Volume 5, Issue 1 , Pages 16-19, January 2012
Is there a need for an undergraduate urological curriculum?
Article Outline
Summary
Objectives
To review Medical student education in urology and assess students self reported knowledge and management competency of common urological conditions. To determine the degree of undergraduate exposure to urology and students intentions to follow a post graduate career in urology.
Methods
Questionnaires were completed by final year medical students prior to final examinations over a five year period to assess exposure to undergraduate urology and consideration of urology as a postgraduate career. Students from a single year were asked to rate their knowledge and management competency with respect to a variety of common urological pathologies.
Results
Students reported low levels of confidence to manage common and emergency urological conditions. Undergraduate exposure to urology is decreasing year on year, with fewer and fewer students considering urology as a future career option.
Conclusions
Undergraduate exposure to urology is poor and as a consequence of this, fewer students are considering a career in urology. This trend needs to be reversed, possibly in part, by the implementation of a defined undergraduate urological curriculum and BAUS needs to foster a greater undergraduate presence to stimulate current medical undergraduates to consider a urological career.
Keywords: Undergraduate, Education, Curriculum
Introduction
In 2001 a postgraduate urological curriculum was successfully implemented providing a firm structure upon which to base one's learning and experience. It eliminated vagueness and enabled trainees to focus more readily for examinations whilst opening the door to competency based assessments.
At present, in the UK, an undergraduate urological curriculum does not exist, however, many other surgical and medical specialities including Obstetrics and Gynaecology have introduced a curriculum in an attempt to standardise undergraduate training and set a minimum standard for all medical students [1].
Historically, urology is both a medical and surgical speciality but unfortunately this is not portrayed through the exposure and education of medical students. Teaching methods and exposure to urology are not standardised and are variable both across the UK and within each particular medical school, potentially impacting greatly on competencies required for common urological conditions, and ultimately the quality of patient care. In many institutions it is possible to complete medical school without any clinical exposure to urology, something mirrored in over 60% of undergraduate schools in the USA [2], [3], [4]
As postgraduate career pathways have to be decided earlier, without exposure as a student, it is feared that fewer students will consider urology as a future career option.
Methods
All final year medical students at Manchester Medical School attending an annual urological revision day were asked to complete a questionnaire to assess 3 key issues. They were asked to honestly say whether or not they would feel confident managing the common and important urological conditions featured in the postgraduate curriculum. Not all aspects of the post graduate curriculum were included as it was felt that the more specialised aspects would be inappropriate and hence we attempted to generalise the basic aspects with a view to clustering of various topics for the sake of simplicity. They were also asked their opinion regarding the usefulness of an undergraduate urological curriculum, and what, in their opinion such a curriculum should cover, bearing in mind their somewhat limited experience and exposure.
Over the previous 5 years, students attending the annual revision day were asked to rate their exposure to undergraduate urology and whether they had ever considered a career in urology.
Students were asked to score their exposure from 1 to 10, with 10 being excellent and 1 being nonexistent.
Results
201 questionnaires were completed at the revision day. In total, 185 students, (88%) thought that an undergraduate urological curriculum would be useful with only 10% being unsure. 81% of the students claimed to be able to catheterise a patient whilst only 56% and 58% were confident to diagnose and manage testicular torsion and ureteric colic respectively (Fig. 1). Whilst 86% and 82% were confident to manage benign prostatic hyperplasia and prostatic carcinoma respectively, only 68% and 21% were confident to manage scrotal swellings and phimosis respectively. When asked what should be included in such a curriculum, the overwhelming majority (>90%) were in favour of all the key parts of the postgraduate curriculum being present (Fig. 2) with the exception of penile cancer which was felt to be a useful inclusion by 76% of students.
Figure 1.
Chart showing final year medical students’ confidence to manage common urological problems.
Figure 2.
Chart showing which urological problems final year medical students think should be included in a proposed undergraduate urological curriculum.
