2 EPIDEMIOLOGÍA Y FISIOPATOLOGÍA DEL CÁNCER DE PRÓSTATA.
B.- FACTORES DE RIESGO Y PROTECCIÓN DEL CÁNCER DE PRÓSTATA.
Before I begin the exploration of the non-clinical key themes, it’s important for context to address the distinction and relationship between clinical and non-clinical skills. This thesis explored the learning of all health professional cadres, therefore examining the clinical and profession specific skills would not be possible within the remit of this thesis. Literature also suggests there are significant parallels between the non-clinical skills gained across professions (13,14).
In terms of clinical development, professionals report greater opportunities to interact with a greater volume and breadth of patients; which had an impact on confidence in decision making (11,24,68). When interviewing trainee doctors about their international
placements, Kiernan et al. described how they attributed this clinical skill development to having greater hands-on experience (24). However, clinical skills development is not a guaranteed outcome of international placements, educators in the same study reported that whilst some professionals who undertook international placements had better clinical skills than their peers, for some there was no difference (24). Hence, international experiences alone are not enough to improve clinical skills, there must be other variables that influence the likelihood of this PPD development.
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Professionals’ PPD intentions are an interesting phenomenon in relation to clinical learning on international placements. It seems that whilst some professionals intend to develop specific clinical skills (often in regards to specific procedures or diseases), many report being surprised by the substantial development of non-clinical skills (43).
Professionals travel to LMICs with the intention of gaining clinical knowledge about unknown procedures, diseases and populations. Tate (43) interviewed 13 returned professionals and found that before they travelled 91% intended to develop specific clinical skills during the placement, whilst only 41% expected to develop leadership skills and 17% efficiency (43). Many of the junior doctors interviewed in this study reported objectives to gain experience in clinical skills that would be difficult to develop in the UK. Although professionals intended to gain clinical skills, much of what they reported to have learnt post-placement were non-clinical ‘soft’ skills that have a more distal professional impact. This indication that personal development often takes precedence over specific professionals skills (i.e. clinical) on international placements is common in the literature involving wider professional fields (33). In a study of international learning in many professions, only 2% of the learning episodes recorded during placements were considered to result in domain-specific professional skill gain, as opposed to 30% of the matched learning experiences domestic placements (33). These findings propose that individuals learn more domain-specific skills in a domestic workplace as opposed to international placements. Or, that the learning experiences that are remembered and recorded in an international environment are non-clinical in nature. This could be due to the fact, that professionals (in Tate’s study for example) don’t intend or expect to learn such skills, so their development is more poignant, resulting in a transformational shift in perspective and awareness of one’s own PPD.
The literature also presents some explanations for the proposed deficit of clinical skills development. There appears to be several factors operating in low income settings which seemingly make it more difficult for some professionals to develop clinical skills
internationally than they would in a domestic environment. One such factor is supervision. Junior staff are often left alone in LMIC facilities; which means having a knowledgeable person to provide support when developing clinical skills is difficult (12,26). Another factor may be that medical equipment is not the same as it would be in the UK (72). British
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professionals may find it difficult to improve clinical skills with equipment that is faulty, outdated or different to the UK.
Whilst there tends to be a precedence in the literature to report non-clinical learning, some papers do report profession-specific clinical skills. For example, doctors describe
improvement in diagnostic skills; nurses learnt how to care for patients with tuberculous; ophthalmologists report exposure to novel surgical techniques; urologists describe using vesico-vaginal fistula surgery (a procedure rarely used in the UK) (16,22,73,74). There is also discussion across professions of ‘going back to basics’, reports of re-engaging with basic science, doing things manually and less reliance on technology (13,75). This PPD development along with lots of the other developments described in this chapter, enhance and underpin all professional’s clinical skills. However, this thesis will not focus on the development of the clinical skills of any particular cadre of staff but rather look at the non- clinical learning that is widely reported to underpin professional learning on international placements.
In summary, there is a general tendency in the literature reviewed to focus on non-clinical skills development. However, a number of papers describe examples of the development of specific professional skills (16,22,73,74). The extent to which this happens in
comparison to a UK environment is not known and to my knowledge has not been studied. There is also no discussion in the literature reviewed about how the clinical learning happens (through what mechanisms). Many professionals seem to have intentions of developing clinical skills as a result of practicing with a greater volume and breadth of patients. But, upon return seem surprised by the often unanticipated development of non- clinical skills (43).