Kamau, C. (2014). Systematic review of new medics’ clinical task experience by country. Journal of the Royal Society of Medicine Open, 5(5), 2054270414525373 [FULL TEXT]

ABSTRACT Objectives: There is a need for research which informs on the overall size and significance of clinical skills deficits among new medics, globally. There is also the need for a meta-review of the similarities and differences between

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    http://shr.sagepub.com/  JRSM Open  http://shr.sagepub.com/content/5/5/2054270414525373The online version of this article can be found at: DOI: 10.1177/2054270414525373 2014 5: JRSM Open  Caroline Kamau Systematic review of new medics' clinical task experience by country  Published by:  http://www.sagepublications.com On behalf of:  The Royal Society of Medicine  can be found at: JRSM Open  Additional services and information for http://shr.sagepub.com/cgi/alerts Email Alerts: http://shr.sagepub.com/subscriptions Subscriptions:  http://www.sagepub.com/journalsReprints.nav Reprints:  http://www.sagepub.com/journalsPermissions.nav Permissions:  What is This? - May 1, 2014Version of Record >> at Birkbeck Library on May 2, 2014shr.sagepub.comDownloaded from at Birkbeck Library on May 2, 2014shr.sagepub.comDownloaded from   Research Systematic review of new medics’ clinical task experienceby country Caroline Kamau Department of Organizational Psychology, Birkbeck, University of London, Malet Street, London WC1E 7HX, UK Corresponding author:  Caroline Kamau. Email c.kamau@bbk.ac.uk  Abstract Objectives:  There is a need for research which informs on the overall size and significance of clinical skills deficitsamong new medics, globally. There is also the need for ameta-review of the similarities and differences betweencountries in the clinical skills deficits of new medics. Design:  A systematic review of published literature pro-duced 68 articles from Google/Google Scholar, of whichnine met the inclusion criteria (quantitative clinical skillsdata about new medical doctors). Participants:  One thousand three hundred twenty-ninenew medical doctors (e.g. foundation year-1s, interns, post-graduate year-1 doctors). Setting:  Ten countries/regions. Main outcome measures:  One hundred twenty-three datapoints and representation of a broad range of clinicalprocedures. Results:  The average rate of inexperience with a widerange of clinical procedures was 35.92% (lower confidenceinterval [CI] 30.84, upper CI 40.99). The preliminary meta-analysis showed that the overall deficit in experience issignificantly different from 0 in all countries. Focusing ona smaller selection of clinical skills such as catheterisation,IV cannulation, nasogastric tubing and venepuncture, theaverage rate of inexperience was 26.75% (lower CI18.55, upper CI 35.54) and also significant. England pre-sented the lowest average deficit (9.15%), followed byNew Zealand (18.33%), then South Africa (19.53%),Egypt, Kuwait, Gulf Cooperation Council countries andIreland (21.07%), after which was Nigeria (37.99%), thenUSA (38.5%) and Iran (44.75%). Conclusion:  A meta-analysis is needed to include data notyet in the public domain from more countries. Theseresults provide some support for the UK GeneralMedical Council’s clear, detailed curriculum, which hasbeen heralded by other countries as good practice. Keywords clinical skills, foundation doctors, induction/orientation,medical education, medical interns Introduction There is some research about deficits in new medicaldoctors’ experiences with different clinical tasks, 1–3 but there is a need for research which informs onthe overall size and significance of the deficit acrossdifferent countries. There is also the need forresearch which compares the size of the deficitbetween countries. It is important to harmoniseinduction curricula in different countries becausethere is a high level of demand for medical profes-sionals, globally, 4 and good opportunities for theirmobility between health systems. Some countries’professional associations, such as the UK GeneralMedical Council, have presented clear guidelinesabout educational and induction curricula, whereassome countries have not yet done this. 2 As a steptowards finding out whether these country differ-ences matter, this article explores and presents asystematic review of the similarities and differencesbetween countries in the clinical skills deficits of newmedics. Methods Searching  The search produced 68 articles. Figure 1 is a flow dia-gram based on Quality of Reporting of Meta-analyses(QUOROM),showingtheprocessofsearching,screen-ing and evaluating articles, and a summary of the rea-sons for exclusion. Appendix 1 shows the QUOROMcheckliststatements. This systematic reviewbeganwitha search of Google Scholar for articles about new doc-tors’ clinical skills. Search words included ‘clinicalskills’, ‘new medic’, ‘new doctor’, ‘newly qualifieddoctor’. This produced 42 articles, two of which wereincluded. 