Learners’ perspective: where and when pre-residency trainees learn more to achieve their core clinical competencies

1. Paper-based survey

The survey consisted of 12 questions based on the core competencies laid forth by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME is a private, nonprofit accreditation body for more than 9,000 residency programs in the United States. In 2002, ACGME identified six ACGME core competencies to be used by graduate medical education programs to evaluate their residents during training. The six ACGME core competencies are patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Each competency is made up of different milestones for each residency program that residents are required to master at key stages of their medical training. These competencies are therefore a standard of measure to evaluate residents-in-training, and it is unreasonable to expect clinicians at the student or even intern-level to be proficient in all categories of competency [5].

In this study, the authors hypothesized that the ACGME competencies could serve as a measure of degree of preparedness for residency training. The ACGME core competencies were therefore not selected to quantifiably measure clinical skill levels, but rather serve as an adapted guide to the common competencies that all preresidency learners should possess. The sixth competency of systems-based practice was omitted as being inapplicable for the purposes of this study. Some of the survey questions were directly inferred from the core competencies, while others sought to measure the truly basic clinical skills that are required of any doctor. The survey was designed with blank spaces for answers instead of an answer choice bank, in an effort to allow for as much unaided recall as possible (see Appendix 1 for full survey questionnaire).

2. Semistructured interviews

Individual interviews were conducted to identify why interns and students regarded a particular department as more conducive to achieving competencies. A total of 50 volunteer participants were selected by convenience sampling, during the clinical rotations of interns and final year medical students at the Department of Emergency Medicine, the home department of the author, for practical purposes. Interviewees were made aware that participation or nonparticipation would not affect their emergency room (ER) rotation evaluation score as an intern or student. The author, in fact, was not privy to, and was furthermore not asked to contribute to the evaluation of students and interns on clinical rotation through his department.

Each interview lasted approximately 5 to 10 minutes, and was based on the questions from the survey. After each question from the survey was asked, the respondent was asked about the specifics of his answer (e.g., “what was it about cardiothoracic surgery that gave you the most interaction with patients and their families?”) and was asked to further expound on the differences with other departments in which they felt did not acquire core competencies.

The results of the survey were tabulated and analyzed in IBM SPSS version 23.0 (IBM Corp., Armonk, USA) for frequency analysis. Chi-square analysis was omitted due to the wide range of responses with many possible answers (departments) showing zero percentile frequency. For each survey question, the top three departments were analyzed; the fourth-ranked departments and beyond showed a sharp drop-off in response rate, with many having a zero response rate. Effective percentages per department are shown in the Appendix 1. The departments with the lowest response rates were extremely diverse, and were not considered of significance.

1. Paper-based survey

Emergency Medicine features prominently among almost all answers, across both interns and students. Another point of interest is the prevalence of General Surgery, Cardiothoracic Surgery, and Urology among intern responses across the vast majority of the questions, but also their relative absence (with the exception of General Surgery) from student responses. Also, many of the departments that were selected by students as being sources of clinical competency (e.g. various departments of internal medicine, notably Infectious Diseases, Pulmonology and to a lesser extent, Nephrology, along with Pediatrics, Obstetrics/Gynecology, and Psychiatry) were not done so by their intern counterparts. Table 1 describes the top responses for each of the 12 questions.

Table 1.

Questionnaire Results

2. Individual interviews

Table 2 shows some of the most illustrative responses elicited during the semistructured interviews, as to why or how respondents answered the survey questions. Many respondents found that a high level of involvement and bestowment of responsibility were motivating factors to perform well and learn more. Interns who had rotated through Emergency Medicine, General Surgery, and Cardiothoracic Surgery shared the perception that by performing a wide range of tasks and duties themselves, they were able to learn and acquire core clinical competencies.

Table 2.

