Effects of the vocational training of general practice consultation skills and medical performance

The effects of the vocational training of general practitioners in the Netherlands on the consultation skills and medical performance of junior doctors were studied. Results obtained at a training institute providing systematic training in these skills (Nijmegen) were compared with those at an institute taking a problem-based learning approach (Groningen). Trainees (n = 63) audiotaped consultations and recorded their medical performance at the start and at completion of training. The skills were evaluated with the aid of validated criteria and medical 'protocols'. Data on 631 pre-training and 624 post-training consultations were compared. Changes in consultation skills and medical performance occurred at both institutes and proved more marked at the institute providing systematic training. Improved medical performance was found to be associated with improved consultation skills. Enhanced clinical knowledge was found to be related to improved medical performance and consultation skills. The most profound changes were found in junior doctors who had started at a lower level of consultation skills and medical performance.     

Pliable but not receptive: concerning the marginal influence of a medical psychology course on the socialization process of doctors

Growth into a professional role requires absorption of knowledge, the learning of skills and the adoption of behavioural patterns and values which are part of a particular profession. In sociological literature this is described as the socialization/professionalization process. In this article the research literature which describes the process is reviewed. However, apart from the many positive aspects of adjusting and conforming, there are also more negative developments in the learning behaviour and attitudes of the future doctor. The Department of Medical Psychology in Amsterdam has structured its teaching programme--in part--to overcome or to decrease such tendencies. This article deals with those parts of the course which attempt to influence medical students' interviewing and interpersonal skills. Research into the effects of this teaching points to a marginal influence in both areas. The author looks for explanations for this, in the light of the research literature. In conclusion, the direction is indicated which could further increase the influence of the medical psychology course on future doctors.     

An analysis of paediatric diagnostic decision-making: how should students be taught?

This study assesses the relative importance of history, examination and investigations in paediatric diagnosis, in the Paediatric Out-patient Department of the Central Middlesex Hospital, London, by means of a questionnaire-based record of 94 consecutive referrals. A diagnosis identical to the final diagnosis was made in 76% of referrals after taking a history. The general practitioner had proposed a diagnosis in 45% in the referral letter. Clinical examination changed the diagnosis in only 15% but increased diagnostic confidence in 33%. Ninety-one per cent of cases were diagnosed without recourse to investigations. Forty-two per cent of children referred had investigations performed. In the majority of paediatric cases the provisional diagnosis reached after taking a history was identical to that after examination or results of investigations were known. Although examination provided a final diagnosis in only 15% of all cases it played an important role in adding confidence in 33%. More educational effort should therefore be directed at clinical history-taking skills and the subsequent purpose of examination.     

The effects of continuing medical education on family doctor performance in office practice: a randomized control study

A randomized controlled study was conducted to determine if specifically designed continuing medical education in the fields of cardiovascular and cancer medicine could change doctor office behaviour significantly. Thirty-one volunteer family doctors from 25 offices participated. Six (three cardiovascular and three cancer) learning objectives were defined. Two educational formats were selected as the independent variables: (1) group interaction opportunities (face-to-face and teleconference); and (2) concisely written newsletters. Chart measures of doctor performance prior to and 6 and 12 months following education served as the dependent variables. The family doctors receiving education were found to perform the recommended behaviours significantly more than those who did not receive the education (P less than 0.05) at 6 months post-education. This difference was maintained at the 12-month post-educational period for one of the educational programmes offered. A carefully planned programme of continuing medical education will result in favourable changes in the office practice of volunteer doctors. These changes can persist for as long as 12 months. Adherence to several essential learning principles is required.     

Can first-year medical students contribute to better care for patients with a chronic disease?

First-year medical students at the University of Western Australia are attached to a patient with a chronic illness in order to begin to understand the world of the chronically ill and their families. The patients are recruited by general practitioner preceptors who have been reticent in accepting first-year students because of their perceived immaturity and lack of medical knowledge. Not only have the preceptors' reservations proven groundless, but the teaching exercise has produced an unintended and positive side in that 35% of students discovered new information which was judged by the patients' general practitioners to be of significant help in the total management of patients' illness. Since these were only first-year medical students, the effect should be much greater with more mature students. Doctors often have incomplete records and act on incomplete information. Medical students are a means of correcting some of these deficits. In return they develop better psychosocial and communication skills and achieve considerable personal development by demonstrating to patients, their preceptors and themselves that they can be useful in contributing to more effective patient care.     

