[Show abstract][Hide abstract] ABSTRACT: The development and maintenance of students’ professional behaviour and attitude is of increasing importance in medical education. Unprofessional behaviour in doctors has the potential to jeopardise patient safety, compromise working relationships, and cause disruption and distress. The General Medical Council issues guidance to medical schools and students describing the standards that should be attained.
Nottingham University medical school introduced a ‘Concerns’ form in 2009, to create a standardised, transparent and defensible means of recording and handling complaints about adverse attitudes or behaviours. This paper reports an audit of the system over the first three years.
The routinely-held database was enhanced with further detail collected from relevant student records. The data were explored in terms of the types of complaint, students who were reported, the people who reported them, and the actions taken afterwards. The data were also mapped to the current GMC guidance.
189 valid forms were generated, relating to 143 students. The form was used by a wide variety of people, including clinical and non-clinical teachers, administrators, Hall Wardens, and fellow students. The concerns ranged from infringements of regulations to serious fitness to practise issues. Most were dealt with by faculty or pastoral care staff but some required escalation to formal hearings. The complaints were mapped successfully to GMC documentation, with the highest proportions relating to the GMC categories ‘Good Clinical Care’ and ‘Working with Colleagues’.
Male and ethnic minority students appeared to be more likely to have a Concern raised, but this is a tentative conclusion that requires a larger sample. Undergraduate (as opposed to Graduate Entry) students may also be at greater risk.
A simple form, freely available, but designed to prevent frivolous or malicious use, has provided valuable data on unprofessional behaviour and the responses elicited. Some parts of the form require improvements, and these are underway to provide more efficient use, audit and review in future.
Preview · Article · Sep 2014 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: Theory suggests that personality traits evolved to have costs and benefits, with the effectiveness of a trait dependent on how these costs and benefits relate to the present circumstances. This suggests that traits that are generally viewed as positive can have a 'dark side' and those generally viewed as negative can have a 'bright side' depending on changes in context. We test this in a sample of 220 UK medical students with respect to associations between the Big 5 personality traits and learning outcomes across the 5 years of a medical degree. The medical degree offers a changing learning context from pre-clinical years (where a more methodical approach to learning is needed) to the clinical years (where more flexible learning is needed, in a more stressful context). We argue that while trait conscientiousness should enhance pre-clinical learning, it has a 'dark side' reducing the acquisition of knowledge in the clinical years. We also suggest that anxiety has a 'bright side' enhancing the acquisition of skills in the clinical years. We also explore if intelligence enhances learning across the medical degree. Using confirmatory factor analysis and structural equation modelling we show that medical skills and knowledge assessed in the pre-clinical and clinical years are psychometrically distinguishable, forming a learning 'backbone', whereby subsequent learning outcomes are predicted by previous ones. Consistent with our predictions conscientiousness enhanced preclinical knowledge acquisition but reduced the acquisition of clinical knowledge and anxiety enhanced the acquisition of clinical skills. We also identified a curvilinear U shaped association between Surgency (extraversion) and pre-clinical knowledge acquisition. Intelligence predicted initial clinical knowledge, and had a positive total indirect effect on clinical knowledge and clinical skill acquisition. For medical selection, this suggests that selecting students high on conscientiousness may be problematic, as it may be excluding those with some degree of moderate anxiety.
[Show abstract][Hide abstract] ABSTRACT: Background
Students who fail to thrive on the Nottingham undergraduate medical course frequently suffer from anxiety, depression or other mental health problems. These difficulties may be the cause, or the result of, academic struggling. Early detection of vulnerable students might direct pastoral care and remedial support to where it is needed. We investigated the use of the short-form General Health Questionnaire (GHQ-12) as a possible screening tool.
Two consecutive cohorts (2006 and 2007) were invited to complete the GHQ-12. The questionnaire was administered online, during the second semester (after semester 1 exams) for the 2006 cohort and during the first semester for the 2007 cohort. All data were held securely and confidentially. At the end of the course, GHQ scores were examined in relation to course progress.
251 students entered the course in 2006 and 254 in 2007; 164 (65%) and 160 (63%), respectively, completed the GHQ-12. In both cohorts, the study and non-study groups were very similar in terms of pre-admission socio-demographic characteristics and overall course marks. In the 2006 study group, the GHQ Likert score obtained part-way through the first year was negatively correlated with exam marks during Years 1 and 2, but the average exam mark in semester 1 was the sole independent predictor of marks in semester 2 and Year 2. No correlations were found for the 2007 study group but the GHQ score was a weak positive predictor of marks in semester 2, with semester 1 average exam mark again being the strongest predictor. A post-hoc moderated-mediation analysis suggested that significant negative associations of GHQ scores with semester 1 and 2 exams applied only to those who completed the GHQ after their semester 1 exams. Students who were identified as GHQ ‘cases’ in the 2006 group were statistically less likely to complete the course on time (OR = 4.74, p 0.002). There was a non-significant trend in the same direction in the 2007 group.
