The proper emphasis on primary care in basic medical education*

The Alma Ata Declaration ‘Health for All by the Year 2000’ lays heavy emphasis on the development of competent primary care services. The World Health Organization does not see different sorts of country, developing or developed, as having the same health problems nor as achieving the same level of health in terms of the amelioration of these problems by the year 2000. In this paper a conceptual model of a rational health service is presented, the shortfalls from it are examined, and whether they reflect deficiencies in basic medical education is considered.     

Medical education in the light of the World Health Organization Health for All strategy and the European Union

Most governments and health professionals clearly recognize that the education of professionals must be adapted to practice in order to meet the needs of the population and of health systems. The role of medical schools, in a world where specialization is becoming a requirement to practice and is highly regulated, needs to be redefined. Medical schools need to transform their specialist training into a community-oriented, generalist education. In this light, the article analyses the European Union directives on medical education, and the recommendations of the World Health Organization (to meet the challenges of the Health for All Policy) and the World Federation for Medical Education. All are designed to reorient medical education to meet the health needs of the population, to reduce health costs, to ensure quality and to permit the free movement of sufficiently qualified health professionals.     

Setting educational priorities for learning the concepts of population health

Following the World Health Organization's policy of 'Health for All by the Year 2000', doctors are increasingly being seen as health care providers to populations of patients, in addition to their more traditional role as doctors to individuals in a one-to-one encounter. In order for doctors to take on this expanded role, they must learn the knowledge and skills appropriate to population health. In this paper, we propose a method of educational priority-setting which allows educational planners to identify those diseases and adverse health conditions most appropriate for studying the concepts of population health. Using the Measurement Iterative Loop of Tugwell and colleagues as a framework, a table of Priority Illness Conditions was developed and compared with a previous priority list developed from a survey of clinical teachers at the McMaster University Medical School. Discussion of the implications for this approach in setting educational priorities at undergraduate, postgraduate and continuing medical education levels is presented, along with a review of possible shortcomings and caveats in using this approach.     

Medical education and the corresponding professional needs of young doctors: the Finnish Junior Physician 88 Study

Summary. The Universities of Kuopio and Tampere in collaboration with the Ministry of Social Affairs and Health and Finnish Medical Association carried out the 'Junior Physician 88' study in 1988, the purpose of which was to shed further light on the life situation and future plans of young doctors and their views concerning undergraduate and postgraduate medical education. The study concerned all the doctors registered during the years 1977–1986 in Finland (   n = 5208  ). After randomization, a postal questionnaire was sent to one half (   n = 2631  ) of these doctors. After the first reminder letter, 1745 questionnaires (66.3%) were returned. According to the views of the respondents undergraduate hospital teaching was adequate but the teaching of practice in health centres, school health care, team-work, health care of the elderly, home health care, rehabilitation, environmental health care and administration did not meet the professional needs of doctors. All doctors were satisfied with the hospital teaching in their undergraduate curriculum. However, only the doctors who graduated from the two modern universities in Kuopio and Tampere were satisfied with their undergraduate health centre teaching.     

Anxiety, depression and stressful life events among medical students: a prospective study in Antalya, Turkey

OBJECTIVE: To assess psychological changes in medical students in Antalya, Turkey during their undergraduate education. The first-year follow-up outcomes are presented in this article. DESIGN: All first-year undergraduate students were given a detailed, self-report questionnaire and another in the second year. They were asked to complete the General Health Questionnaire (GHQ), the Spielberger State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI). SETTING: The Faculties of Medicine, Economics and Physical Education (PE) of the Akdeniz University, Antalya, Turkey. PARTICIPANTS: All first-year undergraduate students in the Faculties of Medicine, Economics and PE who were registered in 1996. RESULTS: The findings showed that psychological test scores on the GHQ, the STAI and the BDI rose significantly in medical students between the first and second years. Using the GHQ, with different cut-off scores, the percentage of students scoring above the thresholds was higher in medical students in year 2, compared with economics and PE students. In addition, the scores for some stressful life events of medical students showed a significant rise from year 1 to year 2. Multiple regression analyses indicated that some stressful life events related to social activities were associated with the psychological test scores for medical students. CONCLUSION: The results indicate that there is a decrease in the psychological health of first-year medical students. Some inadequacies in the social activities of the students might play a role in this type of disturbance.     

