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Arch Dis Child. 2007 April; 92(Suppl1): A71–A74.
PMCID: PMC2066120


Paediatric education

G/THUR/EDU1 An audit of SpR training at a large district general hospital: is it possible to meet the RCPCH standards for core training within the constraints of the EWTD, on a full shift rota?

K. Lamb, M. Zalkin. North Middlesex University Hospital (Great Ormond Street Hospital for Children NHS Trust), London, UK

AimsTo determine if the Standards and Criteria for Core Higher Specialist Training as laid down by the RCPCH are being met by core trainees working a band 2a rota in a large district general hospital.

MethodsAudit forms were sent out and returned by email weekly over 10 weeks. Shifts worked by each registrar were analysed retrospectively from the rota over the same time period.

ResultsTime spent at work between 8.30–5.30; 49%. Time spent out of designated clinical areas; 20% (when out of hours work excluded) 61% (as proportion of total time at work). Clinic attendance; 41% of the recommended number of clinics were attended within the 10 weeks. Teaching; amount attended (weeks audit returned) 42%, bleep rate 75%. Reasons given for non‐attendance were: cancelled 18%, leave 16%, nights 11%, rostered off 12%, clinic 1%, late evening shift 7%. Ward rounds; 3 out of 8 registrars met the standards for ward round attendance. 10% of ward rounds were registrar led.

ConclusionsIt is not possible to meet the current RCPCH recommendations for training whilst working this full shift rota. Simple changes can improve training but still leave RCPCH standards a long way off being met. The factors contributing to lack of training are nights/twilight shifts, rostered time off and the fact that the amount of time spent at work when most training occurs is less than 50%. These factors are difficult or not possible to change. Other hospitals employ similar rotas so we therefore anticipate that these problems with training would be encountered by other core trainees, but further audits are needed to look at this. As the EWTD is here to stay we need to be more innovative with regard to training, to take advantage of the large amount of working time spent in the hospital out of hours, while working reduced total hours. The RCPCH needs to address the training issues highlighted within this audit in light of the recent changes. The training guidelines need to be re‐thought to fit in with how we work today, alongside the competency‐based assessment that Modernising Medical Careers will bring.

G/THUR/EDU2 A decade of paediatric back tapping

E. A. Kieran, R. K. Philip. Mid‐Western Regional Hospital, Limerick, Ireland

Aim(1) To analyse trends in the successful diagnostic lumbar puncture (LP) rates and results among the paediatric and neonatal population at a regional paediatric and level 3 neonatal facility over a 10‐year period. (2) To draw conclusions about our current clinical practice and to suggest best care selection guidelines for immunocompetent and immunised population. (3) To recommend junior doctor training diagnostic lumbar puncture skills.

MethodsA retrospective review of the laboratory data on all successful lumber punctures carried out on patients under the age of 16 years from July 1996 to June 2006 in a regional paediatric and maternity hospital (paediatric drainage population of 100 000, average in‐house birth rate of 4000 per annum). For each positive CSF result information was retrieved on inflammatory markers (total WCC, neutrophils, platelets, CRP), blood culture and PCR results on samples taken during the acute illness.

ResultsA total of 1198 lumbar punctures yielded CSF samples to the laboratory during the study period. Total samples from July 1996 to June 2001 were 724; same from July 2001 to June 2006 were 474, showing a 35% decrease over the second five‐year period. In total 3.8% of samples were positive. Blood cultures were positive in only 42% of patients with positive CSF results. The most common organism was Neisseria meningitidis group B (37%). Hib and Men C vaccines were introduced in 1992 and 2000 respectively and there were only 3 CSF positive Hib and no Men C results since. During the study period the number of paediatric junior doctors increased from 6 in 1997 to 20 in 2005, and that of consultants from 3 to 5.

ConclusionThere is a continued decrease in lumbar puncture rates. There were only a small percentage of positive results in the 2–16‐year age group (26% of total positive). With the proven success of the Hib and Men C vaccine programmes and the current introduction of pneumococcal vaccination, is it necessary to carry out lumbar puncture in all suspected meningitis cases or only in selective circumstances? With the above results showing a significant decrease in frequency of lumbar punctures, along with the increase in number of paediatric trainees, it is reasonable to assume that there could be a decrease in procedure skill and confidence among current junior doctors—should formal practical training be part of current training schemes?

