Teaching the teachers — a needs assessment of tutors for a new clinical skills course

There is an increasing trend in undergraduate education towards teaching clinical skills from a community base. A new clinical curriculum was introduced in Newcastle upon Tyne in 1995, beginning with an integrated clinical skills course. Although the attitudes and views of general practitioners (GPs) towards community-based clinical teaching have previously been reported, their perceived training needs have not been formally identified. The aims of this study were to identify the competencies needed by GPs for community-based clinical skills teaching, to compare and contrast these needs with their hospital colleagues, and to use the results to develop a teaching programme for the clinical tutors involved in the new course. In order of priority, the GPs and hospital tutors expressed similar needs: small-group teaching skills, assessing student needs, giving effective feedback and assessment of student performance, with a preference for the teaching to be organized within local teaching units. Most GPs and hospital tutors (73 and 69%, respectively) requested a distance-learning pack to complement the teaching. General practitioners rated resources for improving their individual clinical skills more highly than their hospital colleagues: for example, videotapes demonstrating examination techniques. Forty-six per cent of GP tutors had received some formal training in teaching methods compared to 29% of hospital tutors. The implications of the results for developing a 'Teaching the Teachers' course for clinical tutors are discussed.     

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.     

Health care ethics teaching for medical students

This paper describes an innovatory teaching programme in health care ethics for medical undergraduates. The general aims and objectives are outlined and the 1990 course is discussed specifically. The course has several unusual features, including the use of performers and the presentation of ethically based decisionmaking implements, which are highlighted. The course is evaluated. The 1990 results are encouraging.     

The lessons of deafness: deafness awareness and communication skills training with medical students

This paper describes a 1-day course on deafness awareness and communication skills with fourth-year medical undergraduates and summarizes their evaluation of the course. Deaf people commonly experience major communication difficulties with doctors. This course gives students an awareness of deafness (and of the insights deaf people can give to an understanding of communication)--the lessons of deafness--and challenges some critical assumptions in medical practice. Students are given personal experience of deafness and of the consequent powerlessness and loss of self-confidence, while also learning new communication skills which they then apply in a role-play consultation with a deaf patient. Systematic evaluation has been built into the programme and student opinion has been unanimously enthusiastic.     

Student and patient perspectives on bedside teaching

A cross-sectional study was undertaken to elicit patient and learner opinions about bedside teaching (BST). Only 48% of learners reported that they had been given enough BST during their undergraduate training, while 100% thought BST to be the most effective way of learning clinical skills. Seventy seven per cent of patients enjoyed BST and 83% said that it did not make them anxious. The preferred site for case presentations was the conference room. Further quantitative studies are needed to investigate perceived impediments to BST from the teachers' point of view.     

Interprofessional education for medical and nursing students: evaluation of a programme

This paper reports and evaluates a programme of interprofessional education for final-year medical students and fourth-year undergraduate BSc nursing students. The programme was designed in the light of social psychological studies of intergroup behaviour (the contact hypothesis). Key features included opportunities to work as equals in pairs and small groups on shared tasks in a cooperative atmosphere. Topics included communication between nurses, doctors and patients, deliberate self-harm by patients, and ethical issues in clinical care. A comprehensive evaluation of the effects of the programme on one cohort of 39 participants revealed that overall attitudes towards the other profession had improved. Participants reported increased understanding of the knowledge and skills, roles and duties of the other profession. The programme was positively evaluated by both groups of participants.     

Identifying with the patient: an intensive programme for medical students

An intensive programme called 'Hospitalization Week' was developed at the medical school of the Ben-Gurion University of the Negev in Israel. The main goal of the programme is to give first-year medical students an opportunity to understand the complexity of the needs and problems of hospitalized patients. To achieve this goal each student accompanies two patients from their arrival at the emergency room throughout their stay in the hospital. The goals and methods of the programme are described and evaluated.     