Results from two cohorts provide insufficient evidence to recommend the routine use of the GHQ-12 as a screening tool. The timing of administration could have a critical influence on the results, and the theoretical and practical implications of this finding are discussed. Low marks in semester 1 examinations seem be the best single indicator of students at risk for subsequent poor performance.
Full-text · Article · Apr 2013 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: The UK Clinical Aptitude Test (UKCAT) was introduced in 2006 as an additional tool for the selection of medical students. It tests mental ability in four distinct domains (Verbal Reasoning, Quantitative Reasoning, Abstract Reasoning, and Decision Analysis), and the results are available to students and admission panels in advance of the selection process. Our first study showed little evidence of any predictive validity for performance in the first two years of the Nottingham undergraduate course.
The study objective was to determine whether the UKCAT scores had any predictive value for the later parts of the course, largely delivered via clinical placements.
Students entering the course in 2007 and who had taken the UKCAT were asked for permission to use their anonymised data in research. The UKCAT scores were incorporated into a database with routine pre-admission socio-demographics and subsequent course performance data. Correlation analysis was followed by hierarchical multivariate linear regression.
The original study group comprised 204/254 (80%) of the full entry cohort. With attrition over the five years of the course this fell to 185 (73%) by Year 5. The Verbal Reasoning score and the UKCAT Total score both demonstrated some univariate correlations with clinical knowledge marks, and slightly less with clinical skills. No parts of the UKCAT proved to be an independent predictor of clinical course marks, whereas prior attainment was a highly significant predictor (p <0.001).
This study of one cohort of Nottingham medical students showed that UKCAT scores at admission did not independently predict subsequent performance on the course. Whilst the test adds another dimension to the selection process, its fairness and validity in selecting promising students remains unproven, and requires wider investigation and debate by other schools.
Preview · Article · Feb 2013 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: Background
10-15% of students struggle at some point in their medicine course. Risk factors include weaker academic qualifications, male gender, mental illness, UK ethnic minority status, and poor study skills. Recent research on an undergraduate medicine course provided a toolkit to aid early identification of students likely to struggle, who can be targeted by established support and study interventions. The present study sought to extend this work by investigating the number and characteristics of strugglers on a graduate-entry medicine (GEM) programme.
A retrospective study of four GEM entry cohorts (2003–6) was carried out. All students who had demonstrated unsatisfactory progress or left prematurely were included. Any information about academic, administrative, personal, or social difficulties, were extracted from their course progress files into a customised database and examined.
362 students were admitted to the course, and 53 (14.6%) were identified for the study, of whom 15 (4.1%) did not complete the course. Students in the study group differed from the others in having a higher proportion of 2ii first degrees, and scoring less well on GAMSAT, an aptitude test used for admission. Within the study group, it proved possible to categorise students into the same groups previously reported (struggler throughout, pre-clinical struggler, clinical struggler, health-related struggler, borderline struggler) and to identify the majority using a number of flags for early difficulties. These flags included: missed attendance, unsatisfactory attitude or behaviour, health problems, social/family problems, failure to complete immunity status checks, and attendance at academic progress committee.
Problems encountered in a graduate-entry medicine course were comparable to those reported in a corresponding undergraduate programme. A toolkit of academic and non-academic flags of difficulty can be used for early identification of many who will struggle, and could be used to target appropriate support and interventions.
Full-text · Article · Dec 2012 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: As part of a wider study into students who experience difficulties, we examined the course files of those who had failed to graduate. This was an exploratory, descriptive study investigating how many students left after academic failure or non-academic problems, or simply changed their minds about reading medicine, and at what stage. The aim of the study was to increase our knowledge about the timings of, and reasons for, attrition. This understanding might help to reduce student loss in the future, by informing selection procedures and improving pastoral support at critical times. It might also assist in long-term workforce planning in the NHS.
Relevant data on admission and course progress were extracted manually from the archived files of students who had failed to graduate from five recent consecutive cohorts (entry in 2000-2004 inclusive), using a customised Access database. Discrete categories of information were supplemented with free text entries.
