Published online: 5 May, TAPS 2020, 5(2), 5-13
https://doi.org/10.29060/TAPS.2020-5-2/OA2168

Simon Tso

Department of Dermatology, South Warwickshire NHS Foundation Trust, Warwick, United Kingdom

Abstract

Background: The transition experience of graduate-entry medicine degree programme students is less well understood as compared to those from undergraduate-entry medicine degree programmes.

Aim: This thematic analysis study aimed to explore the transition experience of graduate-entry medicine degree programme students at a United Kingdom medical school.

Methods: Twenty-one student volunteers from the University of Warwick 4-year graduate-entry medicine degree programme took part in this study with fourteen participants attended a further follow-up interview. Audio recordings of their semi-structured interviews were transcribed verbatim and analysed thematically.

Results: Results revealed three key transition periods within the University of Warwick Medical School’s graduate-entry medicine degree programme. Learning, professional identity development and managing coping strategies were the three key challenging issues dominating their transition experience. Medical students encountered a range of challenging issues throughout their medical school journey that could be categorised under three conceptual themes: challenges associated with the curriculum, challenges associated with their social role and generic life challenges.

Conclusions: The findings from this study could be useful to educators and medical schools in enhancing their student support services. It could also be useful to prospective and existing medical students in understanding the realities of undertaking a graduate-entry medicine degree programme.

Keywords:        Transition, Graduate-entry, Medical Student, Experience, Challenges, Identity

Practice Highlights

  • There are three major transition periods within a graduate-entry medicine degree programme.
  • Students could face challenges due to the curriculum, their social role and generic life events.
  • Participation in patient care activities and observation of role models developed students’ identity.

I. INTRODUCTION

The term ‘transition’ originated from the Latin word ‘trānsitiō’ meaning ‘to go across’. This term had been defined by scholars in different ways. Parkes (1971) described psychological transition as the “abandonment of one set of assumptions and the development of a fresh set to enable the individual to cope with the new altered life space.” (p. 103). Levinson (1978) described transition as a “boundary zone between two states of greater stability. It involves a process of change, a shift from one structure to another” (p. 50). Schlossberg, Waters, & Goodman defined transition as “any event or non-event that results in changed relationships, assumptions and roles” (1995, p. 27). In the context of undergraduate students’ transition through their medical school journey, the literature described three key transition periods: the transition into an undergraduate medicine academic programme, the transition from the pre-clinical to clinical phase of an undergraduate medicine academic programme, and the transition into professional practice as newly qualified doctors (Radcliffe & Lester, 2003). Transitions have also been described within specific modules of the undergraduate medicine academic programme, for example, during dissection training (Lamdin, Weller, & Kerse, 2011). The literature reported medical students could encounter a broad range of challenging issues during these transition periods, which could be categorised under five broad themes: dealing with academic or work-related pressures, challenges of professional socialisation, managing uncertainties, concerns about harming patients (such as due to their lack of knowledge or skills), and general life stressors (such as financial pressures and personal life events; Dyrbye, Thomas, & Shanafelt, 2005; Prince, van de Wiel, Scherpbier, can der Vleuten, & Boshuizen, 2000; Rees & Monrouxe, 2011).

Two studies from the literature have transformed our understanding of medical students’ transition experience within their undergraduate medicine academic programmes. Firstly, the study by Radcliffe and Lester (2003) provided a broad overview of the challenges undergraduate-entry medical students could encounter during their medical school transition experience. The authors conducted an interview-based study with 21 fifth year (final year) medical students from the undergraduate-entry medicine degree programme at the University of Birmingham, United Kingdom. The authors analysed the data using a Grounded Theory approach and reported medical students experienced a series of transition periods within their degree programme. These transitions included role transition from secondary education to the first year of their degree programme, role and knowledge transition from preclinical science student status in the second-year to apprentice doctor in the third-year, and their role and knowledge transition on approaching qualification as doctors. They reported most medical students found the transition from secondary education to an undergraduate medicine academic programme stressful as they had to manage the changes to their lifestyle related to starting university, making new friends and competing with their peers. Many medical students found the less didactic teaching methods in their undergraduate-entry medicine degree programme as stressful (Radcliffe & Lester, 2003).

