Simulation
Reviving post-take surgical ward round teaching Jade Force, Ian Thomas and Frances Buckley, Raigmore Hospital, Inverness, UK
SUMMARY Background: Learning in the clinical environment is an important feature of medical education. Ward-round teaching leads to relevant, applied and lasting learning of knowledge, skills and attitudes; however, on fast-paced ward rounds in specialties such as general surgery, the student experience is often suboptimal, and teaching can be overlooked. Clinical teaching fellows (CTFs) are postgraduate doctors ranging from foundation year-2 (FY2) level through to specialty trainees, who have elected to spend up to 2 years out of the programme to teach medical undergraduates. This article
explores whether CTFs can successfully support the regular delivery of undergraduate medical teaching on the busy post-take surgical ward round (PTSWR). Methods: The CTFs at Raigmore Hospital, Inverness, planned and facilitated weekly, structured teaching sessions to accompany the PTSWR. This educational intervention was evaluated using pre- and post-intervention student questionnaires. The questionnaires focused on student enjoyment and depth of learning using Likert scales and free-text components. Students were also asked about barriers to learning on typical PTSWRs. The consultant surgeons leading on these rounds were issued separate
questionnaires, to gauge their evaluation of CTF support. Results: The main barrier to effective undergraduate ward round teaching was a lack of time on the part of clinical staff. Ward rounds accompanied by CTF support significantly increased student enjoyment (p < 0.0001) and perceived learning (p < 0.0001). Consultant surgeons were supportive of the teaching initiative. Discussion: Support from CTFs on busy PTSWRs optimised student satisfaction, and was welcomed by clinical staff. CTF support could be widened to other busy ward rounds, e.g. acute medical takes, to enhance student learning and reduce the teaching burden on clinical faculty staff.
Learning in the clinical environment is an important feature of medical education
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 109–115 109
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Ward-round teaching seems to have lost its sense of purpose
INTRODUCTION
W
ard-round teaching is a key part of delivering undergraduate medical training. It models professionalism, highlights the complexity of patient care and facilitates the acquisition of facts and practical skills.1,2 In this rich clinical setting students can apply their knowledge and learn skills and attitudes most effectively.3
Despite its educational benefits, ward-round teaching seems to have lost its sense of purpose. The reduction in working hours, as a result of the European Working Time Directive (EWTD), has resulted in fewer clinicians on the ground to deliver teaching.4 A recent study by Claridge estimated that the learning achieved by postgraduate doctors on ward rounds has fallen from 58 to 18 per cent since the introduction of the EWTD.5 It is in the busy post-receiving ward rounds that education appears to have suffered the most: fatigued clinicians have little time to spare, and teaching on the post-take ward round is in decline.6 Looking for ways to improve ward round teaching is essential. Kimble and Behar trialled a novel ward-round teaching tool with junior surgical team members.7 Following each round a junior doctor was allocated a casebased topic to research and present, engaging the clinical team with educational opportunities from the round. Much of the literature on ward-round teaching innovations has come from the postgraduate domain, and there is currently little evidence on how to improve the educational experience of the ward round for undergraduates. Clinical teaching fellows (CTFs) may be able to help support undergraduate teaching on ward rounds. CTFs are clinical trainees from a variety of specialties who can take up to
2 years out of their training programme to develop their interest in teaching. Their primary role is to teach, support and develop the medical undergraduate curriculum, but they also remain engaged in regular clinical duties. CTF posts are funded by the affiliate university and are increasing in popularity, yet there is little in the published literature about their educational impact. Aims of the study To assess if clinical teaching fellows can successfully support medical undergraduate teaching on a busy post-take surgical ward round (PTSWR). Objectives 1. To identify perceived barriers to undergraduate teaching on the PTSWR from the
perspectives of both medical students and surgical consultants. 2. To initiate weekly CTFsupported PTSWRs. 3. To evaluate the impact of CTF support on PTSWR for medical students. 4. To evaluate consultant perceptions of CTF-supported ward rounds.
METHODS Context This study took place at Raigmore Hospital: a district general hospital in Inverness, UK. The surgical department admits approximately 15 acute patients per 24-hour period. The medical personnel on a typical PTSWR are a single surgical consultant, a registrar and a foundation year-1 (FY1) doctor.
