Tomorrow's Doctors Research Articles

Student Selected Components (SSCs): AMEE Guide No 46

Student Selected Components (SSCs) are one of the more innovative recent developments in medical education. Initially established in the UK in the 1990s in response to the General Medical Council's recommendations in Tomorrow's Doctors (1993), they provide students with a significant element of choice and depth of study in the curriculum. SSCs have become an integral part of medical curricula throughout the UK, and to a limited extent the rest of the world. In most cases they contribute to the delivery of learning outcomes broadly encompassing personal, professional and research skills, whilst creating opportunities for students to explore future career options. This AMEE Guide is written for developers of new medical curricula, where SSC-like initiatives offering choice and depth of study, in conjunction with core learning, are being considered. Its aim is to provide insight into the structure of an SSC programme and its various important component parts. It is also relevant for those already involved in SSC development by offering insight into effectively managing, assessing and improving existing programmes, to deliver effective, coherent and core-integrated teaching valued by students and faculty alike.

Overcrowding: Harming the Patients of Tomorrow?

It is 3 AM on August 1st, 2018, in a busy hospital when a 47-year-old male presents with chest pain. The emergency physician on duty, who is a new residency graduate, performs a history and physical, orders an ECG, chest x-ray, and blood work. After reviewing the data, the patient is given aspirin, nitroglycerin, and heparin and admitted to observation for a rule-out with serial enzymes. At 7 AM, the patient’s chest pain worsens and he suffers a cardiac arrest. An autopsy reveals cardiac tamponade and a large thoracic aortic dissection.

Student views on the introduction of anatomy teaching packages into clinical attachments

Following the implementation of the GMC document Tomorrow's Doctors in 1993 the amount of time dedicated to anatomy in undergraduate curricula has been reduced. This has resulted in considerable disquiet among physicians and surgeons with regard to the anatomical knowledge of newly qualified doctors, and also amongst students. This study aimed to assess the perceived student need for anatomical teaching packages to support clinical attachments in the later years of the undergraduate medical curriculum. The views of two groups of students were obtained: Group A were at the beginning of their clinical attachments, whereas Group B had completed all clinical attachments and had sat the final examination. The majority of students indicated that there was a need for the development of a teaching package for anatomy (and other basic sciences) in the later stages of the undergraduate medical curriculum. A high proportion stated that the completion of these packages should be in a self-directed manner with a staff member available. There was a difference between both groups in response to the best time to offer the packages, and in the clinical areas which might be prioritized in such a development. We conclude that the vertical integration of anatomy--perhaps through clinically focused teaching packages--would be welcomed by students as part of their clinical attachments.

Changes in Undergraduate Clinical Psychiatry Teaching in Scotland since “Tomorrow's Doctors”

This paper reviews the factors which have driven changes in undergraduate education in psychiatry since the 1993 publication of "Tomorrow's Doctors",' after which it describes current undergraduate curricula in the four Scottish medical schools teaching clinical psychiatry. Reasons underlying the differences between curricula are discussed. The authors suggest that research in medical education, alongside communication and debate between medical schools and across specialties, would lead to more uniform and evidence-based curricula.

Parasitic Infestations of the Liver and Biliary System in Nigeria

Objective: To review available data on hepatobiliary parasitic infestations management in Nigeria. Methods: Electronic literature, including: Pubmed, Medscape and Google search as well as index medicus search were embarked upon so as to enable in-depth review on the state of hepatic and biliary parasitic infestations in Nigeria. Standard textbooks were also consulted for any additional information. The findings, mostly from some other parts of the world are presented as there were almost no existing accessible data from Nigeria. Conclusion: Hepatobiliary parasitic infestations are such significant causes of morbidity and sometimes, mortality in Nigeria that they require attention by gastroenterologists. This may lead to the practice of modern diagnostic techniques and advancement in training the doctors of tomorrow in our country. IFEMED Journal Vol. 14 (1) 2008: pp. 35-38

Training tomorrow's doctors in diabetes: self-reported confidence levels, practice and perceived training needs of post-graduate trainee doctors in the UK. A multi-centre survey