G/THUR/EDU3 Evaluation of the use of equipment competency checklists

N. K. Sujay, N. J. Shaw. Liverpool Women's Hospital, Liverpool, UK

IntroductionThere is an emphasis on competency‐based training in postgraduate medical education. Validation of competency is important to ensure good clinical governance and documentation of this is required to support CNST standards. In our neonatal unit equipment competency checklists have been introduced for all staff, including medical trainees, to try and ensure the appropriate level of training in the items of equipment specifically used by different staff groups.

AimTo determine whether the competency checklists have been used appropriately by the neonatal SHOs, whether they perceive that other competencies should be added to the checklists and whether use of the checklists may facilitate development of competencies.

MethodAt three months into their current post, the eight neonatal SHOs had their competency check lists reviewed with an SpR. A proforma was completed identifying how many of the checklists had been used and to what extent. SHOs were asked to complete a questionnaire about their perception of the usefulness of the competency checklists, whether other competencies should be included and whether they had any suggestions to improve the training in competencies. SHOs were also tested on the items on the checklists that they had assessed themselves as being competent at.

ResultsAll eight SHOs completed the competency checklists (four incompletely). All rated themselves competent to use the ventilator, Infant Flow Driver and resuscitaire (some after requesting extra training) and all used these items of equipment in routine practice. However, on testing, the eight SHOs failed a total of 26/80 (33%) competency items for the ventilator, 7/64 (11%) for the Infant Flow Driver and 19/120 (16%) for the resuscitaire. With respect to the controls on the monitoring system, only five SHOs used them in routine practice and 44/80 (55%) of competency items were failed. The SHOs all found the competency checklists useful and suggested other items to be added and extra training for some items.

ConclusionsUsing our competency lists has highlighted deficiencies in SHOs competencies and has help to identify items of equipment that perhaps should not be used routinely by SHOs. The lists when used as part of educational supervision may facilitate targeted training to improve these deficiencies.

G/THUR/EDU4 Leadership training in critical care medicine

T. Vince. Children's Acute Transport Service, London, UK

AimsEffective team leadership is imperative to patient outcome, particularly in critical care medicine. Current trainees receive no formal leadership training but may access it through classroom‐based courses. We explored the feasibility and effectiveness of a practical training programme to address this deficit.

MethodsPaediatric critical care trainees in North Thames, seconded to a specialised retrieval service, are expected to maintain a logbook of retrievals. In 2005, all trainees received formal teaching and mentoring on reflective practice, with respect to leadership skills, such as conflict resolution and negotiation. Thereafter, trainees recorded retrievals as episodes of reflection and discussed anonymised cases at daily team meetings. Semistructured questionnaires were used to assess perceptions of reflective learning and identify facilitating or hindering factors. Group interviews with all members of the multidisciplinary team were also conducted to further explore these themes.

ResultsTrainees perceived deficits in leadership skills but were wary of reflective learning at the start of the project. However, despite work intensity, trainees perceived benefits of reflection. Those trainees open to reflection perceived greatest benefits by identifying personal learning needs and modifying practice. While organisational factors facilitated reflection, the strongest facilitator was a supportive curriculum and team. Both organisational and emotional factors (fear of criticism and competency assessment) were deemed barriers. The senior medical team and some nursing staff were sceptical of the benefits of reflection and in the context of reduced trainees' hours, gave greater priority to service delivery and clinical training. This permitted resistant trainees to avoid the practice and adversely influence remaining trainees.

ConclusionsUsing reflective practice, leadership training is effective and can be achieved in a busy post. However, it requires an actively supportive curriculum and environment to facilitate the process and maximise its benefits. This will necessitate a shift in the culture of junior doctor training and commitment from trainees and trainers. While some trainees may find reflective practice unacceptable, identifying alternative cost‐effective means of leadership training is difficult. Efforts should focus on addressing negative preconceptions and integrating reflective practice into current training.

G/THUR/EDU5 The effect of student to teacher ratio on the performance of 4th year medical students in paediatrics

N. Kennedy, M. Shields, M. Stewart, D. Carson. Queen's University, Belfast, UK

BackgroundThe expansion in medical student numbers means that increasing numbers are being assigned to smaller, peripheral units for their clinical attachments. Concern has been raised that effective teaching in these units will be compromised if additional clinical staff are not available.

AimTo study the effect of student to teacher (S:T) ratio on the performance of medical students in their 4th year paediatric attachment.

