Does a brief clerkship change Hong Kong medical students’ ideas about general practice?

OBJECTIVES: This study examines the impact on students of a brief general practice clerkship, during a curriculum that is otherwise almost entirely hospital-based and in a practice environment that often does not encourage good primary care. DESIGN: 15 focus group discussions were held with a total of 110 students, as part of an action research project. Student responses were audiotaped, transcribed and then analysed for recurrent themes. SETTING: General Practice Unit, University of Hong Kong. SUBJECTS: Medical students RESULTS: There was evidence of pre-existing negative stereotypes of general practice, but in many cases these were dispelled by the relationships students developed during their attachment to general practitioners in the community. In an overcrowded curriculum, students ration their time and energy, focusing their learning pragmatically on subjects that have a high profile during examinations. CONCLUSIONS: Even in healthcare and medical school systems that are specialist-dominated, and in which the circumstances of practice do not always encourage high standards of care, the general practice clerkship can allow students to gain an understanding of the importance of primary care, and of the significance of the general practitioner's role in the healthcare system.     

Medical Students' attitudes toward basic sciences: influence of a primary care curriculum

The emerging popularity of family medicine and primary care among medical students with an attendant pressure for clinical relevance in pre-clinical coursework and early clinical exposure has raised questions in the minds of many academicians about the Students' perceived value of basic sciences in such an educational environment.
A comparison was made of attitudes toward the basic sciences between students in two, concurrent, pre-clinical medical school curricula at the University of New Mexico School of Medicine. The conventional curriculum offers a teacher-centered, 2-year curriculum of basic sciences taught predominantly by basic scientists in a lecture format. The experimental curriculum entitled the Primary Care Curriculum (PCC), offers a student-centered, 2-year curriculum in which pertinent basic and clinical science learning is derived primarily from common, primary care, patient problems, discussed in small group tutorials. There are no formal lectures. Half the tutors are primary care clinicians, half basic scientists.
Attitude scales were administered in two successive classes of students in both curricula at the beginning of the first and second terms of the first year. Increased cynicism toward the curriculum and its relevance to future practice was observed among conventional, but not among PCC students. This finding lends support to the hypothesis that modification in educational methods in general and relevant, primary care experience in particular can favourably influence Students' attitudes toward basic sciences.     

General practice in the curriculum in Slovenia

Specific education in primary care in Slovenia developed in 1966, when vocational training for general practitioners was introduced. However, general practice never gained academic acceptance and was not introduced as a separate subject at undergraduate level. With the reform of medical education in Slovenia starting in 1987, family medicine was finally introduced as a specific subject in the final year. The new curriculum introduced a strong emphasis on practice-based teaching and in 1995 the first university department of family medicine was formally established. This article reports the first evaluation of the programme, based on qualitative and quantitative analysis of questionnaires, from students and the general practitioners who were their tutors. The programme was very well accepted by the students, who enjoyed working independently in a friendly environment where their tutors were more facilitators than teachers. The main problem is recognition of tutors by the medical and educational establishment, which will motivate tutors to perform additional educational tasks in the future.     

A survey of primary care physicians' perceptions and needs regarding the precepting of medical students in their offices

OBJECTIVE: To assess the interest, perceptions, and needs of primary care physicians with regard to office-based precepting of medical students. DESIGN: Random survey. SETTING: The New England region of the United States (Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut). PARTICIPANTS: Family physicians, general internists and paediatricians. MAIN OUTCOME MEASURES: These included: (1) practice and preceptor demographics; (2) Likert scale agreement or disagreement with various positive and negative perceptions about precepting students; rating (from unimportant to necessary) of potential benefits from medical schools associated with the support of precepting in the office setting, and (3) comparisons among physician groups to determine differences in perceptions and needs. RESULTS: There is a high level of interest in precepting regardless of primary care specialty, practice structure, payment mechanism, or precepting experience. Negative impacts included decreased productivity and increased length of the day by a median of 60 minutes. Positive impacts included keeping one's own knowledge up-to-date and enhanced enjoyment of practice. Benefits such as academic appointments, continuing medical education credits, faculty development, computer linkages for clinical information and medical library access are rated highly. Monetary payment, whether as a modest honorarium or as compensation for lost time/income, was felt to be important by half of our sample. CONCLUSION: A significant interest in precepting medical students on a regular basis is expressed by primary care physicians in the ambulatory medicine setting. The results of this survey can be used by medical schools to address negative perceptions and to develop appropriate benefits packages to recruit and retain these primary care preceptors.     

