Comparison of student learning in the out-patient clinic and ward round

Summary. In undergraduate medical education there is a trend away from ward-based teaching towards out-patient and community-based teaching. To study the potential effects of this altered emphasis on student learning, a pilot group of final-year medical students at the University of Dundee was asked to keep individual structured log-books. These contained details of patients seen during their 3-week orthopaedic attachment in both a ward and out-patient setting. A comparison of perceived learning in the two settings showed that students learned more from attending an out-patient clinic than a ward round, but did not make full use of the learning potential of either. The setting did not particularly influence the balance of learning as categorized here but only the ward round supplied experience of surgical complications. The amount of learning taking place in an out-patient clinic was influenced by student ability, measured by examination performance, but not by clinic work-load. The implications of increased use of out-patient clinics and the advantages and disadvantages of the approach employed are discussed. It is concluded that in the situation studied student learning in the outpatient setting is as good as or superior to the ward setting but should not totally replace it.     

Teaching in the new NHS: the specialised ward based teacher

OBJECTIVES: To evaluate the effects of introducing specialised ward based teachers (WBTs) who had a broad remit to improve third year medical undergraduates' clinical experience. DESIGN: Quantitative and qualitative methods including interviews with WBTs, participating consultants and SIFT co-ordinator; student questionnaire and evaluations; analysis of Objective Structured Clinical Examination (OSCE) scores to ascertain if exposure to WBTs affected OSCE scores. SETTING: Two university teaching hospitals. PARTICIPANTS: Third year undergraduate medical students from one school of medicine; four WBTs; 25 consultants; SIFT co-ordinator. MAIN OUTCOME MEASURES: Student evaluations. Student questionnaires. Student OSCE scores. Interview data. RESULTS: WBTs had a demonstrable effect on student performance in OSCE examinations. 94% of students either agreed or strongly agreed that WBTs had helped them develop their examination skills and 87% either agreed or strongly agreed that WBTs had helped them develop their history taking skills. Interview data indicated that the consultants and SIFT co-ordinator considered that WBTs made an important contribution to clinical teaching. CONCLUSIONS: This study suggests that specialised WBTs are one way to manage clinical experience and enhance learning of undergraduate medical students. As clinical teaching moves into earlier parts of the undergraduate curriculum and into the community there is potential for this role to be developed.     

Medical student and faculty perceptions of desirable primary care teaching site characteristics

BACKGROUND: As the need to expand and improve primary care teaching experiences has mushroomed, the need to identify desirable preceptor and site characteristics has also grown. PURPOSE: The current study was designed to assess the relative importance students and preceptors place on site versus preceptor characteristics. METHODS: After a required year-long primary care experience, third-year medical students (n=39) and primary care preceptors (n=20) completed a Q-sort exercise. RESULTS: In all analyses preceptor characteristics were ranked highest. The highest ranked item for students and preceptors was 'The preceptor allows student to assume increasing levels of responsibility'. Seven of the highest ranked items appear on both groups' top 10 list. CONCLUSIONS: There is a high level of agreement between students and preceptors that preceptor rather than site characteristics make the vital difference in primary care educational experiences. When students and preceptors disagree, it is because preceptors see their role- modelling characteristics related to relationships with patients as important, while students are more interested in the hands-on learning opportunities afforded by the preceptor.     

A Strategy to Standardize the Learning of Core Clerkship Objectives

Background: Consistent and effective implementation of clinical clerkship objectives remains elusive. Using the behavioral principles of self assessment, active learning and learner differences, we designed an objectives checklist to ensure that all students mastered a core body of internal medicine (IM) knowledge and to facilitate self-directed learning. Methods: We developed a 54-item learning objectives checklist card in the IM clerkship. In a randomized controlled trial by clerkship site and block, students in the intervention group received the checklist card and were instructed to obtain sign off on objectives by faculty and housestaff and to seek teaching, literature, and clinical experiences to satisfy objectives unmet through routine activities. Intervention group faculty and housestaff were oriented to the use of the checklist. Both intervention and control groups received the course syllabus. We assessed learning with faculty and housestaff evaluations, student knowledge self-assessment, and a written examination. Satisfaction with the cards was assessed with written evaluations. Results: There were no significant differences in ward evaluations, examination scores or self-assessed knowledge between students using the learning objectives cards and control groups. Faculty were more likely than students to agree that objectives cards improved education. Conclusions: An intervention designed to guide students in the use of a learning objectives card did not enhance learning as assessed by ward evaluations, a written examination, and satisfaction surveys. It is possible that more sensitive outcome measures could detect differences in knowledge for students using learning objectives checklist cards. This revised version was published online in September 2006 with corrections to the Cover Date.     

