Community-oriented medical education: what is it?

Summary. The pressing need for this communication has emerged from the author's experience in conducting educational workshops, seminars and meetings for the orientation of health professionals in community-oriented medical education. Many questions are raised and many statements made which clearly indicate that the term ‘community-oriented medical education’ (COME) is still misunderstood. It carries a different meaning for different people. Many give it their own meaning and attach to it their own interpretations. This has resulted in wide propagation of the wrong concepts to the detriment of promoting the approach. (It is worth noting that ‘community medicine’ has over the years suffered the same fate. Is it because both terms include the word ‘community’, which often has a poor image for much of the medical profession?) An attempt is made here to clarify the situation by a process of questions and answers, the questions being those frequently asked as such or posed in the form of statements. They are by no means exhaustive. Seven major such questions are addressed with reference to personal experience and the literature.

• 1 What do we mean by COME, community-based education (CBE) and community-based learning (CBL)?
• 2 COME is third-grade medical education producing third-grade graduates and ‘barefoot doctors’.
• 3 COME produces community health doctors/specialists.
• 4 COME is not scientifically based (based only on soft sciences) and basic sciences are neglected.
• 5 Graduates from COME programmes are not competent in dealing with patients as they spend most of their time in the community.
• 6 If it is community-oriented education, then what about the hospital? Is it not part of the community?
• 7 COME is expensive and requires more resources than traditional approaches?

     

Medical Practice as Characterised by Beginning Medical Students

What does medical practice mean to students entering undergraduate medical education? What do these students see as central to the work of a medical doctor? What do they regard as difficult challenges they are likely to face in medical practice? What implications do their perspectives on these questions have for medical education?In the qualitative research study reported in this article, students beginning undergraduate medical education characterised medical practice in a variety of ways. In brief, they characterised medical practice as: (a) helping or saving; (b) diagnosing or treating using required procedures; (c) locating the problem and informing the patient; (d) while diagnosing and treating, interacting in a supportive way; (e) seeking a way forward together; or (f) enabling the patient to better deal with his or her life situation. Some differences based on gender and method of admission to medical education are noted.Implications for medical education include the need to address: variation in characterising medical practice; ways in which medical knowledge and medical care are viewed; non-biomedical aspects as mainstream in the medical curriculum; concerns about difficult human encounters in medical practice; and development of professional identity.     

HIV/AIDS in the visual arts: applying discipline-based art education (DBAE) to medical humanities

CONTEXT AND RATIONALE: Health professions educators have been systematically attempting to insert the humanities into health professions curricula for over 4 decades, with various degrees of success. Among the several medical humanities, the visual arts seem particularly adequate for the teaching/learning of crucial aspects of medicine. Educational efforts in the arts require, however, a sound pedagogical philosophy of art education. Health professions educators need therefore to be aware of educational frameworks in the arts. Discipline-based art education (DBAE) is a recognised contemporary educational framework for the teaching/learning of the arts, which may be adapted to medical humanities. OBJECTIVE: It is the ultimate objective of this essay to share the experience of applying this educational framework to a course in a medical curriculum. METHODS: The author describes a course on the representations of HIV/AIDS in the visual arts, with explicit reference to its objectives, content, instructional features and student assessment in the light of DBAE, whose principles and characteristics are described in detail. RESULTS AND CONCLUSION: Discipline-based art education may be applied to medical humanities courses in a medical curriculum. This essay throws light on how this structure may be particularly useful for designing other pedagogically sound art courses in health professions curricula.     

Medical education in the later 19th century: the science take-over

Summary. Established in 1858, the General Medical Council was responsible, inter alia, for improving the standard of medical education in Britain. It was agreed on all hands that there were serious deficiencies: there was far too much book-learning and not enough practical knowledge; students graduated who were wholly ignorant of important areas of medicine; there were 19 licensing bodies and the criteria for admission to practise differed widely. Debate continued from 1860 to 1890. A major question was, What sort of education should the student have received before he entered medical school? There were four common answers: (1) he should have received the preliminary education of ‘a well-educated gentleman’; (2) he should know a good deal about everything; (3) he should have a better knowledge of science — but how to define science?; (4) he should have done well at school, never mind what he had studied. A second major question was, How should science and practical instruction be combined in the medical curriculum? Many defended the old and not quite dead apprenticeship system; a practical ‘sandwich course’ was even suggested. The debate ended with the Report of the GMC's Education Committee in 1890, which increased the length of the medical course from 4 years to 5 and brought chemistry, physics and biology into the early years. The amount of clinical work, however, although it was supposed to increase, remained very small.     

