Can general internal medicine be taught in general practice? An evaluation of the University College London model

There is national and international interest in increasing the community-based component of undergraduate medical education, but more research is needed on its potential, practicability and effectiveness. The objective of the study was to examine the feasibility and efficacy of general practitioners teaching basic clinical skills to first year clinical medical students in the community. The structure and methods of evaluation of the programme are described. Evaluation tools included semi-structured interviews of general practitioner tutors; student questionnaires; assessment of student performance; and costs of the programme. The great majority of the students found the programme enjoyable (81 out of 81, 100%) and educational (79 out of 81, 97%). Students' perfomance in the end of rotation Objective Structured Clinical Examination suggested that clinical skills are acquired at least as well in the community as in hospital. Tutors identified the personal benefits of this teaching as development of their own clinical skills and the stimulation of teaching. The programme has been successfully expanded from 24 students to 230 students annually and has demonstrated that community-based teaching can usefully contribute to undergraduate medical education in the area of clinical skills teaching. Key practical issues for schools contemplating similar initiatives are presented.     

Basic clinical skills: don't leave teaching to the teaching hospitals

OBJECTIVE: To compare student perception of teaching in general practice (GP), district general hospitals (DGHs) and teaching hospitals (THs) and their examination results. SETTING: The medical school at Queen's University, Belfast. SUBJECTS AND METHODS: A total of 161 medical and 34 dental students completed an objective structured clinical examination and questionnaire at the end of their second semester of basic skills teaching. They scored the course for teaching style, educational value and enjoyment. Teaching attributes of the tutors were similarly recorded. Students were also asked to quantify how time was used and to comment on the course. INTERVENTIONS: A new programme for teaching first- and second-year students basic clinical skills in the community. RESULTS: Teaching in GP and DGHs was reported to be more educational and enjoyable than in the TH. In GP most time was spent being lectured, in DGHs most time was spent with the patient, and in THs, waiting for the tutor. General practitioners and doctors in DGHs were more likely to model positive teaching attitudes such as showing interest in students and providing feedback. The most common complaints related to insufficient time spent with patients in GP and poor tutor preparation in THs. All teaching sites achieved similar examination results. CONCLUSION: Clinical skills can be taught to medical students early in their curriculum using GP tutors. Student preference was strongly for being taught by GPs rather than in THs. Simple steps such as prior preparation and the locating of a suitable patient could markedly improve student experience both in GP and in hospitals.     

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.     

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.     

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.     

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.     

The contribution of general practice to medical education: expectations and fulfilment

The aim of this study was to discover what students expected to learn during their fourth-year general practice attachment, to compare this with their GP tutors' expectations and to determine the extent to which the students' expectations were fulfilled. Questionnaires were used to gather this information; students completed them on the first and last days of the 4-week attachment and tutors shortly after the attachment. Students and their tutors had the highest expectations of the course in helping to raise awareness of the psychological and social aspects of ill health and develop clinical decision-making and management skills. At the end of the course students thought that they had gained most in these areas. Both students and tutors had lower expectations of the course helping to develop physical examination and practical skills and to improve knowledge in certain clinical areas. These were also rated lowest in terms of fulfillment. This study was carried out at a time when it is being suggested that more undergraduate teaching should take place in general practice and that this could include the teaching of practical skills and clinical subjects traditionally associated with hospital-based teaching. The results suggest that the expectations of students and GP tutors would need to be modified, as well as extra resources provided, if there is to be a shift in teaching towards the community.     

Context-bound communication skills training: development of a new method

OBJECTIVES: To examine how communication skills training might be integrated into everyday clinical practice in a manner that is acceptable to clinicians. DESIGN: General practitioners from 3 group practices agreed to take part, in turn, in a study of how to manage difficult consultations about antibiotic prescribing for acute respiratory infections. This provided the opportunity to conduct communication skills training in which lessons learned from one practice were taken into the next. SETTING: United Kingdom general practices. SUBJECTS: Three groups of general practitioners. FINDINGS: Difficulties with the acceptability of a traditional off-site workshop approach, using role play as the main teaching method, led to the development of a new training method (context-bound training), which proved to be practical and acceptable to experienced clinicians. The main features of the method were the delivery of training in the clinicians' place of work, and the transformation of their reported difficult cases into scenarios which they then encountered with a standardized simulated patient before and after brief seminars. Everyday clinical experience was kept in the foreground and 'communication skills' in the background. CONCLUSIONS: The method is acceptable to clinicians and adaptable to a range of clinical situations. It offers potential for improving the communication skills of clinicians both in hospital and primary care settings.     