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Monday: Communicate teaching to students Email student to inform of CTF presence on PSWR and encourage a endance.
Friday:
Thursday: Prepara on for ward round teaching CTF aƩends surgical receiving ward in the evening and familiarises themselves with all new admissions. CTF iden fies theme for the week based on available acute pa ents. For example, upper abdominal pain, urological emergencies. CTF consents 2-3 pa ents within that theme for the medical students to take a history from and examine. (preferably with classic histories and iden fiable signs). CTF reviews the notes and invesƟgaƟon (blood & radiology results) of consented pa ents in readiness for teaching. FY2 teaching fellow able to clarify any queries regarding content with surgical teaching fellow ahead of the session to ensure accuracy of teaching.
Weekly Post-take surgical ward round teaching
Students identified three barriers to PTSWR teaching
CTF and medical students join the PTSWR for aproximately 30-45 minutes. Opportunity for students to observe a range of acute surgical pathology and decision making. CTF on hand during the ward round to answer student quesƟons and facilitate end of bed discussions with students. Students 'break away' from PTSWR and sent to assess pre-idenƟfied paƟents of the week's theme. Students report back to whole group on the pa ents that they have assessed. CTF facilitates session. Specific focus on: 1. Ge ng students to present clerkings in a coherent and concise fashion. 2. Discussing possible differen al diagnoses. 3. Discussing the inves ga ons and management plan that the students would ins gate were they the admi ng junior doctor. 4. Reviewing and discussing the inves ga ons that the pa ent has actually undergone since admission.
Figure 1. Teaching model adopted for post-take surgical ward round teaching Notes: • It is important that each week the CTF identifies a different theme. In this way a broad range of surgical pathology can be taught to the students over the 5-week attachment • On the final week of the block the CTF will undertake an assessment quiz with the students to evaluate what they have learned over the past 5 weeks. A ‘Jeopardy’ quiz is utilised and is described in Figure 2
Pre-intervention In each 5-week general surgery block there are five fourth-year medical students. Students were expected to attend several PTSWRs every week. The feedback from the student clinical evaluation forms (SCEFs) regarding the teaching on these rounds had been consistently suboptimal. Intervention In January 2012 CTFs introduced regular, planned and structured teaching support for fourth-year medical students attending the PTSWR. Once a week, a single CTF would accompany the round [either an FY2 doctor or a specialty trainee (ST4) with a background
in general surgery]. The CTFs were available to provide teaching both during the ward round and afterwards, as outlined in Figure 1, which gives an overview of the teaching model that was adopted. Two important features of the PTSWR are outlined below. 1. Joining the PTSWR: this enables students to see a range of acute surgical pathologies and the management decisions being made. The CTFs were on hand to answer student queries and engage in end-of-bed discussions.
2. Structured discussion: students also break away from the ward round to see preselected patients that fit with the week’s ‘theme’. The students then present to the whole group, with the discussion led by the CTF. This part of the session focuses on what the student would do if they were the admitting junior doctor. The questionnaire The study ran from January 2012 to August 2012, equating to 25 PTSWR sessions with CTF support. Pre- and post-intervention questionnaires (Appendices S1 and S2) were issued to all 25
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Surgeons lacking time was the main barrier to teaching
Figure 2. Using a ‘Jeopardy’-style assessment quiz
medical students who had undertaken surgical blocks during this time period. The questionnaires were anonymous and designed by the CTFs. The questionnaires contained Likert-scale (0–10) questions to assess learning and enjoyment, and free-text sections for students to describe barriers to teaching or to suggest positive and negative aspects of CTF-supported ward rounds. Differences in subjective student learning and enjoyment pre- and post-intervention were analysed using GraphPad, with p < 0.05 taken as the degree of significance. All 10 surgical consultants involved in leading PTSWRs during the study period were issued with separate anonymous questionnaires (Appendix S3). The questionnaire contained a mixture of tick-box answers and free-text responses. The questions addressed whether surgeons felt that the PTWR was a useful learning opportunity for students, whether they felt barriers to teaching existed on such ward
rounds and their appraisal of CTF support. Qualitative data pertaining to perceived barriers to ward round teaching were coded into six emergent themes for analysis. These themes were weighted using the frequencies with which they appeared in the questionnaire.