Spaced education improves the retention of clinical knowledge by medical students: a randomised controlled trial

Purpose Medical knowledge learned by trainees is often quickly forgotten. How can the educational process be tailored to shift learning into longer‐term memory? We investigated whether ‘spaced education’, consisting of weekly e‐mailed case scenarios and clinical questions, could improve the retention of students' learning. Methods During the 2004–5 surgery clerkships, 3rd‐year students completed a mandatory 1‐week clinical rotation in urology and validated web‐based teaching programme on 4 core urology topics. Spaced educational e‐mails were constructed on all 4 topics based on a validated urology curriculum. Each consisted of a short clinically relevant question or clinical case scenario in multiple‐choice question format, followed by the answer, teaching point summary and explanations of the answers. Students were randomised to receive weekly e‐mailed case scenarios in only 2 of the 4 urology topics upon completion of their urology rotation. Students completed a validated 28‐item test (Cronbach's α = 0.76) on all 4 topics prior to and after the rotation and at the end of the academic year. Results A total of 95 of 133 students (71%) completed the end‐of‐year test. There were no significant differences in baseline characteristics between randomised cohorts. Spaced education significantly improved composite end‐of‐year test scores (P < 0.001, paired t‐test). The impact of the spaced educational e‐mails was largest for those students who completed their urology education 6–8 and 9–11 months previously (Cohen's effect sizes of 1.01 and 0.73, respectively). Conclusion Spaced education consisting of clinical scenarios and questions distributed weekly via e‐mail can significantly improve students' retention of medical knowledge.     

It's about TIME: a general-purpose taxonomy of subjects in medical education

Context Modern computer technology permits the creation of detailed, dynamic electronic curriculum maps to facilitate curriculum searching, organisation and quality assurance. However, when attempting to map curricular content, a common question to arise is: ‘To what should we map our curriculum?’ With respect to content (i.e. the subject being taught, learned or examined), mapping to terminal outcomes or competencies may be too broad, whereas mapping to learning objectives is too specific. Methods To address this problem, the authors created TIME‐ITEM (topics for indexing medical education; en Français: index des thèmes pour l’éducation médicale), a hierarchical taxonomy of topics relevant to medical education. It is a general‐purpose, intermediate‐granularity, standardised index that covers the entire range of subject matter in medical education. The content and structure of topics within TIME was developed in consultation with medical educators and librarians at several Canadian medical schools. As far as possible, the language used is standardised to the Unified Medical Language System. Results TIME is available as a web application that allows users from various schools to enter their school‐specific outcomes, competencies and learning objectives, and then link these to the standardised topics in a way that is meaningful to the school. The entire TIME content and structure can then be exported, via xml , to external applications and used as an index for curriculum mapping, meta‐tagging learning objects, or categorising examination questions. TIME can be viewed at http://www.time‐item.org (username: ‘guest’; password: ‘guest’).     

Generalisability of a composite student selection programme

Objectives The reliability of individual non‐cognitive admission criteria in medical education is controversial. Nonetheless, non‐cognitive admission criteria appear to be widely used in selection to medicine to supplement the grades of qualifying examinations. However, very few studies have examined the overall test generalisability of composites of non‐cognitive admission variables in medical education. We examined the generalisability of a composite process for selection to medicine, consisting of four variables: qualifications (application form information); written motivation (in essay format); general knowledge (multiple‐choice test), and a semi‐structured admission interview. The aim of this study was to estimate the generalisability of a composite selection. Methods Data from 307 applicants who participated in the admission to medicine in 2007 were available for analysis. Each admission parameter was double‐scored using two random, blinded and independent raters. Variance components for applicant, rater and residual effects were estimated for a mixed model with the restricted maximum likelihood (REML) method. The reliability of obtained applicant ranks (G coefficients) was calculated for individual admission criteria and for composite admission procedures. Results A pre‐selection procedure combining qualification and motivation scores showed insufficient generalisability (G = 0.45). The written motivation in particular, displayed low generalisability (G = 0.10). Good generalisability was found for the admission interview (G = 0.86), and for the final composite selection procedure (G = 0.82). Conclusions This study revealed good generalisability of a composite selection, but indicated that the application, composition and weighting of individual admission variables should not be random. Knowledge of variance components and generalisability of individual admission variables permits evidence‐based decisions on optimal selection strategies.     

