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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 3  |  Page : 545-551
Value of subspecialty experience in internal medicine undergraduate training

1 Department of Clinical Affairs, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Department of Medical Education, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

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Date of Web Publication7-May-2012


We aimed from our study to assess how students and clinical supervisors perceive students' achievement in the internal medicine subspecialty clinical attachments in comparison with the general attachments. We conducted a cross-sectional study comparing students' self-assessment ratings during the Medicine Block general and subspecialties clinical attachments at our college of medicine during the period between February 2007 and June 2009. We assessed the level of agreement between students' self-assessment in the different subspecialties with their self-assessment in the general attachments. We repeated the same calculation for the supervisors' assessment. Eighty-three students were included; these students attended eight different clinical attachments. A total of 517 self-assessment forms were completed (120 general internal medicine clinical attachments and 397 forms in different specialty attachments). The clinical supervisors completed parallel assessment forms. The undergraduate medical students' perceived their achievement in the subspecialty attachments well. This was similar to their perception of their achievement in the general clinical attachments. The clinical supervisors perceived students achievement in the subspecialties to be similar to their achievement in the general clinical attachments. In conclusion, we do encourage the implementation of specialty and subspecialty undergraduate clinical attachments for all students as part of their curriculum requirements. Furthermore, we encourage the strategic utilization of specialties/subspecialties attachment distribution aiming to enhance students' future interest to achieve balance in the different health specialties/subspecialties manpower. Further research to support this recommendation is needed.

How to cite this article:
Al Kadri HM, Al-Moamary MS, Tamim HM, Al-Kadi MT. Value of subspecialty experience in internal medicine undergraduate training. Saudi J Kidney Dis Transpl 2012;23:545-51

How to cite this URL:
Al Kadri HM, Al-Moamary MS, Tamim HM, Al-Kadi MT. Value of subspecialty experience in internal medicine undergraduate training. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Dec 7];23:545-51. Available from: http://www.sjkdt.org/text.asp?2012/23/3/545/95798

   Introduction Top

General clinicians are the leaders and the core group to provide basic training for undergra­duate students, foster basic and clinical re­search and provide solid foundation for all. [1] However, the enormous expansion of scientific knowledge and the specific developments with­in certain medical fields make it difficult for individuals to stay abreast of a single specialty. Therefore, the need for expertise at a subspecialist level has increased. Based on subspecialty practice, clinicians can focus their efforts on their area of expertise, and link with experts of similar interests.

Subspecialty medical system expansion may result in a better patient care, but parallel to its expansion there will be an inevitable decline in the number of generalist clinicians. [1],[2] This de­cline may negatively affect undergraduate and postgraduate teaching and training activities. [1],[2] The negative effect of subspecialty system on students' training was highlighted even in den­tal training. A strict subspecialty system has its effect on undergraduate and postgraduate cur­ricula; thus, very little time is devoted to stu­dents' training on subspecialties subjects. [3] The result is graduates who have never been ex­posed to some important clinical skills resul­ting in a negative effect on students' professio­nal identity, self-efficacy and the development of applied knowledge related to these subjects. [4],[5],[6],[7]

We have observed a great interest and de­mand of our undergraduate medical students to rotate in various subspecialties' clinical attach­ments. On the other hand, there was a concern among our clinical supervisors regarding the importance and impacts of these subspecialties clinical attachments on the undergraduate stu­dents' achievement. There is a paucity of stu­dies on this subject in the medical literature.

We aimed in this study to determine the value of subspecialty experience in undergraduate training by comparing the students self-assess­ment and perception of their achievement in the subspecialty clinical attachments and their general attachments as well as the clinical su­pervisors' assessments.

   Methods and Subjects Top

This study was conducted at the College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS, COM), Riyadh, Saudi Arabia, during the period between Feb­ruary 2007 and June 2009. The college imple­ments a four-year problem-based learning (PBL) curriculum for male graduate students. The curriculum is composed of two years of pre-clinical and two years of clinical clerkship phases. The clinical clerkship phase is divided into blocks that cover the major specialties (Medicine, Surgery, Pediatrics, Family and Community Medicine, and Obstetrics and Gynecology). In each specialty block, students ro­tate in different general and subspecialty cli­nical attachments. By the end of each clinical attachment, students complete a self-assessment form [Figure 1]. The form includes 10 main assessment items that are scored based on a Likert scale from 0 to 3, where 0 represents poor students' achievement and 3 represents outstanding students' achievement. The inclu­ded items assess the main aspect of students' learning in the clinical attachments. The items cover students' abilities to record patients' illness histories, social and family histories, properly perform and report physical examina­tions, establish a diagnosis, appropriately order medical tests and outline a management plan. The same items will be utilized by the clinical supervisors to assess students' performance in the clinical attachments.
Figure 1. Self-assessment and supervisor assessment form utilized for data collection

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We carried out a quantitative cross-sectional study on a group of students and their clinical supervisors during the general medicine block and subspecialties clinical attachments. We assessed the level of agreement between stu­dents' self-assessment in the different subspecialties of the internal medicine block with their self-assessment in the general internal medicine attachments. We repeated the same calculation for the supervisors' assessment of the same students in the same block.