RESULTS A total of 18 out of 25 (72%) medical students returned preintervention questionnaires, compared with 24 students (96%) who returned post-intervention questionnaires. Five of 10 consultant surgeons (50%) returned their questionnaires. Barriers to PTSWR teaching Students identified three barriers to PTSWR teaching: surgeons not having enough time to teach, being unapproachable or conducting the rounds at too fast a pace. Consultant surgeons identified with some of the student themes, but also commented on overcrowding during ward rounds, background noise
and lack of student enthusiasm as additional barriers. Both students and consultants (83 and 100%, respectively) agreed that surgeons lacking time was the main barrier to teaching (Figure 3). Student assessment of PTSWR teaching The mean student enjoyment scores for standard versus CTFsupported ward rounds were 4.44 and 9.46, respectively. Students enjoyed CTF-supported ward rounds significantly more than standard rounds (p < 0.0001). Students felt that they learned more on the CTF-supported ward rounds, with mean scores of 4.06 and 9.63, respectively. This was a significant difference (p < 0.0001) (Figures 4 and 5). Emergent themes from student feedback were the importance of the CTF in providing a nonthreatening contact on the ward round and the worth of discussing differential diagnoses and management plans from the
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Perceived barriers to teaching on a surgical ward round
viewpoint of an FY1 doctor (Figure 6).
100
90
80
70
Responses (%)
60
50
Students Surgeons
40
30
20
Consultant assessment of PTSWR teaching All consultant surgeons agreed that the PTSWR offered good learning opportunities for medical undergraduates and felt that CTF support had been useful. All consultants felt that a CTFsupported ward round should be offered at least once per week in the department.
Detailed organisation contributed to the success of the teaching
10
DISCUSSION
0 Crowded
Noisy
Surgeons don't have enough time
Students unenthusiastic
Surgeons unapproachable
Fast paced
Figure 3. Perceived barriers to post-take surgical ward round (PTSWR) teaching according to medical students and consultant surgeons How do students rate their enjoyment of the surgical PTWR pre- and post-teaching fellow support? 16
14
Number of students
12
10
8
6
How much students enjoy the PTSWR without teaching fellow input
4
2
How much students enjoy the PTSWR with teaching fellow input
0 1
2
3
4
5 6 7 Score (Likert scale 0-10)
8
9
10
Figure 4. Student enjoyment of post-take surgical ward round (PTSWR) before and after the intervention How do students rate their learning on the PTSWR pre- and post- teaching fellow support? 20
18
16
14
Number of students
The main barrier to teaching identified by both students and consultants was the surgeon’s lack of time. This is understandable, as PTSWRs begin at 0800 h and commonly cover between 15 and 30 patients. Emergency operating lists commence at 0845 h. These time constraints could also explain the poor questionnaire return rate from consultant surgeons.
12
How students rate their learning on the PTSWR without teaching fellow input
10
How students rate their learning on the PTSWR with teaching fellow input
8
6
4
2
0 1
2
3
4
5 6 7 Score (Likert scale 0-10)
8
9
10
Figure 5. Student learning post-take surgical ward round (PTSWR) before and after the intervention
Our results correlate closely with findings from the postgraduate literature. Claridge found that 79 per cent of FY1 doctors thought time constraints were the major obstacle to being taught on ward rounds, and that environmental factors (e.g. noise) were also significant barriers.5 Spencer identified the opportunistic nature of clinical teaching as a major barrier to its success.8 Our CTF-supported ward rounds were deliberately structured with different themes each week to maximise the pathology taught. Detailed organisation contributed to the success of the teaching; this is also seen in the structured clinical teaching described by Raupach.1 A drawback of the study is that we report Kilpatrick level-1 data (reaction evaluations) on student enjoyment and perceived learning.9 Although we appreciate that such results may
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The results of this study are generalisable to other busy rounds
Posi ve comments
Nega ve comments
It was useful going back a er the ward round to see pa ents with interes ng stories and having the opportunity to discuss Having someone to point out what is happening on the ward round is really helpful Excellent teaching I was able to present acute surgical cases in a low -stress environment One of the teaching sessions went on for over 2 hours which was too long It is great seeing pa ents and discussing findings
there are six teaching fellows, and this is mirrored in deaneries throughout the UK. Supporting ward rounds with CTFs may be a useful deployment of CTF resources in institutions where they are available. Importantly, the results of this study are generalisable to other busy rounds, such as the acute medical take, and we emphasise that looking for ways to structure regular teaching can maximise learning on ward rounds.