ObjectiveTo assess the confidence, practices and perceived training needs in diabetes care of post-graduate trainee doctors in the UK.MethodsAn anonymised postal questionnaire using a validated 'Confidence Rating' (CR) scale was applied to aspects of diabetes care and administered to junior doctors from three UK hospitals. The frequency of aspects of day-to-day practice was assessed using a five-point scale with narrative description in combination with numeric values. Respondents had a choice of 'always' (100%), 'almost always' (80–99%), 'often' (50–79%), 'not very often' (20–49%) and 'rarely' (less than 20%). Yes/No questions were used to assess perception of further training requirements. Additional 'free-text' comments were also sought.Results82 doctors completed the survey. The mean number of years since medical qualification was 3 years and 4 months, (range: 4 months to 14 years and 1 month). Only 11 of the respondents had undergone specific diabetes training since qualification.4(5%) reported 'not confident' (CR1), 30 (37%) 'satisfactory but lacked confidence' (CR2), 25 (30%) felt 'confident in some cases' (CR3) and 23 (28%) doctors felt fully confident (CR4) in diagnosing diabetes. 12 (15%) doctors would always, 24 (29%) almost always, 20 (24%) often, 22 (27%) not very often and 4 (5%) rarely take the initiative to optimise gcaemic control. 5 (6%) reported training in diagnosis of diabetes was adequate while 59 (72%) would welcome more training. Reported confidence was better in managing diabetes emergencies, with 4 (5%) not confident in managing hypoglycaemia, 10 (12%) lacking confidence, 22 (27%) confident in some cases and 45 (55%) fully confident in almost all cases. Managing diabetic ketoacidosis, 5 (6%) doctors did not feel confident, 16 (20%) lacked confidence, 20 (24%) confident in some cases, and 40 (50%) felt fully confident in almost all cases.ConclusionThere is a lack of confidence in managing aspects of diabetes care, including the management of diabetes emergencies, amongst postgraduate trainee doctors with a perceived need for more training. This may have considerable significance and further research is required to identify the causes of deficiencies identified in this study.

Involving medical students in research

Involving medical students in research

How clinical communication has become a core part of medical education in the UK

This paper sets out to analyse and interpret the complex events of the last 20 years in order to understand how the teaching and learning of clinical communication has emerged as a core part of the modern undergraduate medical curriculum in most medical schools in the UK. The paper analyses the effects of key political, sociological, historical and policy influences on clinical communication development. Political influences include: the effects of neo-liberalism on society and on the professions in general; the challenging of traditional notions of professionalism in medicine; the creation of an internal market within the National Health Service, and the disempowerment of the medical lobby. Sociological influences include: the effects of a 'marketised' society on medicine and subtle shifts in the doctor-patient relationship because of this; the emergence of globalised information through the Internet, and the influence of increased litigation against doctors. Historical influences include: the effects of a change in emphasis for medical education away from an inflated factual curriculum towards a curriculum that recognises the importance of student attitudes and the teaching and learning of clinical communication skills. Policy influences include the important effects of Tomorrow's Doctors and the Dearing Report on the modern medical curriculum. The paper concludes with a developmental map that charts the complex influences on clinical communication teaching and learning and a brief commentary on the growing body of teachers who deliver and develop the subject today.

Exploring barriers to teaching behavioural and social sciences in medical education

Tomorrow's Doctors provides guidance about what is considered core knowledge for medical graduates. One core area of knowledge identified is the individual in society: graduates are required to understand the social and cultural environments in which medicine is practised in the UK. Yet, despite the presence of the behavioural and social sciences (B&SS) in medical curricula in the UK for the past 30 years, barriers to their implementation in medical education remain. This study sought to discover medical educators' perceptions of the barriers to the implementation of B&SS. Medical educationalists in all UK medical schools were asked to complete a survey identifying what they felt were the barriers they had experienced to the implementation of B&SS teaching in medical education. A comparison of our findings with the literature revealed that these barriers have not changed since the implementation of B&SS in medical education. Moreover, the barriers remain similar across medical schools with differing ethos and strategies. Various agendas within the hidden curricula create barriers to effective B&SS learning in medical education and thus need further exploration and attention.

Female feticide in India: Issues and concerns

The preference for a son continues to be a prevalent norm in the traditional Indian household. This is evident from the declining sex ratio which has dropped to alarming levels, especially in the northern states according to Census 2001 reports. The proliferation and abuse of advanced technologies coupled with social factors contributing to the low status of women such as dowry, concerns with family name and looking up to the son as a breadwinner has made the evil practice of female feticide to become common in the middle and higher socioeconomic households, especially in the northern states. Despite the existence of the Prenatal Diagnostic Techniques Act, there is a dire need to strengthen this law since the number of convictions is despairingly low as compared to the burden posed by this crime. Moreover, it is necessary to gear efforts against the cultural, economic and religious roots of this social malady by woman empowerment and intensive Information, Education and Communication campaigns. The medical colleges and professional bodies have a vital role to play by sensitizing medical students who are the doctors of tomorrow.