MethodsFrom Sept 2001–Dec 2005, 775 students completed an 8‐week paediatric module which included a 6‐week clinical attachment. Performance in the four components of the assessment (in‐course case commentary and tutor assessment, end‐of‐course clinical and written examination) and overall score were compared with individual S:T ratio. Potential confounding variables included student gender, unit students were assigned to, number of students in their group, number of clinical teachers in the unit, and timing of the attachment (students complete paediatrics in one of 5 blocks per year)

ResultsMedian (range) S:T ratio in each unit, 0.89 (0.25–1.4). 143 students were assigned to the tertiary unit, 632 to one of 7 peripheral units. S:T ratio was significantly lower (p<0.001) in the tertiary unit (mean 0.59, SD 0.18) compared with that in peripheral units (mean 0.87, SD 0.21). In univariate analysis female students had significantly higher marks than males in each component; the unit and timing of the attachment had small but statistically significant effects on student performance; S:T ratio had no effect. In multiple regression, R2 for a model including these factors was low at 0.04. After accounting for gender, unit and timing, S:T ratio had a significant inverse effect on clinical examination score, but on no other part of the assessment or total mark. A lower S:T ratio was associated with a higher clinical exam score.

ConclusionAlthough students performed better in the clinical exam component of the 4th year paediatric assessment if the S:T ratio was lower, there was no effect on the other components or overall score. Gender, the unit students were attached to and the timing of the attachment had a greater influence on performance in the assessment.

JMacDonaldA survey of staff attitudes to increasing medical undergraduate education in a district general hospital. Med Educ200539 pp 688-95

G/THUR/EDU6 Mutual benefits of formal senior house officer‐led medical student teaching in two busy paediatric departments with a university teaching hospital

S. Rajapaksa1, S. Gough2, D. Nathan3. 1Royal Berkshire Hospital, Reading, UK; 2Lincoln County Hospital, Lincoln, UK; 3Queen's Medical Centre, Nottingham, UK

AimsThe expansion in medical student numbers means potential for student anonymity and decreased patient exposure. We organised a pilot study to qualitatively assess a junior doctor (SHO level) led student mentoring programme, to see if it was mutually beneficial for SHOs and medical students within the paediatric department of two University Hospitals.

MethodThirteen SHOs and 26 medical students volunteered to take part. One consultant oversaw the project. Participants formed mentoring partnerships with 1 to 2 students over the 10‐week medical student placement and completed a learning contract. Partnerships mutually decided content and timing of teaching sessions. The SHO mentoring scheme ran alongside the existing teaching programme—that is, consultant/middle grade tutorials and bedside teaching sessions. At the end, each participant completed a purpose designed questionnaire consisting of free text questions and statements asking them to rate various aspects of their experience on a Likert scale (1–10).

Results88% students and 92% SHOs completed feedback. The median number of teaching sessions completed was 3.5 with wide variation. SHOs found the experience enjoyable (median 9.5); felt more confident to teach (median 8.5); without impairment of clinical duties (median 1) nor increased workload excessively (median 1). Medical students found having a SHO mentor useful (median 9.5); it allowed them to practise clinical skills in a relaxed environment (median 9.75); ask questions not brought up in a formal environment (median 9) and easy to contact SHO (median 8). Minimal sessions were cancelled due to clinical commitments (median 2). Students who delayed contacting their mentor initiated the programme halfway through their paediatric attachment.

ConclusionThis study shows medical students appreciate the extra support and paediatric SHOs value the teaching experience. SHO mentoring is cost effective and a useful component of undergraduate teaching. Generic teaching/training responsibilities could be formally included within junior doctors' posts within the MMC structure.

G/THUR/EDU7 Using scenario development and enactment to teach medical students about paediatric emergency conditions and to practice skills appropriate for foundation year one doctors

F. Hampton1, G. Birrell2. 1James Cook University Hospital, Middlesbrough, UK; 2Faculty of Medical Sciences, University of Newcastle, UK

AimsThe undergraduate medical course has been evolving to produce doctors with appropriate knowledge and skills to function as foundation year ones (FY1s). This should ideally include exposure to emergency situations in children. With curriculum revision reaching final year in 2005 we aimed to develop an innovative theoretical session to cover FY1 management of some relatively uncommon paediatric emergencies unlikely to be encountered during a 3‐week paediatric attachment.