Reconceptualizing the Domain and Boundaries of Family Life Education

Many scholars have defined family life education (FLE), and some have differentiated it from other family‐related fields. For example, Doherty (1995) provided a definition of the boundaries between FLE and family therapy; however, we believe those criteria can be improved. We explore the professions of family life education, family therapy, and family case management using the questions why, what, when, for whom, and how? After examining these questions for each role, we introduce the domains of family practice to differentiate among them. The approach defines FLE and encourages appropriate collaboration among the fields. Suggestions are made for using this model for career exploration, reviewing job requirements to assess role consistency and clarity, and for determining the need for and appropriateness of referral and collaboration.     

Doctors' views of their first year of medical work and postgraduate training in the UK: questionnaire surveys

Objective The first year of postgraduate work for newly qualified doctors in the UK, the pre‐registration year, is spent working intensively in training posts under supervision. Our aim was to report the views of pre‐registration doctors on these posts. Design Questionnaire survey. Subjects All medical graduates of 1999 and a 25% sample of graduates of 2000 from all UK medical schools. Main outcome measures Doctors' views on the pre‐registration house officer (PRHO) year, recorded as ratings in answers to questions and statements about the year. Results In reply to the question ‘How much have you enjoyed the PRHO year overall?’, rated on a scale from 0?10 (0 = no enjoyment; 10 = enjoyed it greatly), 44% of respondents (1341/3068) gave scores of 8–10; in all, 83·2% of respondents gave scores in the upper half of the scale (≥6). However, there were criticisms of specific aspects of working conditions. Only a third agreed that their training during the year had been of a high standard. Posts in medicine were rated more highly than those in surgery for quality of training. Differences in views held by women and men junior doctors were few. However, where differences existed, women were slightly more positive about their work than men. Conclusion Most graduates enjoyed the pre‐registration year but there is still considerable scope for improvement in working conditions and training. Men and women gave similar responses, which suggests that later divergence in their career pathways is not attributable to different views formed about work in their pre‐registration year.     

Professionalism and the basic sciences: an untapped resource

CONTEXT: Medical, technological and societal developments influence doctors' professional responsibilities and present challenges to educating medical students about professionalism. Medical education about professionalism generally focuses on behaviours and competencies which are taught primarily by clinicians in clinical courses and settings. DISCUSSION: Many professional competencies in medicine parallel those in science. We consider here whether medical professionalism can also be taught through the basic science courses which often initiate medical education, and which are typically taught by scientists. CONCLUSIONS: Like doctors, basic science faculty staff can teach professional competencies to medical students. Science faculty are well situated to teach professional competencies and should do so. They can model how to pursue evidence and manage conflicting information. They can also provide explicit messages to students about professional competencies and their value, and create learning objectives that reinforce those messages.     

Current Status of Nutrition Training in Graduate Medical Education From a Survey of Residency Program Directors

Introduction: Nutrition leaders surmised graduate medical nutrition education was not well addressed because most medical and surgical specialties have insufficient resources to teach current nutrition practice. A needs assessment survey was constructed to determine resources and commitment for nutrition education from U.S. graduate medical educators to address this problem. Methods: An online survey of 36 questions was sent to 495 Accreditation Council for Graduate Medical Education (ACGME) Program Directors in anesthesia, family medicine, internal medicine, pediatrics, obstetrics/gynecology, and general surgery. Demographics, resources, and open‐ended questions were included. There was a 14% response rate (72 programs), consistent with similar studies on the topic. Results: Most (80%) of the program directors responding were from primary care programs, the rest surgical (17%) or anesthesia (3%). Program directors themselves lacked knowledge of nutrition. While some form of nutrition education was provided at 78% of programs, only 26% had a formal curriculum and physicians served as faculty at only 53%. Sixteen programs had no identifiable expert in nutrition and 10 programs stated that no nutrition training was provided. Training was variable, ranging from an hour of lecture to a month‐long rotation. Seventy‐seven percent of program directors stated that the required educational goals in nutrition were not met. The majority felt an advanced course in clinical nutrition should be required of residents now or in the future. Conclusions: Nutrition education in current graduate medical education is poor. Most programs lack the expertise or time commitment to teach a formal course but recognize the need to meet educational requirements. A broad‐based, diverse universal program is needed for training in nutrition during residency.     

