Volume 5, Issue 1 , Pages 4-10, January 2012
Medical students’ exposure to Urology in the undergraduate curriculum, a web based survey
Article Outline
- Summary
- Introduction
- Materials and methods
- Results
- Discussion
- Conclusions
- Conflict of interest
- Acknowledgements
- Appendix 1.
- References
- Copyright
Summary
Objective
Urological knowledge and skills are lacking in junior doctors and Urology is undersubscribed for specialist training. Lack of exposure as undergraduates may be responsible. We aimed to assess Urology exposure, confidence about managing common conditions and career prospects, in current UK medical students.
Methods
All UK medical schools were contacted. Final year students were asked to complete an online survey about Urology.
Results
610 responses were received. Only 42% of respondents had a compulsory clinical attachment in Urology, lasting on average 1 week. 46% had compulsory attachments partially based in Urology, mainly with other surgical specialities. Common urological activities had been attended by >50% of respondents, however 6% had not attended any. Over 80% of respondents received teaching on common Urology topics except for urological emergencies (62%). Lectures and anatomy sessions were the main teaching methods. 87% of teaching was from Urologists. Most respondents felt ‘confident’ managing common urological problems, but 32% felt ‘not very confident’ with urological emergencies. Only 14% of respondents would consider a career in Urology.
Conclusion
Urology experience is not compulsory in UK medical schools and is variable. Final year students lack confidence managing urological emergencies and have limited interest in Urology as a career. Development of a Urology undergraduate curriculum should help address these issues.
Abbreviations: BAUS, British Association of Urological Surgeons, CV, Curriculum Vitae, EWTD, Early Working Time Directive, FY1, Foundation Year One Doctor, GMC, General Medical Council, GP, General Practice, JCST, Joint Committee on Surgical Training, MDT, Multi-disciplinary team, ST, Speciality Training, TRUS, Trans-rectal ultrasonography, UK, United Kingdom, US, United States
Keywords: Undergraduate education, Urological emergencies, Junior doctors, Specialist training, Career guidance
Introduction
The Urology teaching that undergraduates receive is variable. Regardless of career intentions, junior doctors will meet urological problems in the wards, emergency department and GP. At least 5–10% of GP visits and 20% of acute hospital surgical referrals are Urology-based [1], [2], and yet there is no national undergraduate curriculum for Urology. Tomorrow's Doctors [3], which requires less time focused on hospital specialities, with more GP and student-choice, has exacerbated this problem. A lack of teaching and clinical exposure while at medical school will mean junior doctors are unprepared to deal with urological problems they see when starting work, particularly on call.
Compared to other surgical specialities, Urology is relatively undersubscribed. Recent evidence from the JCST shows Urology is the least competitive of the surgical sub-specialties at ST3, with a ratio of approximately three applicants to one place [personal communication from JCST]. Career choices are influenced by clinical experience of the speciality and positive role models [4], [5]. Time spent as an undergraduate in Urology may allow students to learn about the variety of the subject, the balance between medical and surgical interventions, use of new technologies, and lifestyle and training issues. With over 50% of medical students now being female, a surgical career may be rejected due to presumed lifestyle barriers [6].
Lack of exposure to Urology at undergraduate level may mean junior doctors are inadequately prepared for starting work. It may also mean they are less likely to choose Urology as a career. We used a web-based survey to evaluate the current Urology exposure and teaching final year UK medical students receive.
Materials and methods
A comprehensive list of all GMC-approved medical schools with final year medical students (29), and a list of contact emails for the UK surgical societies was obtained. Emails were sent to each surgical society asking if they would agree to be a representative for the study, and publicise the link to their final year members when asked, either by email or their websites. An online survey about Urology exposure in final year medical undergraduates was created on SurveyMonkey.com® (see Appendix 1). It consisted of 14 questions. It was divided into 4 sections – introduction, experience, teaching and careers. The link was then sent to the surgical societies. The survey was live from the beginning of October 2010 until the end of January 2011. If 10 responses from each medical school were not achieved by November 2010, reminder emails were sent to the appropriate surgical societies. The link was also then sent to medical societies and the undergraduate office of that medical school, using contact emails from their websites, asking them to publicise the link to their final year medical students. At the end of the data collection period, the link was deactivated and the data was analysed using Excel 2007®.