I liked going through the blood results and inves ga ons properly
CONCLUSION
Really useful to break down cases and go through history, diagnosis and management, including simple things like prescribing fluids Having a teaching fell ow ask me ques ons at the end of the bed during the ward round made me concentrate on what was happening far more, rather than dri ing off Some mes the ward rounds got a bit crowded with lots of medical students coming to the teaching, which made it difficult for me to ask ques ons It was especially useful to think about what I would do next if I was the FY1 doctor managing a pa ent
Ward-round teaching is a useful education tool that is often challenged by the burdens of the clinical environment. CTFs can facilitate undergraduate learning on ward rounds to help overcome many of the barriers to effective learning in the workplace.
Such a useful piece of teaching to consolidate what I have learned during the week. The Jeopardy quiz was good to consolidate knowledge Immediate feedback on examina on and treatment plans. I feel safe, every session is organised and useful Great to chat to a pa ent then talk it through in detail with the teaching fellows, helped me understand and form a differen al diagnosis. Learned so much more than on a normal ward round. Good to complement other teaching at end of week. Great idea! More me for explana ons. Useful talking through inves ga ons and management
REFERENCES 1.
Raupach T, Ander S, Pukrop T, Hasenfuss G, Harendza S. Effects of “minimally invasive curricular surgery” – a pilot intervention study to improve the quality of bedside teaching in medical education. Med Teach 2009;31:425–430.
2.
Ker J, Cantillon P, Ambrose L. Teaching on a ward round. BMJ 2009;338:770–772.
3.
Ruesseler M, Obertacke U. Teaching in daily clinical practice: how to teach in a clinical setting. Eur J Trauma Emerg Surg 2011;37:313–316.
4.
British Medical Association. Time’s up 1 August 2004: a guide on the EWTD for junior doctors. London: British Medical Association; 2004.
5.
Claridge A. What is the educational value of ward rounds? A learner and teacher perspective. Clin Med 2011;11:558–562.
6.
Dewhurst G. Time for change: teaching and learning on busy post-take ward rounds. Clin Med 2010;10:231–234.
7.
Kimble A, Behar N. Work-based learning in a surgical wardround setting. Clin Teach 2009; 6:229–232.
8.
Spencer J. Learning and teaching in the clinical environment. BMJ 2003;326:591–594.
Teaching is so much more useful, as condi ons are explained and we had me to work out care. I feel we learned a lot more this way. It felt less threatening having a teaching fellow to ask on the round. I would like lots more of these sessions if possible
Figure 6. All positive and negative student comments regarding support from clinical teaching fellows (CTFs) on post-take surgical ward rounds (PTSWRs)
not extrapolate to higher levels of future student attainment, our results have been positive and worthy of reporting. In addition, as one student reasonably reflected, with CTF support there were sometimes too many people on the SPTWR. We are therefore considering expanding the teaching to twice-weekly, with a cap of two
or three students attending each session. The use of CTFs to support teaching is a considerable resource in terms of time and money, with the cost of a CTF being around £30 000 per annum; however, CTF posts are becoming increasingly popular. In the North of Scotland Deanery
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9.
Kilpatrick DL. Evaluating Training Programmes: The four levels. San Francisco: Berrett-Koehler.
SUPPORTING INFORMATION Additional supporting information may be found in the
online version of this article at http://onlinelibrary.wiley.com/ doi/10.1111/tct.12071/ suppinfo Appendix S1. Pre-intervention questionnaire issued to the medical students.