Next, the study by Rapport et al. (2009) offered insights into graduate-entry medical students’ transition experience through their medical school journey. The authors conducted an interview-based study with 44 medical students from the Swansea University Medical School, United Kingdom, to explore the impact of the students’ previous degree programme and life experience on their current degree programme experience. The data was analysed using thematic analysis and the study findings highlighted that prior work and life experiences had a significant and positive impact on their current graduate-entry medicine degree programme experience—findings that were consistent with my own observations (Tso, 2019). Students’ prior experiences had helped them understand complex concepts in professionalism, ethics and reflective learning, as well as how to manage patient encounters (Rapport et al., 2009). The impact of this study could have been greater if the scope of the authors’ investigation were to include graduate-entry medical students’ transition experience into professional practice as doctors.

II. METHODS

This study aimed to make a sociological contribution to understanding the transition experience of medical students from graduate-entry medicine degree programmes. The research question was ‘what are the challenges experienced by graduate-entry medicine degree programme students during their transition through medical school training?’

A two-staged interview-based study was conducted to explore the transition experience of graduate-entry medicine degree programme students at the University of Warwick in the United Kingdom. All registered students from the University of Warwick 4-year graduate-entry medicine degree MB ChB programme were invited to take part in the study via a student society’s electronic mailing list. One electronic mailing reminder was sent to all potential participants. Medical students who have suspended their studies and medical students from other medical schools undertaking placements at the University of Warwick were excluded. There were over 650 registered medical students. A mixed volunteer and quota (by student year group) sampling strategy was used to ensure representation of medical students from across all year groups.

Twenty-one students volunteered to take part in stage one semi-structured interviews each lasting between 30 to 45 minutes. Fourteen of 21 (67%) stage one participants volunteered to attend a follow-up stage two semi-structured interview each lasting between 15 to 25 minutes (took place approximately four to thirteen months following their previous interviews). The stage one and stage two interview questions were summarised in Table 1. All the interviews were audio-recorded using a digital recording device. Audio recordings of their semi-structured interviews were transcribed verbatim. Participants were invited to check and comment on the contents of their interview transcripts.

Stage one interview questions Stage two interview questions
What does the term transition mean to you? Can you describe what has happened during your last academic year?
What has happened in the degree programme? During stage one interview, you mentioned (provide an example of an issue the participant raised during stage one interview). What do you think about it now?
What will happen over the next one year? Which issues are going to be challenging?
Will you be interested to participate in the follow-up interview?

Table 1. Interview questions

In contrast to Braun and Clarke’s (2006) six-phase thematic analysis method where data analysis begins after completion of data collection, in this study, phase one to four of thematic analysis began with the first available interview transcript. When additional interview transcripts became available, the author tested if the new codes fit into the previously conceived themes. If the new codes did not fit, then the themes could be changed, removed or new themes added until the themes appear to form a coherent pattern. This process enabled the refinement of the themes. After the last interview transcript was analysed, the author proceeded to perform phases five and six of thematic analysis on the whole dataset.

III. RESULTS

A. Characteristics of Study Participants

The characteristics of the 21 stage one and 14 stage two interview participants were summarised under Table 2. Of the seven students that did not take part in stage two interviews, three students did not respond to three repeated electronic mail interview invitations that were sent over a two-month period and four students replied that they were unable to take part in stage two interviews. Non-attendees volunteered reasons for non-participation including academic commitments, lack of time or the long distance to travel from their regional placements to the two research sites. Following stage one interviews, one participant reported having failed an end of first-year examination and had to repeat the year one.

Characteristics of stage one interview participants (n = 21) Characteristics of stage two interview participants (n = 14)
Year group 29% (6/21) were first-year students;

19% (4/21) were second-year students;

42% (9/21) were third-year students;

10% (2/21) were fourth-year students

7% (1/14) were first-year students;

29% (4/14) were second-year students;

14% (2/14) were third-year students;

43% (6/14) were fourth-year students;

7% (1/14) were Foundation Year 1 doctors

Age (years) Mean 26.0; Median 25.0; Range 22-33 Mean 27.6; Median 28.5; Range 22-34
Gender 43% (9/21) were females;

57% (12/21) were males

43% (6/14) were females;

57% (8/14) were males

Ethnicity 80% (17/21) were White Caucasians;

10% (2/21) were South Asians;

5% (1/21) were Chinese;

5% (1/21) were from the Middle East

79% (11/14) were White Caucasian;

7% (1/14) were South Asians;

7% (1/14) were Chinese;

7% (1/14) were from the Middle East

Education 86% (18/21) had a degree related to natural science* or health+ subjects;

14% (3/21) had a degree in other subjects^

79% (11/14) had a degree related to natural science or health subjects;

