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Quality of teaching in chemical pathology: ability of interns to order and interpret laboratory tests
  1. J C Stanfliet,
  2. J Macauley,
  3. T S Pillay
  1. Division of Chemical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town
  1. Professor T S Pillay, Division of Chemical Pathology, Department of Clinical Laboratory Sciences, University of Cape Town and National Health Laboratory Service, Groote Schuur Hospital, Cape Town; profts.pillay{at}uct.ac.za

Abstract

Background and objective: There has been a steady decline in the overt teaching of many basic and pathology sciences in the medical curriculum worldwide. As interns are the doctors most likely to request and act on tests, an assessment of their confidence in dealing with laboratory investigations was undertaken.

Methods: Interns at two hospitals in Cape Town, South Africa, were asked to complete a structured questionnaire designed to assess their confidence in ordering and interpreting a number of tests. The questionnaire also probed their desire for further teaching and the preferred delivery vehicle for such teaching.

Results and conclusions: 61 out of 117 questionnaires were returned. Interns were confident in the use of common tests, but 23% were not confident in interpreting a test that they were confident in ordering. All respondents felt they would benefit from teaching in at least one area and lectures were the preferred method, although the majority felt it very likely that they would complete an online tutorial if available. The results suggest that institutions need to devise strategies to fulfil the learning needs of new graduates in the area of chemical pathology and clinical biochemistry.

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Take-home messages

  • Junior doctors feel underprepared and steps should be taken to counteract this. There should be increased exposure to laboratory medicine at some point in training.

  • Greater attention needs to be devoted to teaching undergraduates the basis of rational ordering of laboratory tests.

There is a worldwide demand to increase the number of doctors in the developing world and in industrialised economies.1 This has led to concerns in the type of doctors being produced with an apparent reduction in teaching time devoted to the pathology sciences and an increase in communication skills inter alia. The impact of such changes is not entirely clear.

The local experience at the University of Cape Town is similar to that of many faculties worldwide with the recent introduction of problem-based learning (PBL),2 aiming to facilitate integration of multiple disciplines via structured case histories, in small supported groups. This has arisen because of the continued exponential and unprecedented expansion of medical knowledge and a desire to switch from learning “the facts” to learning how to become lifelong learners, and the learning of concepts.4 Early international experience suggests that there is no difference in the self-perception of doctors exposed to such curricula, with respect to their science and clinical knowledge, compared with graduates from traditional schools.7

Despite biochemistry being a major part of the research and knowledge base of diverse medical specialties including, but not limited to, genetics, paediatrics, pharmacology, immunology and others,2 reports indicate that there has been a significant reduction in the time available to teach it.3

As to whether newly qualified doctors feel prepared to practice medicine the evidence is not clear.5 A recent survey, undertaken with a cohort of newly graduated British doctors, found that many felt unprepared by their undergraduate experiences for life in hospital and felt that there was too much time spent on communication at the expense of practical clinical courses; yet a third felt that undergraduate teaching in laboratory medicine and biochemistry were particularly irrelevant,5 in spite of the important role of laboratory medicine in clinical decision making.

Junior doctors are usually the first point of contact with patients, and thus it is not surprising that the majority of investigations ordered are by them.6 Yet explicit undergraduate training in the rational ordering of tests appears to have no impact and the requesting patterns appear largely driven by the preference of the concerned consultant medical specialist.6

However, there still exists the potential problem of tests being ordered reflexively or routinely without the requesting physician feeling confident in their interpretation. For example, most doctors would be confident to order an ECG in a patient presenting with features of acute coronary syndrome, but they might not feel confident in reading the ECG produced.

