Student perceptions of a new integrated course in clinical methods for medical undergraduates

CONTEXT: In line with recent General Medical Council recommendations a new, 8-week integrated course in clinical methods has been introduced into the undergraduate curriculum at Leicester University. OBJECTIVES: To describe student perceptions of the course and to identify areas for improvement. DESIGN: A questionnaire survey. SETTINGS: These were 50 general practices, three teaching hospitals and the academic Department of General Practice and Primary Health Care. SUBJECTS: A total of 180 third- and fourth-year medical students. RESULTS: The questionnaires were completed by 93% of students. The latter expressed higher satisfaction with practice teaching compared with hospital teaching, on a 5-point scale, with regard to questions on 'teaching content' (4.0 vs. 2.7, P < 0.0001) and 'teaching process' (4.1 vs. 2.7 P < 0.0001), which was reinforced by free text comments. Of the respondents, 92% agreed that their teaching practice had satisfied the required teaching timetable and 87% of students found their departmental tutor enthusiastic and stimulating. CONCLUSION: It is possible to deliver an integrated course in clinical methods, teaching generic clinical skills, in a mix of hospital and practice settings. Nevertheless there were substantial differences in student perceptions of the relative quality and impact of teaching in the two settings. This may be related to the more detailed programme of preparation of practice teachers and the greater extent to which practice teachers were required, and able, to create protected time for the teaching task. These differences should be minimized if hospital teachers undergo similar preparation for the teaching task and have similar levels of protected teaching time.     

Designing a community-based fourth-year obstetrics and gynaecology module: an example of innovative curriculum development

INTRODUCTION: This paper describes the design and evaluation of the community-based obstetrics and gynaecology module at St Bartholomew's and the Royal London School of Medicine and Dentistry. This module sets out to comply with the General Medical Council's recommendations of encouraging students to consider the community perspective, and places less emphasis on a disease-orientated approach. OBJECTIVES: The development of the module, issues of improving student acceptance of the course, staff development and the benefits of community teaching in obstetrics and gynaecology are discussed. MODULE ORGANIZATION: The 2-week module precedes the 8-week hospital obstetrics and gynaecology firms that occur in the fourth undergraduate year. The course is organized into three components: general practice, departmental teaching, and self-directed learning. Students are allocated to general practices for their clinical teaching, for eight sessions. Seven departmental sessions are run by the Academic Department of General Practice and Primary Care. These include a review of the students' self-directed learning. EVALUATION AND CONCLUSION: Evaluation data are reported for the three components of the course. Overall the majority of students rated the module as useful, GP attachments being most favourably received. The majority of students have grasped the basic obstetric and gynaecological history and examination skills and found this useful before starting their hospital firms. Aspects of a specialist subject, such as, obstetrics and gynaecology, can be taught successfully in the community and GP tutors are, as yet, an untapped source of excellent obstetric and gynaecology teaching.     

Medical students'' evaluations of different levels of medical ethics teaching: implications for curricula

Although medical ethics has become a part of the curriculum of almost every medical school, medical students' perceptions of the value of medical ethics have not been documented. This paper reports the evaluations given by 137 preclinical and 216 clinical medical students to different levels of medical ethics teaching at the College of Human Medicine and the College of Osteopathic Medicine of Michigan State University. The results indicate (1) that students' satisfaction with medical ethics teaching is directly linked to how much they receive, (2) that students overwhelmingly prefer the input of both ethicists and doctors to teaching by either alone, and (3) that a preclinical medical ethics course followed by explicit medical ethics teaching in clinical training is a promising model for achieving an adequate level of medical ethics teaching within medical education.     