Appendix S2. Post-intervention questionnaire issued to the medical students. Appendix S3. Feedback questionnaires on ward round teaching issued to consultants.
Ward-round teaching is a useful education tool
Corresponding author’s contact details: Dr Jade Force, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ, UK. E-mail: jadeforce1@gmail. com
Funding: None to declare. Conflict of interest: None to declare. Ethical approval: The chair of the University of Aberdeen’s College Ethics Review Board considered this work and made the following comments: ‘The intention was to evaluate a local innovation designed to improve the local delivery of teaching; I can confirm that, in my opinion, such an exercise would not require approval by the CERB.’ doi: 10.1111/tct.12071
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Reviving post-take surgical ward round teaching Jade Force, Ian Thomas and Frances Buckley, Raigmore Hospital, Inverness, UK
SUMMARY Background: Learning in the clinical environment is an important feature of medical education. Ward-round teaching leads to relevant, applied and lasting learning of knowledge, skills and attitudes; however, on fast-paced ward rounds in specialties such as general surgery, the student experience is often suboptimal, and teaching can be overlooked. Clinical teaching fellows (CTFs) are postgraduate doctors ranging from foundation year-2 (FY2) level through to specialty trainees, who have elected to spend up to 2 years out of the programme to teach medical undergraduates. This article
explores whether CTFs can successfully support the regular delivery of undergraduate medical teaching on the busy post-take surgical ward round (PTSWR). Methods: The CTFs at Raigmore Hospital, Inverness, planned and facilitated weekly, structured teaching sessions to accompany the PTSWR. This educational intervention was evaluated using pre- and post-intervention student questionnaires. The questionnaires focused on student enjoyment and depth of learning using Likert scales and free-text components. Students were also asked about barriers to learning on typical PTSWRs. The consultant surgeons leading on these rounds were issued separate
questionnaires, to gauge their evaluation of CTF support. Results: The main barrier to effective undergraduate ward round teaching was a lack of time on the part of clinical staff. Ward rounds accompanied by CTF support significantly increased student enjoyment (p < 0.0001) and perceived learning (p < 0.0001). Consultant surgeons were supportive of the teaching initiative. Discussion: Support from CTFs on busy PTSWRs optimised student satisfaction, and was welcomed by clinical staff. CTF support could be widened to other busy ward rounds, e.g. acute medical takes, to enhance student learning and reduce the teaching burden on clinical faculty staff.
Learning in the clinical environment is an important feature of medical education
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 109–115 109
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Ward-round teaching seems to have lost its sense of purpose
INTRODUCTION
W
ard-round teaching is a key part of delivering undergraduate medical training. It models professionalism, highlights the complexity of patient care and facilitates the acquisition of facts and practical skills.1,2 In this rich clinical setting students can apply their knowledge and learn skills and attitudes most effectively.3
Despite its educational benefits, ward-round teaching seems to have lost its sense of purpose. The reduction in working hours, as a result of the European Working Time Directive (EWTD), has resulted in fewer clinicians on the ground to deliver teaching.4 A recent study by Claridge estimated that the learning achieved by postgraduate doctors on ward rounds has fallen from 58 to 18 per cent since the introduction of the EWTD.5 It is in the busy post-receiving ward rounds that education appears to have suffered the most: fatigued clinicians have little time to spare, and teaching on the post-take ward round is in decline.6 Looking for ways to improve ward round teaching is essential. Kimble and Behar trialled a novel ward-round teaching tool with junior surgical team members.7 Following each round a junior doctor was allocated a casebased topic to research and present, engaging the clinical team with educational opportunities from the round. Much of the literature on ward-round teaching innovations has come from the postgraduate domain, and there is currently little evidence on how to improve the educational experience of the ward round for undergraduates. Clinical teaching fellows (CTFs) may be able to help support undergraduate teaching on ward rounds. CTFs are clinical trainees from a variety of specialties who can take up to
2 years out of their training programme to develop their interest in teaching. Their primary role is to teach, support and develop the medical undergraduate curriculum, but they also remain engaged in regular clinical duties. CTF posts are funded by the affiliate university and are increasing in popularity, yet there is little in the published literature about their educational impact. Aims of the study To assess if clinical teaching fellows can successfully support medical undergraduate teaching on a busy post-take surgical ward round (PTSWR). Objectives 1. To identify perceived barriers to undergraduate teaching on the PTSWR from the
perspectives of both medical students and surgical consultants. 2. To initiate weekly CTFsupported PTSWRs. 3. To evaluate the impact of CTF support on PTSWR for medical students. 4. To evaluate consultant perceptions of CTF-supported ward rounds.