Effectiveness of problems used in problem-based learning

Where problem-based learning (PBL) is the main method used in medical curricula, the literature suggests that it is crucial that the problems used are effective in facilitating students to identify relevant learning issues. These learning issues guide the students' studying. The present investigation explores the extent to which students identify relevant issues following exposure to prepared paper problems. In the preparatory year, in an Introduction to Medicine module, four groups of students were exposed to six themes (Health Care System, Environment and Health, Alternative and Islamic Medicine, Chronic Illness, Infectious Diseases, and Prevention and Health Promotion). Each group had two facilitators per theme. Having discussed the prepared problems, the students identified learning issues which were collected for the purpose of the study. Two content experts, using a Likert scale, analysed learning issues for their concordance to staff objectives per theme. Kappa coefficients were computed for the six PBL themes in order to assess inter-rater agreement. Learning issues identified as having no relationship to theme objectives were further analysed for their relevance to theme objectives. No objective was totally omitted by any student group. There was a 100% concordance of objectives to learning issues demonstrated over four themes. The relationship of learning issues to theme objectives ranged from 55–85% in the theme on health care system, and 73–94% in the theme on environment and health. Irrelevant learning issues were identified in the first two PBL themes addressed. Kappa coefficients over the six PBL themes varied from 0·49 to 0·82.     

The social contract challenge in medical education

Medical education has been criticized for loss of touch with the health needs of society. A social contract implies that medical schools, their students and teaching staff have certain rights and privileges in return for serving society. Commitment to this important reciprocal relationship makes it necessary to ensure that medical students gain understanding of the basic health needs of the communities they will serve. Health, Illness and the Community (HIC) is a mandatory course in the first and second years of the curriculum at the University of Toronto. Its goal is to provide students with community learning experiences by involving over 300 community agencies as learning sites. The course takes place one half-day per week throughout first and second year. All 177 students initially work with patients in their homes and in public health units and related agencies. Students are then assigned to agencies using health determinants and health promotion strategies. In the second year, each student selects an agency in the community, and carries out for the entire year a major project focused on the interaction of a health problem with a social issue. This educational initiative has been received well by community agencies and patients. Teaching staff have been enthusiastic and students have performed very well. A major obstacle has been the negative attitudes of some students to community-based learning, but these appear to be improving with time. Involving multiple agencies as learning sites is a feasible method for enabling students to learn about community health needs.     

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.     

Trends in the number and administrative characteristics of medical school health promotion programmes

Over the course of almost 10 years, 1988-97, there has been a significant decline in the number of United States and Canadian medical schools offering health promotion programmes for students. All efforts should be made to enhance the overall health and well-being of medical students and to increase the number of health promotion programmes for them.     

Training of Kuwaiti medical doctors and their specialty choices: sociocultural impact

Kuwait has a comprehensive and well-structured health care system. However, to deliver such care the country relies on expatriate medical doctors. This paper attempts to discuss the sociocultural influences on the training of Kuwaiti medical doctors and their specialty choices in order to gauge future requirements of the Kuwaiti Health Services.     

Education in primary care psychiatry: research-based audit

This paper describes some of the difficulties faced by the KCGP Mental Health Education Fellows in designing an educational initiative to enhance the recognition and management of psychiatric illness in general practice. The initiative was evaluated using a consensus technique over six meetings which took place between 1993 and 1995. The results of the exercise illustrated the value of utilizing a validated instrument in identifying mental health problems, but when employed without support created disillusionment and a lack of confidence in the learner. However, when the instrument was applied as part of a wide educational process examining current practice, learners were stimulated to examine and change their behaviour by synthesizing newly acquired knowledge with their own previous clinical experience.     

