A structured course teaching junior doctors invasive medical procedures results in sustained improvements in self-reported confidence

Discussion

The procedures described in this study are essential skills for the acute medical physician and form part of the core medical training (CMT) curriculum.⁴ Opportunities for training are being eroded by implementation of the European Working Time Directive, but the emphasis is still on learning new techniques in the acute setting with formal teaching programmes infrequently available. A limited number of studies, principally from the USA, have looked at the attitudes of trainees to training in invasive procedures, and these have identified substantial levels of discomfort – in one such study this was despite the trainees having performed the prerequisite number of procedures to achieve independence.^5,6

Approaches other than model-based training include the use of cadavers, which has been shown to improve competence and outcomes,^7–9 but its use is limited by practical constraints. A ‘procedure firm’, to which trainees were assigned for two weeks, produced only modest improvements in confidence.¹⁰ The use of models has been shown in various settings to improve competency and confidence.^11–13 Models are available for the teaching of a number of procedures and while even the best of these have limitations in terms of realism, they can provide a useful platform on which to base procedure skills training prior to their application on patients. Many hospitals have skills laboratories equipped to varying degrees with these resources. Importantly, whereas patient-based training by necessity has to consider, foremost, the clinical needs of the patient, the use of models allows a strictly learner-centred experience. Educational research has shown that deliberate practise and immediate structured feedback are crucial to skills acquisition¹⁵ and structured learning within the environment of the clinical skills laboratory enables this in a safe environment and encourages reflective learning.¹⁶ A number of studies have shown the benefits of model-based training – dedicated training sessions or courses which include practical instruction on models have been shown to improve competency and confidence.^11–14,17 However, no data are currently available for patient outcomes. The use of simulation-based training is also gaining ground in surgery and is increasingly recognised as a useful tool for safe, learner-centred training.^18,19 This was given particular emphasis in the recent chief medical officer's annual report.²⁰

Likert scales have been previously used to assess the confidence of trainees in aspects of performing medical procedures and were deemed an appropriate tool for use in this study.^5–7,10 The data presented in this study would be strengthened by the presence of a control group: the intention of the course was to offer training to as many junior doctors as wished to attend and a control group would therefore have been subject to selection bias. Furthermore, controlling for clinical experience in a hospital where trainees rotate through a variety of posts would have been difficult. Assessment of competence was outside the scope of the one-day course: the intention was to improve confidence and provide a basis of familiarity with the procedure. Furthermore, it was felt that formal assessments after a relatively short course were inappropriate and could potentially undermine the primary objective of the course. Assessment of competence could not have been achieved by a self-reported questionnaire as the poor association between self-reported competence and objective competence is well documented.²¹ Whether or not they attended the course, all trainees would have appropriate supervised training on patients. It is hoped that this study will provide a foundation for further work: the effect on a course such as this on the subsequent acquisition of procedural skills, particularly in terms of time needed to achieve objective competence, would be of particular interest in the setting of a controlled trial.

This study has shown that a simple relatively inexpensive course produces sustained improvement in trainee confidence in the medium term and it is anticipated that this foundation would enhance learning and skill acquisition when subsequently performed in the clinical setting. The popularity of the course among FY trainees (who made up 69% of attendees) was surprising as the course had not been specifically targeted at this group. This training is likely to be of greatest benefit prior to clinical exposure and should be considered as part of FY and CMT programmes.