METHODS Context This study took place at Raigmore Hospital: a district general hospital in Inverness, UK. The surgical department admits approximately 15 acute patients per 24-hour period. The medical personnel on a typical PTSWR are a single surgical consultant, a registrar and a foundation year-1 (FY1) doctor.
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Monday: Communicate teaching to students Email student to inform of CTF presence on PSWR and encourage a endance.
Friday:
Thursday: Prepara on for ward round teaching CTF aƩends surgical receiving ward in the evening and familiarises themselves with all new admissions. CTF iden fies theme for the week based on available acute pa ents. For example, upper abdominal pain, urological emergencies. CTF consents 2-3 pa ents within that theme for the medical students to take a history from and examine. (preferably with classic histories and iden fiable signs). CTF reviews the notes and invesƟgaƟon (blood & radiology results) of consented pa ents in readiness for teaching. FY2 teaching fellow able to clarify any queries regarding content with surgical teaching fellow ahead of the session to ensure accuracy of teaching.
Weekly Post-take surgical ward round teaching
Students identified three barriers to PTSWR teaching
CTF and medical students join the PTSWR for aproximately 30-45 minutes. Opportunity for students to observe a range of acute surgical pathology and decision making. CTF on hand during the ward round to answer student quesƟons and facilitate end of bed discussions with students. Students 'break away' from PTSWR and sent to assess pre-idenƟfied paƟents of the week's theme. Students report back to whole group on the pa ents that they have assessed. CTF facilitates session. Specific focus on: 1. Ge ng students to present clerkings in a coherent and concise fashion. 2. Discussing possible differen al diagnoses. 3. Discussing the inves ga ons and management plan that the students would ins gate were they the admi ng junior doctor. 4. Reviewing and discussing the inves ga ons that the pa ent has actually undergone since admission.
Figure 1. Teaching model adopted for post-take surgical ward round teaching Notes: • It is important that each week the CTF identifies a different theme. In this way a broad range of surgical pathology can be taught to the students over the 5-week attachment • On the final week of the block the CTF will undertake an assessment quiz with the students to evaluate what they have learned over the past 5 weeks. A ‘Jeopardy’ quiz is utilised and is described in Figure 2
Pre-intervention In each 5-week general surgery block there are five fourth-year medical students. Students were expected to attend several PTSWRs every week. The feedback from the student clinical evaluation forms (SCEFs) regarding the teaching on these rounds had been consistently suboptimal. Intervention In January 2012 CTFs introduced regular, planned and structured teaching support for fourth-year medical students attending the PTSWR. Once a week, a single CTF would accompany the round [either an FY2 doctor or a specialty trainee (ST4) with a background
in general surgery]. The CTFs were available to provide teaching both during the ward round and afterwards, as outlined in Figure 1, which gives an overview of the teaching model that was adopted. Two important features of the PTSWR are outlined below. 1. Joining the PTSWR: this enables students to see a range of acute surgical pathologies and the management decisions being made. The CTFs were on hand to answer student queries and engage in end-of-bed discussions.