Results
610 final year medical students completed the online survey (∼9% response rate). There were responses from all 29 UK medical schools surveyed, with a median of 18 per school (range 2–50).
Urology experience. 42% of respondents had a compulsory clinical attachment in Urology alone, lasting on average 1 week, most commonly in the 4th year of training. 46% of respondents had compulsory clinical attachments in other surgical specialties (usually General surgery), with Urology exposure incorporated into the attachment. The remaining 12% of respondents had no clinical attachment in Urology during their training. Over 50% of respondents had attended most common urological activities (flexible cystoscopy, outpatient clinics, theatre, etc.), but 6% had not attended any (although in each case, other respondents from the same medical school answered that they had attended activities) (see Fig. 1).
Figure 1.
Percentage of final year medical students surveyed who had attended common urological activities.
Teaching. 18% of respondents, from 22 different UK medical schools, did not think they could access a copy of the medical curriculum (although in each case, other respondents from the same medical school answered that they had accessed the curriculum). Over 80% of respondents had teaching on common urological topics, however only 62% had teaching on urological emergencies (see Fig. 2). The main teaching methods were lectures and anatomy sessions, and 87% of respondents had received teaching from dedicated Urologists. 24% had received their urological teaching from GPs.
Figure 2.
Percentage of final year medical students surveyed who received specific teaching on the following urological topics.
Confidence managing urological problems. Most respondents reported being ‘somewhat confident’ and above at managing common urological problems. However, 32% of respondents said they were ‘not very confident’ about managing urological emergencies (see Fig. 3).
Figure 3.
Confidence of final year medical students surveyed about the following common urological topics.
Careers. The most popular career intention was medicine (37%), followed by surgery (23.2%) and GP (21.2%). 18% were uncertain. Of those considering a career in surgery, 25.6% would consider specialising in Urology. Reasons for not choosing Urology included other career choices, competition ratios, lifestyle issues and inadequate knowledge or experience of the specialty.
Discussion
The lack of Urology exposure in the UK undergraduate curriculum was noted in 1966 [7] and yet there has been little improvement over the past four decades, either here or in the US [8]. Previous research into this topic has been based on information from medical schools and Urology consultants [1], whereas this survey shows the perspective of final year medical students. The online medium was chosen to enable easy distribution across the UK, and because current students are computer-literate. The survey took 5
min to complete, to increase the likelihood that students would participate. While a 9% response rate overall to the survey (potential final year student numbers were around 7000 [9]) is disappointing, a representative sample has been obtained from UK medical schools. Although it is possible that more students with an interest in a surgical career would complete the survey due to utilising surgical societies as the main distributor, there was a good cross-section interested in all careers paths.
Of the current final year medical students who responded, over half did not have to complete a compulsory clinical attachment in Urology. Of these, not all had an attachment partially based in Urology. This would explain why a substantial proportion of the final year medical students who responded had attended none or few of the common urological activities listed, and why other studies have shown high numbers of foundation doctors starting work without having performed basic skills such as catheterisation [10]. If about 7000 FY1s start work every August [11], at least 60 would not have had any clinical experience of Urology. Due to the often ill-defined nature of surgical placements, students may get limited exposure to urological problems. With the increasing subspecialisation of surgery, it is not appropriate that medical students are placed generically within surgery, with a lottery determining which specialities they then experience.
Medical undergraduates should be gaining clinical exposure to the clinical situations they will meet throughout the rest of their careers. For over 50% of them, this will mean seeing urological problems as a GP (5–10% of referrals) [12]. Tomorrow's Doctors [3], advocates a stream-lined core curriculum with more time spent in the community, gaining experience of commonly presenting clinical problems. However, although an increasing proportion of medical students will end up working as GPs, they will first spend at least 4 years post qualification working predominantly in hospital. This will involve rotations through medical and surgical subspecialties and working on call. Junior doctors need to be prepared for the 20% of Urology-based acute surgical referrals. Students should receive at least 2–3 weeks of Urology during medical school with a focus on the common urological problems they are likely to manage as junior doctors [1].