Interview Results

1. The emergency medicine phenomenon

In Korea, interns in the ER usually work 24 hour shifts, alternating between 24 hours on-duty and 24 hours off-duty. When a new patient is admitted to the ER, they are responsible for first-contact; they perform initial history-taking and physical examination, filter through the patient’s previous medical records, formulate a working hypothesis for differential diagnoses, and then involve an emergency medicine resident or staff member for further work-up. Initially, if the differential is obvious (e.g., appendicitis suspected in a young patient with no underlying diseases, complaining of right lower quadrant abdominal pain and definite rebound tenderness), the intern will often issue orders for blood-work, imaging, hydration and pain control. After the ER resident has seen the patient and initial work-up is complete, if the patient requires further examination or admission to a different department, the resident will call for a consult. At this point, the intern and the resident usually have a short discussion; they review the patient’s complaint and history, the results from the work-up (lab results and imaging findings), and the resident explains the rationale behind the referral. The intern then usually asks some questions he may have. Once this clinical discourse is complete, the intern is then responsible for contacting the on-duty resident of the referral department (e.g., general surgery for a case of appendicitis). The intern then briefs the on-duty resident and walks him through the process from admission to referral.

One of the most telling responses to the question “When were you asked to act like a doctor and work on your own?” was “When the Emergency Medicine resident was asleep from exhaustion, and I felt I had to do something to help the patient.” When put in the role of caregiver, regardless of volition, interns often appear to be able to provide adequate initial medical care to most noncritical patients.

In sum, interns play a crucial role in the patient management process of the ER in Korea. They actively practice nearly all core clinical skills that are required by the ACGME, and the questionnaire results reflect this. This is in line with trends across the globe of many faculties moving away from rote memorization and toward a more immersive, hands-on approach to learning. Duong, of the Emergency Medicine department at the University of California in San Francisco, recently revamped its emergency medicine rotation, getting rid of lectures completely, turning the course into a series of hands-on labs where students practice skills such as suturing, wound care, splinting and eye exams [6]. This is a phenomenon that is already present in our internship program.

On the other hand, students showed less of a positive response rate for Emergency Medicine across the survey. This can likely be traced to the nature of their duties, or lack thereof, in the ER. Like most other clinical clerkship rotations, students in the ER have a largely passive, observational role. Their clinical duties are often limited to taking electrocardiograms, or assisting with procedures, and their participation in discourse is dependent on the often rare, active voluntary engagement by attendings, residents and fellows. Nevertheless, Emergency Medicine showed a relatively high response rate when compared to other departments on the questionnaire. This can likely be attributed to the bedside clinical teaching that occurs in the ER. When there is less of a patient load, residents will sometimes voluntarily undertake bedside teaching by instructing students in physical examination on current patients. At other times, students are asked to perform 1-minute briefings (similar to the SNAPPS [Summarize-Narrow-Analyze-Probe-Plan-Select] model and 1-minute preceptor educational model [7]) on current ER patients. These findings correlate with those of Aldeen and Gisondi [8], who found that the ER is ideal for bedside teaching, due the high volume of patients and the acute nature and variety of the presenting diseases, leading to a multitude of opportunities to teach. The semistructured interviews revealed that students found such instances to be particularly helpful and insightful. It is possible that if students were more involved in the ER under a systematic training approach, their survey results would likewise reflect stronger confidence in their core competency skills.

2. The residency shortage departments

Other departments that showed remarkable response rates in the survey included General Surgery, Cardiothoracic Surgery, and Urology. These surgical departments share certain characteristics that are likely responsible for these results. The first is that these departments are the least popular in terms of resident application rates [9]. Because of this shortage of residents, many hospitals, including the author’s, have resorted to utilizing interns as stand-ins for residents. These intern-resident hybrids are responsible for admitting patients, responding to referrals from the ER, preoperative evaluation, booking operating room schedules and postoperative care. All of this is, of course, conducted under the supervision of attending staff members in each department.

This recent phenomenon has bestowed, voluntarily or not, unprecedented responsibility upon the shoulders of interns. The intern interviews revealed surprisingly high satisfaction rates with these roles. Many interns stated they were learning new skillsets, such as difficult patient management, how to interact with family members of patients, and primary care basics (pain control, hydration management, and consultations with other departments). During morning rounds they were responsible for bedside briefings, were the primary medical recordkeepers, and were required to be aware of the clinical course of each patient under their care. Many responded in the interviews that the skills they acquired over the course of their rotations through these three departments would be aspects of their clinical skillset they would carry over to residencies in their respective departments in the years to come. Other studies have shown that when such Entrustable Professional Activities are bestowed upon clinicians, they can effectively bridge the gap between educational theory and clinical practice [10]. Clearly, this lesson is applicable in the context of Korean medicine as well.

