Learning environments, given the limited time and available resources, may play a crucial role in teaching undergraduate clinical urology. Purposes of the present study were: 1) to determine in which environment students best acquire knowledge and skills on certain topics, 2) to investigate whether they consider exposure in urology as sufficient for future patient management, and 3) to assess whether the above are influenced by different institutional environments and possible specialty choices. Students were asked anonymously to fill in a survey in order to check out the environment in which they believed their acquisition of knowledge and skills (15 items) was best, and whether they felt confident in managing certain urological problems (11 items). Data were analyzed using the chi-square test in relation to gender, future specialization plans, and school of origin. All educational environments except from the operating room provided at least moderate benefit. Differences exist between institutions in learning environments preferences. For certain subjects more than 5% of the students stated they did not acquire the corresponding knowledge or skills. For the majority of the problems addressed, more than 50% of respondents felt confident in managing them. Gender, possible career choice and educational environment preference had marginal or negligible effect on self-confidence development. Based on the results of this study seeing patients and student-oriented conferences represent the most suitable setting for acquiring basic clinical urology knowledge and skills. Moreover, given the plans for an integrated European medical curriculum and despite the differences in health care systems throughout Europe, a standardized core undergraduate curriculum in urology is of outmost importance.
A medical specialty is defined as a medical science field in which other physicians lack the required knowledge and training.1 Medical specialization is necessary because it is impossible to gain the required knowledge during undergraduate medical training, and to best handle organ system-specific medical problems. Despite major international differences in undergraduate medical training, a common thread is to frame medical knowledge through a range of required core courses.2
Although urology is a highly specialized field, urological patients present with a wide range of symptoms. Handling these patients requires a minimum urological knowledge and skills given the commonality of urological diseases. Therefore, urology training in medical schools should equip all future physicians with at least a base level of knowledge and skills to recognize and address urological cases.3 As far as undergraduate urology training, European medical schools have fallen behind those in the United States. The American Urological Association has defined appropriate urological medical coursework.4-6 However, in the United States and the United Kingdom, a continuous decline in the percentage of medical schools that offer undergraduate studies in urology has been reported,5,7-10 a fact that should also be responsible for the great difference in the way general practitioners handle urological problems in comparison to that recommended by urological guidelines.11-13
The aim of the study was to determine the educational environment in which medical students presume that they acquired all the necessary knowledge and expertise in defined problems. Moreover, to report students’ self evaluation in knowledge sufficiency in handling problems, and to research the level at which the above mentioned studied factors differ based on gender, future medical specialty and university attendance in two different European medical schools.
MATERIALS & METHODS
Questionnaires (see appendix) were distributed to 58 Italian and to 118 Greek medical students of Ancona University and Athens University respectively. Similar questionnaires were used in past studies in the United States.14 The questionnaires were filled in anonymously by all students attending the winter semester, the last day of their rotation in urology during the second year of clinical training. Besides noting their gender, future specialization plans, and training evaluation, students were asked to provide an answer to the following questions: a) “in which educational environment did you acquire knowledge on the following topics” (see appendix), b) “within your training time in which educational environment did you learn how to perform the following tests” (see appendix), and c) “following my training in urology I feel capable of handling the following problems” (see appendix). Correlations of answers to students’ characteristics were identified using the chi square test.
Despite the differences in the number of students and the time of urology training, the types of educational activities utilized by the two schools (i.e. ward, outpatients, emergency room, operating room, staff meetings, informal resident teaching, formal teaching by staff members, and student-oriented conferences) were the same (Table 1). In the first two questions, ten topics of most importance for urological cognition and five important skills for urological diagnosis and management were included, while eleven most common problems of the everyday practice were assessed.
The percentage of male and female students varies significantly between the two countries (x2=5.87 p=0.015). In particular, the percentage of male students was higher in Athens (55.9%) compared to Ancona (35.1%). General evaluation of urology training differed significantly between groups (Table 2). On the whole as well as separately by school of origin, training evaluation was independent to gender (x2=5.62 p=0.131 for all students, x2=1.35 p=0.508 for Ancona and x2=5.9 p=0.116 for Athens students). A small percent of students had chosen urology as future possible specialization. In general however, no highly significant difference was noted between the future specialization plans of Athens and Ancona students, with the exception of surgery specialization choice and the percentage of the undecided (Table 3). On the whole, training evaluation did not interfere with future specialization plans (x2=8.03 p=0.782).
The answers given to the question: “in which educational environment did you acquire knowledge on the following topics”, are analytically presented in Table 4. Educational environment preferences differed significantly with topic; in every topic there were also significant differences among students stratified by school of origin. Students’ first choice was student-oriented conferences for “urinary tract infections”, “hematuria” and “lithiasis”; lectures from staff members for “prostate cancer”, “erectile dysfunction”, “urinary incontinence”, “diseases of the scrotum”, and “testicular torsion”; examination of patients at the ward for “benign prostatic hyperplasia”; and, individual study for “sexually transmitted diseases”. In certain subjects such as sexually transmitted diseases, erectile dysfunction, urinary incontinence, and diseases of the scrotum, more than 5% of students of both schools stated that they did not acquire any knowledge.
On the question “within your training time in which educational environment did you learn how to perform the following tests”, the answers are depicted in Table 5. Again, educational environment preferences differed significantly with topic, and in every topic there were also significant differences among students stratified by school of origin. Examining patients at the ward was students’ first choice for abdominal examination, while the outpatient department was preferred as the best environment to acquire knowledge on how to insert a Foley catheter and how to examine the abdomen and perform a digital rectal examination. More than 20% of students stated that they did not acquire any knowledge on digital rectal examination and examination of the scrotum, while 18.9% and 9.7% of them did not acquire any skills on how to insert a Foley catheter and examine the abdomen, respectively.
The answers to the question “following my training in urology I feel capable of handling the following problems” were the following (Table 6):
- “… to interpret urinalysis”: Ancona students felt more self-secure. On the whole this sense was not related to future specialization plans (x2=8.96, p=0.061). The sense of self-confidence was however related to gender of the respondents as a whole (women felt more confident, x2=3.99, p=0.045), a fact that was not present when data were analyzed separately by school of attendance.
- “…to interpret a KUB X-ray”: In general, Athens students felt more self-secure. On the whole, self-confidence was not related to future plans of specialization (x2=7.55, p=0.109) and it was present on both Ancona (x2=4.59, p=0.331), and Athens students (x2=2.12, p=0.712). Self-confidence was not related to gender (x2=2.47, p=0.115), although it was present in Athens (x2=2.56, p=0.109), but not in Ancona students (Ancona male students felt more confident, x2=5.41, p=0.019).
- “…to interpret an intravenous pyelography”: Athens students felt more secure. On the whole, this sense was related to future specialization plans (self-secured was higher among students planning on urology or any other surgical specialty, x2=9.72, p=0.045) although this was not valid when data were analyzed separately by school of attendance. Self-confidence was not related to gender (x2=2.35, p=0.124). “…to interpret renal scintigraphy”: Ancona students felt more secure, although a high percent of students of both medical schools were negative on the matter. This was not related to future plans of specialization (x2=4.47, p=0.346), stated by both Ancona (x2=4.26, p=0.37) and Athens students (x2=4.69, p=0.32). Self-confidence was not related to gender (x2=0.99, p=0.319), a fact that was not present on Ancona (men felt more confident, x2=7.17, p=0.007) but it was valid for Athens students (x2=0.04 p=0.826).
- “…to handle a patient with urinary retention”: Athens students felt more secure. This sense was related to future specialization plans (students planning on urology or any other surgical specialty felt more confident, x2=11.17, p=0.024), a fact not valid for both Ancona (x2=2.65, p=0.617) and Athens students (x2=7.84, p=0.097). Self-confidence was related to gender (males felt more confident, x2=4.03, p=0.044), a fact that was depicted neither in Ancona (x2=0.23, p=0.63) nor in Athens students (x2=2.18, p=0.139). The educational environment on which expertise on Foley catheter insertion was acquired influenced greatly the percentage of students who felt self-confident (x2=28.21, p&=60;0.001; more students preferred the outpatient department while a few of them stated that they did not acquire skills on the subject). This phenomenon was not present on Ancona students (x2=4.93, p=0.668) but on Athens students (x2=19.35, p=0.007; a high percent preferred the outpatient department while a small percent stated that they did not acquire skills on the subject).
- “…to handle a patient with renal colic”: No difference was noted between Ancona and Athens students. On the whole, this sense was not related to future specialization plans (x2=1.52, p=0.822) of both Ancona (x2=1.97, p=0.74) and Athens students (x2=1.88, p=0.757). Gender was not related to this question (x2=1.27, p=0.259), a fact that was valid for Athens students (x2=0.062, p=0.802), but not for Ancona students (x2=4.29, p=0.038).
- “…to recognize a urethral trauma”: Ancona students felt more secure. This sense was not related to future specialization plans (x2=4.71, p=0.318) or to gender (x2=0.424, p=0.514), as reported of both Ancona (x2=3.53, p=0.473 and x2=0.396, p=0.528 respectively), and Athens students (x2=3.69, p=0.448 and x2=0.231, p=0.63 respectively).
- “…to treat a patient with urinary tract infection”: No differences were noted between students of two schools. This sense was however related to future specialization plans (students planning on urology or any laboratory specialty felt more self-secured, x2=10.9, p=0.027) but this was not valid for either Ancona (x2=4.66, p=0.323) or Athens students (x2=8.32, p=0.08). This sense was also not related to gender as far as the Ancona students are concerned (x2=0.347, p=0.555), although Athens female students felt more secured than males (x2=4.93, p=0.026). The educational environment on which knowledge was acquired on the subject did not influence the percentage of students who felt secure (x2=11.86, p=0.105). This was valid for the Ancona students (x2=3.9, p=0.272), while on the contrary there was a major differentiation on the answers given by Athens students (x2=21.73, p=0.002; only a few of those feeling confident preferred the ward, most favored the emergency room and student-oriented conferences).
- “…to evaluate a patient with stone disease”: No major differences were noted between students of two schools. This sense was not related to future specialty plans (x2=2.61, p=0.624) as stated by both Ancona (x2=3.49, p=0.478) and Athens students (x2=1.46, p=0.832). The same applied for gender (x2=0.84, p=0.359), in both Ancona (x2=0.67, p=0.412) and Athens students (x2=2.37, p=0.123). The educational environment on which knowledge was acquired on the subject did not influence the percentage of students who felt secure (x2=12.76, p=0.12) as well as by school (x2=1.38, p=0.966 for Ancona, x2=13.5, p=0.06 for Athens).
- “…to evaluate a patient with hematuria”: Differences were not noted between students of two schools. The sense was not related to future specialty plans (x2=3.02, p=0.553) of both Ancona (x2=1.92, p=0.749) and Athens students (x2=2.67, p=0.612). The same applied for gender (x2=0.23, p=0.625), in both Ancona (x2=0.56, p=0.451) and Athens students (x2=0.12, p=0.721). The educational environment on which knowledge was acquired on the subject did not influence the percentage of students who felt secure (x2=6.94, p=0.325) as well as by school (x2=2.31, p=0.804 for Ancona, x2=10.62, p=0.1 for Athens).
10) “…to put the indication for prostate biopsy”: No major differences were noted between students of two schools. On the whole, this sense was not related to future specialty plans (x2=2.49, p=0.645), this being valid for both Ancona (x2=2.45, p=0.652) and Athens (x2=1.41, p=0.842) as well as to gender (x2=0.18, p=0.663). The educational environment on which knowledge was acquired on the subject did not influence the percentage of students feeling secure (x2=11.32, p=0.125).
A reasonable time frame for urology training has been reported to be at least two to three weeks during the last years of undergraduate medical education.8,15 The time frame for urology training at Athens and Ancona Medical Schools is ten and thirty days, respectively. Time exposure between the two medical schools for the different educational environments was similar, although one major difference was significantly more time spent on student-oriented conferences in the University of Athens. In the United States only 38% of medical schools offer undergraduate training in Urology.5 In the United Kingdom 31% of medical schools do not include Urology as part of the core curriculum.15
Traditionally, it is considered that students’ training in urology should take place in the ward and in the operating room.14 This study revealed that knowledge can be acquired in other ways as well, like patients’ examination in the outpatient department and emergency room as well as lectures and student-oriented conferences. Approximately one-quarter of students stated that they acquired knowledge in certain subjects with complementary personal study, while a small percent found attendance in the operating room useful. Differences in educational procedures followed by the two schools may reflect upon different perceptions of students as far as the educational environment on which they acquired knowledge or skills on certain subjects is concerned. The majority of the Ancona students acquired knowledge through didactic conferences, while Athens students declared a wider variety of choices.
The suitability of traditional teaching (i.e.ward/operating room) was questioned in two recent studies. In one study students rated patients’ examination in the outpatient department as the best educational environment.14 In a second investigation students in the outpatient/clinic based setting had a greater chance to examine patients and to acquire knowledge and experience compared to the group in the ward/operating room based setting.16 This study also showed that personal study was of major importance for some topics (20.6% for urinary tract infections, 24% for sexually transmitted diseases, 10.3% for erectile dysfunction, 12% for scrotum diseases and 13.1% for testicular torsion). Comparatively, the respected percentages of United States students14 were quite similar: 12%, 38%, 4%, 20% and 27%. The reason why the specific educational environment was chosen was neither defined in our study, nor in the United States study.14 The importance of individual study as a way to acquire knowledge and experience in medicine should not be underestimated. The introduction of new technology and personal computers in education has signed successful application in Urology. An “Interactive Urology” software was successfully tested in Australia,17 while highly effective was training through the assistance of a personal computer in examining a virtual urological patient with prostate cancer, erectile dysfunction or lower urinary tract symptoms at Bristol Urological Institute.18 A similar program focused on the evaluation and treatment of a patient with hematuria was successfully applied at University of Texas.19
Learning from resident teaching was declared in a variety of percentages based on the topic. Similar were also the percentages in a respected study in the United States,14 a fact that highlights the important role of residents in undergraduate medical training. In another United States study it was revealed that 67% of medical students stated that the residents played an important role in education and that they owe them one third of the acquired knowledge.20
Patient examination is considered as the first step students make in clinical medicine. However, some students did not have any experience examining the abdomen (9.7%), the prostate (21.1%) and the scrotum (24%). Urology preceptors should not assume that students have examination experience, which has been reported by doctors beginning their postgraduate specialization.21,22 Additionally, some students indicated that they did not have any experience inserting a Foley urethral catheter (18.9% in total, 35.1% of the Ancona and 11% of the Athens students).
Many students in the study stated that after their training, they felt capable of handling certain medical problems. Reduced sense of sufficiency was noted in interpreting renal scintigraphy results (71.9% of Ancona and 84.8% of Athens students). This can be explained by the lack of didactic conferences on the subject. Significant differences between Ancona and Athens students were noted in a series of matters and reflect the differences in the educational procedures of both departments. Confidence to handle certain matters was, in general, independent of gender and future specialization plans. However, one study showed that fist year surgery residents presented a higher percent in correct evaluation of urological problems compared to internal medicine residents.23
Our study revealed that knowledge and skills in urology can be achieved through a variety of educational environments. Limitation of the study was not being able to discern whether theoretical knowledge could be applied successfully in real practice. Benchmarking different educational programs among European countries will help determine common standards in medical education throughout Europe based on general principles of the European Communities Directive 93/16, and perhaps lead to common learning outcomes.24
- Williams, D.I. The development of urology as a specialty in Britain. BJU International. 1999; 84(6): 587-594.
- Anonymous. Medical Curricula in European Countries. WHO European Center for Integrated Health Care Services, 1999.
- Spratt, J.S. and Papp, K.K. Practicing primary care physicians’ perspectives on the junior surgical clerkship. American Journal of Surgery. 1997; 173(3): 231-233.
- Rous, S.N., and Teitelbaum, H. To determine educational objectives for undergraduate urologic teaching. Results of a comprehensive study. Urology. 1974; 3(1): 107-111.
- Benson, G.S. The decline of urological education in United States medical schools. The Journal of Urology. 1994; 152(1): 169-170.
- Teichman, J.M.H., Weiss, B.D. and Solomon, D. Urological needs assessment for primary care practice: implications for undergraduate medical education. The Journal of Urology. 1999; 161(4): 1282-1285.
- Culp, O.S., Burns, E., Flocks, R.H., Higgins, C.C., Hotchkiss, R.S., Vest, S.A., and Weyrauch H.M. The present status of undergraduate urologic training: report of the committee to study urology in medical schools. The Journal of Urology. 1956; 76(4): 309-322.
- Rous, S.N., and Mendelson, M. A report on the present status of undergraduate urologic teaching in medical schools and some resulting recommendations. The Journal of Urology. 1978; 119(3): 303-304.
- Rous, S.N., and Lancaster, C. The current status of undergraduate urological training. The Journal of Urology. 1988; 139(6): 1160-1162.
- Cowan, F.M., and Adler, M.W. Survey of undergraduate teaching in genitourinary medicine in Britain. Genitourinary Medicine. 1994; 70(5): 311-313.
- Collins, M.M., Barry, M.J., Bin, L., Roberts, R.G., Oesterling, J.E. and Fowler, F.J. Diagnosis and treatment of benign prostatic hyperplasia: practice patterns of primary care physicians. Journal of General Internal Medicine. 1997; 12(4): 224-229.
- Olesen, F., and Oestergaard, I. Patients with urinary tract infection: proposed management strategies of general practitioners, microbiologists and urologists. The British Journal of General Practice. 1995; 45(400): 611-613.
- Roberts, R.G. Prostate cancer, screening, and the generalist physician. The Journal of Urology. 1994; 152(5 pt 2): 1693-1694.
- Teichman, J.M.H., Monga, M. and Littlefield, J.H. Third year medical student attitudes toward learning urology. The Journal of Urology. 2001; 165(2): 538-541.
- Shah, J., Billington, R., Manson, J. and Vale, J. Undergraduate urology: a survey of current provisions and guidelines for a core curriculum. BJU International. 2002; 89(4): 327-330.
- Kerfoot, B.P. and DeWolf, W.C. Does the outpatient setting provide the best environment for medical student learning of urology? The Journal of Urology. 2002; 167(4): 1797-1799.
- Khadra, M.H., and Guinea, A.I. Interactive urology: an evaluation. The Australian and New Zeland Journal of Surgery. 1996; 66(7): 478-480.
- Elves, A.W.S., Ahmed, M. and Abrams, P. Computer-assisted learning; experience at the Bristol Urological Institute in the teaching of urology. British Journal of Urology. 1997; 80(suppl 3): 59-62.
- Teichman, J.M.H. and Richards, J. Multimedia to teach urology to medical students. Urology. 1999; 53(2): 267-270.
- Bing-You, R.G. and Sproul, M.S. Medical students’ perceptions of themselves and residents as teachers. Medical Teacher. 1992; 14(2-3): 113-118.
- York, N.L., Niehaus, A.H., Markwell, S.J. and Folse, J.R. Evaluation of students’ physical examination skills during their surgery clerkship. American Journal of Surgery. 1999; 177(3): 240-243.
- Sachdeva, A.K., Loiacono, L.A., Amiel, G.E., Blair, P.G., Friedman, M. and Roslyn, J.J. Variability in the clinical skills of residents entering training programs in surgery. Surgery. 1995; 118(2): 300-308.
- Martin, L.F., Bell, R.A., Harty, J.I., Spratt, J.S. and Polk, H.C. Jr. Are learning objectives useful in evaluating medical school course and instructor performance? Southern Medical Journal. 1995; 88(12): 1241-1248.
- Leinster, S. Standards in medical education in the European Union. Medical Teacher. 2003; 25(5): 507-509.
NOTE: Please refer to the complete PDF file for the referenced Tables and Figures