Health promotion projects: skill and attitude learning for medical students

OBJECTIVES: The aim of this health promotion project is to introduce students to appropriate skills and attitudes--as well as knowledge about health promotion strategies and methods. As part of this process, standardized procedures have been established to ensure that the projects are scientifically and ethically appropriate and adequately supervised. This project-centred course introduces the discipline of health promotion to third-year medical students at Monash University. It is aimed at introducing students to the range of health promotion concepts, providing them with experience of health promotion activities and involving them in consideration of the scientific, political and ethical issues arising from doctors' participation in health promotion. DESIGN: As the major learning and assessment component of the unit, students participate in self-selected project groups of three to five students. Each group develops a topic for a health promotion activity in the community, carries out that project and presents the results as a poster as well as a written report. SETTING: Monash University. SUBJECTS: Third-year medical students. RESULTS: Sixty per cent of each student's mark for the unit is based on the project. The posters produced by the project groups are placed on public display in a major teaching hospital for a week at the end of the unit. Public display of the posters helps each student to appreciate the variety of possible health promotion activities, and to appreciate health promotion as a scientific discipline. It also makes the project findings available to the public. CONCLUSIONS: Student evaluation of the project, and community response to the projects--especially the poster display-- indicate that the project is both a highly effective learning experience and a health-promoting activity in its own right.     

Disease prevention and health promotion: a study of medical students and teachers

All students at the Royal Free Hospital School of Medicine (n = 508 ) were surveyed on their self-reported smoking and drinking habits, attitudes to disease prevention and health promotion in general, attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught at the beginning of the 1993–1994 academic year (response rate 75.2%). The teaching staff (n = 271 ) were also surveyed on their attitudes towards the teaching of disease prevention and health promotion, and their perception of what was taught (response rate 74.2%). Seventeen per cent of the students reported they were current smokers and 81% drank alcohol. Four factors were extracted from the responses to the items on disease prevention and health promotion in general and these represented the importance of health, a patient-centred approach, patient responsibility and a doctor-centred approach. Clinical students and those who were older were more likely to have a ‘patient-centred’ approach to disease prevention and health promotion. Sixty per cent of clinical and 44% of pre-clinical teachers aimed to teach about disease prevention and health promotion. The topics reported by students as most likely to have been taught in detail are smoking and health, alcohol and health, immunization, and breast and cervical screening. However, all these topics were reported as having been taught in detail by less than 50% of the students. The majority of students and teachers believe that teaching about disease prevention and health promotion should be integrated into all years of the curriculum and all clinical firms. Teachers were significantly less likely than students to believe that students should learn more about disease prevention and health promotion, and that learning about prevention is as important as learning about diagnosis and treatment. We believe that, in order to build on the positive features highlighted in this study, agreed aims and objectives should be developed and teaching about disease prevention and health promotion should be integrated both horizontally and vertically throughout the curriculum.     

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.     

An evaluation of introductory courses in environmental health

Introductory courses in environmental health are intended for doctors newly appointed to the emergency duty rotas of the Medical Officer for Environmental Health. Three courses have been held in Bristol between 1984 and 1987. They have been evaluated with a problem management questionnaire completed by 44 of the 47 participants before and after the teaching. Seventy-four per cent (23/31) of a comprehensive list of aspects that could be considered were mentioned by less than 30% of respondents at the beginning of the course and 65% (20/31) of these aspects were mentioned by at least 30% more participants at the end of the course than before it. There were no differences in these patterns between respondents who attended the different courses. The findings support the need and educational worth of such courses, and help to identify learning deficiencies. Problem management questionnaires are useful in their evaluation.     