Why? What? and How? IT provision for medical students in general practice

OBJECTIVES: The aim of this paper is to discuss the increasing use of computers in undergraduate medical education and explore the why, what and how of providing IT facilities to undergraduate medical students when they are on placement in general practice. Adequate computing facilities are usually available within hospitals and medical schools, however, major changes are taking place in undergraduate education resulting in more teaching being undertaken in the community. Students will therefore need access to comparable facilities whilst in primary care settings in order for their training not to be compromised. SETTING: This paper describes one initiative addressing this need: the University Linked Practices (ULP) project in the Department of General Practice and Primary Care at St. Bartholomew's and the Royal London School of Medicine and Dentistry. DESIGN: We discuss the ways in which computers are currently being used in medical education and discuss some of the merits and drawbacks that are associated with this increasing drive to computerization.     

Providing early clinical experience in primary care

Undergraduate courses in British medical schools are changing following recommendations from the General Medical Council. Increasing emphasis has been placed on teaching in the community. Nottingham Medical School has pioneered the teaching of basic clinical skills in primary care during the pre-clinical course to help produce an integrated curriculum. This qualitative study evaluated the first two years of the new early clinical experience course at Nottingham by using interviews with 19 students and their GP tutors. Students claimed to have gained confidence in talking to patients, their understanding of the role of the doctor and the importance of the doctor-patient relationship. Students were less confident about examining patients and some reported having had little opportunity to practice examination skills. Half the students thought that the early clinical visits had helped them to understand and be more motivated to learn their basic medical sciences course. The newly recruited GP teachers were highly motivated, very positive about the early clinical teaching and all wanted to continue to teach the pre-clinical students. Difficulties in providing the course included communication with students and staff, organization of student travel and variation in the quality of teaching. However, the Nottingham early clinical experience course has shown that basic clinical skills can be successfully taught to pre-clinical students in primary care.     

An evaluation of a course for undergraduate teaching of general practice

This paper presents an evaluation of the undergraduate fifth year course of teaching in general practice in the Queen's University, Belfast. Two Modified Essay Question papers were randomly selected from those used for some years past in the Department of General Practice, as learning aids and class tests. These were administered to twelve randomly selected groups of students before and after completion of a five week course of teaching. Results show that the composite mean MEQ scores doubled between pre- and post-course tests. The correlation coefficients tabulated do not indicate that the marked improvement in mean scores before and after the course in general practice was influenced to any extent by knowledge acquired in other disciplines. The overall findings clearly establish the value of small group clinical teaching of general practice based on a problem orientated approach to learning. They suggest that the intellectual skills and attitudes required in the 'holistic' approach to problem solving in general practice may differ in some ways from the skills required in specialized areas of medicine. The evaluation justifies the time spent on clarifying the undergraduate educational objectives.     

Audit encourages an evidence-based approach to medical practice

OBJECTIVES: This study was designed in order to identify any changes taking place in students' ability to incorporate research evidence into clinical practice after the introduction of an evidence-based medicine session into their audit teaching. DESIGN: We chose to look at the references cited in students' audit projects as a way of making a retrospective assessment of their ability to use evidence. Each of a sample of 221 projects was analysed for the number and accuracy of references, the phase of the audit cycle in which the references were cited, the topic chosen and the use of computers. A smaller sample were assessed for quality. SETTING: The Department of General Practice at Glasgow University. SUBJECTS: Final-year medical students. RESULTS: We found that there was an increase in quality and quantity of citation of references by the students over a 3-year period which corresponded with changes in teaching methods. CONCLUSIONS: It is possible that this increase in the quantity and quality of reference citation by final-year students was in response to a change in the content of teaching sessions, but there may be other reasons for this. The experience of researching and carrying out the projects has given students first-hand experience of the techniques of evidence-based medicine. Requiring students to state their information sources and include a copy of the abstracts from cited papers would assist further studies of this kind.     

Constructing a new course for undergraduate teaching of general practice

This paper outlines in Part I the method used to analyse and re-define a set of educational objectives on which a new course of teaching of general practice in the later clinical years is based. Part II describes the course, the learning methods, behavioural attainments and the techniques of evaluation to be implemented. A year was spent on the exercise by a group which comprised the professorial head, consultant senior lecturer and a senior registrar tutor from the Department of General Practice, Queen's University, Belfast, and a consultant educationalist, a senior lecturer, Department of Education, of the same University.     