Learning for real life: patient-focused interprofessional workshops offer added value

Objectives This paper reports relevant findings of a pilot interprofessional education (IPE) project in the Schools of Medicine and Healthcare Studies at the University of Leeds. The purpose of the paper is to make a contribution towards answering 2 questions of fundamental importance to the development of IPE. Is there a demonstrable value to learning together? What types of IPE, under what circumstances, produce what type of outcomes? Design Pre‐registration house officers (PRHOs), student nurses and pre‐registration pharmacists attended a series of 3 workshops intended to develop participants' understanding about each other's professional roles, to enhance teamworking and to develop communication skills. Evaluation covered the process of development of the workshops, the delivery of the workshops and their effects on both facilitators and participants. Results The course was well received by the participants. The learning reported by the participants reflected 2 project objectives. Participants emphasised communication skills – both with other professionals and patients ? and the development of increased awareness of others' roles. These 2 aspects were interlinked. Conclusions The project aims and 2 of the learning outcomes were achieved. There was a demonstrable value to learning together, particularly with regard to interprofessional communications. This project was effective and can make a contribution towards answering the question ‘What types of IPE, under what circumstances, produce what type of outcomes?’     

How specific is case specificity?

Objectives Case specificity implies that success on any case is specific to that case. In examining the sources of error variance in performance on case‐based examinations, how much error variance results from differences between cases compared with differences between items within cases? What is the optimal number of cases and questions within cases to maximise test reliability given some fixed period of examination time? Methods G and D generalisability studies were conducted to identify variance components and reliability for each examination analysed, and to optimise the reliability of the given test composition (1, 1.5, 2, 3, 4 and 5 questions per case), using data from 3 key features examinations of the Medical Council of Canada (n = 6342 graduating medical students), each of which consisted of about 35 written cases followed by 1–4 questions regarding specific key elements of data gathering, diagnosis and/or management. Results The smallest variance component was due to subjects; the variance due to subject–item interaction was over 5 times the interaction with cases (on average, 0.1106 compared with 0.0195). Relatively little variance was due to differences between cases; about 80% of the error variance was due to variability in performance among items within cases. The D study showed that reliability varied between 0.541 and 0.579, was least with 1 item per case and highest at 2 and 3 items per case. Conclusions The main source of error variance was items within cases, not cases, and the optimal strategy in terms of enhancing reliability would use cases with 2–3 items per case.     

Educational impact of in-training assessment (ITA) in postgraduate medical education: a qualitative study of an ITA programme in actual practice

Objectives To investigate the experiences and opinions of programme directors, clinical supervisors and trainees on an in‐training assessment (ITA) programme on a broad spectrum of competence for first year training in anaesthesiology. How does the programme work in practice and what are the benefits and barriers? What are the users' experiences and thoughts about its effect on training, teaching and learning? What are their attitudes towards this concept of assessment? Methods Semistructured interviews were conducted with programme directors, supervisors and trainees from 3 departments. Interviews were audiotaped and transcribed. The content of the interviews was analysed in a consensus process among the authors. Results The programme was of benefit in making goals and objectives clear, in structuring training, teaching and learning, and in monitoring progress and managing problem trainees. There was a generally positive attitude towards assessment. Trainees especially appreciated the coupling of theory with practice and, in general, the programme inspired an academic dialogue. Issues of uncertainty regarding standards of performance and conflict with service declined over time and experience with the programme, and departments tended to resolve practical problems through structured planning. Discussion Three interrelated factors appeared to influence the perceived value of assessment in postgraduate education: (1) the link between patient safety and individual practice when assessment is used as a licence to practise without supervision rather than as an end‐of‐training examination; (2) its benefits to educators and learners as an educational process rather than as merely a method of documenting competence, and (3) the attitude and rigour of assessment practice.     

Continuing Medical Education Case Study Series

Increasing interest in continuing medical education is reflected in greater demand for educational programmes. Content and educational strategies should be appropriate to the needs of the target audience. Proper matching of content and strategies to target needs of users requires the instructional design to be carefully planned and based on a needs-assessment study. We illustrate the influence of educational needs on content and learning strategies through an educational programme for general practitioners on the subject of malignant melanoma. Its design includes: i. a trigger leaflet; ii. a core text; iii. a set of interactive case studies; iv. a job-aid card; v. a follow-up leaflet; and vi. recorded messages available by telephone. It addressed, in particular, the key decision to be taken by the general practitioner: ‘When should I refer a patient with a suspected early melanoma: when should I merely reassure the patient?’ Doctors were invited, in the programme, to make decisions about referral of patients. They received immediate feedback on their decisions. Various strategies reinforced this feedback.     