Over 5 years a total of 901 completed questionnaires were returned. The mean scores out of 10 for urological exposure decreased year on year from a mean of 3.97 in 2006 to 1.78 in 2010 (Fig. 3) and those considering urology as a career followed the same trend, falling from 26% to 7.4% over the same time period (Fig. 4)
Figure 3.
Urological exposure in medical school from 2006 to 2010.
Figure 4.
Percentage of final year medical students who have considered pursuing urology as a postgraduate career.
Discussion
Undergraduate exposure to urology appears to be on the decline [5], although it must be appreciated that this may not be reflected elsewhere in the UK and in Europe where previous studies have reported wide variation in the delivery of urological undergraduate education [6]. Indeed in other countries, urological exposure as an undergraduate would appear to be much greater than in the UK with over 50% of surveyed students in British Columbia feeling that their undergraduate exposure to urology was adequate [7], whilst in France approximately 25% of students have a urological attachment [8] compared with almost 70% in some states in the USA [9]. A recent EAU initiative surveyed 400 participants across 34 countries and found that 25% of medical graduates had no exposure to urology what so ever [10].
This, of course may impact upon clinical care with a recent survey suggesting that poor exposure to urology as an undergraduate resulted in poorer patient care in the community [11].
In this survey, students were most comfortable in managing BPH, incontinence, infection and carcinoma of the prostate, (all with over 80% self declared competency), which is in keeping with other reported series from around the world [7], and is reflected in those areas of urology deemed to be most valuable following graduation [12].
Over 80% of students claimed to be competent in catheterisation which echoes a previous UK study in Oxford in which over 90% of students were taught catheterisation [13]. This, however contrasts with other published series which report similar competency in the region of 50% [8]. This is possibly as a consequence of the stipulation that catheterisation must be assessed and signed off prior to graduation at Manchester Medical School.
The response from the students suggests a desire for an undergraduate urological curriculum and a need for increased clinical urological exposure.
Very similar findings and concerns have recently been highlighted by a study in Bologna suggesting that decreasing undergraduate exposure and fewer considering urology as a career is also a European issue [14]. Because the mobility of doctors in the EU is a constitutional right, the Bologna Convergence Programme suggests that a European curriculum should be implemented and an educational standard should be set [15].
The issue remains regarding the content of a proposed undergraduate urological curriculum. The students surveyed responded in an almost universally favourable way in relation to all topics suggested being included in a curriculum. There appeared to be a marked lack of discrimination between topics and hence it is difficult to use this information to build on work previously published showing those aspects of urology deemed necessary in an undergraduate curriculum by Urological Consultants as detailed by Shah et al., in 2002. In this nationwide survey, haematuria, testicular torsion, testicular examination and urethral catheterisation were cited as the most important factors for an undergraduate curriculum [16].
The implementation of a focused undergraduate curriculum would set a minimum standard for all UK graduates and ensure basic competencies are met before entering Foundation Training. Introducing a curriculum would stimulate exposure and re-instate urology as an important speciality and convert it from a passive to an active undergraduate learning pathway. This is re-enforced by recent findings that report over 90% of medical undergraduates feel that a specialty specific undergraduate curriculum is of significant value [5], [17].
Recommendations
We recommend that further work is done by the BAUS Office of Education to determine the content of a proposed undergraduate urological curriculum to include both knowledge and skill acquisition. One proposal would be that the current UK postgraduate curriculum is adopted and pruned to reflect undergraduate and Foundation Training requirements in a way that will allow potential career urologists to continue seamlessly on to the postgraduate curriculum.
The main components of an undergraduate urological curriculum may include the following:
Increasing undergraduate exposure to urology is essential to ensure basic competencies and to also ensure that all students are at least considering urology as a career before it is too late.
Conflict of interest
The authors declare that there are no conflicts of interest.
References
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PII: S1875-9742(11)00186-8
doi:10.1016/j.bjmsu.2011.11.001
© 2011 British Association of Urological Surgeons. Published by Elsevier Inc. All rights reserved.
Volume 5, Issue 1 , Pages 16-19, January 2012
