Introduction Medical students extend their preparatory learning on entering the clinical work environment, by joining their clinical team as peripheral participants and start to care for “real” patients. This learning is situated, experiential, varied, mainly unstructured, highly dependent on clinical opportunities (affordances), and students’ motivation to learn (learner agency). Students ideally contribute to workplace activities, which allow their practical skills, confidence and professional identity to evolve. This study sought to investigate senior students’ perspectives in their early stages of workplace learning, by using social learning theory as a framework. The focus is on team integration, practical skills performance, professional development and their evolving professional identity. Methods Between 2015 and 2018, we conducted five focus groups, with a total of 36 volunteers, out of a possible 200 (18% Stage 3 (Year 3)) medical students. Each focus group session was audio recorded and transcribed verbatim. Participants were de-identified, and framework analysis used the theoretical frameworks of communities of practice, and workplace affordances to gain insight into their work-place learning experience during the first two months of their clinical rotation. Results Thirty-six students out of 200 (18%) attended focus groups over a four-year period. The results are presented using the theoretical frameworks of community of practice and workplace affordances and presented as themes of: meaning, “learning as experience”, practice, “learning as doing” community, “learning as belonging”, and identity, “learning as becoming”. Discussion Participants reported many positive examples of workplace learning while dealing directly with patients. Students were also exposed to ethical dilemmas and unexpected risks in the workplace. These included lack of site orientation, unsupportive teams, lack of supervision, and students’ inability to initiate agency, all of which contributed to their workplace uncertainty. Performing manageable tasks for their team provided a role in their community of practice, strengthening their identity as evolving doctors. Exposure to both positive and negative role models allowed students to reflect on ethical issues, further extending their own professional identities. Summary Participants were quick to observe and report workplace dynamics as they were exposed to the positive and negative aspects of the hidden curriculum. This allowed them to reflect on patient safety, and ethical concerns promoting the development of their professional identity.

Introduction: On commencing internship, new medical graduates (new interns) are often required to perform core procedural skills under differing levels of supervision. This variability o f knowledge and experience with procedural skills can place patient safety at risk. Consequently, in 2012, we developed a targeted, intensive, 3-day training course for our pre-intern (PrInt) students. The aim of this study was to evaluate the intern preparation package by exploring interns' self-reported knowledge, confidence, and experience in key procedural skills during the early months of internship. Methods: Between 2012 and 2016, 5 cohorts of Print students (n=223) participated in our course. In the following years 2013-2017, the game 5 cohorts, at 4-5 months into their internship, were surveyed anonymously and invited to attend focus groups. Descriptive statistics and thematic analysis were used to analyze data. Results: Of the 223 interns, 91 (41%) responded. Of the 91, 82 (93%) agreed that the intern preparation package provided during Print had been beneficial to their practice as an intern. Awareness of potential risks to patient safety was high, ranging from infection control at 89/89 (100%) to 87/90 (97%) for patient identification. Confidence in performing procedural skills varied from moderate in identifying nasogastric tube placement on X-ray (66/89; 85%), to equal least confidence in managing cardiac-related emergencies (53/90; 59%) and identifying the correct placement of peripherally inserted central catheter lines on X-ray (52/89; 58%). Major qualitative findings: The preparation package had refreshed interns' procedural skills ability and awareness of risks to patient safety. Integration into the clinical team was positive, but requests to perform procedural skills on day 1 was unexpected. Conclusion: Interns reported that they had gained substantial benefit from their preparation package, and they performed practical procedures from day 1, further highlighting the need for an intensive preparation course immediately prior to entering internship.

BACKGROUND:It is widely known that the opportunity for medical students to be observed and to receive feedback on their procedural skills performance is variable in the senior years. To address this problem, we provided our Pre-Intern (PrInt) students with "one-to-one" formative feedback on their ability to perform urethral catheterization (U/C) and hypothesized that their future practice of U/C as interns would benefit. This study sought to evaluate the performance and practice of interns in U/C 4-5 months after having received feedback on their performance of U/C as PrInt students.METHODS:Between 2013 and 2014, two cohorts of interns, (total n=66) who had received recent formative feedback on their U/C performance as PrInt students at Central Clinical School, were invited to complete an anonymous survey. The survey contained nine closed unvalidated questions and one open-ended question, designed to allow interns to report on their current practice of U/C.RESULTS:Forty-one out of 66 interns (62%) completed the survey. Thirty-five out of 41 respondents (85%) reported that the assessment with feedback during their PrInt term was beneficial to their practice. Thirty of 41 (73%) reported being confident to perform U/C independently. Eleven out of 41 respondents (27%) reported that they had received additional training at intern orientation. Nine of the 11 interns (82%) reported that they had a small, but a significant, increase in confidence to perform U/C when compared with the 30 of the 41 respondents (73%) who had not (p=0.03).CONCLUSION:Our results substantiate our hypothesis that further education by assessment with feedback in U/C during PrInt was of benefit to interns' performance. Additional educational reinforcement in U/C during intern orientation further improved intern confidence. Our results indicate that extra pre- and post-graduation procedural skills training, with feedback, should be universal.