A community of scholars or scholars of the community? A note on the limits of relevance

Universities are increasingly expected to be accountable for the large sums of public money they spend. Universities in Australia are currently under pressure to turn out graduates who are technically trained for immediate entry into the work force. Universities are expected to teach knowledge and skills which are relevant to what the community needs now. If the universities accept such obligations of accountability and relevance, what are the implications for the university enterprise? Over the past decade, medical schools have attempted to spell out their purposes, writing their overall goals and then specific objectives to guide teaching in all departments. These lists of goals and objectives usually incorporate a strong orientation to meeting current community needs. One expression of these community needs is the call for ‘Health for all by the year 2000′, supported by all governments through the World Health Organization. Turning out graduates to provide community health care would be a relevant goal which an accountable medical school could hardly deny. What evidence is available about university responses to such needs?     

The place of primary health care in medical education in the United Kingdom: a survey

Primary health care has been held to be the foundation of any rational health system. The principle was fully endorsed by the Alma-Ata Conference in 1978, and has become the main policy of the World Health Organization. Important implications are involved for the education and training of doctors and other health care professions.
An enquiry was conducted by personal interviews of those most responsible for the teaching of primary health care in the United Kingdom, to enquire about the status of primary health care in the curricula of U.K. medical schools, and about the standing of general practice. The enquiry also explored the degree of awareness among medical educators about the Alma-Ata Declaration. The leading representatives of primary health care in the medical schools made it clear that the teaching of primary health care varied greatly in the importance accorded to it and the resources made available for it by medical schools. Almost half the respondents were unaware of the support for greater emphasis on primary health care that had been specified in the Alma-Ata Declaration.     

Advanced training in biomedical ethics: a curriculum in clinical specialty programmes

Summary. Medical ethics play an essential role in the practice of medicine, in the care of individual patients, in the allocation of health care resources, and in the formulation of health care policy. A specific body of knowledge, ‘biomedical ethics’, has developed which applies ethical theory to biomedical practice. This has provided doctors with tools systematically to integrate rational ethical analysis into clinical decision-making. Training in the discipline of biomedical ethics is now required for all doctors in Canada. The goals, content areas, learning objectives, and learning methods considered appropriate for advanced training in this field for medical specialists are provided in this paper. Six topic areas are discussed: introduction to ethical theory, clinical ethics, professional ethics, ethics of human experimentation, ethics of health policy, and independent study. Ways this curriculum could be organized and evaluated are also offered.     

Facility with the English language and problem-based learning group interaction: findings from an Arabic setting

The Faculty of Medicine and Health Sciences (FMHS), United Arab Emirates (UAE) University is in a unique position to explore issues related to English language proficiency and medical student performance. All students entering the FMHS have English as a second language. This study focused on the issues of students' proficiency in English as measured by the TOEFL test, student background factors and interaction in problem-based learning (PBL) groups. Using a modification of Bales Interaction Process Analysis, four problem-based learning groups were observed over four thematic units, to measure the degree of student interaction within PBL groups and to compare this to individual TOEFL scores and key background variables. The students' contributions correlated highly with TOEFL test results in the giving of information (range r = 0.67-0.74). The female students adhered to interacting in English during group sessions, whereas the male students were more likely to revert to using Arabic in elaborating unclear phenomena (p < 0.01). The educational level of the student's mother was highly predictive of TOEFL scores for the male students, but not for female students. Multivariate analysis was undertaken to analyse the relative contribution of the TOEFL, parental education and years of studying in English. The best predictor of students' contributions in PBL groups was identified as TOEFL scores. The study demonstrates the importance of facilitating a locally acceptable level of English proficiency prior to admission to the FMHS. However, it also highlights the importance of not focusing only on English proficiency but paying attention to additional factors in facilitating medical students in maximizing benefits from interactions in PBL settings.     

The teaching of child health in a medical college in central India

Aware of the importance of a knowledge of children and skill in their care, the World Health Organization and the Government of India have been working together to improve the training and education of the medical student in that subject. To that end the Organization has supported the work of a committee of medical educators, which has studied the teaching of child health and has published an experimental curriculum suitable for use in medical colleges in India ( 'Ad hoc' Committee on Education and Training in Paediatrics; WHO, 1970 , 1971 , 1974 , 1975 ). This article tells of the experience with that curriculum in one medical college in Central India since 1974. It is first necessary to indicate the position of medical education in the country.