The Value of Paediatrics Placements: Confidence or Competence? [Letter].

Dear editor,

We read with great interest the study by Teh et al1 regarding the evaluation of the effect of paediatric placements on self-perceived confidence. The subgroup analyses regarding modifiable and unmodifiable factors were fascinating. We appreciate their efforts in conducting this study; however, there are several confounding factors that were not addressed which may impact the study’s validity and need addressing.

First, it is not clear if all the students undertook their placement at the same hospital or at different hospitals across the Imperial College Healthcare Trust; thus, the results may be prone to selection bias. In our experience, the quality of clinical supervision varies considerably between clinical placement sites; consequently, not all students necessarily receive an equal standard of clinical supervision and teaching, which may affect their self-perceived confidence. Indeed, previous studies have reported that the site of placements may impact trainees’ and students’ experiences, reasoning that most health promotion and delivery occur in community hospitals where students can build relationships and understand the continuity of care. Contrastingly, university hospitals are often equipped with subspecialty services exposing students to a greater case mix and breadth of diagnostics and therapeutics.2 In examining this variation, a study by Worley et al showed that students in a rural attachment outperformed metropolitan students in academic performance.3 A more recent study also went on to examine the impact of placements on medical students’ confidence, and secondarily analysed the influence of the attachment site; although this showed no difference, it would have been interesting to see if Teh et al would have yielded similar results.4

Furthermore, it is worth noting that one of the primary objectives of placements is to aid medical students in their acquisition of knowledge and transition into their future roles as junior doctors. As the authors mention, placements influence medical students’ performance in the summative Practical Assessment of Clinical Examination Skills (PACES). Hence, whilst confidence is certainly necessary to participate in clinical activities, we wonder whether competence is a more appropriate indicator of an attachment’s impact. Along this vein, a study in Australia demonstrated no relationship between junior doctors’ self-reported confidence and their performance in clinical skills assessment.5

The findings of this study are critical, but further understanding of the factors underpinning students’ confidence is crucial, and we wonder whether a broader subgroup analysis would provide a deeper insight. For example, the study assumed that each student attended clinical attachments to a satisfactory or equal level; in reality, attendance may have been more varied. Additionally, paediatric conditions are commonly recognised to follow seasonal variations, and the approximately-five-month duration of this study may have influenced the amount and variation of cases a student was exposed to. This study may benefit from encompassing these factors under its modifiable and un-modifiable factors analysis. Such an exploration may consequently inform more actionable strategies medical students might implement to improve their confidence or urge changes in national or local medical curricula such as earlier exposure to paediatrics during medical school.