1,2 The search was repeated on Google web toinclude non-indexed journals from more countries andalso adding regionally used labels (e.g. ‘medicalinterns’) and country names. This produced 26 articles,seven of which were included. 5–11 Selection The criteria for inclusion were as follows: the datashould be published and quantitative; the sample ! 2014 The Author(s)Creative Commons CC-BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission providedthe srcinal work is attributed as specified on the SAGE and Open Access page (http://www.uk.sagepub.com/aboutus/openaccess.htm).  Journal of the Royal Society of Medicine Open;5(5) 1–11DOI: 10.1177/2054270414525373  at Birkbeck Library on May 2, 2014shr.sagepub.comDownloaded from   should be new medical doctors or at an equivalentlevel; the article should report the percentage of respondents with experience or inexperience in eachclinical skill or provide scores that can beconverted into percentages. There was no  a priori  definition of experience; articles which used compar-able methods of operationalising experience wereincluded. Figure 1.  A flow diagram showing the process of searching, screening and evaluating articles, and a summary of the reasons forexclusion. Excluded ( n  = 21) Reasons: Qualitave data No data (e.g. conference abstracts) No data per clinical skill (e.g. summary across a range) Experience defined ambiguously Confidence self-rangs OSCE scores Not yet equivalent to new medics Survey of others’ views about new doctors Excluded n  = 38 Reasons Sample: not equivalent to new medics (e.g., medical students, mixed samples) Potenally relevant arcles idenfied and screened (maximum N = 48,900 from Google Scholar; maximum N = 12,800 from Google) Retrieved for more detailed evaluaon ( n  = 68) Full-text retrieval of arcles Excluded approximate n  = 61,632 Reasons Non-medic sample Not data about clinical procedures Not primary data (e.g. policy or curricular websites) Potenally appropriate for inclusion ( n  = 30) Preliminary inclusion ( n  = 10) 1-3; 5-11 Withdrawn ( n  = 1) Reason : Data from England 3 collected 13 years ago and before GMC curriculum changes Included ( n =9) 1-2; 5-11 2  Journal of the Royal Society of Medicine Open 5(5)  at Birkbeck Library on May 2, 2014shr.sagepub.comDownloaded from   Validity assessment Nine articles met all criteria, and their extracted dataare reported in Table 1. Details of the articles’ rawscores and conversions to percentages are reportedbelow. Data abstraction The searches, conversions of data into percentagesand calculations were conducted by the author manu-ally and using SPSS. Study characteristics The first article 1 provided data from 30 postgradu-ate year-1 doctors (PGY1s) in New Zealand, whowere asked about their clinical skills at the start of their postgraduate year and again at the end. Datafrom Time-1 were used for this analysis. The PGY1swere given a 134-item questionnaire and asked torate their experience with a procedure using a 0 to5 scale, whereby 0 ¼ ‘never heard of the procedureor skill’; 1 ¼ ‘know the principle’; 2 ¼ ‘observed, ordone on a model’; 3 ¼ ‘done with supervision orassistance’; 4 ¼ ‘have done independently’; 5 ¼ ‘verycomfortable with this skill – mastered’. 1(pp.1–2) Theresearchers then coded responses of 3 or higher asexperience, and the percentages reported representedthe respondents who had performed a given skillunder supervision, independently or mastered it.The second article 2 provided data from Egypt,Kuwait, Gulf Cooperation Council countries andIreland. There were 91 medical interns who indi-cated the number of times they had performedeach clinical skill, and therefore the researchersreported the percentage that had never performedeach skill. The third article 5 represented data from100 medical clerks (equivalent to medical interns).The authors measured the frequency of clerks whohave performed each task under observation  < 2times, 2–5 times, 6–9 times and  > 10 times. Thefourth article 6 represented data from 91 foundationyear-1 doctors; they were recruited from 16 NHStrusts in the Mersey Deanery region of England.The authors asked them to rate their preparednessfor each task on a scale ranging