Making and sharing decisions about management with patients: the views and experiences of pre-registration house officers in general practice and hospital

OBJECTIVES: To explore the views and experiences of pre-registration house officers (PRHOs) in general practice and hospital settings regarding the concept of patient partnership and their experience of involving patients in management decisions. DESIGN: The 12 PRHOs who had graduated from British universities and who were working within the Yorkshire Deanery were interviewed towards the end of their four-month general practice attachments. The interviews were semi-structured and analysed qualitatively. RESULTS: Three major themes emerged. The PRHOs perceived differences in approach between consultations carried out in hospital and primary care settings, with general practitioners being more likely to share information and decisions with patients. As medical students, the PRHOs had little opportunity to practise sharing information and management decisions with patients, and variable experience of this after graduation. On the whole they were favourable to the concept of patient partnership. CONCLUSIONS: Medical students and PRHOs lack training and opportunities to decide on management and discuss this with patients and yet, particularly in general practice settings, they have to practise these skills. The PRHOs had begun to develop strategies to decide how much information to give to patients and to what extent to involve patients in management decisions. This is an area that needs further consideration when planning both undergraduate and postgraduate medical education.     

Differences in curriculum emphasis in US undergraduate and generalist residency education programmes

OBJECTIVES: Little attention has been paid to the differential emphasis undergraduate and graduate medical education programmes place on the broad competencies that will be needed for practice in an increasingly managed health care environment. The purpose of this study was to determine differences in emphasis that undergraduate and primary care graduate medical education programmes are currently placing on 33 broad practice competencies, compared with the emphasis they ideally would like to give them, and the barriers they perceive to curriculum change. DESIGN: Subjects were surveyed by mailed questionnaire. A reminder postcard and follow-up mailing were sent to non-respondents. SETTING: US allopathic medical schools. SUBJECTS: Academic deans identified by the Association of American Medical Colleges (AAMC) and generalist (family medicine, internal medicine, paediatrics and obstetrics-gynaecology) residency programme directors identified by the American Council on Graduate Medical Education (ACGME). RESULTS: Findings revealed that residency programmes placed greater emphasis on the study's broad curriculum topics than did undergraduate medical education programmes. Statistically significant differences were found in current emphasis for 12 topics and ideal emphasis for six topics. Both groups identified an already crowded curriculum and inadequate funding as the top two barriers to curriculum change. CONCLUSIONS: The differences in curriculum emphases and perceived barriers to curriculum change most probably reflect the different realities of undergraduate and graduate medical education programmes, i.e. academics vs. a focus on immediate practice realities.     

RURALISING THE UNDERGRADUATE MEDICAL CURRICULUM THROUGH CONSULTATION WITH KEY STAKE HOLDERS

ABSTRACT: This paper describes the approach taken at the University of Queensland to broaden the scope of curriculum design to involve rural general practitioners, medical students and rural health care consumers. A form of nominal group process in serial telephone teleconferences was used, with a group of rural general practitioners, to develop and pilot curriculum content, learning strategies and assessment methods. Medical students assisted in the evaluation of the curriculum and representatives of rural organisations were consulted about the value of hosting medical students in rural communities. The three groups made significant contributions to the project. The results will be trialed for the entire year 6 cohort (240 students) in 1995 and will form the basis of the planned rural practice term in the new graduate course.     

Interns'' evaluation of their preparation for general practice: a comparison between the University of Tromsø and the University of Bergen

A total of 168 interns who have graduated from the Medical Schools of Bergen and Tromsø were asked about various aspects of the medical curriculum. In Bergen the curriculum has a traditional structure with a pre-clinical and a clinical part, but in Tromsø the pre-clinical and clinical subjects are integrated. In addition, the students in Tromsø spend long periods in municipal hospitals and in the primary health care service. We were interested in how the interns from the two universities evaluated their respective curricula and how prepared they felt for their current work. There was a response rate of 86% to the questionnaire. The results showed that the interns from Tromsø are more satisfied with their education and feel more confident in their practical skills than the interns from Bergen. They are also more motivated for future work in general practice. In our opinion the main reason for these results is the difference in curricula in the two medical schools. Other possible reasons are also discussed.     

