Practically prepared? Pre-intern student views following an education package: a response.

Dear editor

I read with interest the paper authored by McKenzie and Mellis regarding the delivery and student feedback of an educational package, as part of the pre-internship module, designed to improve clinical skills, including procedural skills, of final-year medical students.1 The educational package was delivered prior to students commencing their clinical attachment component of the module and consisted of didactic-, group-, and case-based teaching sessions. Given the significant improvements in the self-reported confidence of students following the pre-internship module, and from my own experience, I agree with the authors that an intensive educational program is highly valuable at improving the skills and confidence of students prior to commencing clinical practice.

In the UK, the General Medical Council requires UK medical schools to integrate “student assistantships” into the final year of medical school, before the medical student transitions into a practicing first-year postgraduate doctor (“Foundation Year 1” or “F1”).2 Depending on the medical school, the student assistantship is of varying length and is intended to closely integrate students into the health care team so that they may obtain more practical experience of a newly qualified doctor’s role. During this assistantship, students should perform a diverse set of supervised practical procedures on patients, ranging from measurement of body temperature to catheterization and skin suturing.2 It has been shown that student assistantship model does improve the student’s preparedness for clinical practice.3,4

While it is encouraging to see the success of student assistantships, there is still potential for improvement, especially with regard to procedural competencies. It is no surprise that over the years of medical school, most students have had the opportunity to take a blood sample or insert a cannula, without the need of an assistantship. Opportunities such as these regularly present themselves on clinical placement, and most clinical staff permit students to practice these skills on suitable patients. However, despite the presence of student assistantships, the results of this study demonstrate that a sizeable proportion of medical students had still not had the opportunity to sufficiently practice several important procedural skills, including the insertion of a nasogastric tube, the performance of an electrocardiogram on a patient or a peer, and the insertion of a urinary catheter. Furthermore, some students may have only practiced a procedure on one patient and, in the case of urinary catheters, students may have only practiced on one gender alone. As such, the fact remains that not all students will have had the opportunity to sufficiently practice all fundamental procedural skills before transitioning into a practicing doctor, even with the presence of student assistantships.

Rather than advocating for lengthier assistantships or placements, I believe that small efforts can enhance overall student exposure, and thus confidence, in procedural skills. This includes encouragement of clinical staff to support and facilitate regular opportunities for students to practice procedural skills from the very start of clinical placements, and where students have felt that they have had insufficient experience of a particular procedure, medical schools should offer reasonable alternatives, such as access to models for practice on under clinical guidance.

Dear editor

Thank you for providing the opportunity to respond to the letter by Mr Dowlut.

We wish to thank Mr Dowlut for his thoughtful feedback on our recent manuscript.1 It is deeply encouraging that the importance of educational programs of this nature are recognized.

We strongly agree with the benefits of “shadowing” or “assistantship” prior to medical graduates transitioning into pre-vocational training. More recently, ““shadowing” has been made mandatory in Australian hospitals to allow new interns to “shadow” the outgoing intern in the week prior to commencing clinical duties. Further education is also made available at intern orientation, and whilst beneficial, these sessions are not yet standardized and do vary from region to region.

Despite the benefits of “shadowing”, or “student assistant-ships”, we agree the variations in opportunities to observe and perform core procedural skills remain. Hence, the reported value of intensive educational programs such as ours in improving the skills and confidence of students prior to commencing pre-internships.