Attitude of medical students towards psychiatry

Findings are presented from a survey of all medical students at the College of Medicine, Abha, Saudi Arabia dealing with students' attitudes towards specialization in psychiatry. The health region of Asir in south-west rural Saudi Arabia, of about one million inhabitants, needs Saudi Nationals to specialize in psychiatry to provide planned future delivery of services. Medical students all over Saudi Arabia, however, have not been choosing psychiatry for their specialization after graduation. The Scientific Committee for Mental Health, convened at the Ministry of Health in Riyadh in February 1986, invited representatives of psychiatry from medical schools in the nation to discuss this priority topic. A year later, a new course called 'Introduction to Psychosomatic Medicine' was introduced as an elective for medical students with its practice at the general hospital. It tries to introduce students to 'voluntary and active as against passive learning ... and problem-solving rather than imposed memorizing' of medicalized forms of psychiatry, an innovation compared with the previous conventional method. A significant difference in attitude was demonstrated between students who had their exposure to psychiatry from this course and those who followed only the conventional methods of learning.     

Audit in general practice: educating medical students

This paper describes the third stage in the evolution of methods of teaching on audit in general practice at the Department of General Practice, University of Glasgow. The authors asked the final year students to develop, carry out and submit a written report on an audit project devised by themselves, after briefing and with continued support. Every student asked was successful in producing a report and the standard was generally very high, although only two students completed the audit cycle in the 4 week period. More than half the students (51.7%) found the project valuable or very valuable. As many as 90.6% understood audit better or much better after doing the project and 83.4% thought that the project should continue to be part of the GP attachment. Seventy-eight per cent of the GP tutors thought that teaching audit to undergraduates in general practice was valuable or very valuable, 64.4% reported that the audit had been of benefit to their practice, and 89.9% thought that audit should continue to be part of the GP attachment. This method of teaching students about audit was the most successful of three methods tried. It has produced benefits both for students and for the general practices to which they were attached, ultimately producing benefits for patients.     

An evaluation of medical student behaviours in communication

An evaluation of fourth-year medical student behaviours in communication with real patients in general practice is reported using two different formats of rating scale. The study was performed in the clinical base of the Department of General Practice, the Queen's University, Dunluce Health Centre, Belfast. In all, 475 interviews were rated, 238 being first interviews and 237 second interviews. The format of the rating scale was not found to be a significant variable. Factor analysis of the rating scale item scores produced five factors, which fell into two clear groupings. Factors 2 and 4 represent communication skills, which could have been acquired through normal social learning. Factors 1, 3 and 5 constitute more technical and professional skills not usually employed in normal social intercourse. Analysis of data from first and subsequent interviews indicates that the students in the study had acquired professional skills, which require special teaching. These are identified in Factors 1, 3 and 5 and require a proper emphasis in training.     

Early patient contact in primary care: a new challenge

BACKGROUND: The Medical School of Lund University, Sweden, has introduced an early patient contact course, including training in communication and examination skills. The course runs parallel with theoretical subjects during the students' first two-and-a-half years. General practitioner (GP) participation is gradually increasing, and in the last half-year of the course GPs in all health centres in the area are involved. Little is known about the GPs' interest, competence and time for this new task. AIM: To describe the GPs' attitudes towards teaching and the rewards and problems they experience. SUBJECTS: 30 GPs teaching third-year medical students. METHOD: Semistructured interview study. Data analysis by a method described by Malterud. RESULTS: The attitude towards teaching was mostly positive and the teachers were confident about teaching examination procedure. Among rewards of teaching, improved quality of clinical practice was the main theme, but imparting knowledge to others, contact with enthusiastic students, and gains in self-esteem were also mentioned. Problems with teaching were mostly due to external factors such as lack of time and space, but concern about a negative effect on patient care was also recognized. Educational objectives of the course were not completely accepted. GPs were not fully aware about what to expect from the students, with subsequent problems concerning how to assess students' performance and how to give effective feedback. CONCLUSIONS: The teaching of junior medical students is maintained by the GPs' enthusiasm for teaching. However, teacher training is required and the crucial issues of time and space have to be considered.     