There are currently no national guidelines for Urology undergraduate education in the UK. Urology exposure and teaching varies widely between medical schools. This would explain why a proportion of our final year medical students did not know what was on their curriculum or even how to access it. Instead of the well-rounded medical graduates the system intends to produce, many students are not confident in managing common urological emergencies. Although the majority of final year students receive some Urology experience and teaching, it is clearly not sufficient. This is an issue of patient safety, and when extrapolated to other subspecialties, contributes significantly to the difficulties faced at the start of new appointments.
The development of an undergraduate curriculum is required, with standard setting endorsed by the GMC, with implementation by all UK medical schools. It would also require cooperation of community and hospital doctors. Undergraduate education needs to be a priority within practices, hospitals and particularly academic departments [12], despite the pressures of service provision and EWTD.
Urology undergraduate education may also influence recruitment into Urology. Early student exposure to surgical specialities has been shown to increase the likelihood of following a future surgical career path [4], although positive role models and post graduate experience are more important in some studies [5]. Both exposure to a speciality's variety (pathological and interventional) and interaction with current trainees, to allow discussion of training and lifestyle issues, encourages future interest [4], [5]. Thus, lack of exposure to Urology as an undergraduate means that interest in the specialty never starts and never has chance to influence career decisions. This is unfortunate because junior doctors are under increasing pressure to choose a career path early on, to get adequate experience and opportunities to enhance their CV for applications to core or specialist training. Also, with the increasing number of female medical graduates and low number of female surgical trainees – only 13% of Urology trainees [personal communication from JCST], the need to provide exposure to positive role models is increasingly important [13].
Conclusions
There needs to be publication of a national undergraduate Urology curriculum for UK medical schools. This should specify the theory and clinical exposure medical students should receive before graduation. It would need to be accepted and endorsed by the GMC as part of a national medical undergraduate syllabus. Clinical attachments in Urology should be compulsory to increase hands-on experience and teaching by specialist doctors. Delivery would require collaboration between medical schools, Urologists and doctors actively involved in undergraduate teaching. Experiences and teaching within the university and community need to be coordinated with that in hospitals. This would ideally ensure that junior doctors are capable and confident in managing urological emergencies when they start work, increasing patient safety. The concurrent exposure to urological problems, and time spent with trainees will increase awareness of the speciality and should encourage consideration of Urology as a career choice.
Conflict of interest
No conflicting interests. No monetary sponsorship involved.
Acknowledgements
We are grateful to all the society and medical school staff who advertised this survey to their members, and to the final year medical students who took the time to fill out this survey.
Appendix 1.
References
- . Undergraduate urology: a survey of current provisions and guidelines for a core curriculum. BJU International. 2002;89(4):327–330
- . Morbity statistics from general practice. Fourth National Study 1991–2. London: Royal College of General Practitioners, Office of Population Censuses, and Department of Health; 1995;
- General Medical Council. Tomorrow's Doctors. London. GMC; 2003.
- Medical student entry into general surgery increases with early exposure to surgery and to surgeons. Current Surgery. 2006;63(6):397–400
- . Recruitment in urology: a national survey in the UK. Annals of the Royal College of Surgeons of England. 2004;86(3):186–189
- . Women and medicine. The future. London: Royal College of Physicians; 2009;
- . The loss of formal undergraduate teaching time in urology could cripple the growth of our specialty. The Journal of Urology. 1966;95(2):133–134
- . The current status of medical student urological education in the United States. The Journal of Urology. 2008;179(3):1087–1090[discussion 1090–1]
- . Final report of the education and training regulation policy review: recommendations and options for future regulation of education and training. 2010;Available from: http://www.gmc-uk.org/Patel_review.pdf_39254211.pdf [September 2011]
- . The urological foot soldier: are we equipping our foundation-year doctors?. Bulletin of the Royal College of Surgeons of England. 2010;92(8):284–287
- . Foundation programme oversubscription. BMJ Careers. 2010;(December):http://careers.bmj.com/careers/advice/view-article.html?id=20001686#
- . Surgery in the undergraduate curriculum report by the Education and Professional Development Committee of SARS. Bulletin of the Royal College of Surgeons of England. 2005;87(4):138–139
- . Women in surgery: do we really understand the deterrents?. Archives of Surgery (Chicago, Ill.: 1960). 2006;141(4):405–407[discussion 407–8]
PII: S1875-9742(11)00183-2
doi:10.1016/j.bjmsu.2011.10.005
© 2011 British Association of Urological Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 5, Issue 1 , Pages 4-10, January 2012