Community-based training in family medicine--a different paradigm

INTRODUCTION: Community-based education is an important strategy for training students appropriately for delivering primary health care services. A community-based training rotation in Family Medicine and Primary Care was introduced at the University of Stellenbosch, South Africa, in January 1998. OBJECTIVE: The aim of this study was to explore the perceptions of final year medical students about the new rotation and to provide feedback on the value of this experience to the Faculty. In this article we explore the influence of differing world views held by biomedically oriented training institutions and the systems view of life adhered to by the discipline of Family Medicine on attempts to reform medical education. METHOD: Quantitative and qualitative curriculum evaluation methods, including a questionnaire and focus groups discussions, were used. Students rated the value of the block as 7.8 out of 10. RESULTS: Eighty-eight percent of students felt that there should be an earlier exposure to Family Medicine and Primary Care in their training. The main themes identified from the qualitative results supported the literature findings and included the difference in type of practice between tertiary and primary levels of care and the value of learning a new approach to patient care. Despite the fact that the results emphasized the importance of including community-based training in Family Medicine and Primary Care at an early stage in the medical curriculum, resistance to implementation was encountered. This led to reflection on possible reasons on why the recommendations of the study were not immediately adopted into the curriculum.     

Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical Course

BACKGROUND: Medical students receive increasing amounts of their clinical education in a primary care setting. The educational possibilities of such attachments are still being explored. AIM: To report the evaluation of a small, radical innovation to provide students with a long-term community attachment which integrated with hospital-based education. METHOD: Between 1993 and 1998, 13 medical students completed 15-month attachments with a single general practice in England. The course offered them experience in the major clinical specialties throughout this period. Students were exposed to specialist as well as generalist education in the context of patients with whom they could establish a continuing relationship. The innovation was evaluated by its feasibility, by students' examination results, by analysis of clinical experience, through formal student feedback and by cost. RESULTS: The course was practicable in a particular setting with academic leadership. The students all passed their exams. They had wide, appropriate clinical experience even though the attachment was to a single practice. When they returned to the hospital environment, students did not feel themselves at a disadvantage compared with traditional students. The costs of the course are controversial: placement costs were higher than in the hospital, but those for facilities were lower. CONCLUSION: It is possible to run a course like this successfully. It remains the most radical attempt to share clinical education in the UK between primary and secondary/tertiary care. Further research is required into providing long-term clinical attachments in NHS primary care settings.     

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.     

Influence of Third-Year Clerkships on Medical Student Specialty Preferences

Purpose – The purpose of this study was to investigate influences on third-year medical students' specialty preferences. Method – A survey questionnaire was mailed to third-year medical students at two medical schools. The questionnaire asked students to rate the degree to which various aspects of the third-year curriculum and perceived specialty characteristics influenced their specialty preferences. Results – A total of 214 (70%) of eligible students responded, of whom 46% were female and 57% preferred primary care (PC) specialties. The most frequently cited influential clerkship was internal medicine. Most clerkships (72%) had a positive influence on students' preferences. PC clerkships had more positive influences than non-primary care (NPC) clerkships, especially among PC-oriented students. The most influential aspects of clerkships were faculty and residents, especially in PC clerkships. For both PC- and NPS-oriented students, the diagnostic and patient-related characteristics of their preferred specialties were highly influential. PC-oriented students were more likely to be attracted to prevention and biopsychosocial aspects of specialties, and NPC-oriented students to the opportunity to do procedures and intervene in illnesses. Student gender appeared to have little influence on response patterns, except as a proxy for specialty preference, which, for women, was more likely to be a primary care specialty. Conclusion – These findings suggest that the third-year clerkships, especially at non-university sites, play an important role in specialty choice, and that factors attracting students to PC differ significantly from those attracting students to NPC. This revised version was published online in July 2006 with corrections to the Cover Date.     