from 1 to 5, andthey operationalised good preparedness as a score of ‘quite well prepared’ or better. The fifth article 7 rep-resented data from 89 newly qualified doctors inSouth Africa, who were surveyed about their intern-ship experiences with different tasks. Theyresponded using a scale ranging from 1 to 5,whereby 4 represented the ability to perform thetask independently and 5 the ability to teach itto someone. The sixth article 8 represented datafrom 681 PGY1s (medical interns) in USA. Theauthors also surveyed medical programme directorsto identify the tasks that 66% of them believe aretasks that medical interns should be able to performindependently without prompting or coaching. Theseventh article 9 represented data from 84 medicalstudents in Nigeria who had just completed theirlast lecture. The authors reported the number of students with 0 attempts of each clinical procedure;an attempt was defined as the number of times theprocedure had been successfully performed. Theeighth article 10 represented data from 93 graduatesin Nigeria who were about to begin their medicalinternships. The study focused on urethral catheter-isation, and the authors reported the percentagewho responded that they could do this under super-vision or independently. The ninth article 11 repre-sented data from 70 medical interns in Nigeria andfocused on episiotomies, a procedure frequentlyexpected of interns in Nigeria. Quantitative data synthesis From the first article, 1 each value was subtractedfrom 100 to obtain the percentage of respondentswho had never performed a given skill under super-vision, independently or mastered it (listed inTable 1). The data from the second article 2 wereextracted and reported in Table 1. The data extractedinto Table 1 from the third article 5 represented thepercentage with the least experience ( < 2 times). Fromthe fourth article, 6 the frequency of the new doctorswho rated themselves as being less than ‘quite wellprepared’ was converted into a percentage and listedin Table 1. The scores from the fifth article 7 wereconverted into percentages; the levels of inexperiencein Table 1 were then calculated by subtracting thesevalues from 100. The percentages of interns in thesixth article 8 who responded that they cannot inde-pendently perform a task which 66% of medical pro-gramme directors said is expected of medical internswere calculated for Table 1 (excluding managementor judgement tasks not measured in other studies andalso including clinical procedures measured by sev-eral other articles in the current review). From theseventh article, 9 the data in Table 1 are the percentageof respondents who had not successfully attemptedeach procedure. The data extracted from theeighth article 10 represented the percentage whoresponded that they could not perform the procedureunder supervision or independently. The dataextracted from the ninth article 11 represented the per-centage of interns who had not ever performed theprocedure. Kamau  3  at Birkbeck Library on May 2, 2014shr.sagepub.comDownloaded from   Table 1.  Proportion of new doctors without sufficient task experience, by country. y Task Proportion withoutexperience (%) y Data Country1. Abscess drainage 40 5 Iran2. Abscess drainage 53 1 New Zealand3. Abscess drainage 40 8 USA4. Abscess examination anddrainage17.6 2 Egypt, Kuwait, Gulf CooperationCouncil, Ireland5. Airway care 5.2 6 England6. Anaesthetic (local) 12.4 7 South Africa7. Anaesthetic (local) 7 1 New Zealand8. Anaesthetic (local) 13.3 6 England9. Anorectoscopy, proctoscopy/sigmoidoscopy34.1 2 Egypt, Kuwait, Gulf CooperationCouncil, Ireland10. Application of traction 79 1 New Zealand11. Arterial blood gas 61 8 USA12. Arterial blood sampling 100 9 Nigeria13. Arterial puncture 1.7 6 England14. Arterial puncture 7 1 New Zealand15. Artificial ventilation 42.9 2 Egypt, Kuwait, Gulf CooperationCouncil, Ireland16. Assessment of level of consciousness (GCS)23 1 New Zealand17. Bag/mask skills 45.24 9 Nigeria18. Bandage/strapping application 23 1 New Zealand19. Bimanual palpation of adnexae 3 1 New Zealand20. Blood (phlebotomy) 28 8 USA21. Blood (phlebotomy) 40 5 Iran22. Blood film – examination of 47.3 2 Egypt, Kuwait, Gulf CooperationCouncil, Ireland23. Blood glucose (glucometer use) 13 8 USA24. Breech delivery 36.4 7 South Africa25. Cannulation (IV) 91 5 Iran26. Cannulation (IV) 4.76 9 Nigeria27. Cannulation (IV) 0 1 New Zealand (continued) 4  Journal of the Royal Society of Medicine Open 5(5)  at Birkbeck Library on May 2, 2014shr.sagepub.comDownloaded from 
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