This study was conducted during three conse­cutive medicine blocks. These blocks are based on different general and subspecialty clinical attachments. Students included in this study spent a minimum of two weeks in each of these clinical attachments. All students ro­tating through the medicine block during the academic years 2007, 2008 and 2009 were in­cluded. The same clinical supervisors have su­pervised students' clinical attachments during the three academic years during which the study was conducted. Each student rotated through selected rotations of the following subspecialty clinical attachments: cardiology, gastroenterology, hematology, intensive care unit (ICU), nephrology, psychiatry, neurology and dermatology. All students had mandatory rotations in one or more general internal medi­cine attachments.
"Clinical attachment" refers to any clinical specialty or subspecialty where the students are assigned to clinical supervisors who will implement specific curriculum objectives on their students' training. "Clinical supervisor" refers to experienced clinicians who imple­ment the curriculum objectives and enhance patients' protection and safety. They implement formal process of professional support and teaching to the students. Moreover, their role is to enable individual students to develop knowledge and competence and assume res­ponsibility for their own practice.

Ethical approval was obtained from the KSAU-HS, COM Research Committee.

   Statistical Analysis Top

A score for each of the two Likert scales (the students' and the supervisors') was calculated by summing up the answers to obtain a con­tinuous variable representing the overall result of the measurement under consideration. Stu­dents' and supervisors' continuous scores for each item in the questionnaire were compared; the level of agreement between the two conti­nuous scores was assessed by calculating the Interclass Correlation Coefficient. Statistical significance was defined as P-value ≤0.05. Data management and analyses were carried out using the SAS software (SAS, Release 9.1, SAS Institute Inc. 2002, Cary, NC, 1999, USA).

   Results Top

We included 83 students in our study. They attended eight different clinical attachments. A total of 517 self-assessment forms were com­pleted; 120 forms of general internal medicine clinical attachments and 397 forms of different specialty attachments. Their clinical super­visors across all these attachments completed parallel assessments of the students.

[Table 1] summarizes the total scores of all students included in the study on the different assessed items. It also presents students' self-assessment scores agreement with their clini­cal supervisors' scores. We found a positive correlation between the students' self-assess­ments and their supervisors' assessments on all questions. The difference between the students' self-assessment and their supervisors' assess­ment was found to be significant for the stu­dents' ability to take patients history (P =0.01), establish differential diagnosis and problem lists (P = 0.001), understand basic and clinical science concepts related to the studied cases (P < 0.0001), select appropriate investigations and establish management plans (P = 0.01), and the students' overall progress in the case ma­nagement (P = 0.005). The overall scores of both the students and their supervisors were positively correlated. The overall difference between the students' and their supervisors scores was statistically significant (P = 0.005), with a tendency of the students to over-score themselves.
Table 1: Comparison between the study students' and supervisors' ratings for each of the 10 different assessed activities.

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[Table 2] summarizes the stratified data based on the different clinical attachments where students rotated. There was a positive corre­lation between students' self-assessments and their supervisors' assessments across all the clinical attachments; the general internal medi­cine attachments and the subspecialties. This correlation was stronger for the general com­pared with the subspecialties (correlation = 0.70 and 0.28, respectively). The difference between the students' and the supervisors' assessments was significant for both the ge­neral and the subspecialty attachments (P-value <0.0001 and 0.07, respectively).
Table 2: Comparison between the study students' and their supervisors' ratings for each of the different clinical attachments.

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We compared the students' self-assessments in the general internal medicine attachments with those in the different subspecialties attachments. The correlations were in general weak ranging between -0.26 and 0.26. There was no significant difference between the stu­dents' self-assessments in the general compared with the different subspecialties attachments [Table 3].
Table 3: Comparison between the study students self-assessments in the general internal medicine attachments with their self-assessment in the subspecialty attachments.

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The same calculation was repeated conside­ring the supervisors' assessment of the students in the general attachments compared with those in the subspecialties. The correlations were in general weak, ranging between -0.12 and -0.15. There was no significant deference in the assessments across the entire general and subspecialty attachments [Table 4].
Table 4: Comparing the clinical supervisors' assessments in the general internal medicine attachments with the subspecialty attachments.

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   Discussion Top

We have found in this study that the under-graduate medical students and their supervi­sors perceived their achievement in the sub-specialty attachments well. This was similar to their perception of their achievement in the general clinical attachments. However, the students tended to overestimate their own self-assessment compared with their supervisors' assessment in both the general and the sub-specialties attachments.

Self-assessment forms are implemented to emphasize what students have learned, reflect on future work and identify the need for change. [8] Students reported that self-assessment made them more critical and structured in their work. They perceived self-assessment as chal­lenging, helpful and beneficial. [9] According to Boud, [10] many people believe that student-de­rived marks cannot be used in formal grading procedures, because they are inaccurate and tend to make high-achieving students underestimate their performance and low-achieving students overestimate their performance. [9],[11] . Moreover, many social psychologist researchers have concluded that much of what we want to know about ourselves resides outside of conscious assessment. [12] Hence, the reliability of students self-assessments should be considered carefully when comparing them with those of the super­visors. The detected difference in the marking between the studied students' and the super­visors' clinical attachment assessments was not expected to affect the study result even with the persistence of these differences across the general and subspecialties clinical attach­ments.