MethodsWe outlined 4 scenarios: diabetic ketoacidosis, severe asthma, prolonged febrile seizure and a septic neonate. 2–4 students worked together in designated time to develop their case in more detail from the brief introduction provided. The students devised a full history, details of examination findings, results of investigations and a management plan with written drug and fluid charts. From this they also developed a score sheet to mark their colleagues. A detailed written work‐up of an acute allergic reaction was provided as an example. Pre‐prepared results and local protocols were available from a resource pack at the request of the devising students. The scenarios were then enacted over 3 hours in groups of 6–8 students with a facilitator. As well as being the information source for their scenario, each student led part of another scenario as an FY1 while the facilitator kept time and checked accuracy.

ResultsFeedback from regular course monitoring is available from 51 (94%) of 54 students attending over 2 years. Six students felt it was their best paediatric teaching session, 2 their worst. Many students used positive words such as “useful” (9); “good” “excellent” or “fun” (24); “good for prescribing” (7); “learnt loads” (5). Several commented that it made them feel like FY1s and that it was the first time they really had to think on their feet (“highlighted what I didn't know but thought I did”). It was an intense session for some. A few highlighted that more time would be useful for the enacting, and that it may have worked better in the clinical skills laboratory with props available.

ConclusionThis innovative way of teaching has proved very popular with the students. It has highlighted to them the importance of decision making and writing prescriptions and has made them feel like FY1s. Many showed great enthusiasm devising the scenarios, suggesting they were learning from this as well as from the enactment. That the teaching style did not suit everyone is not unexpected with the range of students and individual learning styles.

G/THUR/EDU8 Do we effectively communicate to parents what is wrong with their sick child? A study of communication skills of junior doctors

A. Soni, S. Kapoor. Scunthorpe General Hospital, Scunthorpe, UK

AimsTo investigate whether parents are informed and able to understand the diagnosis of their sick child. To also study communication skills of paediatric junior doctors and paediatric nurse practitioners.

MethodsThis was a prospective study. Consecutive patients attending the assessment unit of our Paediatric Department during May 2006 were included in the study. Patients who required admission to ward were not included. Parents were asked to fill in a questionnaire just before they were leaving the assessment unit. They were asked to record what they understood their child is suffering from. They were also asked questions on the communication skills of the doctor/nurse practitioner they had seen. A record was kept of the diagnosis made by the discharging doctor.

ResultsForty five parents filled and returned the questionnaire. 93.3% (42 out of 45) parents rated the doctor whom they saw as excellent or very good. 97.8% parents felt they were able to understand what they were told about their child's condition and an equal number felt very confident in looking after their child now. However only 57.8% (26 out of 45) parents were able to say correctly what their child was suffering from.

ConclusionIt is important that parents are aware of their child's diagnosis. In our study only slightly more than half of the parents were able to correctly say their child's diagnosis in spite of being very satisfied with the communication skills of the doctor/nurse practitioner who saw them.

G/THUR/EDU9 Can we teach paediatric communication skills to student doctors in just 40 minutes?

C. Brown, H. Davies, J. Hurst. University of Sheffield, Sheffield, UK

AimsGood communication skills are inherent to good medical practice and need to be learned as early as possible during training to optimise the skill. Although student doctors at our medical school are taught generic communication skills in other areas during their training, their only opportunity to learn skills specific to the triadic paediatric consultation exist in a 40 minute interactive slot. We wanted to assess how effective the teaching of these skills was during this extremely short session.

MethodsThe session involves a brief resume of the important aspects of communication, and consultation structure, and then asks students to identify good practice from a video showing 12 brief clips of real patients where good consultation behaviour was modelled. A questionnaire was designed to allow students to give feedback on the session and also to allow identification of key learning points, surprises and ideas to practice in their placement.

ResultsOverall the session was well received with 132/152 students rating the session as useful, and 114/152 rating the session as highly enjoyable. Key learning points included involving the child, 104/152 (68%), structuring the consultation, 83/152 (55%), and using appropriate language/intonation, 79/152 (52%). Although some students claimed not to be surprised by any aspect of the consultations, many commented on the level of skill needed by the doctor to conduct the consultation well, 40/152 (26%), and also on the amount of patient involvement they saw being demonstrated, 34/152 (22%). When asked to identify how they could use their learning points most students stated that they would involve the child more, 49/152 (32%), structure the consultation appropriately, 45/152 (30%) or simply practice on placement, 41/152 (27%).