Characteristics of senior medical students at Belfast

This paper analyses and discusses the degree of homogeneity existing in the medical school student population of the Queen's University, Belfast, in relation to certain characteristics: social class, academic attainment, admission standards, intelligence test scores, and personality. Findings are compared with those reported in earlier studies elsewhere. No sex difference in social class distribution of Queen's medical students is noted. There is a much lower proportion of social class I students and a higher social class III proportion, than shown elsewhere in Britain ( Johnson, 1971 ). Women constitute 38% of the medical school student population, a proportion in line with the 40% reported as the overall British percentage ( Brit. Med. J., 1976 ). Females are shown to have a significantly better overall academic record than males, related to intelligence, aptitude for certain subjects and probably to behavioural and attitudinal differences to study and medical care. No significant sex differences are noted in relation to entry qualifications, intelligence, and the personality factors of extraversion and neuroticism. Male A-level scores in the present study are useful predictors of academic success in the medical course, but this is only true for females up to 2nd M.B. stage. General practice is the exception for both sexes, there being no significant correlations with general practice scores. Highly intelligent females and males below their group intelligence mean performed significantly better in learning situations in general practice as reflected in general practice scores, than highly intelligent males. The data may reflect different attitudes to whole person care and varying abilities to integrate knowledge and to define problems in primary care. These findings, including the sex differences in the factors related to academic attainment in the later clinical years of the medical curriculum, may have implications with regard to present selection procedures to most medical schools based solely on A-level grades.     

Specialty choice and understanding of primary care among Japanese medical students

To assess specialty choice and understanding of primary care among Japanese medical students, all students from seven Japanese medical schools (three public and four private) were surveyed, using a written questionnaire. A total of 3377 students provided data for the study. Of the students surveyed, 89.8% wanted to become clinicians, and 79.3% wanted to have general clinical ability. About half of the respondents, 54.9%, replied that they had some, or great, interest in primary care, but it was found that their understanding of primary care was inadequate. Almost half (56.3%) of the students answered that they had some idea of what a general practitioner did. This proportion was nearly the same through all years of medical school. While 1245 (36.9%) students (most of them in the fifth or sixth year) replied that they had received some clinical training while working in hospitals, only 203 (6.0%) students had worked in private clinics (the sites where most primary care is still provided), and 129 (3.8%) students had experience in providing home visits and home care. An even greater number, 64.3%, replied that they had inadequate information about the career options available to them. The study found that although many Japanese medical students want to obtain broad clinical competence, their understanding of primary care is insufficient. In order to increase the number of primary care providers the system of medical education in Japan must provide primary care doctors to act as role models, and must make available information about postgraduate primary care programmes. These programmes need to be increased, as do rewarding positions for programme graduates.     

Structured packs for independent learning: a comparison of learning outcome and acceptability with conventional teaching

OBJECTIVES: The GMC recommends that students become independent learners, while tutor time is an increasingly precious resource. A set of structured learning materials requiring students to undertake and reflect on practical tasks in five learning areas was developed. DESIGN: The study used a randomized control trial to evaluate the effectiveness of using these structured learning materials in place of conventional teaching for 228 third-year undergraduate students and 55 teachers, on both hospital and community based medical and general practice firms. Evaluation involved assessing student performance on an examination question and a writing task, together with a student and tutor satisfaction questionnaire. SETTING: King's College School of Medicine and Dentistry, London. SUBJECTS: Third-year medical (first-year clinical) undergraduates. RESULTS: No significant difference in learning outcome was found for students on community- and hospital-based medical and general practice firms between students who had used the structured materials and those who had had conventional teaching on the same topic. The packs were acceptable to tutors and students. CONCLUSIONS: Such resources represent a mid-point between formal didactic teaching and self-directed learning. They may be particularly suitable for promoting independent learning for students on traditional medical courses. They offer an appropriate way to cover certain topics in the clinical curriculum and help to protect tutor time for topics which cannot be effectively taught in other ways.     