Teaching clinical skills to new medical students: the Oman experience

The College of Medicine at the Sultan Qaboos University (SQU) in Oman took up the challenge of moving away from a didactic emphasis in the teaching of family and community health by actively involving students in health care, requiring some clinical skills, as early as possible. This paper describes the experience of the Department of Family and Community Health at SQU of the feasibility of training first-year medical students in the measurement of blood pressure within a few days. Our experience showed that proper training before starting field-work can teach clinical skills to students who have had no prior exposure to medical subjects. There was a strong correlation between the measurements of blood pressure of 638 individuals by the students and the supervisors. This experience at SQU has encouraged us to implement the idea of family- and community-based clinical exposure for every class. Teaching of clinical skills is feasible in the field for new entrants, provided there is adequate orientation beforehand and skilled supervision of the students in small groups.     

Evaluation of a pilot project to use computers in a rural general practice term

ABSTRACT: In 1998, the Department of General Practice (Faculty of Medicine and Dentistry, University of Western Australia) ran a pilot project to use computers in a sixth year rural general practice term. Students were provided with a laptop computer to take into rural and remote areas throughout Western Australia during their 4-week clinical attachment. An email mailing list was set up for course participants to share experiences and complete set learning activities specifically related to rural general practice. An evaluation of this pilot project found that students felt less isolated on rural attachments, course outcomes were improved and rural preceptors were more involved in the programme. The development of a teaching and learning programme that involves the use of computers in rural general practice for undergraduate students has the potential to improve the quality of their medical education.     

A communication skills course for preclinical students: evaluation of general practice based teaching using group methods

Summary. Teaching preclinical medical students about doctor-patient communication gives them an opportunity to develop their interviewing skills prior to their having to elicit lists of symptoms in their clinical years. General practitioners should be among the more efficient interviewers in clinical medicine and therefore able to make important contributions to the teaching of interviewing skills. This paper describes the aims, objectives and methods of the preclinical communications skills course at St George's Hospital Medical School. The contribution of the Division of General Practice and Primary Care to the teaching of interviewing skills in the preclinical course has been evaluated using rapid group methods. Students were asked to identify examples of specific interviewing behaviours in videotaped general practice consultations, and to judge whether the behaviours were helpful or unhelpful in eliciting relevant information from the patient. Students who had been given experience in interviewing patients in small groups led by general practitioners identified significantly more helpful and unhelpful interviewing behaviours in the taped consultations than students who had not received the small-group teaching. Students rated the teaching as relevant and effective in terms of giving insights into the interviewing skills they needed to develop. Group methods of evaluation such as these might prove useful to other medical schools with class sizes of 150 students or more.     

Patient-centred consultations: a comparison of student experience and understanding in two clinical environments

OBJECTIVES: To explore students' perspectives on doctor-patient communication. DESIGN: We interviewed students in focus groups before and after their placements. In semistructured interviews they were asked about their experiences of learning through clinical contact, with particular emphasis on patient-centred consultations, on the wards and during their community attachment. Students whose clinical skills training remained hospital-based were also interviewed to compare the range of experiences. SETTING: Leeds University. SUBJECTS: Third-year medical students. RESULTS: During hospital training students are rarely introduced, either through teaching or observation, to the idea of patient-centred consultations. In contrast both the principles underpinning and/or the practice of such consultations were routinely encountered during the general practice placement. Students considered the community attachment to have helped them appreciate the value of exploring patients' concerns both in terms of enhancing the patients' overall healthcare experience and promoting effective clinical management. While they considered the nature and purpose of hospital care to be qualitatively different from that conducted in the community, the relevance of adopting a patient-centred approach on the wards was confirmed. CONCLUSIONS: Recommendations for clinical training are made. The relevance and best use of community and hospital-based attachments need to be evaluated further.     