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.     

Students' perceptions of the relative advantages and disadvantages of community-based and hospital-based teaching: a qualitative study

AIMS: To obtain the perceptions of first-year clinical medical students of the relative advantages and disadvantages of community-based and hospital-based clinical teaching. METHODS: A qualitative study. A purposive sample of first-year clinical medical students who had experienced both community-based and hospital-based teaching was invited to participate in individual semistructured interviews or focus groups. Interviews and focus groups were audiotaped and transcribed to facilitate content analysis of the data. A total of 24 students participated in individual interviews and a further 18 took part in focus groups. RESULTS: Respondents identified advantages and disadvantages specific to teaching in each setting. Chief advantages of hospital-based learning were perceived to include learning about specialties and the management of acute conditions, and gaining experience of procedures and investigations. Community-based learning was perceived as particularly appropriate for learning about psychosocial issues in medicine, for increasing students' awareness of patient autonomy and for improving communication skills. In addition, aspects of organization and of teaching methods employed by community tutors, although not site-specific, were viewed as conducive to a positive educational experience. Students perceived some areas, such as clinical skills acquisition, to be equally well learned in either setting. DISCUSSION: As community-based teaching forms a greater proportion of the undergraduate medical experience, medical educators must find ways of determining the specific advantages that community and hospital settings can contribute to undergraduate learning and of using these resources effectively to develop comprehensive and integrated curricula. Innovations in teaching methods may also be necessary to provide an effective educational experience and promote active learning.     

A process evaluation of medical ethics education in the first year of a new medical curriculum

BACKGROUND: Despite the recent increase in activity in the field of medical ethics education, few evaluative studies have been carried out. Most studies have taken place in North America, in curricula where teaching is discipline-based, and have concentrated on outcome rather than on the curricular processes adopted. AIM: To evaluate the process of medical ethics education in the first year of a new learner-centred, problem-based, integrated medical curriculum. METHOD: A qualitative, multi-method approach was adopted using open questionnaires, focus groups and tutor evaluation rating scales. The study involved all 238 students in the first year of the new medical curriculum, and the 30 clinical tutors who facilitated ethics learning. A stratified sampling technique was used to choose focus group participants. RESULTS: Small group teaching proved highly acceptable to both students and tutors. Tutors' teaching skills were central to its effectiveness. Tutors played an important role in promoting students' appreciation of the relevance of medical ethics to clinical practice, and in establishing a climate where constructive criticism of colleagues' actions is acceptable. Course integration, including the provision for students of clinical experiences on which to reflect, was an important aid to learning. Students and tutors were noted to be driving the ethics curriculum towards having a contextual rather than theoretical base. CONCLUSION: This evaluation identified those aspects of the medical ethics course which contributed to its effectiveness and those which detracted from it. This information will be used to inform future development.     

Factors influencing the communication skills of first-year clinical medical students

The aim of this study was to examine the factors influencing medical students' communication skills. The sample comprised all first-year clinical students. Thirty-two received teaching in communication skills during the year; the remaining 56 did not. Students' career preferences, attitudes towards communication skills and confidence in their ability to communicate with patients were assessed by questionnaire at the beginning and end of the year. At the end of the year each student was videotaped interviewing a simulated patient. Students' communication skills were assessed on the basis of this interview by raters using a standardized rating scale, and by patient questionnaires. While there was some evidence that brief communication skills training improved skills, sex of student was a more significant predictor of level of skill. Students who perceived communication skills as less relevant to medicine and those who were more confident about their own communication skills were more likely to prefer a career in hospital medicine. Students' judgements of their ability to communicate effectively were poor. In the main there was no relationship between confidence and level of skill: where they were related, the association was negative. The benefits from communication skills training might be enhanced by involving hospital doctors in the teaching, and providing students with detailed video feedback on their skills at the outset.     

Attitudes of patients to medical student participation: general practice consultations on the Cambridge Community-Based Clinical Course

The clinical medical students on the Cambridge Community-Based Clinical Course (CCBCC) derive part of their training by taking part in consultations between patients and their general practitioners. Patients' attitudes to this arrangement and their support for student training in a general practice setting are an important factor in the development of community-based education. A postal questionnaire seeking information from patients achieved an 84% response rate. Both the numerical results and the patients' comments are presented. Patients proved generally supportive of the community-based course and some identified positive benefits to themselves from this provision. The large majority of patients did not mind the presence of medical students during consultations, although there are some areas in which patients are less willing to involve students.     