Pre-registration rotations into general practice: the concerns of pre-registration house officers and the views of hospital consultants

AIMS: To explore the concerns of pre-registration house officers (PRHOs) and the views of hospital consultants in relation to pre-registration rotations with a general practice component. METHOD: As part of a larger qualitative study evaluating how a group of 24 PRHOs learn in hospital and primary care settings, face-to-face semistructured interviews were conducted with the PRHOs, and semistructured telephone interviews with the PRHOs' educational supervisors were carried out. RESULTS: The interviews with the PRHOs highlighted their concerns about how consultants might view PRHO rotations into general practice. However, the majority of consultants interviewed recognized and valued specific aspects of the experience to be gained by PRHOs in general practice, including the relationship between primary and secondary care; communications skills; specific clinical skills, and an understanding of the natural course of illnesses. The experience was seen as valuable for PRHOs considering either a general practice or a hospital career. Of the 17 consultants, 10 were also confident that 4-month placements in surgery and medicine would give PRHOs adequate experience in either specialty, providing the placements were sufficiently busy. CONCLUSIONS: Medical school deans and medical students considering PRHO rotations with a general practice component can be encouraged by the fact that, in this small study, the majority of hospital consultants interviewed valued the specific experience offered by these rotations, and felt that adequate medical and surgical experience could be gained in busy 4-month hospital placements.     

Does community‐based experience alter career preference? New evidence from a prospective longitudinal cohort study of undergraduate medical students

CONTEXT: Previous studies have shown that most medical students want a hospital-based career, but the protagonists of community-based teaching predict that increased community exposure within undergraduate curricula will alter subsequent career preferences. OBJECTIVES: To evaluate the impact on career preference and other attitudes of a year with substantial community exposure, compared with a year of hospital-based learning. DESIGN: Questionnaire to student cohort before and after two consecutive levels of the course, one with, and the other prior to, substantial community placement. SETTING: Sheffield Medical School. SUBJECTS: Total of 260 students in the third and fourth year of the MBChB degree. RESULTS: There were significant differences in career preference and attitude to primary care after the year with a community placement, with more students expressing a preference for a community-based career. This was particularly true for women, and less true for non-European students. Conversely, the hospital-based students, especially men, showed a significant change toward hospital-based careers. CONCLUSION: The findings support the hypothetical advantages of shifting medical education to primary care settings, both in encouraging a career in general practice and in the retention of appropriate professional attitudes.     

Social issues in medicine: a follow-up comparison of senior-year medical students'' attitudes with contemporaries in non-medical faculties

A comparison of first-year medical students' attitudes to social issues in medicine with attitudes of non-medical first-year students in 1983 found that the medical group was less conservative towards general social issues but more conservative in relation to those areas which closely affect the doctor's role, particularly the place of allied health professions and government intervention in health care. This paper reports a follow-up study of the same groups of students when they had reached senior years in their respective courses. While medical student conservatism on general social issues continues to be no greater than other student groups there is a marked increase in conservatism of attitudes towards government involvement in health care and regulation of costs. Attitudes to allied health professions and preventive care remain unchanged but senior medical students are significantly less likely to recognize social factors as determinants of illness than they were when they commenced the study of medicine. Specific curricular attention to social and behavioural medicine does not appear to counteract the predominantly biomedical perspective students experience in teaching hospitals, the major venue for their clinical education.     

What can students learn from studying medicine in literature?

OBJECTIVE: To identify what students can learn from studying medicine and literature as part of a final-year special study module in general practice. METHOD: The project reports and evaluation forms completed by all eight students who had chosen to study medicine and literature as part of their special study module in general practice at Nottingham University Medical School were analysed qualitatively. RESULTS: Students said that they gained a greater understanding of the patient's experience of illness, as a result of the texts they had read. They learned how illness can affect family or friends of the patient and about the psychological impact of physical illness. Most students thought their future care of patients would be influenced by what they had learned. Studying medicine in literature during a clinical attachment allowed students to draw comparisons between literature and their clinical experience. DISCUSSION: This study is based on a small number of students who chose to study medicine in literature. The results may not be generalizable to all medical students and not all students may be receptive to this method of learning. However, we recommend that students who are interested should be given the opportunity to study medicine in literature during their clinical years. This can enable them to reflect on their clinical experience and can provide a more profound understanding of the consequences of illness for the patient and their family.