21% (3/14) had a degree in other subjects

Work experience 38% (8/21) had no prior full-time work experience;

14% (3/21) had work experience outside healthcare settings=;

48% (10/21) had work experience in healthcare settings±

29% (4/14) had no prior full-time work experience;

21% (3/14) had work experience outside healthcare settings;

50% (7/14) had work experience in healthcare settings

Note: * Chemistry, Biology, Biochemistry, Genetics and Biomedical Science degrees;
+ Pharmacology, Radiography and Clinical Technology degrees;
^ Geography, Engineering and Information Technology degrees;
= Sports Coaching, Engineering and Business Consultancy; and
± Allied healthcare professionals and first responders in emergency rescue services.
Table 2. Characteristics of medical students taking part in stage one and stage two interviews

B. Defining the Term ‘Transition’

Medical students described three key elements to the term transition: a change in circumstances, the impact of the changes, and how individuals managed the change. They described a transition could be related to a physical or a psychological change that could be brought on by predictable events. Some students described that self-awareness was a requisite for an individual to recognise that a transition has taken place. Transitions could also bring risks and uncertainties.

“Transition shifted my entire life from what it was, from what I did in undergraduate biology degree to medical school. I am leaving my friends behind as well and my family… Coming here [graduate-entry medicine degree programme] is the whole uprooting of what was normal, and what was comfortable.”

(Third-year medical student)

Based on medical students’ descriptions and discourse of the term transition, in this paper, transition was defined as ‘any change in circumstances that could impact upon how individuals perceived themselves or their surroundings and the management of the change in circumstances’.

C. The Transition Periods Within a Graduate-Entry Medicine Degree Programme

Three major transition periods could be identified within the 4-year graduate-entry medicine degree programme using the definition of transition described above. These major transitions were: the transition into a graduate-entry medicine degree programme, the transition from phase one to phase two of the curriculum and on approaching qualification as newly qualified Foundation Year 1 doctors. Each of the major transition periods was characterised by three key themes of personal and professional growth and development: learning, professional identity development and developing coping strategies (Table 3). Minor transition periods could also be identified during periods when students rotated to new clinical placements as they encountered significant changes to the learning environment and socialisation experience.

Theme: The transition into a graduate-entry medicine degree programme
Sub-themes Description
Learning Students had to learn basic medical sciences knowledge and gain early patient contact experience.
Professional identity development Students had to build a new professional identity while reconciling with their previous professional or educational identity.
Developing coping strategies Students had to identify and utilise their coping strategies to manage the challenging issues they encountered at the start of their degree programme.
Theme: The transition from phase one to phase two of the curriculum
Sub-themes Description
Learning Students continued to expand their repertoire of knowledge and clinical skills. They had to apply their phase one knowledge and experience into their learning experience in phase two. There was a shift towards an andragogical learning style.
Professional identity development Students continued to develop their professional identity through professional socialisation with clinical staff.
Developing coping strategies Students had to identify and utilise their coping strategies to manage the challenging issues emerged from phase two of the curriculum and to continue balancing their work-life commitments.
Theme: Approaching qualification as newly qualified Foundation Year 1 doctors
Sub-themes Description
Learning Students continued to expand their repertoire of knowledge and clinical skills in preparation for their professional role as doctors. There was an increasing emphasis on developing their skills in clinical reasoning, diagnosis and patient management planning.
Professional identity development Through working closely with clinical teams and undertaking clinical tasks expected of Foundation Year 1 doctors, they gradually acquired the values, knowledge, skills and behaviour appropriate to become a Foundation Year 1 doctor and their professional identity as a member of the doctor and healthcare community gradually solidified.
Developing coping strategies Students continued to balance their work-life commitments as they approached qualification.

Table 3. The three key themes of personal and professional growth that characterises medical students’ transition experience through their degree programme

D. The Transition into a Graduate-Entry Medicine Degree Programme

During this period, all students had to learn new scientific and non-scientific concepts covering a broad range of topics that they had not learnt before. Some students found the change from being a knowledgeable person to a complete novice as overwhelming and some even viewed themselves as generic university students unconnected to the medical community. As they adapted to their new status as students of a graduate-entry medicine degree programme, many students reported noticing changes to their learning styles (as compared to their previous degrees), financial situation (a change to their standard of living on their return to student status) and socialisation experience (challenges in maintaining existing relationships and forming new ones in the medical school).

“We are still learning how to be a medical student.”