Familial factors in going to medical school

Attending medical school has long been known to be strongly familial. We set out to discover whether this tendency has been altered by recent procedures for selection of medical students. Preclinical medical students in the University of Wales College of Medicine, Cardiff and first-year zoology students completed a self-report questionnaire on the frequency of going to medical school among their first- and second-degree relatives. Thirteen per cent of the first degree relatives of the medical student proband group had attended medical school, compared with approximately 0.22% of the general population, giving a 'relative risk' of 61. Twenty-one per cent of the siblings over age 18 years of the medical student probands had been or were currently in a medical school, compared with 4% of the zoology student proband siblings. We conclude that going to medical school remains highly familial and this is probably largely determined by environmental/cultural and social factors. However, it is possible that genetic factors contribute in a non-specific way, e.g. via their influence on general intelligence.     

Family and community health in a new medical school

The planning and implementation of a curriculum for a department of family and community health in a new medical school in a developing country presents special problems. The evolution of the programme at Sultan Qaboos University in the Sultanate of Oman is described and discussed.     

The market and educational principles in continuing medical education for general practice

In an attempt to increase participation by established general practitioners (GPs) in continuing medical education (CME) the Department of Health in 1990 created an allowance (the Postgraduate Education Allowance, PGEA) to be spent by GPs on the educational provision of their choice. Although the PGEA has increased attendance by established GPs at educational activities, the market created in CME provision has favoured low cost activity of questionable value. This paper examines criteria for the validation of general practice CME, based on the principles of adult learning, which could be used to manage this market. Failure to adopt an appropriate validating process could lead to the PGEA becoming discredited and the imposition of periodic reaccreditation as a means of enforcing participation by GPs in CME.     

Choice of general practice for postgraduate training among medical graduates and undergraduates in Nigeria

A questionnaire survey of career choices was carried out among 112 medical graduates, after one year's internship (group I), during their National Youth Corps programme in Kaduna, Lagos, Cross River and Oyo states of Nigeria, and 365 final-year medical undergraduates (group 2) in the colleges of medicine in the corresponding states. A total of 13% in group I and 40% in group 2 were undecided as regards their first choice. Obstetrics and gynaecology was the most popular first choice in both groups. General practice ranked fifth among group I, but displaced surgery to rank second among group 2. The differences were statistically significant. A total of 41% of group I and 46% of group 2 preferred to work in a teaching hospital, reflecting the high preference for surgical specialties. Twenty-six per cent and 33.7% of respondents in groups 1 and 2 respectively wished to own their own practice or work in the private sector. General practice is a new specialty and its growth is supported by a national postgraduate training programme. A shift towards general practice is seen compared with previous studies of career preference among Nigerian medical graduates and students. This may be due to a changing balance of supply and demand in the medical work-force, or a better assessment of the nation's health problems and manpower needs.     

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.     

Teaching of primary health care in practice: a model using local health centres in undergraduate medical education

In Finland primary health care has a long historical background. The local communities, the state and the church have at various times and places been responsible for primary health care during the last few centuries. In 1972, a major reform took place when a new Primary Health Care Act came into force. In the same year two new medical faculties, at Kuopio and Tampere Universities, began to educate undergraduate medical students. In both of these new medical schools special attention was focused on the teaching of primary health care. Today practical teaching, which takes place at a primary health care centre, forms an important part of medical education at Kuopio University. This teaching of undergraduate students is part of the regular duties of general practitioners and public health nurses in the primary health care centres of eastern Finland that have agreed to collaborate in the teaching programme. The main principles are presented for the teaching programme in primary health care at the University of Kuopio.     

Teaching of medical ethics

Teaching medical ethics in Manchester within the introductory course of obstetrics and gynaecology is a joint activity with the Centre for Social Ethics and Policy. This interdisciplinary teaching has evolved through lecture sessions with small-group discussions dealing with topics of interest in human reproduction. The small-group discussion have been replaced by an open debate conducted by the students. Their own involvement and participation and an exposure to the disciplines of the humanities has broadened their approach to different ways of problem-solving of these real issues.     