1188 students registered over the five-year entry period and 73 (6%) failed to graduate. The highest rates of attrition (46/1188, 4%) occurred during the first two years (largely preclinical studies), with 34 students leaving voluntarily, including 11 within the first semester, and 12 having their courses terminated for academic failure. Seventeen left at the end of the third year (Honours course plus early clinical practice) and the remaining ten during the final two clinical years. The reasons for attrition were not always clear-cut and often involved a mixture of academic, personal, social and health factors, especially mental health problems.
The causes of attrition are complex. A small number of students with clear academic failure might require individual educational interventions for remediation. However, this could have substantial resource implications for the Faculty. Mental health problems predominate in late course attrition and may have been undisclosed for some time. The introduction of a structured exit interview may provide further insight, especially for those students who leave suddenly and unexpectedly early in the course.
Preview · Article · Jun 2012 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: Widening access to medical school is a priority in medical selection. If disadvantaged students do not apply, interventions cannot be effective. To date, no studies have examined factors that predict who chooses to apply to medicine and if socio-demographics influence the profile of those who apply to study medicine.
A large database provided by the UK University and Colleges Admissions Service on all 1,225,156 applicants to UK universities over a 3-year period (2002-2004) was analysed. The relationship between demographics, preference to study medicine and academic performance prior to entry (A level score) were explored using logistic and linear regression and path modelling.
Those applying to study medicine were more likely to be female, non-white, of higher socio-economic status and from fee-paying schools. Applying to study medicine was associated with increased academic entrance performance over and above socio-demographic factors. Importantly, in those applying to study medicine socio-demographic inequalities in entrance exam performance was either reduced (for ethnicity and SES) or abolished (for sex and schooling).
It is argued that early interventions are needed to increase applications for certain groups to help to reduce socio-demographic inequalities in entrance exam performance and hence medical school admissions.
[Show abstract][Hide abstract] ABSTRACT: An earlier study at Nottingham suggested that 10-15% of the medical student intake was likely to fail completely or have substantial problems on the course. This is a problem for the students, the Faculty, and society as a whole. If struggling students could be identified early in the course and additional pastoral resources offered, some of this wastage might be avoided. An exploratory case study was conducted to determine whether there were common indicators in the early years, over and above academic failure, that might aid the identification of students potentially at risk.
The study group was drawn from five successive cohorts. Students who had experienced difficulties were identified in any of four ways: from Minutes of the Academic Progress Committee; by scanning examination lists at key stages (end of the first two years, and finals at the end of the clinical course); from lists of students flagged to the Postgraduate Deanery as in need of extra monitoring or support; and from progress files of those who had left the course prematurely. Relevant data were extracted from each student's course progress file into a customised database.
1188 students were admitted over the five years. 162 (14%) were identified for the study, 75 of whom had failed to complete the course by October 2010. In the 87 who did graduate, a combination of markers in Years 1 and 2 identified over half of those who would subsequently have the most severe problems throughout the course. This 'toolkit' comprised failure of 3 or more examinations per year, an overall average of <50%, health or social difficulties, failure to complete Hepatitis B vaccination on time, and remarks noted about poor attitude or behaviour.
A simple toolkit of academic and non-academic markers could be used routinely to help identify potential strugglers at an early stage, enabling additional support and guidance to be given to these students.
Preview · Article · Nov 2011 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: The UK Clinical Aptitude Test (UKCAT) was introduced in 2006 as an additional tool for the selection of medical students. It tests mental ability in four distinct domains (Quantitative Reasoning, Verbal Reasoning, Abstract Reasoning, and Decision Analysis), and the results are available to students and admissions panels in advance of the selection process. As yet the predictive validity of the test against course performance is largely unknown.The study objective was to determine whether UKCAT scores predict performance during the first two years of the 5-year undergraduate medical course at Nottingham.
We studied a single cohort of students, who entered Nottingham Medical School in October 2007 and had taken the UKCAT. We used linear regression analysis to identify independent predictors of marks for different parts of the 2-year preclinical course.
Data were available for 204/260 (78%) of the entry cohort. The UKCAT total score had little predictive value. Quantitative Reasoning was a significant independent predictor of course marks in Theme A ('The Cell'), (p = 0.005), and Verbal Reasoning predicted Theme C ('The Community') (p < 0.001), but otherwise the effects were slight or non-existent.
This limited study from a single entry cohort at one medical school suggests that the predictive value of the UKCAT, particularly the total score, is low. Section scores may predict success in specific types of course assessment.The ultimate test of validity will not be available for some years, when current cohorts of students graduate. However, if this test of mental ability does not predict preclinical performance, it is arguably less likely to predict the outcome in the clinical years. Further research from medical schools with different types of curriculum and assessment is needed, with longitudinal studies throughout the course.