2. Structured discussion: students also break away from the ward round to see preselected patients that fit with the week’s ‘theme’. The students then present to the whole group, with the discussion led by the CTF. This part of the session focuses on what the student would do if they were the admitting junior doctor. The questionnaire The study ran from January 2012 to August 2012, equating to 25 PTSWR sessions with CTF support. Pre- and post-intervention questionnaires (Appendices S1 and S2) were issued to all 25
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 109–115 111
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Surgeons lacking time was the main barrier to teaching
Figure 2. Using a ‘Jeopardy’-style assessment quiz
medical students who had undertaken surgical blocks during this time period. The questionnaires were anonymous and designed by the CTFs. The questionnaires contained Likert-scale (0–10) questions to assess learning and enjoyment, and free-text sections for students to describe barriers to teaching or to suggest positive and negative aspects of CTF-supported ward rounds. Differences in subjective student learning and enjoyment pre- and post-intervention were analysed using GraphPad, with p < 0.05 taken as the degree of significance. All 10 surgical consultants involved in leading PTSWRs during the study period were issued with separate anonymous questionnaires (Appendix S3). The questionnaire contained a mixture of tick-box answers and free-text responses. The questions addressed whether surgeons felt that the PTWR was a useful learning opportunity for students, whether they felt barriers to teaching existed on such ward
rounds and their appraisal of CTF support. Qualitative data pertaining to perceived barriers to ward round teaching were coded into six emergent themes for analysis. These themes were weighted using the frequencies with which they appeared in the questionnaire.
RESULTS A total of 18 out of 25 (72%) medical students returned preintervention questionnaires, compared with 24 students (96%) who returned post-intervention questionnaires. Five of 10 consultant surgeons (50%) returned their questionnaires. Barriers to PTSWR teaching Students identified three barriers to PTSWR teaching: surgeons not having enough time to teach, being unapproachable or conducting the rounds at too fast a pace. Consultant surgeons identified with some of the student themes, but also commented on overcrowding during ward rounds, background noise
and lack of student enthusiasm as additional barriers. Both students and consultants (83 and 100%, respectively) agreed that surgeons lacking time was the main barrier to teaching (Figure 3). Student assessment of PTSWR teaching The mean student enjoyment scores for standard versus CTFsupported ward rounds were 4.44 and 9.46, respectively. Students enjoyed CTF-supported ward rounds significantly more than standard rounds (p < 0.0001). Students felt that they learned more on the CTF-supported ward rounds, with mean scores of 4.06 and 9.63, respectively. This was a significant difference (p < 0.0001) (Figures 4 and 5). Emergent themes from student feedback were the importance of the CTF in providing a nonthreatening contact on the ward round and the worth of discussing differential diagnoses and management plans from the
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Perceived barriers to teaching on a surgical ward round
viewpoint of an FY1 doctor (Figure 6).
100
90
80
70
Responses (%)
60
50
Students Surgeons
40
30
20
Consultant assessment of PTSWR teaching All consultant surgeons agreed that the PTSWR offered good learning opportunities for medical undergraduates and felt that CTF support had been useful. All consultants felt that a CTFsupported ward round should be offered at least once per week in the department.
Detailed organisation contributed to the success of the teaching
10
DISCUSSION
0 Crowded
Noisy
Surgeons don't have enough time
Students unenthusiastic
Surgeons unapproachable
Fast paced
Figure 3. Perceived barriers to post-take surgical ward round (PTSWR) teaching according to medical students and consultant surgeons How do students rate their enjoyment of the surgical PTWR pre- and post-teaching fellow support? 16
14
Number of students
12
10
8
6
How much students enjoy the PTSWR without teaching fellow input
4
2
How much students enjoy the PTSWR with teaching fellow input
0 1
2
3
4
5 6 7 Score (Likert scale 0-10)
8
9
10
Figure 4. Student enjoyment of post-take surgical ward round (PTSWR) before and after the intervention How do students rate their learning on the PTSWR pre- and post- teaching fellow support? 20
18
16
14
Number of students
The main barrier to teaching identified by both students and consultants was the surgeon’s lack of time. This is understandable, as PTSWRs begin at 0800 h and commonly cover between 15 and 30 patients. Emergency operating lists commence at 0845 h. These time constraints could also explain the poor questionnaire return rate from consultant surgeons.