The parallel rural community curriculum: an integrated clinical curriculum based in rural general practice

INTRODUCTION: In an attempt to address the rural medical workforce maldistribution and the concurrent inappropriate caseload at the urban tertiary teaching hospitals, Flinders University and the Riverland Division of General Practice decided to pilot, in 1997, an entire year of undergraduate clinical curriculum in Australian rural general practice. This program is called the Parallel Rural Community Curriculum (PRCC). This paper is a discussion of the aims of the programme; student selection; practice recruitment; curriculum structure, and academic content, together with lessons learnt from the evaluation of the first cohort of students' experience of the course. METHODS: Independent external evaluators undertook a thematic analysis of a series of structured interviews of students and faculty involved in both the PRCC and the traditional curriculum. The mean examination results were determined and a rank order comparison of student academic performance was undertaken. RESULTS: The eight selected volunteer students reported greater access to patients and clinical learning opportunities than their mainstream counterparts and learned clinical decision making in the context of the whole patient, their family, and the available community resources. They identified patients with 'core' clinical conditions and had a longitudinal exposure to common diseases, whereas hospital-based peers had a cross-sectional exposure to highly filtered illness. The PRCC students' academic performance improved in comparison with that of their tertiary hospital peers' and in comparison to their own results in previous years. CONCLUSION: The PRCC curriculum has cut across the traditional clinical discipline boundaries by teaching in an integrated way in rural general practice. It has affirmed the potential role of true generalist physicians in undergraduate medical education.     

Family attachments and medical sociology: a valuable partnership for student learning

This paper reports association within a curriculum of a theoretical programme in medical sociology for undergraduate medical students with a practical family attachment. These two components constitute the 'sociology' element of a course in behavioural science, and have equal weight for assessment purposes. Recognition of, on one hand, the mutuality of the two elements, and on the other, their similar but distinct theoretical underpinnings, suggests that such an association has the benefit of retaining the individual contributions of each component to student learning, while enabling theoretical and practical components to inform each other. Both are administered from the Department of General Practice of the University of Sheffield, UK. The consequences of such an educational provision are discussed.     

Psychiatric training for family doctors: what do GP registrars want and can a brief course provide this?

CONTEXT: About 40% of British General Practitioners (GPs) train formally in a psychiatric post as part of their general practice training, but such training may not fully meet the needs of future GPs. A specific course in psychiatry for family doctors has run in Manchester for more than a decade. METHOD: Semi-structured interviews conducted with GP registrars before attending the Manchester course in psychiatry with questionnaire follow-up afterwards to ascertain (a) the training 'wants' of GP registrars and (b) whether the course was providing them. RESULTS: GP registrars most frequently wanted training in communication skills, how to access the resources that are available to GPs, the detection of psychiatric illness, drug treatment and the management of aggression. The course was successful in satisfying the first three but failed in the last two. There was trend for those who attended Manchester Medical School, which scored significantly higher on number of topics covered at undergraduate level, to perceive a greater need for training than those who attended other medical schools. However, there was no evidence to link self-perception of greater need with having already worked in general practice during postgraduate training. CONCLUSIONS: More attention needs to be paid to how to address the specific mental health skills training requirements of GP registrars both within the attachment in psychiatry and during the practice year. Preliminary research is required to devise teaching packages before they are entirely satisfactory for GP education.     

A new approach to course development in geriatric medicine

A new course in Geriatric Medicine was initially conducted in four District General Hospitals, ten students attending each centre. The course, in the second clinical year, was established in the Department of Geriatric Medicine at Birmingham University by Professor Isaacs. The interview technique described was used from the outset as a means of formative evaluation. Undergraduates were randomly selected from each centre at the end of a course, and the results incorporated into a written report which was corrected by the students and distributed to the tutors. The results proved invaluable in evaluating students needs, attitudes and responses to the course. The interview gave unique information not obtainable from questionnaires, essays or exam questions, and enhanced the students feelings of participation in course development. Overall the information seems reliable and consistent and a valuable tool in curriculum design. The time involved was not excessive and leads us to recommend this approach as one method for continuing curriculum development which involves both the students and the tutors.