Preview · Article · Jul 2010 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: To determine whether there are risk factors in a doctor's time at medical school that are associated with subsequent professional misconduct.
Matched case-control study. Setting Records from medical schools and the General Medical Council (GMC).
59 doctors who had graduated from any one of eight medical schools in the United Kingdom in 1958-97 and had a proved finding of serious professional misconduct in GMC proceedings in 1999-2004 (cases); 236 controls (four for each case) were selected by systematic sampling from matching graduation cohorts. Case-control status was revealed by the GMC after completion of data entry.
Odds ratios for being a "case," with multivariable conditional logistic regression of potential risk factors including pre-admission characteristics and progress during the course. These data were obtained from anonymised copies of the students' progress files held by their original medical schools.
Univariate conditional logistic regression analysis found that cases were more likely to be men, to be of lower estimated social class, and to have had academic difficulties during their medical course, especially in the early years. Multivariable analysis showed that male sex (odds ratio 9.80, 95% confidence interval 2.43 to 39.44, P=0.001), lower social class (4.28, 1.52 to 12.09, P=0.006), and failure of early or preclinical examinations (5.47, 2.17 to 13.79, P<0.001) were independently associated with being a case.
This small study suggests that male sex, a lower socioeconomic background, and early academic difficulties at medical school could be risk factors for subsequent professional misconduct. The findings are preliminary and should be interpreted with caution. Most doctors with risk factors will not come before the GMC's disciplinary panels.
[Show abstract][Hide abstract] ABSTRACT: To determine whether the UK Clinical Aptitude Test (UKCAT) adds value to the selection process for school leaver applicants to medical and dental school, and in particular whether UKCAT can reduce the socioeconomic bias known to affect A levels.
Applicants to 23 UK medical and dental schools in 2006.
9884 applicants who took the UKCAT in the UK and who achieved at least three passes at A level in their school leaving examinations (53% of all applicants).
Independent predictors of obtaining at least AAB at A level and UKCAT scores at or above the 30th centile for the cohort, for the subsections and the entire test.
Independent predictors of obtaining at least AAB at A level were white ethnicity (odds ratio 1.58, 95% confidence interval 1.41 to 1.77), professional or managerial background (1.39, 1.22 to 1.59), and independent or grammar schooling (2.26, 2.02 to 2.52) (all P<0.001). Independent predictors of achieving UKCAT scores at or above the 30th centile for the whole test were male sex (odd ratio 1.48, 1.32 to 1.66), white ethnicity (2.17, 1.94 to 2.43), professional or managerial background (1.34, 1.17 to 1.54), and independent or grammar schooling (1.91, 1.70 to 2.14) (all P<0.001). One major limitation of the study was that socioeconomic status was not volunteered by approximately 30% of the applicants. Those who withheld socioeconomic status data were significantly different from those who provided that information, which may have caused bias in the analysis.
UKCAT was introduced with a high expectation of increasing the diversity and fairness in selection for UK medical and dental schools. This study of a major subgroup of applicants in the first year of operation suggests that it has an inherent favourable bias to men and students from a higher socioeconomic class or independent or grammar schools. However, it does provide a reasonable proxy for A levels in the selection process.
[Show abstract][Hide abstract] ABSTRACT: At Nottingham University more than 95% of entrants to the traditional 5-year medical course are school leavers. Since 2003 we have admitted graduate entrants (GEM) to a shortened (4-year) course to 'widen access to students from more disadvantaged backgrounds'. We have recently shown that the GEM course widens academic and socio-demographic diversity of the medical student population. This study explored whether GEM students also bring psychological diversity and whether this could be beneficial.
We studied: a) 217 and 96 applicants to the Nottingham 5- and 4-year courses respectively, applying in the 2002-3 UCAS cycle, and, b) 246 school leavers starting the 5-year course and 39 graduate entrants to the 4-year course in October 2003. The psychological profiles of the two groups of applicants and two groups of entrants were compared using their performance in the Goldberg 'Big 5' Personality test, the Personal Qualities Assessment (PQA; measuring interpersonal traits and interpersonal values), and the Lovibond and Lovibond measure of depression, anxiety and stress. For the comparison of the Entrants we excluded the 33 school leavers and seven graduates who took the tests as Applicants.Statistical analyses were undertaken using SPSS software (version 16.0).
Graduate applicants compared to school leaver applicants were significantly more conscientious, more confident, more self controlled, more communitarian in moral orientation and less anxious. Only one of these differences was preserved in the entrants with graduates being less anxious. However, the graduate entrants were significantly less empathetic and conscientious than the school leavers.