Audit: teaching medical students in general practice

Summary. Audit is being seen as an increasingly important topic for medical students. Many departments of general practice in the UK now incorporate audit as part of their course work. It remains controversial as to whether this is perceived to be worthwhile by the students. Following an introductory seminar final-year medical students at the University of Glasgow were asked to perform a case-note review of 10 randomly chosen diabetic patients for a number of process and outcome measures during their practice attachments. Feedback was given in their final teaching session. 128/153 (84%) students completed an evaluation of the course on their knowledge and attitudes to audit. Unsurprisingly, 39% found the data collection boring or very boring; however, 60% found the feedback session very interesting or interesting. Both the data collection and the feedback were considered relevant by the majority of students (57% and 70% respectively). Students' self-reported knowledge also dramatically increased (P < 0.0001 ).     

Communication, stress and distress: evolution of an individual support programme for medical students and doctors

BACKGROUND: The stress and distress that can be associated with poor communication is well recognised. The problem of how to manage this effectively has yet to be solved. METHODS: In December 2001, the Communication Skills Unit sited in the Department of General Practice in the University of Wales, College of Medicine set up a pilot project for medical students and qualified doctors who were perceived to have communication difficulties. Referrals were made via the deaneries following an agreed format. Initial assessments were used to build an individually tailored programme addressing clients' needs. DISCUSSION: Throughout the year a variety of problems were encountered ranging from language difficulties to bullying and mental health issues. Anecdotal evidence of improvements has been clear, but measuring the outcome of this intervention has proved to be more challenging. Our efforts are now focused on refining assessment and evaluation. This type of service can provide the link between national and local initiatives as well as helping to develop strategies for assessment and training in communication.     

An experiment in problem-based learning

Summary: Problem-solving skills are important for medical students and problem-based learning (PBL) is especially suited to general practice. Therefore an experiment using a form of PBL was introduced into a new 4-week course in general practice for final rotation students at the University of Glasgow in the session 1992–93. The experiment aimed to introduce students to an alternative method of learning to the traditional one previously used by them in their course, to encourage teamwork and to encourage the use of alternative methods of obtaining information. The method, centred around allowing the students to investigate problems they choose themselves, is described. The evaluation of the course by written standard form, free written comments and audiotape recorded interviews with a one in four sample of the class is presented.
Summary: The students selected many interesting problems and used many different and unusual sources of information in researching them. This method of learning was compared with the parallel lecture course and was thought by the students to be more interesting but less relevant than the lecture course.
Summary: The experiment showed that it is possible to introduce a problem-based form of learning into a new course in parallel with more traditional methods of teaching and for it to be at least partially successful for students much more used to a traditional didactic curriculum. Ways of improving the course in the future to make it more sensitive to the students' learning needs are discussed.     

Improving the psychiatric skills of the general practice trainee: an evaluation of a group training course

Fourteen general practice trainees took part in a course specifically designed to improve their psychiatric interviewing skills. The trainees were instructed in the problem-based model and were taught in a group setting with the use of videotape feedback. A significant improvement was demonstrated in the trainees' ability to identify psychiatric illness accurately, and there were significant changes in their interview behaviours after training. Those who were below average before training showed the greatest improvement. The implications of these findings are discussed. Group video feedback training is as effective as one-to-one video feedback training in improving the psychiatric interviewing skills of GP trainees, and could be more widely employed in general practice vocational training.     

Evaluating family counselling skills training for family practice

Educational programmes for family practice should develop family counselling skills of students to moderate levels of competence. Few specific training programmes are part of the regular curriculum and of these few are evaluated. Twenty-three residents enrolled in a 2-year family practice programme in Toronto, Canada participated in a non-randomized control intervention study to assess a specific training programme. Pre-training counselling skills, and ability were assessed using two types of generally recognized measurement instruments, the Carkhuff Stems of Communication Skills and the Carkhuff Discrimination Index. The treatment group entered the training programme which involved supervised family counselling 8 half-days each week for one month as part of their usual rotations. They completed a second set of instruments following this course to assess immediate within-group change and then both they and the control group completed a set about one year later to measure differences. Initial scores for all residents showed a less than 'minimally facilitative' level of counselling response on both empathy and warmth dimensions. Following the course, the treatment group scored above this level and significantly better than the control group. Furthermore, the former showed a 20% improvement in ability to discriminate between effective and ineffective helping responses which was sustained over one year, while the control group's scores became worse. Teaching of counselling skills can be effective.