BACKGROUND:Graduating medical students enter their internship with varied levels of practical experience in procedural skills. To address this problem, many medical schools have introduced intensive skill training courses immediately prior to graduation. This study examines the impact of a pre-intern (PrInt) education package, consisting of a short intensive course, followed by a one-month clinical attachment. METHODS:In September 2014, all PrInt students (n = 53) at the Central Clinical School (Sydney, NSW, Australia) attended three days of intensive training. This included a didactic introduction, case-based scenarios, and interactive workshops. This was followed by four weeks of targeted, experiential learning during a clinical attachment (PrInt term). Immediately prior to training and following PrInt, all students were invited to complete a six-domain questionnaire containing 40 subscale closed questions to assess their knowledge, experience, and confidence in key practical skills essential for a successful internship. RESULTS:A total of 41/53 (77%) students completed an identical questionnaire prior to PrInt, and 37/53 (70%) immediately following PrInt. Respondents reported statistically significant increases in their experience, ability, knowledge, and confidence in a number of domains. The key changes were the following: knowledge of pharmacy skills (mean improvement = 26.48, confidence interval 95% [CI 95%] = 17.29-35.66, p ≤ 0.0001) and management of procedural skills (mean = 24.46, CI 95% = 16.58-32.34, p ≤ 0.0001). Despite the positive overall increase in most domains, some subscale results remained low following the educational package; only 44% students had inserted a nasogastric tube; only 44% reported confidence in commencing patients on warfarin; and only 42% in managing a hospital emergency. Surprisingly, there was a slight decline both in confidence in communicating with members of the hospital team (10%) and in awareness of the causes of hypoglycemia (7%). CONCLUSION:Final year students perceived substantial benefit from an educational package specifically aimed at improving their practical skills immediately prior to internship.

Rahul Rajesh Amin, Rohin Patel, Prashant Bamania Faculty of Medicine, Imperial College London, Kensington, London, United KingdomWe read with great interest the study by McKenzie et al,1 which explores the impact of providing feedback to students on their ability to carry out a clinical procedure. This study was particularly interesting to us as fifth-year medical students at Imperial College London who have learnt several clinical skills during rotations. A noteworthy finding was that education involving providing feedback to students had a positive impact on their performance.1 Furthermore, the recommendation that clinical skills training be accompanied with feedback resonated strongly with us.Authors’ replySusan McKenzie1 Annette Burgess2 Craig Mellis11Central Clinical School, 2Education Office, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia Thank you for the opportunity to respond to the letter by Dr Amin and colleagues. We wish to thank Dr Amin and colleagues for their interest in our recent article1 and have found their feedback encouraging for our work. We find the use of electronic feedback to be of particular interest as we are currently developing a similar electronic application for the use of students’ “smart phones”. We anticipate by capturing feedback in this manner, students have a great opportunity to reflect on their procedural skills performance, and to be able to improve their skills when necessary.View the original paper by McKenzie and colleagues.

There is a growing demand for "near peer" teaching in the delivery of medical curriculum. Experienced senior physicians are increasingly more occupied with competing demands on their time and expertise. As a result, junior medical staff (1-4 years after graduation) are taking on more teaching responsibilities. The aim of this study was to gain an understanding of the motivations of junior doctors to teach medical students. While many studies have dealt with motivations of senior clinicians and specialists in their fields, there is no data on the reasons why the junior doctors teach. 161 junior clinicians teaching at our clinical school completed questionnaires (response rate 90%). Most tutors (41%) were interns (first year after graduation) and over half of them (55%) had completed a formal Teachers Training program. We found the main motivation to teach was to improve their own knowledge (80% strongly agreed) and enjoyment (72% strongly agreed). Other, less powerful motivating factors were: teaching would assist with their academic career (especially the more junior tutors); it was a duty to profession; result of inspiration by their own teachers or mentors; and because they felt responsible for the students. By developing an understanding of junior clinicians' motivation to teach, we may be able to promote a continued interest in teaching amongst both current and new junior medical staff.

Background : There is an expectation that interns can perform the core procedural skill of male catheterisation; however, it is unclear if our medical graduates are competent to do so, because there is no formal practical skills exit assessment in our current programme.Aim : We sought to investigate the level of experience, the self-reported confidence, and measured competency of our pre-intern (PRINT) students to perform the procedural skill of male catheterisation.Methods : We asked 100/147 (68%) PRINT students to complete a questionnaire to elucidate their experience and confidence prior to being practically assessed on a plastic manikin, using a faculty member validated 26-item checklist. Students were also invited to attend focus groups to help identify factors that had contributed to their practical performance.Results : Between 2010 and 2012, 100/147 (68%) PRINT students completed a questionnaire prior to being formatively assessed. The mean score for self-reported confidence was 78.3/100 (95% CI 74.8-81.8), and the mean performance score was 85.6/100 (95% CI 83.2-87.9); however, the correlation coefficient between the confidence score and performance score was weak (r = 0.18). Three focus groups were conducted, with a total of 12/100 (12%) students attending. Although students reported that they had sound knowledge of the skill, the lack of opportunity to perform the skill in the clinical setting had led to mediocre performance outcomes.Conclusion : We found no significant correlation among the level of experience, the self-reported ability and actual performance when students were assessed under direct observation.