3. The shift in responses

Certain departments featured prominently in student responses in the survey, but were absent from intern responses. Noticeably, Pediatrics, Infectious Diseases and to a lesser extent, Nephrology were some of the departments with the highest frequency of student responses. The student and intern interviews were insightful in deciphering this shift. Students responded that these departments offered some of the best bedside clinical teaching and student involvement. Pediatrics, for example, required active participation of the clerks during rounding, with question-and-answer sessions between patients. They were also asked to consider themselves responsible for their patients, and were frequently asked to comment on their patients. Some students reported that they were required to keep their own progress reports, subject to evaluation at the end of the rotation, of the patients that had been under their care. In the internal medicine department of Infectious Diseases, students at certain hospitals reported they were given patient cases on a daily basis. In the morning after rounding, the attending professor would assign consultation cases to each student (e.g., a patient in Orthopedics had developed a fever, and the Department of Infectious Diseases was consulted to investigate the cause). The students would spend the entire day poring over medical records, interviewing the patient and performing a physical examination, and conduct self-study, all of which culminated in the afternoon rounds, during which a clinical discourse would ensue between the attending physician and the student clerk. The student would present his findings and differential diagnosis hypotheses to the professor, and they would have a clinical debate as to how to best treat the patient and how to respond to consultations.

Interns were asked about their roles in the very same departments. Their responses were less positive; most were relegated to the same administrative tasks they performed in other departments, with close to zero involvement in the clinical decision-making process. One intern went as far as to say during his interview that he felt his “most important duty was making sure the coffee was ready for the morning briefing.” While certain departments show promise, they often fall short of providing the full spectrum of education, and their interns felt that they are still viewed in the traditional manner: as a cheap source of labor, hired to perform mostly rote and medial tasks as a rite of passage into residency.

These findings demonstrate that when given the opportunity and the responsibility with proper supervision, pre-resident clinical trainees were more than capable of performing clinical practice. An increased level of involvement appears to lead to more enjoyable learning experiences, and as the final end-product, better-performing clinicians. Student clerks may likewise benefit from such increased involvement.

The fact that the departments of Emergency Medicine or Surgery assigned interns and students more clinical duties and first-contact experience does not necessarily mean that clinical training was more effective in and of itself. Effective training occurs under proper supervision with timely feedback and appropriate introspection. This study is based on self-reported subjective opinions of the learners, and high satisfaction rates do not directly reflect a more systematic, organized teaching approach on the part of Emergency Medicine or Surgery. However, when compared with mere shadowing or simple nonclinical tasks, being able to experience clinical encounters first-hand with a sense of responsibility and a perceived need for decision-making appears to be an important first step in acquiring core clinical competencies. These findings suggest that as teachers, we must provide learners with more opportunities to get involved in actual patient care and should trust the learners’ ability to contribute.

4. Limitations

This was a cross-sectional study, with participating interns and students having been chosen as a convenience sample during respective mandatory conferences. Although participation was voluntary, the convenience sample was taken from a captive audience. The sample size is relatively small, and the study was conducted at a single institution. It should be noted that the design of this study is such that participants’ self-reported subjective opinions are assessed, rather than an objective method in which actual clinical competency acquisition is measured in a quantifiable manner. Whether the respondents actually acquired the aforementioned competencies in the reported departments is an unknown and unproven factor, as there is no proven correlation between high satisfaction rates and skill acquisition or teaching quality. Furthermore, there is a possibility for observer bias in the responses of the interns, as the author is affiliated with the Department of Emergency Medicine.

This study, although preliminary, outlines areas that show promise in the development of clinical education. We identified common factors among the departments in which pre-residency learners felt they acquired core clinical skills: an environment in which trainees are highly involved in clinical duties, are expected to make first-contact patient encounters, participate in clinical discourse, interpret investigative results, and arrive at their own conclusions. These lessons are potentially applicable to the clinical education of student clerks as well. Perhaps with further study, a curriculum that more fully engages and involves students and interns can lead to more productive, enjoyable and effective clinical training. Further study is warranted to determine whether these findings are indicative of true acquisition of clinical competence.