Medical students in a time of HIV: education and the duty to treat

This article concerns medical education about the ethics of professional duties and treatment of HIV-infected patients. The issue at hand is not whether medical students have a duty to treat HIV-infected patients, since it is a matter of consensus that they do. Medical schools have reasserted that risks are inherent in medicine, and that medical school admission should be based on the willingness to accept some risks, in addition to intelligence and personal skills. Those who wish to avoid risks are free to enter other professions. While it is imperative to assert a duty to treat, this requires thoughtful explanation to match the understandably high anxiety levels of many medical students.     

The rating of pre-clerkship examination questions by postgraduate medical students: an assessment of quality and relevancy to medical practice

OBJECTIVE: To determine whether postgraduate students are able to assess the quality of undergraduate medical examinations and to establish whether faculty can use their results to troubleshoot the curriculum in terms of its content and evaluation. SUBJECTS: First and second year family medicine postgraduate students. MATERIALS: A randomly generated sample of undergraduate medical examination questions. METHODS: Postgraduate students were given two undergraduate examinations which included questions with an item difficulty (ID) > 0.60. The students answered and then rated each question on a scale of 1-7. RESULTS: The percentage of postgraduate students answering each question correctly correlated significantly with the average perceived relevance (Examination 1: r=0.372; P < 0.05; Examination 2: r=0.458; P < 0.05). Questions plotted for average postgraduate/undergraduate performance ratio versus the average perceived relevance were significantly correlated (Examination 1: r=0.462; P < 0.01; Examination 2: r=0.458; P < 0.05). CONCLUSIONS: This study offers a method of validating question appropriateness prior to examination administration. The design has the potential to be used as a model for determining the relevancy of a medical curriculum.     

Teaching bioethics to medical students: the Newcastle experience

Summary. Over the past two decades in the USA, bioethics has become an accepted component of medical education, whereas in Australia, 10 years or even less would encompass the history of most existing programmes. Given the legendary conservatism of medical schools in Australia and the intractability of the medical curriculum, this is still a remarkable achievement. But does the teaching of bioethics change the thinking and/or decision-making behaviour of medical students or practitioners exposed to such courses? Those involved know only too well how difficult such courses are to design and evaluate since the connection between ethics education and practice is not known and may never be demonstrated to the satisfaction of critics. Critics not only seek answers to the questions of whether the teaching of bioethics makes a difference, which is a fair question, but they also seek answers to the question of whether bioethics should be taught in medical schools. Can bioethics be taught? Whose bioethics is being taught? What does the trained bio-ethicist contribute? Some of these questions arise from misunderstanding and some reflect the still too dominant view in medical schools which divides disciplines into those which provide ‘practical skills’, and those which contribute only theoretical and therefore peripheral knowledge. The authors will address these questions in the light of their experience at Newcastle, Australia, where the Faculty of Medicine has been teaching bioethics for over a decade.     

Is it me or is it them? Factors that influence the passing of underperforming students

Context Research has found that clinical assessments do not always accurately reflect medical student performance. Barriers to failing underperformance in students have been identified in other vocational settings. Is ‘failure to fail’ an issue for medical educators in the UK, and, if so, what are its determinants? Methods We carried out a qualitative focus group study exploring the views of medical educators (general practitioners, hospital doctors and non‐clinical tutors) from two different UK medical schools. To make sense of a potential multitude of factors impacting on failure to fail, we selected the integrative model of behavioural prediction to underpin our data collection and analysis. Results Ten focus groups were carried out with 70 participants. Using both theory and data‐driven framework analysis, we identified six main themes relevant to the integrative model of behavioural prediction. These are: tutor attitudes towards an individual student; tutor attitudes towards failing a student; normative beliefs and motivation to comply; efficacy beliefs (self‐efficacy); skills and knowledge, and environmental constraints. Discussion Many different factors impact on medical educators’ failure to report underperformance in students. There are conflicts between these factors and the need to report competence accurately (i.e. duty to protect the public). Although some of the barriers identified are similar to those found in previous studies, using a theory‐based approach added value in that it facilitated a richer exploration of failure to fail. Insights offered in this study will be used to plan a questionnaire study and subsequent intervention to support medical educators in accurately reporting underperformance in students.