(First-year medical student)

“I have thrown off many indulgences that I was quite used to when I was having salaried work. At one stage when I was a locum, I spent one weekend in [work] and one weekend in Europe [on holiday]. I had some extravagance, I used to eat in very nice restaurants, used to have a personal [fitness] trainer… [as a medical student now] just trying to cut down on the extravagance.”

(Third-year medical student)

“…that was quite a big transition [moving from being a clinical assistant practitioner to a medical student]. Going from being part of a functional team achieving goals, dealing with people coming in, having a specific role that was valued and respected [as a clinical assistant practitioner], to being a passive observer and a consumer [as a medical student]. It was a change from focusing on the needs of the people coming in and my colleagues who were working to the same ends, to suddenly being told that everything I was doing [as a student] was for my own benefit and if I wanted to succeed, I had to do x, y and z to meet the learning objectives set out for us.”

(Fourth-year medical student)

E. The Transition from Phase One to Phase Two of the Curriculum

This transition period occurred halfway through the second year of the degree programme. Learning in phase one predominantly took place in a classroom-based environment with students reporting the curriculum objectives was clearly defined. They learnt about basic medical sciences and individual body systems, had some exposure to the clinical environment and there was a strong emphasis on group work and collaborative learning. On the other hand, learning in phase two predominantly took place in clinical settings as a pair of students. They had to learn to integrate and apply their prior knowledge during their clinical placements. The rotational nature of their clinical placements meant they were frequently meeting new clinical staff. Phase two had a strong emphasis on self-directed learning and students had to keep a learning portfolio of their clinical encounters. The learning outcome of the phase two curriculum was perceived by the students to be less clearly defined as compared to phase one. Together with the self-directed learning nature of the phase two curriculum, students initially found it challenging to organise and make sense of their learning experience, monitor their learning progress and to be certain that they were achieving the curriculum objectives. When they encountered new first-year medical students, they were able to reflect upon their own experience and noticing their personal and professional growth in the degree programme.

“You suddenly see the newbies [new first-year medical students] coming in who do not know anything yet and makes you feel you have actually learnt a lot in a year. It does feel like a big step up to second year.”

(Second-year medical student)

“[The challenge of phase 2 was] being able to link things together. Because at the moment I feel like I am very focused on a certain system. If I go and do a history I will be very cardiology orientated. Whereas next year I need to start thinking about [differential diagnosis]… I need to think more about if they are in the emergency room, they are not going to tell me I have got an endocrine problem. So thinking more laterally… but for at the moment I am doing cardiology, so I only think cardiology and heart failure.”

(Third-year medical student)

F. Approaching Qualification as Newly Qualified Foundation Year 1 Doctors

This transition period occurred around the fourth (final) year of the degree programme. During this transition period, students described one of their key tasks was to prepare for professional practice as doctors. As they progressed through the fourth year of their degree programme, they had to develop competency in applying their knowledge and skills into actual practice, develop the confidence in their own decision making and learning to prioritise their workload.

“I have seen myself as a junior doctor when I was doing my nights [night shift] last week. We were in the Acute Medical Unit. There were fifty patients and one registrar. Basically, he told us to do as much as we want to do. So we ended up prescribing—obviously he [the supervising registrar] signed it. We ended up doing everything a junior doctor would do like cannulation, prescribing, history taking, assessing and talking to relatives. That is the only time I felt like actually I can do this [being a doctor]. Whereas if I am sitting in a clinic at the back of a room and not talking to a patient then I do not feel like I am a doctor, I do not feel I am involved.”

(Fourth-year medical student)

G. Challenges Encountered by Medical Students During Their Transition and Their Coping Strategies

The challenging issues students encountered during their degree programme could be categorised under three broad themes according to the nature of the challenges. These categories were challenges related to the curriculum, challenges related to the social role of medical students and generic life challenges. Table 4 provided examples of these challenging issues. Most challenging issues, especially generic life challenges, were relevant to all transition periods. However, some challenging issues were much more likely to be encountered or its impact more noticeable at specific transition periods. For example, the difficulties in learning a large volume of concepts in students’ transition into a graduate-entry medicine degree programme, and the challenges of dealing with death and dying as they approached qualification as newly qualified doctors.

Theme: Challenges experienced by medical students that are related to the curriculum
Sub-themes Examples
Academic work-related pressures Students described it was challenging to learn large volumes of concepts. Some students failed their examinations. Students experienced uncertainties about how to monitor their learning progress.
Adaptation to changing learning environment Students said it was challenging to adjust to self-directed learning as they moved from phase one to phase two of the curriculum.