ConclusionDespite the very short time available for this session the key features of the triadic consultation seem to have been addressed, and recognised and identified as points to practice by the students. While longer communication sessions remain desirable, important aspects of paediatric communication skills can be taught in just 40 minutes.

G/THUR/EDU10 Audio‐visual calibration tools for examiners: the use of a “standardised student” to train undergraduate paediatric examiners

S. Wilson, G. Tudor‐Williams, H. Davies, M. Blair. Imperial College, London, UK

BackgroundOur university recently changed to a new form of formative, in‐course assessment for medical students in paediatrics, the mini‐clinical evaluation exercise (mini‐CEX). All examiners differ in their stringency (the “hawk/dove phenomenon”), and we saw this as an ideal opportunity to address interrater differences as well as train examiners in mini‐CEX.

AimsTo evaluate the usefulness of a training DVD at mini‐CEX examiner training workshops, as a pilot for assessing the effect of feedback on the scoring tendencies of undergraduate paediatric examiners.

MethodsSubjects were an opportunity sample of 27 paediatricians, paediatric registrars and staff grade paediatricians participating in 2 mini‐CEX training workshops. They scored a DVD depicting a “standardised student” taking a paediatric history or examining a child at 3 levels of competency. Scores were charted to create a frequency histogram and the results fed back to examiners. The critique of the “student” was discussed and scores at the extremes explored with examiners. Results of the opportunity sample were compared to a “gold standard” score derived from the assessment of the same DVD clip by 5 experienced undergraduate paediatric examiners.

ResultsInterrater reliability was high for the “below expectations student” but low for the “meets expectations/borderline student” (MEBS), indicating wide variation in the expectations of paediatric clinicians examining at undergraduate level. Of a possible 24 marks (minimum 6), the median mark for the MEBS was 16 (range 10–20). Examiners were often unaware whether they were “hawks” or “doves” until scoring tendencies were explored in the training session. All workshop participants felt the training DVD helped them to better understand the mini‐CEX process. The median of the experienced examiners was also 16, with a much narrower range (14–17) which we have previously reported.

ConclusionsExaminers found the DVD scoring session helpful to familiarise themselves with mini‐CEX and identify their rating style. Further work is in progress to objectively evaluate whether feedback about scoring tendency and comparison to a score agreed by experienced examiners will modify extreme scoring behaviour.

G/THUR/EDU11 Analysis of the new examination for DCH and MRCPCH

S. Newell2, A. Davies‐Muir1, T. Lissauer3, G. Muir1. 1RCPCH, London, UK; 2Leeds Teaching Hospitals, Leeds, UK; 3St Mary's Hospital, London, UK

The MRCPCH part 1a and DCH written examination was designed to test basic clinical knowledge, equating to training during a 4–6 month training post. It is a criterion referenced exam, screened to avoid bias or linguistic complexity, common to DCH (general practitioners) and MRCPCH. It has run for over 2 years in the UK and 20 overseas centres. It was anticipated that the MRCPCH candidates would perform better than DCH candidates, and that there may be a difference between UK and overseas graduates.

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Abstract G/THUR/EDU11

Performance analysis of the last 6 sittings of this examination shows a overall pass rate of 47.9%; total number of candidates 6188 (mean per sitting: 1031). The pass rate is stable among UK graduates. Overall, the pass rate is higher in the DCH group (n = 1347) than in the MRCPCH group (n = 4841) (p<0.001). However, analysis by place of graduation shows that this difference is limited to the overseas graduates (p<0.001) while there is no significant difference between UK graduates taking DCH or MRCPCH (p>0.5). There is a striking gulf between the UK (n = 1374; overall pass rate 81.1%, SD 2.7% across the 6 diets) and overseas graduates (n = 4814; overall pass rate 38.4%, SD 8.3% across the 6 diets) (p<0.001). There is no evidence of improvement in overseas MRCPCH candidates over the last 2 years.

The examination provides a stable method of assessment with an appropriate pass rate in the UK graduates. Our college needs further to address the causes of the poor performance by overseas graduates which may lie in content orientation, language, question format, training or access to examination preparation.