Moving to Problem-Based Learning (PBL) in Libya – the Sooner the Better

To The Editor: The authors are to be commended on this highly valuable and succinctly written editorial [1]. It is undoubtedly very useful to encourage tutors and lecturers to make their teaching more interactive and non-threateningly challenging for students. The authors provided numerous useful suggestions for developing learners’ problem-solving skills. Problem-solving skills are an important component of PBL. In PBL students are presented with the problem rather than the information (or knowledge). Encouraged by their “facilitator” they explore the problem; demonstrate team working skills, independent thinking and problem-solving skills. They build profiles of self-directed learners with good generic skills like communication and presentation skills. The role of the facilitator is extremely important. It does not stop at supervising the process and ensuring inclusive practice. It extends to providing constructive feedback. The importance of constructive feedback in clinical teaching can not be overemphasised as its role extends beyond pedagogy. The goal of clinical training is expertise in the care of patients. Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all [2]. Facilitators will need to be trained for the task. Knowledge, skills and attitude (the latter incorporates professionalism) are the main components of learning in the medical field. Contrary to the traditional teaching, which puts more emphasis on knowledge and some skills (often technical) assuming other skills and attitudes are learnt by intuition and experience, PBL (in medical education) recognises the importance of equipping tomorrow's doctors with important skills like communication skills. Communication skills do not reliably improve with time and experience [3]. In my opinion, it is hard to argue that communication between doctors and patients and the concept of team working are not issues that require attention in Libya. PBL approach incorporates all that as a package in its teaching modules as well as its assessment methods. Moreover, PBL approach affords medical students with ample opportunity of bedside teaching from their first year of study, and therefore, maximising their learning opportunities from patients. “To study the phenomena of the disease without books is to sale an uncharted sea. Whilst to study books without patients is not to go to sea at all” Sir William Osler (1849–1919) Finally, if improving patients’ quality of care is the desired outcome then adopting PBL approach should be seen as one of the ways forward. However, this will require not only enthusiastic and highly motivated students and tutors, of which there are plenty in Libya, but commitment from healthcare and educational organisations’ leadership. Our role as clinicians and teachers should be highlighting the advantages, be prepared to debate, share experience and gather the momentum for a forward move.

Education in Veterinary Pathology: Innovations and Global Challenges

The emphasis and location of pathology within veterinary curricula have undergone much change over recent years, and yet pathology can be viewed as a central ‘‘cog’’ in the whole curriculum. Traditionally this cog was located at the mid-point of curricula, forming the bridge between pre-clinical and clinical work. In this context, we can learn much from the human medical world—in particular, the change to more integrated curricula that occurred in the United Kingdom in wake of the ‘‘Tomorrows Doctors’’ documents, as described in this issue by Reid. The resulting concern from the ‘‘disciplines’’ about the consequences of potential loss of identity within these new integrated curriculum models was profound with a danger, as described elsewhere, that ‘‘while the medical education train accelerates away, pathologists are at risk of being left on the platform arguing the benefits of steam.’’ New and innovative approaches to learning and teaching in veterinary pathology using case-based approaches are described in this issue that embrace integration yet maintain the identity of the discipline. The utility of technology as it relates to ‘‘virtual microscopy’’ is also described in several articles—both for histopathology and for cytopathology—and there is good evidence to suggest real benefits to the quality of teaching and learning in this traditionally challenging area.

The Scottish approach to enhancing antimicrobial stewardship

In 2002, the Scottish Executive produced the Antimicrobial Resistance Strategy and Scottish Action Plan, which highlighted antimicrobial stewardship as a key objective in combating resistance. An important response, as a part of the Ministerial Healthcare Associated Infection Task Force work programme was the publication of 'Antimicrobial Prescribing Policy and Practice in Scotland: recommendations for good antimicrobial practice in acute hospitals' in 2005. This article briefly reviews the core components of the Scottish approach, reviews progress with some key goals and explores how many of these goals are being taken forward through a cohesive Scottish national multifaceted strategy, which incorporates primary and secondary care. Much of this will spring from the current review of the Scottish Action Plan. While recognizing the significant progress achieved by the Appropriate Antimicrobial Prescribing for Tomorrow's Doctors Project Group in the education of undergraduate medical students, the article also reviews the NHS Education Scotland-supported Scottish National Antimicrobial Prescribing Project, aimed at foundation training doctors in Scotland. We hope that this experience can be shared and further developed with colleagues within the United Kingdom and European Union.