One student described that each change in clinical placement in phase two could be stressful as one has to adapt to new learning environment and new clinical teams.

Impact of institutional policy The University of Warwick Medical School introduced a new case-based learning curriculum in 2015. One student had to repeat the first academic year under the new curriculum.
Theme: Challenges experienced by medical students that are related to their social role
Sub-themes Examples
Challenges of professional socialisation Students reported incidents where they had challenging professional interactions with faculty members and clinical staff. One student described the presence of large group of phase one medical students was not welcomed by nurses and her reluctance to engage with the support services to address her academic underperformance. Several students described they had encountered negative role models.
Professional identity development Development of a professional identity was not an automatic and seamless process but one that took time to build. The challenges of professional identity development were highlighted by students’ encounters of new or uncomfortable experience, which prompted them to think about their role and identity. For example, students putting on their stethoscopes and hospital identity badges for the first time, being misrecognised by clinical staff as doctors and receiving health advice requests from family and friends. Dealing with death and dying, an important element of their future role as doctors, was also described as challenging experiences.
Theme: Generic life challenges
Sub-themes Examples
Financial challenges Students described general concerns about their finance and student debts. Some decided to take up part-time employment to help with their financial situation.
Personal life events One student experienced a burglary. One student experienced a period of illness leading to examination failure. Moving accommodation during their degree programme could also be stressful.
Maintain work-life balance Students described the academic demands of their degree programme could be stressful and impacted upon opportunities to maintain relationships. There was a need to reconsider their work-life balance as their level of commitments evolved over time.
Developing coping strategies Students had to find ways to cope with the challenging issues arising in their degree programme. They had to actively cope with the cognitive adjustment from being an experienced and knowledgeable individual to their new role as a learner. They had to identify new learning strategies to cope with the self-directed learning nature of the phase two curriculum. One student reported using a maladaptive coping strategy when dealing with a period of illness.
Living with a disability Some students with disabilities described the stigma of living with a disability and one student had received abusive comments directed at her disability.

Table 4. The challenging issues medical students could encounter during their graduate-entry medicine degree programme

Students described they used a wide range of coping strategies to manage the challenging issues arising from their transitions and degree programme. Using the categorisation system by Weiten and colleagues, these coping strategies could be categorised under adaptive and maladaptive coping strategies (Weiten, Lloyd, & Dunn, 2008, p.136). Examples of coping strategies students used in managing the challenges presented by their degree programme were summarised in Table 5.

Challenging issues Adaptive Coping Strategies Maladaptive Coping Strategies
Appraisal-focused Problem-focused Emotion-focused
Academic / work-related issues Attend teaching on how to prioritise clinical workload, acceptance Active coping, seek guidance about curriculum objectives Leisure, sports Allowing oneself to burnout
Developing a professional identity Develop own understanding of acceptable professional behaviours through observation of role models Active engagement in patient care activities to help them develop their professional identity
Managing health advice requests Help the individual seeking advice to understand health information and direct them to other sources of help To give advice on the diagnosis and management of the health issue Showing empathy and offering emotional support
Disability issues Working with the institution to assess their disability issues Ask for reasonable adjustments, find out available support services, active coping Not seeking help
Generic life challenges Acceptance, devise strategies to reduce expenditures, positive framing Active coping, take up part-time employment to help with finance Emotional venting, leisure Bring laundry back home to wash

Table 5. Examples of adaptive and maladaptive coping strategies used by medical students when dealing with challenging issues arising from their degree programme

IV. DISCUSSION

The transition into university was a well-recognised transition period perceived by most university students as a particularly challenging and stressful time (Fisher & Hood, 1987; Fisher & Hood, 1988; Thurber & Walton, 2012). Despite an in-depth literature search, only one study from the medical education literature was noted to have acknowledged the start of an undergraduate medicine academic programme as a transition period (Radcliffe & Lester, 2003), which was associated with a change in the medical students’ lifestyle, socialisation experience and learning style. However, Radcliffe and Lester (2003) only included final year medical students in their study sample and students in other year groups may offer a different perspective about their transition experience.

In this study, students’ description of the term transition was used to define and identify the three major and the minor transition periods within a graduate-entry medicine degree programme, which was in keeping with findings from the published literature on medical student transition experience. This study offered further insights into student experience at the start of their graduate-entry medicine degree programme, which could be associated with significant changes to medical students’ identity, approach to learning, socialisation experience and standard of living.