Teaching medical students about the appropriateness of social and sexual contact between doctors and their patients: evaluation of a programme

The purpose of this study was to assess the impact of an educational intervention on medical students' attitudes toward social and sexual contact with patients by doctors from three medical specialties (general practice, obstetrics/gynaecology and psychiatry). Medical students from two consecutive fifth year classes at one medical school participated in one 3 hour session that included instruction on the standards of the profession that prohibit doctor–patient sexual contact. Students were assigned to either intervention groups or control groups and responded to an anonymous questionnaire (overall response rate 66·8% ; n=141). As many as 14·5% of control group students thought it was (sometimes or usually) appropriate for general practitioners to date their own patients and at least 3% thought it appropriate for members of any of these three medical specialties to engage in sexual contact with their own patients. However, there were no significant differences in attitudes toward hugging, dating or sexual contact with current patients between those who had attended the seminar and the control groups. The session significantly influenced attitudes regarding obstetrician/gynaecologists and psychiatrists hugging and having sexual contact with former patients. These findings are discussed in relation to a need for expansion of such instruction.     

Psychological size and distance: emphasising the interpersonal relationship as a pathway to optimal teaching and learning conditions

BACKGROUND: Positive interpersonal relationships between teachers and learners increase the quality of learning. The purpose of this study was to investigate psychological size (perceived status) and psychological distance (perceived emotional connectedness) in medical teaching interactions and their impact on the teaching and learning process. METHOD: A total of 45 paediatric preceptor/resident pairs engaged in longitudinal continuity training experiences at different sites were surveyed about teaching effectiveness, satisfaction with teaching, and the psychological size and distance in the relationship between each pair. RESULTS: Both residents and preceptors perceived the resident as having a smaller psychological size compared to the preceptor. Residents perceived greater psychological distance in the relationship than did preceptors, and this distance was significantly related to both residents' satisfaction with particular preceptors and their perception of the preceptors' effectiveness. CONCLUSIONS: Psychological size and distance contribute to effective and satisfactory teaching. Investigating additional aspects of the teaching-learning relationship should help identify optimal educational conditions.     

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.     

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.     

An innovative model for teaching and learning clinical procedures

CONTEXT: Performing a clinical procedure requires the integration of technical clinical skills with effective communication skills. However, these skills are often taught separately. OBJECTIVES: To explore the feasibility and benefits of a new conceptual model for integrated skills teaching. : Design A qualitative observation and interview-based study of undergraduate medical students. METHODOLOGY: Medical students performed technical and communication skills in realistic clinical scenarios (urinary catherization and wound closure), using latex models connected to simulated patients (SPs). Procedures were observed, videorecorded and assessed by tutors from an adjoining room. Students received immediate feedback from tutors and SPs, before engaging in a process of individual feedback through private review of their videotapes. Group interviews explored the response of students, SPs and tutors. Data were analysed using standard qualitative techniques. SUBJECTS: Fifty-one undergraduate students were recruited from the Faculty of Medicine, Imperial College, London. RESULTS: The scenarios provided a realistic simulation of two common clinical situations and proved feasible in terms of time, facilities and resources within this institution. Students found the opportunity to integrate communication and technical skills valuable, challenging and an appropriate learning experience. Immediate feedback was especially highly valued. Some students found difficulty integrating technical and communications skills, but benefited from conducting two procedures in the same session. CONCLUSION: The integrated model was feasible and was perceived to be valuable. Benefits include the opportunity to integrate, within a safe environment, skills which are often taught separately. Promoting reflective practice may enable the successful transfer of these integrated skills to other procedures.     

An introductory ''survival course'' for first-year medical students: a brief account of the course

Summary. At the School of Medicine, Tromsø, Norway, an intensive 2-day week-end course was offered to students in the first year of their studies. The content covered study approaches and study skills, learning issues, strategies for improving the current curriculum, and preparing for the first comprehensive final examination. A brief account of the content and outcome is presented.     