Khromova and Gray undertook a study in Sheffield, UK, to ascertain the confidence of junior doctors in ordering laboratory investigations.3 This showed that a significant proportion of doctors were confident in ordering tests they were not confident in interpreting. Furthermore, it was evident that additional teaching in clinical biochemistry (chemical pathology) was needed and requested by the doctors who wished to have them in the form of small group tutorials.3

METHODS AND RESULTS

We undertook a study to ascertain the self-assessed confidence of interns in requesting and interpreting a number of pathology laboratory investigations using a structured anonymous questionnaire given to the 117 interns practising at Groote Schuur and Red Cross Children’s War Memorial Hospitals in August 2008 (see supplementary files). Ethics approval was obtained from the University of Cape Town Ethics Board and permission to undertake the study from Dr Vorster, Medical Superintendent.

Sixty-one out 117 questionnaires were returned giving a response rate of 52.1%, which compares with similar studies.3 7 Two were not filled in completely; however all data obtained were analysed. Sixty respondents were interns, one was a registrar, and there were no responses from community service medical officers or medical officers.

Fig 1 depicts the self-perceived confidence in ordering tests, and fig 2 depicts the confidence in interpreting the test results obtained. Urea and electrolytes, liver function tests, protein assays, thyroid stimulating hormone and iron studies were areas in which all respondents felt confident to some degree in requesting and largely in interpreting.

Figure 1

Confidence of interns in the requesting of tests.

Figure 2

Confidence of interns in interpreting tests.

In contrast the short synACTHen test, urinary sodium and osmolality, parathyroid hormone and magnesium and phosphate studies were test groups that produced the most anxiety. Overall 23% were not confident in interpreting results they were confident requesting.

Fig 3 shows that only 30% of respondents were very confident in analysing results in the presence of haemolysis, whereas 59% were not very confident. This is reflected in that 63.9% of respondents felt they would benefit from teaching in this area. It was also found that in the two other areas in which further instruction would be beneficial was in the short synacthen test and urine sodium and osmolality. Explicit requests were also made for teaching in blood gas analysis.

Figure 3

Confidence in the interpretation of results from haemolysed samples.

Interestingly although all respondents reported feeling confident to some degree in requesting and ordering thyroid stimulating hormone, 14.8% requested teaching in this area; similarly for liver function tests, 13.1% and for urea and electrolytes. 4.9% wanted teaching in areas in which all were confident.

Sixty-five per cent felt that the best period for receiving further teaching would be as interns, although the mode of instruction was evenly divided between lectures, online tutorials and small group teaching. Fifty-two per cent felt they would be very likely to complete an online tutorial if available.

DISCUSSION

Our results indicate that, although on the whole, interns based at Groote Schuur and Red Cross Children’s War Memorial Hospitals are confident in ordering and interpreting a number of laboratory investigations, there are a few areas of concern. They are confident with the common investigations but not so with more complex and less common investigations. This is also the case in the setting of interferents such as haemolysis. All respondents felt they would benefit from teaching in at least one area. Interestingly, there appeared to be a preference by a small majority to have lectures rather than small group teaching, which forms the basis of much of the current curriculum.

A few possible limitations in our study are as follows. First, a selection bias as a result of the response rate might indicate that only those interns who felt they wanted to receive further teaching might respond. However, the converse could be argued, that the more self-confident would be more likely to respond. Short of making this a compulsory undertaking and having some way to identify who has and who has not responded, which would invalidate the ethics approval, this appears to be insuperable, but we point out that our measured response rate matches that obtained elsewhere.

Second, this is a subjective assessment and merely measures confidence and not competence. Third, a three-point scale was used and greater discrimination might have been obtained via a five-point scale.

The scheduling of such requested teaching would be problematic given the large and varied workload borne by the interns. Online tutorials might be useful, possible as an adjunct, in this regard, given that more than half felt they were very likely to complete one if offered. It is to be recommended therefore that teaching institutions give strong consideration to the development of online tutorials and attempt to bridge the gaps in undergraduate pathology teaching. This will result in the more rational use of laboratory testing and will impact on the healthcare budget, which is always under continual pressure.

REFERENCES

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