G/THUR/EDU12 Outcomes and evaluation of a multinational internet‐based postgraduate education programme in neonatology

M. Hall1, M. Cuttini2, A. Flemmer3, G. Greisen4, N. Marlow5, A. Schulze3, S. Smith1, P. Truffert6, A. Valls i Soler7. 1Department of Neonatal Medicine, Princess Anne Hospital, Southampton, UK; 2Unit of Epidemiology, Ospedale Pediatrico, Rome, Italy; 3Ludwig Maximilians Universitat Hospital, Munich, Germany; 4National University Hospital, Department of Pediatrics and Neonatology, Copenhagen, Denmark; 5Child Health, Queens Medical Centre, Nottingham, UK; 6Service de Medecine Neonatale, Hopital Jeanne de Flandre, Lille, France; 7Hospital de Cruces, Basque Country University Medical School, Bilbao, Spain

AimTo investigate the role of internet‐based postgraduate education in neonatology.

MethodsRecruitment of neonatal trainees was via email contact with members of the ESPR. Potential participants completed an online application form which recorded demographic data and reasons for wanting to participate. Over 1 year, 6 specialist neonatal modules were delivered within a European Neonatal Virtual Learning Environment (VLE). 12 neonatologists acted as online tutors to the groups of cross‐cultural trainees. The project was funded by the Leonardo da Vinci European Programme. Qualitative and quantitative data were collected from trainees and tutors at the start, midpoint and end of the project, using online questionnaires and login/activity data collected from the VLE. The questionnaire focused on 3 main areas: the extent to which the programme had achieved its aims and learning outcomes, the quality of the teaching and learning environment and the teaching and learning experience.

Results109 trainees from 14 countries expressed an interest in the programme; 52% were female. Reasons for wanting to participate included a desire to increase theoretical knowledge (50%), the opportunity to experience online learning (21%) and the benefits of networking (15%). 101 trainees started the programme; 11 withdrew for personal or professional reasons. At the midpoint 75% of the remainder were still participating and 41% completed the programme. Of the 90 trainees, 95% were contactable at the end of the project; 78% provided evaluation data. The most widely reported reason for non‐participation was lack of time (53%). 90% of responders reported that the programme had “added value” to their current training; 59% identified this as the up‐to‐date and flexible curriculum and 10% the multinational networking. More than 90% of both trainees and tutors would recommend the programme and would participate again.

ConclusionExternal evaluation indicates that this flexible online approach to postgraduate education meets a range of learning needs and styles that is not easy to replicate in other contexts. By adopting this modality, networking, collaboration and the sharing of best practice can add value to educational programmes. For this approach to become integrated into training programmes, consideration would need to be given to accreditation, professional recognition and the allocation of protected time.

G/THUR/EDU13 Teaching clinical skills in palestine: challenges and solutions of distance teaching

A. Morris1, T. Waterston3, N. Maraqa4, M. Rudolf2. 1Leeds Teaching Hospitals Trust, Leeds, UK; 2Leeds Primary Care Trust, Leeds, UK; 3Newcastle General Hospital, Newcastle, UK; 4Ramallah Government Hospital, Ramallah, Palestinian Territory, Occupied

IntroductionOver the last year the RCPCH Child Health Development Programme (Palestine) has run the first part of a pilot International Certificate of Child Health in Ramallah. This is designed as a course for qualified primary healthcare professionals (both medical and nursing) to develop and strengthen their paediatric assessment and management skills thus improving the medical care of children in this conflict‐torn country. The course, for a group of approximately 10 participants, consists of 11 modules that cover the breadth of child health.

AimTo develop a module to effectively teach clinical skills.

Challenges“Distance Teaching” for this module needed a greater emphasis on psychomotor domain learning, and presented a challenge as delivery was by a third party with a potentially unknown level of understanding of both the subject and of teaching skills. The extremely busy wards were also felt not to provide reliable teaching opportunities. IT facilities were available, but internet connections were very slow.

SolutionA blended learning package of hands‐on experience, e‐learning and workbooks aiming to cover higher order interpretation and decision making skills were developed. A systems‐based, case‐centred teaching package with images and video, requiring participants to complete answers in a pre‐written workbook was devised to meet this need. This would lead to group discussion with answers and revision of the topic with supplementary images and video. Detailed tutors' notes, alongside the course textbook, enabled a tutor of limited knowledge to answer potential questions.

EvaluationFollowing the implementation of the course we travelled to Palestine to deliver the course assessment and evaluate the experiences of the students and tutor. An overview of the course and module was obtained and specific difficulties and learning points were drawn.

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