Response to “The anatomy demonstrator of the future: An examination of the role of the medically‐qualified anatomy demonstrator in the context of tomorrow's doctors and modernizing medical careers”

Response to “The anatomy demonstrator of the future: An examination of the role of the medically‐qualified anatomy demonstrator in the context of tomorrow's doctors and modernizing medical careers”

Oncology Curriculum in Developing Countries and the Lessons to Be Learned

TO THE EDITOR: We read with great interest the article by Gaffan et al on educating undergraduate medical students about oncology. We come from a developing country where oncology teaching was effectively nonexistent. We admire the efforts invested in creating an oncology curriculum for training. Oncology is an ever-expanding field, and with the current progress in research of new treatment modalities and the ever-aging population, this trend will no doubt continue. Trained properly, the doctors of tomorrow will be in a better position to understand and subsequently better manage this complex group of patients. From our personal perspectives, having moved to the United Kingdom where the management of oncologic conditions is much more aggressive and effective, we can appreciate the importance for the early foundations of knowledge. Good undergraduate training is dependent not only on the teaching methodology, but also on the curriculum content, which we acknowledge can be hard to balance for such a vast subject. Both aspects, however, seem to have been thoroughly addressed by the Oncology Education Committee of the Cancer Council of Australia, with its work on the ideal oncology curriculum, and by Gaffan et al, regarding the teaching methods. While we appreciate the epidemiologic differences and variability of disease between the developed and developing worlds, we would like to see this approach to training being mirrored in Pakistan for the future generations of doctors. Developing countries with limited research resources must make use of the ideal oncology curriculum. This would be an immense contribution to the medical community of the lessdeveloped countries.

Improving antimicrobial prescribing through knowledge and skills

Sir, In their recent qualitative study of factors influencing antimicrobial prescribing by non-consultant hospital doctors De Souza et al. found that undergraduate education, hospital guidelines and concerns about emerging resistance were minor influences on prescribing practice. Prescribing was more influenced by instruction passed down through a hierarchical system and subsequently on personal experience. This will lead to poor adherence to local guidelines and inevitably poor prescribing. Poor prescribing by new UK graduates, often due to a lack of an integrated scientific and clinical knowledge base, and the lack of practical prescribing instruction for undergraduates are wellrecognized problems. Clinician education has been found to be the most effective workplace intervention on improving antibiotic selection in a recent systematic review. One apparent barrier to appropriate antimicrobial prescribing is the lack of awareness among senior and training grade clinicians of the local and national resources available to support decision making, including local hospital protocols. Prescribing guidelines appear to be ineffective unless accompanied by educational or financial incentives. Whilst in NHS hospitals it is unlikely that we will be able to meaningfully financially reward individuals or even clinical groups it would seem that optimizing prescribing through improving knowledge and clinical skills may be a more pragmatic approach. At Ninewells Hospital and Medical School in Dundee a concerted and multi-disciplinary effort has been made over recent years to promote and improve prudent antimicrobial prescribing through greater engagement in the undergraduate medical school curriculum and continuing postgraduate educational meetings. Pro-active promotion of local good practice guidance through a variety of educational activities is one such example. Audits of knowledge and behaviour regarding sepsis and antimicrobial therapy among training-grade doctors showed promising improvements between 1999 and 2003 as a result of these initiatives. However, these evaluations and those of others have highlighted the need for clinically focussed and sustainable national learning tools that address the technical and non-technical knowledge and skills of the antimicrobial prescriber. An outcomes based web-based program (Appropriate Antimicrobial Prescribing for Tomorrows Doctors: APT) for teaching and reflective learning of antimicrobial prescribing has recently been developed by infection specialists and medical educationalists and has been adopted by medical schools throughout the UK. The primary resource for the APT project is an interactive website (http://www.dundee.ac.uk/ facmedden/APT/index.htm) with access to clinical worked examples, prescribing exercises, self-assessment tools and a reflective learning logbook. Although the emphasis is on prudent prescribing of antibiotic therapy the principles learned through APT can be applied to all areas of prescribing. In our medical school this forms an integral part of clinical infection teaching in the fourth year that also includes recognition, diagnosis and management of common infections, infection control and health protection aspects of infection. This teaching is delivered by infectious disease physicians, microbiologists, infection control nurses, pharmacists and public health clinicians. Evaluation of this program through student and staff feedback has revealed very positive results and we are presently evaluating student knowledge through a series of short exams at the beginning and end of each attachment, and at the end of the year. In line with national Scottish Recommendations for improving antimicrobial prescribing practice in Scotland the APT work has been further adapted for providing mandatory online e-based training and assessment for foundation doctors in Scotland through the Doctors Online Training System (DOTS) developed by NHS Education Scotland (NES) (https://www. nhsdots.org/nhsdots/dotsx/login.asp). This site is password protected and linked to the NES Healthcare Acquired Infection portal (http://www.nes.scot.nhs.uk/hai/). At any given time there are more than 1600 foundation doctors in Scotland who will have to undertake this mandatory exercise and show evidence of satisfactory completion of this module. This program, through clinical vignettes, revises, evaluates and then reinforces the principles and practices taught at undergraduate level for foundation doctors. An extension and probable further adaptation of this program is proposed for more senior training and non-training grade doctors and ultimately non-medical prescribers. Any persons outside Scotland interested in this work should please contact dilip.nathwani@nhs.net. Ongoing evaluation of this program will inform its further development and impact.