This study reported there could be a series of minor transition periods within the phase two curriculum as students rotated to different clinical placements. They were described as minor transitions in this study as only one student had explicitly reported encountering these transition periods and its impact on the student was limited as compared to the major transition periods. Seltz, Montgomery, Lane, Soep and Hanson (2014) explored medical students’ experience of working with frequently rotating paediatric inpatient attending physicians who change over on a weekly basis. The authors reported that these frequent changes could be an emotionally stressful experience for some students, as they had to adapt to different patient care and teaching styles. Furthermore, the lack of continuity with the attending physician made it more challenging for students to demonstrate their learning and personal growth as well as building a professional relationship (Seltz et al., 2014). The challenging issues described by Seltz et al. (2014) could be relevant to the experience of medical students in this study as they offered a potential explanation towards the finding of minor transition periods and their potential impact on medical student experience.

This study highlighted a wide range of challenging issues graduate-entry medicine degree programme students could encounter in their degree programme, which were also in keeping with the findings from the literature review. The exploration of these challenging issues provided an alternate avenue to examine students’ development of a professional identity. The development of a medical student’s professional identity involved complex social interactions between individual medical students and the social structure they belong to (Goldie, 2012). Mann (2010) described “professional identity development is both a personal and social process and is not separable from the knowledge and skills that are required” (pp. 64-65). In this study, phase one medical students spent the majority of their time learning in a classroom-based environment focusing on the acquisition of basic knowledge and skills. It was possible that due to limited professional socialisation opportunities with health professionals, some students perceived themselves simply as a university student only as they did not feel connected to the wider doctor and healthcare communities. When second-year students met the new first-year medical students, they were able to reflect upon their personal and professional growth.

Hay, Smithson, Mann and Dornan (2013) described experience-based learning, learning through supported participation, helped to address medical students’ learning skills needed to be effective workplace learners. This has an impact on medical students’ sense of belonging to a community and professional identity development (Hay et al., 2013; Wenger, 1998). In this study, when students commenced phase two, they frequently observed doctors and other health professionals providing care to patients. Their level of participation in community activities gradually increased over phase two. Through their situated learning experience such as observation of role models and active peripheral participation in patient care activities (such as undertaking the tasks expected of newly qualified Foundation Year 1 doctors), they gradually solidified their professional identity as a doctor.

Despite the modest study sample size of 21 volunteers from a single centre, this has yielded 35 datasets. The volunteers originated from across all year groups and they were highly motivated in sharing their experience, including sensitive information such as disability, examination failure and the challenges they encountered during their medical school journey. By interviewing study participants twice, this provided the opportunity to follow-up their progress. However, this study has limitations. Only 14 of 21 study participants attended the stage two follow-up interviews. Very few study participants had volunteered examples of their shortcomings or their negative attitudes or behaviours, potentially due to social desirability bias, recall bias and the lack of trust.

V. CONCLUSION

This study provided a broad overview of the transition experience of students in a graduate-entry medicine degree programme. Developing an awareness of the challenging issues students could face during their degree programme, their transition experience and professional identity development, could empower faculty and clinical staff in identifying students potentially in need of support. The study findings could also be useful to prospective and existing medical students in understanding the realities of undertaking a graduate-entry medicine degree programme.

Notes on Contributors

Simon Tso, MD, MB BChir, MRCP, is a consultant dermatologist. He completed this research project as part of his Doctor of Medicine degree with the University of Warwick, United Kingdom. He was responsible for all aspects of the study including the approval of the final version of the article.

Ethical Approval

This study was approved by the University of Warwick Biomedical Research Ethics Sub-Committee (Reference: 169-01-2012).

Acknowledgements

The author would like to thank Asim Yousuf, Nina Owen, Mike Smith, Emma Kirk, Dr Jane Kidd and Dr Mandy Barnett for their assistance with refining the conception and design of the study, Dr David Davies for supervising the final submission of the research degree thesis, and Dr William Hunt for his valuable feedback on the manuscript.

Funding

This study was supported by the Institute for Advanced Teaching and Learning, University of Warwick, United Kingdom.

Declaration of Interest

The author report no conflict of interest. The author is responsible for the content and writing of the article.

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*Simon Tso
Department of Dermatology,
Warwick Hospital, Lakin Road,
Warwick, CV34 5BW, United Kingdom
Tel: +44 1926 495 312 Extension 4569
Email: simontso@doctors.org.uk