Our students have identified their subspecialties attachments as important and perceived it as beneficial, similar to the general attach­ments. A basic knowledge of a specialty is re­quired in the management of patients with certain medical conditions such as learning the salient points unique to different specialties, gaining confidence in specific examination skills, developing the ability to recognize dif­ferent emergencies and understanding the indications for specialties and subspecialties referrals. [13] Adequate exposure coupled with quality teaching and teaching time are needed to achieve the goal. [14]

The type and quality of students' undergradduate teaching is known to influence their selection and preferences for specialties in the future. [15],[16] As a result, the trends in graduate students' career choice among specialties have varied greatly. [17] For example, in the USA, there is a recent decrease in the percentage of medi­cal student graduates choosing a primary care career and fewer medical students choosing general surgery as a carrier, with slow decline from 7.8% in 1987 to 5.2 in 2002. [18] Such a decline in any specialty may be a result of different educational and cultural effects, and it usually has a great impact on the national physician workforce and on patients' safety. Encouraging the undergraduate students' attachments in the different specialties and subspecialties domains accompanied with high quality teaching and supervision may result in the development of students' interest, reduce the decline in students' number in some specialties/subspecialties and result in more ba­lanced manpower across the different special­ties nationwide.

Few weaknesses of this study should be addressed. The students of the study were all males, and female students usually tend to self-assess their achievement more accurately than males and may underestimate their achievements. [19] Moreover, we did not explore the effect of the social and educational back­ground and the health care system on the accuracy of this result. Finally, further res­earch utilizing more objective assessment methods such as Objective Structured Clinical Examinations and Multiple Choice Questions are recommended.

We conclude that the undergraduate medical students' rotation in general or subspecialty attachments did not affect students' perception of their learning. We do encourage strategic implementation of specialty and subspecialty undergraduate clinical attachments for all stu­dents as part of their curriculum requirements. Further research on the effect of the social and educational background and the health care system on students' perception of their diffe­rent clinical attachments are needed. [21]

   References Top

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2.Lumley JS. Subspecialisation in medicine. Ann Acad Med Singapore 1993;22:927-33.  Back to cited text no. 2
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5.Fernald DH, Staudenmaier AC, Tressler CJ, Main DS, O'Brien-Gonzales A, Barley GE. Student perspectives on primary care precep-torships: enhancing the medical student preceptorship learning environment. Teach Learn Med 2001;13:13-20.  Back to cited text no. 5
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9.Orsmond P, Merry S. A study in self- assessment: tutor and students' perceptions of perfor­mance criteria. Assessment and Evaluation in higher education 1997;22:357-69.  Back to cited text no. 9
10.Boud D. Enhancing learning through self-assessment. Kogan Page. London; 1995.  Back to cited text no. 10
11.Mires GJ, Friedman Ben- David M, Preece PE, Smith B. Educational benefits of student self-marking of short- answer questions. Medical Education 2001;23:462-6.  Back to cited text no. 11
12.Bargh J, Charrand T. The unbearable automaticity of being. Am Psych 1999;54:462-79.  Back to cited text no. 12
13.Noble J, Somal K, Gill HS, Lam WC. An ana­lysis of undergraduate ophthalmology training in Canada. Can J Ophthalmol 2009;44:513-8.  Back to cited text no. 13
14.Bellan L. Ophthalmology undergraduate edu­cation in Canada. Can J Ophthalmol 1998;33: 3-7.  Back to cited text no. 14
15.Saigal P, Takemura Y, Nishiue T, Fetters MD. Factors considered by medical students when formulating their specialty preferences in Japan: findings from a qualitative study. BMC Med Educ 2007;7:31.  Back to cited text no. 15
16.Madan AK, Frantzides CT, Quiros R, Dujovny N, Tebbit C. Effects of a laparoscopic course on student interest in surgical residency. JSLS 2005;9:134-7.  Back to cited text no. 16
17.Newton DA, Grayson MS. Trends in career choice by US medical school graduates. JAMA 2003;290:1179-82.  Back to cited text no. 17
18.Richardson JD. Workforce and lifestyle issues in general surgery training and practice. Arch Surg 2002;137:515-20.  Back to cited text no. 18
19.Minter RM, Gruppen LD, Napolitano KS, Gauger PG. Gender differences in the self-assessment of surgical residents. Am J Surg 2005;189:647-50.  Back to cited text no. 19
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21.Cambell RW. The Objective of a Community-Based Current Cardiology Training Program: Community-Based. Am J Cardiol 1975;36: 569-70.  Back to cited text no. 21

Correspondence Address:
Hanan M.F. Al Kadri
Associate Professor and Consultant Obstetrics and Gynecology, Associate Dean Female Medical Student Branch, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, P. O. Box 57374, Riyadh 11574
Saudi Arabia
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