Nineteenth Century Medical Education for Tomorrow's Doctors

Many of the ideas contained within the GMC's 'Tomorrow's Doctors' could be considered as old ideas reworked for modern medical education. Sir John Struthers, a pioneer in the field of medical education, touched on many of the issues in 'Tomorrow's Doctors' in his writings published over one hundred years ago. The study of the history of medicine, often neglected by members of our profession in the search for new ideas, is not only of interest, but is valuable to current and future medical education. History illustrates the mistakes of the past, but also helps highlight the successes and insights that remain applicable and relevant today.

Cross-referencing the Scottish Doctor and Tomorrow's Doctors learning outcome frameworks

Learning outcomes, organised into systems or frameworks which describe and define the output of an educational programme, are being created and used in healthcare education with increasing frequency (Harden , 2002). Medical schools may be required to conform to more than one such outcome framework. For example, both the UK General Medical Council (GMC) and the Scottish Deans’ Medical Curriculum Group (SDMCG) have created and published a systematic learning outcome framework for medical graduates. Although both of these publications are concerned with undergraduate medical education, they differ in their aims, and structure. In order to use, evaluate and validate them, a cross-referencing system which relates each learning outcome statement, term or groups of terms is required. This paper describes the cross-referencing exercise undertaken by the SDMCG, the philosophy behind it, the practical steps taken, the findings, the lessons learnt and reflections upon how this work may be taken forward. It will be of interest to all those who are involved in curriculum development using outcomes, and especially those who use the GMC's Tomorrow's Doctors or the SDMCG's Scottish Doctor frameworks and those who are interested in education informatics in general.

Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30

Much has been written about the benefits and applications of Peer Assisted Learning (PAL) in the literature. Curriculum developers increasingly consider PAL as a vehicle to help undergraduate healthcare students learn to teach; an outcome which has received more attention in the UK since the General Medical Council stated in Tomorrow's Doctors that medical graduates must 'Be able to demonstrate appropriate teaching skills'.This guide is primarily designed to assist curriculum developers, course organisers and educational researchers develop and implement their own PAL initiatives. It is structured around a PAL planning framework consisting of 24 questions. The questions are grouped in threes, around eight themes. Each question is discussed with reference to the PAL literature and other related subjects, and is exemplified by responses from a recent PAL project developed at The University of Edinburgh. Working through the 24 questions, particularly with discussion in a small planning group, will enable readers to efficiently develop their ideas for PAL into comprehensive and practical project plans cognisant of current educational theory, existing PAL literature and the local context.The framework is particularly suitable for those who want to develop healthcare undergraduate PAL initiatives yet have little or no experience of PAL, as it provides an introduction to the relevant literature field and a step-by-step process for the design and implementation of such projects. It will also be of interest to those with experience of PAL and those seeking a structured framework for planning non-PAL curriculum developments in undergraduate healthcare curricula.

Placing the patient at the core of teaching

Background: In the revised undergraduate medical programme at the University of Dundee, medical students visit a patient with a chronic illness in the patient's own home. Students’ learn about the patient's experience of their chronic illness/disease over time. It is known as ‘the patient journey’. The concept of ‘the patient journey’ emerged from Tomorrow's Doctors (2003) in light of the need to increase community-based education.Description: The evaluation was carried out using a focus group. Students indicated that community-based education can show them real life in a home context; early contact with a patient enabled them to have a better understanding of patient-centred medicine; meeting a patient early brings reality and continuity to their careers and a clearer understanding of the patient's condition.Conclusions: Further work may clarify the specific long-term values of the patient visit and how it may support teaching and learning within the first three years of the curriculum.