covering the breadth of roles, in sufficient depth, was challenging. Participants reported a bias favouring the appraisal of the responsible officer role above others including clinical work. Appraisal and revalidation was perceived to have the potential to improve the healthcare standards and support both personal development and institutional quality improvement. CONCLUSIONS: Responsible officers play a central role in the revalidation process. Getting responsible officer appraisal right is central to supporting those individuals to in turn support doctors and healthcare organisations in continuous quality improvement. The complexity and importance of the role of responsible officer may make achieving an appraisal of all roles of such individuals problematic. This evaluation suggests responsible officer appraisal was perceived as educational and effective

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search

Background: Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. Methods: A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. Results: The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. Discussion: Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. Conclusion: Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environment

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes