Abstract
The objectives of this study are to determine self-assessed knowledge and skills in sexual health and HIV medicine in preregistration house officers and to explore undergraduate experiences of teaching and assessment in these subjects prior to the launch of National Core Learning Outcomes in Sexual and Reproductive Health and HIV. The study was designed as a postal questionnaire survey. The participants were all UK medical graduates of August 2004. The response rate 1737/4746 (36%). The main outcome measures were Doctors’ views on their preparedness to manage patients with sexual health and HIV-related problems. Since graduation, 90% of respondents had seen at least one patient with a sexually transmitted infection or HIV-related issue. Seventy-six percent felt confident to take a sexual history. In all, 63% and 53% felt competent in male and female genital examination, respectively. Forty-three percent felt they could conduct an appropriate HIV pretest discussion and 59% felt they could recognize clinical indicators suggestive of HIV. Seventy-eight percent had been formally assessed in sexual health and 55% in HIV medicine. Increased confidence in sexual history taking, HIV pretest discussion and recognition of HIV indicators was associated with a longer duration of teaching and formal examination. In conclusion, although the proportion of recent graduates confident in sexual history taking is encouraging, their lack of skill in discussing HIV testing, risk assessment and recognition of possible HIV presentations must be addressed. Integration of National Core Learning Outcomes into all undergraduate curricula is a key step in reducing inconsistencies in undergraduate training.
INTRODUCTION
The deteriorating sexual and reproductive health of the UK is widely acknowledged. 1–3 Delayed identification and treatment of sexually transmitted infections (STIs) increases transmission and disease burden. 4 Late diagnosis of HIV is a major contributor to morbidity and mortality and a significant proportion of late presenters pass through secondary and/or primary care without consideration of HIV as a possible diagnosis and without an offer of HIV testing. 5,6 A steady rise in the number of people living with HIV has already greatly increased their presentations in a wide range of clinical settings and there is growing support for mainstreaming HIV testing. It is essential that medical students are equipped with the necessary knowledge, skills and attitudes to manage people with sexual health, HIV and reproductive health-care needs irrespective of their eventual specialization. The National Strategy for Sexual Health and HIV for England 7 clearly states that there is an expectation of a basic level of competence for all doctors covering several areas within the broader context of sexual health.
Inconsistencies in undergraduate medical education in genitourinary (GU) medicine across the UK are a long-standing issue. 8,9 A specialty-led National Consensus Document for a core GU medicine and HIV curriculum was published in 1999, 9 but this has had limited success in correcting the discrepancies in teaching. In a further step to improve standards, the specialist professional societies in sexual and reproductive health and HIV united to produce a set of core learning outcomes reflecting the changing needs of students and universities and the priorities of the National Strategy. 7 The societies propose that national adoption of the learning outcomes will bring improvements to undergraduate education, providing graduating doctors with the relevant skills, knowledge and attitudes for better patient management to improve the sexual health of the nation.
This study determines recent medical graduates’ views on their undergraduate educational experience and their preparedness to manage patients with sexual health and HIV-related problems as a benchmark against which the impact of the Core Learning Outcomes in sexual and reproductive health and HIV 10 can be measured. Work in other specialities has identified the need for more focus on specific competencies and emphasized the need for a formalized curriculum. 11,12 To our knowledge, no previous studies have considered doctors’ self-assessed skills and knowledge in sexual health and HIV in the UK or internationally.
METHODS
We developed our questionnaire using the Core Learning Outcomes in Sexual and Reproductive Health and HIV 10 as a reference for knowledge and skills questions and used both tick box responses and five-point Likert scales. We revised the questionnaire after a pilot phase with a small group of pre-registration house officers (PRHOs).
We searched the General Medical Council register for all provisionally registered doctors who first entered the register between May and November 2004, excluding non-UK-trained doctors as we were primarily interested in UK undergraduate experience. We sent each doctor a letter explaining the nature and purpose of the study, a study questionnaire and a prepaid return envelope. We took the return of the completed questionnaire as consent to take part in the study.
Questionnaires were sent in May 2005 to allow sufficient time for the PRHOs to have encountered patients with sexual and or HIV-related needs since graduation. The questionnaires were anonymized, but coded to allow a second round of questionnaires to be sent out to non-responders six weeks after the first one.
Data from returned questionnaires were double entered into a database by a data entry company. Associations between explanatory factors and confidence measures were presented as odds ratios with 95% confidence intervals and testing based on logistic regression. The simultaneous association of multiple explanatory factors was examined using multiple logistic regression. Agreement between related items was assessed using the kappa statistic. All analysis was performed in Stata 9.
The East London & City Research Ethics Committee stated that this study did not need to be reviewed by a research ethics committee.
RESULTS
In all, 1729 completed questionnaires were received for analysis from 4746 eligible PRHOs (36.4% response rate). Sixty-six percent of respondents were women (n = 1131, 42.7% response rate) and 34.4% men (n = 593, 28.7% response rate), and this difference in response rate was significant (P < 0.001). Some questions were not answered by all respondents. If the denominator was less than 1729, this is indicated below.
Undergraduate education and assessment
We asked respondents to consider the core and/or optional sexual health and HIV education they had received during their undergraduate studies. Ninety-eight percent (n = 1692/1721) of respondents had received GU medicine teaching at some point and for 91% (n = 1523/1721) this was part of their core undergraduate curriculum. In contrast, only 73% (n = 1213/1696) had HIV medicine included in their core curriculum and 8.7% (n = 148/1696) had received no HIV teaching at all.
There was considerable variation in curriculum time devoted to GU medicine and HIV teaching. In all, 88.1% (n = 1466/1663) had received one or more days of GU medicine teaching (median 2–5 days, range: no teaching to over 10 days). Less time had been devoted to HIV medicine: 50.6% (n = 799/1579), had one day of HIV teaching or less (median 1 day, range: no teaching to over 10 days).
Respondents had experienced a wide variety of teaching methods. These included: teaching by a health-care professional in outpatient clinics, lectures, small group seminars and video-based sessions and all were felt to be effective. Teaching which involved patient contact in clinic was rated as ‘extremely effective’ by over half our sample (data not shown).
The majority of students (77.9%, n = 1334/1713) had been formally assessed in GU medicine. However, only 54.6% (n = 928/1699) reported any type of formal assessment in HIV medicine at any stage in their undergraduate training. Respondents reported a variety of assessment methods. Of those reporting assessment in GU medicine and/or HIV, 72.1% (982/1362) had been examined with multiple choice questions, 61.6% (839/1362) had experience of objective structured clinical examinations (OSCE) and 55.6% (758/1362) extended match questions.
Postgraduate experience of patients with sexual health and/or HIV-related problems
At the time of our survey, most of our respondents had been working for a minimum of six months following graduation. Almost all (90.1%, n = 1553/1725) had seen at least one patient with an STI and/or HIV-related problem. More than half (53.9%, n = 930/1725) had seen more than three patients of either type and 52.7% (n = 909/1724) had referred one or more patients to a GU medicine or HIV physician. PRHOs who graduated from London medical schools were more likely to have encountered patients with HIV (407/485, 83.2%) than those who trained elsewhere (911/1236, 76.1%, P = 0.001). However, there was no association between experience of patients with other STIs and location of training.
Respondents’ perceptions of their skills and knowledge in a variety of sexual health and HIV-related areas are shown in Table 1.
PRHOs self-perception of skills/knowledge in sexual health and HIV medicine
STI = sexually transmitted infection; GU = genitourinary
*Bold type indicates the median response
For male and female examination, reported competence was significantly higher if the respondent was the same gender as the patient. The lowest rate of competence reported was by male respondents for female examination at 37% (n = 217/593), and the highest by male respondents for male examination at 74% (n = 438/592).
Factors associated with confidence in key skill areas
Logistic regression and multiple logistic regression analysis of associations between factors in undergraduate education and key sexual health and HIV competencies are shown in Table 2.
Factors involved in self-assessed confidence in skills/knowledge
*Adjusted for those other factors in the table and also: gender, ethnicity and whether teaching part of a specialist module
†If any examination
Greater confidence in taking a sexual history, discussing HIV testing with patients and recognizing indicators of HIV infection were all independently associated with inclusion of sexual health and HIV in the core curriculum and longer duration of teaching. Confidence in the examination of female patients was also independently associated with a longer duration of teaching, although confidence in examination of male patients was significantly associated with the duration of teaching on univariate analysis, significance was lost on multivariate analysis. The reasons for this are unclear.
Experience of any type of examination in sexual health and HIV was associated with greater confidence in these skills on univariate analysis, but this was not significant in the multivariate model. As one might expect, experience of an OSCE examination was independently associated with confidence in these areas, whereas no such association was apparent for confidence in knowledge-based questions, for example knowledge of genital anatomy and physiology (data not shown). Associations with confidence in discussing partner notification were similar to those with taking a sexual history and discussing HIV testing (data not shown).
The overall level of confidence in action required after a sharps injury and potential risk of blood-borne viruses was high (93.5%, n = 1612/1724). No association was observed between confidence and duration of teaching, type of teaching or assessment (data not shown).
DISCUSSION
Policy context
In 2006, sexual health became one of the six National Health Service (NHS) priority areas. 13 This and the earlier National Strategy for sexual health and HIV 7 have focused efforts by specialist and primary care service providers on improving the nation's sexual health by widening access to sexual health care by offering services in a diverse range of settings. The strategy also advocated easier access to HIV testing in order to address the high proportion of undiagnosed HIV infections, 14 and proposed that all health-care professionals should have a greater awareness of HIV infection in order to meet the needs of the growing number of HIV-positive people who present to a wide variety of specialist and non-specialist medical services. Our data from recent graduates support this: almost all PRHOs had encountered patients with sexual health and HIV-related needs in their first year after graduation and more than half had seen more than three patients with an STI or more than three with known HIV infection. With an estimated 63,500 adults living with HIV in the UK at the end of 2005, 15 doctors need to be competent and confident in basic skills in these areas in order to manage patients safely and appropriately in the year after qualification as well as later in their careers.
Undergraduate student experience
There have been substantial specialty-led educational efforts at the postgraduate level to improve the skills of health-care providers in order to support these service changes. 16 However, as our study and previous studies show, similar educational investment has not occurred at the undergraduate level. A survey of all UK medical schools in 2000 reported considerable variation in undergraduate teaching experience in sexual health with a median of 12.5 hours (range 3–55 hours) devoted to sexual health teaching. 17 Our respondents report similar variations in teaching time with a median of 2–5 days (range 0.5–10 or more days). Seventy percent reported receiving more than two days of GU medicine teaching activities. The picture for HIV is more worrying, with over half of our respondents reporting one day or less spent on HIV medicine. Assessment is equally patchy: almost three-quarters of our sample had been assessed in sexual health but only just over half of the respondents had received any assessment in HIV medicine. It appears that this growing need for greater knowledge and skills in HIV medicine for all doctors has not been recognized by curriculum planners. Some universities still appear to view HIV medicine as the preserve of the specialist, with little role in the undergraduate curriculum.
Confidence in knowledge and skills
If we are to reach the targets set out in the National Strategy for Sexual Health and HIV for England, 7 basic skills around diagnosis and management of STI and HIV should be within the reach of all graduates, regardless of specialty. 10 It is encouraging that, in general, respondents were confident in their communication skills around sexual health issues. The vast majority felt they were able to give advice on safer sex and over 75% felt prepared to take a sexual history. However, only 63% of PRHOs felt competent in genital examination of male patients and just over half for female patients. Two-thirds felt they knew when it is appropriate to refer patients to GU medicine services. Similar deficits were described from an audit of accident & emergency (A&E) doctors and gynaecologists practices as far back as 1993. 18
Current screening campaigns for HIV in the UK rely on targeted assessment of risk and screening as appropriate and mandate that HIV testing is carried out with full informed consent. 19 In this context, it is worrying that only 43% of recent graduates felt able to conduct an appropriate HIV risk assessment/pretest discussion. The literature on willingness, confidence and competence in HIV risk assessment and pretest discussion suggests that our findings reflect an international problem. 20,21 Around 40% of PRHOs did not feel competent in recognizing common presentations of possible HIV infection in undiagnosed patients. The combination of this gap in HIV diagnostic skills and a lack of perceived confidence in HIV risk assessment may mean that many opportunities for timely HIV diagnosis are missed. This can only result in poorer outcomes for patient care. 5,6
The finding that only 39% of respondents felt prepared to discuss partner notification (informing sexual partners of their exposure to a STI and facilitating testing and treatment) for STIs is worrying as this is fundamental to STI management. 22 Recent National Institute of Clinical Excellence guidance 23 stresses the importance of partner notification to the management of patients with STIs regardless of where they present. Although we would not expect recent graduates to be highly skilled in partner notification, there is an expectation of basic competence in this area and clearly more emphasis is needed at the undergraduate level to achieve this.
The high level of confidence about what to do following an occupational needlestick injury (94% felt confident) was unrelated to duration or type of teaching or assessment (data not shown). This may indicate that this is a result of postgraduate rather than undergraduate training or of HIV prevention advice given to undergraduates planning to undertake elective placements in high-prevalence areas.
Factors associated with greater confidence
In this study, longer duration of teaching, inclusion of sexual health and HIV in the core (non-optional) curriculum and provision of a clinical assessment (OCSE) were all independently associated with greater confidence in PRHOs’ ability to competently perform fundamental sexual health and HIV medicine skills. Respondents expressed high levels of satisfaction with clinic-based teaching methods. However, a number of medical schools have moved away from teaching students in the sexual health clinic environment as they cannot accommodate the rise in student numbers at a time when service pressures are reducing clinicians’ availability to teach. More work is needed to understand which elements of this type of learning the students value most and how we can most effectively manage the competing pressures of service provision and meaningful clinic-based teaching.
Limitations
We acknowledge that limitations to our study design may have introduced bias in our findings. We present data from just over 1700 PRHOs, but our response rate was disappointing (despite using a number of methods known to improve response rates) 24 when compared with previous questionnaire surveys of PRHOs. 25 The ratio of female to male graduates in the database was 56:44; the female:male ratio for those who responded was 66:34. Men were therefore under-represented in our sample. It is possible that the specific nature of the questionnaire meant that respondents were doctors with more of an interest in sexual health and HIV than non-responders, which may have led to a bias towards more optimistic assessment of confidence in these areas than might be the case for all PRHOs. The GMC Medical Register was used to identify eligible doctors, but it is believed that for many doctors the registered address is not their current residential address (Jane Janeaway, General Medical Council, personal communication). This may have contributed to further attrition.
Our study relied on self-reports as an indication of experiences and of confidence. It is important to exercise caution in assuming that confidence is a wholly robust surrogate marker for competence as data from published studies in this area are conflicting. 26–28 Measures of confidence within this paper, therefore, must be interpreted within this context.
Recommendations
This study provides much needed evidence upon which to base strategies for addressing the current shortfall in UK medical graduates’ confidence in basic sexual health and HIV medicine skills. We believe that curriculum planners, supported by sexual health and HIV specialists, should adopt the following three strategies: inclusion of sexual health and HIV medicine in the core (non-optional) curriculum by utilizing the core learning outcomes in sexual and reproductive health and HIV 10 as a reference tool; ensuring adequate curriculum time is spent on sexual health and particularly HIV-related activities; and including key sexual health and HIV skills in existing OSCE-type examinations. These recommendations are within reach of every UK medical school and we urge specialists to review the undergraduate curricula at their own medical schools and urgently address any shortfalls.
Footnotes
ACKNOWLEDGEMENTS
We are very grateful to all the PRHOs who took time to participate; Dr Helen Mitchell for early assistance with study design, Dr Kitty Mohan for providing a junior doctor perspective, Abacus Ltd for data entry, Ms J Chapman, Ms Helen Burgess for administrative support and the BASHH undergraduate working group: Claudia Estcourt (Institute of Cell & Molecular Science, Queen Mary University of London and Ambrose King Centre, Barts and the London NHS Trust, London), Nick Theobald (Chelsea & Westminster Hospital, London), Loay David (Department of GU Medicine, George Eliot Hospital, Nuneaton, Warwickshire), Anne Edwards (Oxford Department of Genitourinary Medicine, Churchill Hospital, Oxford), Helen Mitchell (Centre for Sexual Health & HIV Research, University College London), Martin Fisher (Brighton and Sussex University Hospitals), David Goldmeier (St Mary's Hospital, London), Paddy Horner (Bristol Royal Infirmary, Bristol), Melinda Tenant-Flowers (Department of Genitourinary/HIV Medicine, Caldecot Centre, King's College Hospital, London), Jyoti Dhar (Leicester University Hospital, Leicester)
The BASHH publication ‘Core learning outcomes in sexual and reproductive health and HIV for medical undergraduates’ can be accessed at