The need for teaching in medical audit: a survey in one medical school

Summary: Summary. A questionnaire survey was carried out among senior clinical teachers at Newcastle upon Tyne Medical School, UK about their current practice and attitudes toward the teaching of medical audit in the undergraduate curriculum. A response rate of 88% was achieved. Less than a fifth of respondents provided such teaching, but the majority were in favour of seeing the topic introduced. A variety of teaching methods were used, and feedback from students was generally favourable. A number of concerns were expressed, including the problem of curriculum overload, the timing of the teaching, and the need to ensure that the learning was experiential with a minimum of theoretical teaching. Those who were in favour of introducing such teaching, or who were unsure, were also concerned about pressures on curricular time, but some felt in addition that the topic was more appropriately a postgraduate one. A short attitude scale demonstrated a skew towards favourable attitudes among the whole group. The implications of the survey for teaching about audit and quality are discussed.     

Identifying core skills for the medical curriculum

A survey was undertaken at the University of Sheffield Medical School to identify clinical and other professional skills which are required on graduation and to assess whether and when these skills have been acquired. The purpose of the survey was to identify core practical skills, defined as skills which the majority of clinical firms require and which, in addition, were used by the majority of Pre-registration house officers (PRHOs). The survey was conducted by questionnaires which were circulated to the following four sample groups (number in sample: % response rate): (1) consultants in clinical firms taking undergraduates and post-graduates from Sheffield Medical School (63: 75%); (2) house officers starting their pre-registration year (118: 52%); (3) house officers ending their pre-registration year (120: 43%); and (4) undergraduates starting their final year (110: 65%). The questionnaire contained a stimulus list of 31 clinical and four personal skills with an opportunity for respondents to list other skills they felt to be important. Of the 35 skills listed on the questionnaire, 26 were identified as core practical skills. Fifteen of the core skills had been acquired by the majority of students by the time they graduated, 13 of which were acquired prior to the final undergraduate year. Core skills not acquired as an undergraduate were acquired as a PRHO. The survey acted as a quality control mechanism for teaching at both undergraduate and post graduate levels and provided the basis of a medical school core of practical skills on the basic medical education continuum.     

Child disability case studies: an interprofessional learning opportunity for medical students and paediatric nursing students

CONTEXT: We describe an interprofessional learning (IPL) opportunity for pre-qualification medical and paediatric nursing students using community-based case studies of disabled children and their families. METHODS: A total of 160 students were randomly allocated into interprofessional and uniprofessional pairs. Each pair visited a disabled child at home and school and presented their experience to the rest of the group. Quantitative and qualitative evaluation methods were used to explore the learning experience. Data collection tools included a scale measuring attitudes towards IPL, which was completed by all students before and after their visits and focus groups. RESULTS: The value of the community setting and independent working of the case study was appreciated by the students. The intimacy involved in working in IP pairs demonstrated both positive and negative features. Nursing students showed more open and positive attitudes towards IPL than medical students. Nursing students in IP pairs appear to have benefited most from the exercise, notably in terms of confidence and self-esteem. Professional differences in communication skills and approach were identified as particular learning points for all students. CONCLUSIONS: The added value of combining quantitative and qualitative research methods is well demonstrated by this study. Learning opportunities from the case study were greater as a result of working interprofessionally. Student attitudes towards IPL and professional stereotyping changed as a result of this IPL exercise. The importance of the social context of learning and the contact hypothesis are supported by our findings.     

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.     

Teaching of medical ethics: implications for an integrated curriculum

This paper reports on an investigation into the teaching of medical ethics and related areas in the medical undergraduate course at the University of Queensland. The project was designed in the context of a major curriculum change to replace the current 6 year course by an integrated, problem-based, 4 year graduate medical course, which began in 1997. A survey of clinical students, observations of clinical teaching sessions, and interviews with clinical teachers were conducted. Data obtained have contributed to curriculum development and will provide a baseline for comparison and evaluation of the graduate course in this field. A view of integrated ethics teaching is advanced in the light of the data obtained.     

Training doctors for the year 2000

The World Health Organization's strategy, Health for All by the Year 2000, presents a challenge to those responsible for training doctors. Doctors are needed who are concerned to promote health not just treat disease. A review of the medical undergraduate curriculum is required to achieve this. We describe a small step towards this by the restructuring of a community medicine teaching programme so that students are introduced to health promotion and the principles of Health for All.