This study has shown that school leaver and graduate entrants to medical school differ in some psychological characteristics. However, if confirmed in other studies and if they were manifest in the extreme, not all the traits brought by graduates would be desirable for someone aiming for a medical career.
Full-text · Article · Nov 2009 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: It has been suggested that studying non-science subjects at A-level should be compulsory for medical students. Our admissions criteria specify only Biology, Chemistry and one or more additional subjects. This study aimed to determine whether studying a non-science subject for A-level is an independent predictor of achievement on the undergraduate medical course.
The subjects of this retrospective cohort study were 164 students from one entry-year group (October 2000), who progressed normally on the 5-year undergraduate medical course at Nottingham. Pre-admission academic and socio-demographic data and undergraduate course marks were obtained. T-test and hierarchical multiple linear regression analyses were undertaken to identify independent predictors of five course outcomes at different stages throughout the course.
There was no evidence that the choice of science or non-science as the third or fourth A-level subject had any influence on course performance. Demographic variables (age group, sex, and fee status) had some predictive value but ethnicity did not. Pre-clinical course performance was the strongest predictor in the clinical phases (pre-clinical Themes A&B (knowledge) predicted Clinical Knowledge, p < 0.001, and pre-clinical Themes C&D (skills) predicted Clinical Skills, p = or< 0.01).
This study of one year group at Nottingham Medical School provided no evidence that the admissions policy on A-level requirements should specify the choice of third or fourth subject.
Preview · Article · Jan 2009 · BMC Medical Education
[Show abstract][Hide abstract] ABSTRACT: The undergraduate medical course is demanding. Each year, a small number of students 'struggle', for academic or other reasons. Recent studies at Nottingham reported anecdotal evidence that those who struggle disclose a much higher incidence of psychological distress than those who do not struggle.
The study aimed to assess whether a group of students with mental health problems were more likely to have a pre-admission history of similar problems.
Three year-cohorts of medical students were classified as struggling or not on the course, and whether they disclosed mental health problems during their course. The Nottingham Occupational Health Service carried out a confidential review of pre-admission health questionnaires.
Students who struggled on the course and disclosed mental health problems were more likely to have a relevant pre-admission history. One third of those with a positive history disclosed a further significant episode.
Existing pastoral care mechanisms may need to be enhanced in order to identify and support potentially vulnerable students.
[Show abstract][Hide abstract] ABSTRACT: This study aimed to examine whether a graduate entry course widens access to medicine.
We carried out a retrospective study at the University of Nottingham Medical School of socio-demographic and academic data collected by the Universities and Colleges Admission Service (UCAS). Study participants comprised all applicants to the 5-year (mainly school-leavers) and 4-year (graduates only) medical courses for admission in October 2003.
In 2002-03, there were 2392 applicants for the 5-year course and 1235 applicants for the 4-year course. Significantly, applicants for the 4-year course comprised more males, were more socio-economically deprived and had lower UCAS tariff point scores compared with applicants for the 5-year course. These differences were preserved in those students who eventually started on either of the 2 courses in October 2003 (254 and 94 students for the 5- and 4-year courses, respectively). Comparing entrants with non-entrants (mainly rejected students), those joining the 5-year course were younger, were less socio-economically deprived, were more likely to be White and had higher UCAS tariff point scores than non-entrants, but there were no significant gender differences. Those joining the 4-year course were more likely to be White and had higher UCAS tariff point scores than non-entrants. By contrast with entrants to the 5-year course, entrants to the 4-year course were significantly older than non-entrants.
Graduate entrants to medicine widen academic and socio-demographic diversity in the medical school student population.
Full-text · Article · Apr 2008 · Medical Education
[Show abstract][Hide abstract] ABSTRACT: To determine the risk factors for poor performance at different stages of the undergraduate medical course.
Longitudinal retrospective cohort study of progress on a 5-year undergraduate medical course.
The University of Nottingham medical school.
All students (594) who joined the course in 3 consecutive years were followed throughout their course until graduation, even if this was delayed.
Risk factors for poor performance varied at different stages on the course. Students with lower A levels were at increased risk throughout, but primarily in the pre-clinical course. Non-white ethnicity was also a risk factor, independent of domicile, but this was associated more strongly with lower marks on the clinical course. Males and those who received a later offer of a place were at some risk throughout the course. Overall attrition from the course was 5%, and 34/594 students (6%) spent more than the normal 5 years on the course.
School performance remains an important indicator of ability to cope with the pre-clinical course. Further research is required to understand why ethnic minority students may be more at risk at all stages, but particularly in the clinical course, and to increase their use of existing support services if necessary.
No preview · Article · Feb 2007 · Medical Education