Standardized patients in the early acquisition of clinical skills

OBJECTIVES: Facing dramatic reductions of inpatient beds and fewer faculty tutors, the Queen's University medical school has had to consider alternatives to the traditional inpatient encounter for the early acquisition of clinical skills. The purpose of this study was to investigate the feasibility and impact on students of a model for a first-year clinical skills course, using exclusively standardized patients in place of inpatients, and using a smaller ratio of faculty to students. DESIGN: Twenty volunteers were selected from the first-year class of 75 students to participate as the experimental group. The remaining 55 students formed the control group. SETTING: Queen's University medical school, Ontario, Canada. SUBJECTS: First-year medical students. RESULTS: In measures of student satisfaction with the amount of performance feedback received during the course, there was a non-significant trend towards greater satisfaction among the experimental group compared to the control group. This occurred despite a tutor to student ratio of 1.5:10 in the experimental group compared to 3:10 in the control group. In the student evaluation of their tutors, mean scores for the two groups were 4.28 for the experimental group and 4. 06 for the control group (P = 0.10). The mean OSCE scores for the two groups were 76.4 for the experimental group and 76.5 for the control group (P = 0.93). There is no practical or statistical difference in either of these two scores. CONCLUSIONS: We conclude that this new model is feasible, was well received by the students and that the reduced tutor to student ratio and lack of inpatient encounters did not appear to adversely affect their learning.     

CeMENT: evaluation of a regional development programme integrating hospital and general practice clinical teaching for medical undergraduates. The Community-Based Medical Education in North Thames

OBJECTIVES: To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates. DESIGN: A multifaceted approach employing quantitative and qualitative techniques. SETTING: All medical schools in North Thames Region. SUBJECTS: Students, GP tutors and hospital specialists. RESULTS: The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess. CONCLUSIONS: This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project's key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure.     

Child health surveillance: development of a multicentre course and its evaluation

With increasing numbers of general practitioners wishing to provide child health surveillance during the 1980s and the expected further increase with the 1990 General Practice Contract, a course in child health surveillance was developed. The content of the course was determined by a needs assessment of Welsh general practitioners in combination with the expectations of paediatricians already involved in educating doctors in community child health. A multicentre course with prepared materials was developed. Teaching methods reflected adult learning needs, included practical clinical competencies and was centred in small groups each led by local tutors. The course was held annually on three occasions, with 220 participants in total. The materials and teaching methods were highly acceptable to the participants, and evaluation demonstrated a significant increase in knowledge and confidence. All participants reached the required clinical competence, six after further teaching. The content, teaching methods, and evaluation methods were altered in the light of feedback, resulting in a 'stand alone' course with built-in evaluation, which is now being provided by local tutors. This study has demonstrated the feasibility of providing a course for large numbers of doctors, using predominantly small-group teaching and discussion with local tutors. We are grateful to all the participants and especially the tutors.     

Clinical skills education: outcomes of relationships between junior medical students, senior peers and simulated patients

Objectives  Peer-assisted learning (PAL) has been reported to have educational benefits in cross-year, small-group teaching in other contexts. Accordingly, we explored whether senior medical students are effective tutors for their junior peers in clinical skills education, and how the participants in the learning triad (tutors, learners and simulated patients [SPs]) perceive the learning environment created in PAL.
Methods  Year 2 students were randomly allocated to one of two groups for skills training. Group 1 ( n  = 64) were tutored by volunteer Year 6 students, and Group 2 ( n  = 67) by paid doctors. The results of both groups in a clinical skills examination were compared using an independent samples t -test. Qualitative data, obtained from Year 2 students ( n  = 125) by written questionnaire and Year 6 students ( n  = 11) and SPs ( n  = 3) by focus group interviews, were analysed for themes.
Results  Students receiving PAL did at least as well in the clinical skills examination as students with qualified tutors (difference in mean total score: 0.7 marks out of 112; 95% confidence interval − 3.8 to 2.4). The PAL environment was perceived as 'comfortable' and fostered the development of confidence in all participants. Peer tutors created a more active learning environment than doctor tutors for both learners and SPs and reported personal benefits from teaching.
Conclusions  With appropriate support, volunteer Year 6 student tutors are as effective as graduate doctors for small-group structured tutorials in clinical skills. Educational relationships were forged between all participants in the learning triad.