12
How students rate their learning on the PTSWR without teaching fellow input
10
How students rate their learning on the PTSWR with teaching fellow input
8
6
4
2
0 1
2
3
4
5 6 7 Score (Likert scale 0-10)
8
9
10
Figure 5. Student learning post-take surgical ward round (PTSWR) before and after the intervention
Our results correlate closely with findings from the postgraduate literature. Claridge found that 79 per cent of FY1 doctors thought time constraints were the major obstacle to being taught on ward rounds, and that environmental factors (e.g. noise) were also significant barriers.5 Spencer identified the opportunistic nature of clinical teaching as a major barrier to its success.8 Our CTF-supported ward rounds were deliberately structured with different themes each week to maximise the pathology taught. Detailed organisation contributed to the success of the teaching; this is also seen in the structured clinical teaching described by Raupach.1 A drawback of the study is that we report Kilpatrick level-1 data (reaction evaluations) on student enjoyment and perceived learning.9 Although we appreciate that such results may
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 109–115 113
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The results of this study are generalisable to other busy rounds
Posi ve comments
Nega ve comments
It was useful going back a er the ward round to see pa ents with interes ng stories and having the opportunity to discuss Having someone to point out what is happening on the ward round is really helpful Excellent teaching I was able to present acute surgical cases in a low -stress environment One of the teaching sessions went on for over 2 hours which was too long It is great seeing pa ents and discussing findings
there are six teaching fellows, and this is mirrored in deaneries throughout the UK. Supporting ward rounds with CTFs may be a useful deployment of CTF resources in institutions where they are available. Importantly, the results of this study are generalisable to other busy rounds, such as the acute medical take, and we emphasise that looking for ways to structure regular teaching can maximise learning on ward rounds.
I liked going through the blood results and inves ga ons properly
CONCLUSION
Really useful to break down cases and go through history, diagnosis and management, including simple things like prescribing fluids Having a teaching fell ow ask me ques ons at the end of the bed during the ward round made me concentrate on what was happening far more, rather than dri ing off Some mes the ward rounds got a bit crowded with lots of medical students coming to the teaching, which made it difficult for me to ask ques ons It was especially useful to think about what I would do next if I was the FY1 doctor managing a pa ent
Ward-round teaching is a useful education tool that is often challenged by the burdens of the clinical environment. CTFs can facilitate undergraduate learning on ward rounds to help overcome many of the barriers to effective learning in the workplace.
Such a useful piece of teaching to consolidate what I have learned during the week. The Jeopardy quiz was good to consolidate knowledge Immediate feedback on examina on and treatment plans. I feel safe, every session is organised and useful Great to chat to a pa ent then talk it through in detail with the teaching fellows, helped me understand and form a differen al diagnosis. Learned so much more than on a normal ward round. Good to complement other teaching at end of week. Great idea! More me for explana ons. Useful talking through inves ga ons and management
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Teaching is so much more useful, as condi ons are explained and we had me to work out care. I feel we learned a lot more this way. It felt less threatening having a teaching fellow to ask on the round. I would like lots more of these sessions if possible
Figure 6. All positive and negative student comments regarding support from clinical teaching fellows (CTFs) on post-take surgical ward rounds (PTSWRs)
not extrapolate to higher levels of future student attainment, our results have been positive and worthy of reporting. In addition, as one student reasonably reflected, with CTF support there were sometimes too many people on the SPTWR. We are therefore considering expanding the teaching to twice-weekly, with a cap of two
or three students attending each session. The use of CTFs to support teaching is a considerable resource in terms of time and money, with the cost of a CTF being around £30 000 per annum; however, CTF posts are becoming increasingly popular. In the North of Scotland Deanery
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SUPPORTING INFORMATION Additional supporting information may be found in the
online version of this article at http://onlinelibrary.wiley.com/ doi/10.1111/tct.12071/ suppinfo Appendix S1. Pre-intervention questionnaire issued to the medical students.
Appendix S2. Post-intervention questionnaire issued to the medical students. Appendix S3. Feedback questionnaires on ward round teaching issued to consultants.
Ward-round teaching is a useful education tool
Corresponding author’s contact details: Dr Jade Force, Raigmore Hospital, Old Perth Road, Inverness, IV2 3UJ, UK. E-mail: jadeforce1@gmail. com
Funding: None to declare. Conflict of interest: None to declare. Ethical approval: The chair of the University of Aberdeen’s College Ethics Review Board considered this work and made the following comments: ‘The intention was to evaluate a local innovation designed to improve the local delivery of teaching; I can confirm that, in my opinion, such an exercise would not require approval by the CERB.’ doi: 10.1111/tct.12071
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