Community family medicine teachers' perceptions of their teaching role

OBJECTIVES: Our study explored community preceptors' perceptions of their teaching role, to better understand effective ambulatory and community-based teaching. METHODS: Bandura's social cognitive theory and Sch?n's notion of reflective practice guided conceptual development of an interview exploring preceptors' views of their role, teaching goals, teaching techniques, student assessment practices, factors affecting teaching and learning, and balance of patient and student needs. Preceptors reflected also on a significant personal teaching experience. A total of 17 highly student-rated preceptors participated. A trained interviewer conducted each interview; all were transcribed and subjected to content analysis. RESULTS: Preceptors (male, 14; female, 3) described learner-centred approaches, setting goals jointly with the student. Demonstration, guided practice, observation and feedback were integral to the experience. Preceptors saw student comfort in the environment as key to effective learning; they attempted to maximize students' learning and breadth of experience. They wanted students to understand content, "know-how" and "being a family physician". Patients remained the primary responsibility, but learners' needs were viewed as compatible with that responsibility. Many preceptors perceived a professional responsibility as "role models". CONCLUSIONS: Preceptors recognized the dynamic environment in which they taught students, and they described strategies which demonstrated how they adapted their teaching to meet the needs of the learner in that environment. These teachers combined learner-centred approaches with sound educational practices, broad learning experiences, attention to student learning and concern for development of professional expertise and judgement. These findings may assist faculty development in family medicine, and other disciplines, in providing effective ambulatory care teaching.     

Guidelines for public health practitioners serving as student preceptors

Student fieldwork and service learning are valuable strategies for developing the skills of future public health professionals. Practitioners who serve as preceptors to students often receive little preparation for guiding and evaluating students. Findings from a review of fieldwork and service learning literature and a program evaluation of an undergraduate public health program at a large southern public university were used to construct guidelines for the practitioners supervising students in the field. These guidelines should aid practitioners in their role as preceptors of public health students. The guidelines address assessing student competencies, developing student competencies, writing learning objectives, evaluating students, maximizing the student precept or relationship, and managing problems.     

A comparison of performance by medical and midwifery students in multiprofessional teaching

AIM: At Dundee University, midwifery and medical students are taught obstetrics together in a 2-week intensive course. We set out to test the hypothesis that staff time and effort could be saved by using shared resources in teaching a multidisciplinary group of students to an acceptable level. METHOD: In order to measure the knowledge gain by two different groups of students, we tested the students before and after a timetabled computer-assisted learning (CAL) session focusing on how to interpret a cardiotocograph (CTG). Also, half of each student group was given extra CTG teaching before the CAL session. RESULTS: The medical students (n=38) increased their median score from 9 to 17 after the CAL (P<0.001) but the midwifery students (n=13) only increased their median score from 12 to 14 after the CAL (n.s.). However, when given a tutorial and CAL, the post-test scores for both medical and midwifery students were similar and significantly higher than pre-test scores (median score increase from 8.5 to 18 for medical students, P<0.001, n=34, and from 9 to 16 for midwifery students, P<0.01 n=11). There was no significant knowledge gain by the medical students who undertook the additional tutorial. CONCLUSION: We conclude that shared resources could be used by medical and midwifery students to reach equivalent levels of skill in CTG interpretation. However, in order to achieve equivalence, staff time and effort was wasted as medical students were given unnecessary tuition.     

Student attitudes to surgical teaching in provincial hospitals

Objective: The ever‐increasing pressure on metropolitan teaching hospitals to rationalise budgets and increase productivity has resulted in a dwindling amount of teaching opportunity for the medical student population. One solution to the problem was to utilise a largely untapped resource in South Australia, namely the provincial hospitals, however, student opinion regarding such a radical change had yet to be determined. Design: A questionnaire was circulated among an entire year group of medical students who would be undertaking the revised surgical curriculum with rural attachments. Setting: In October 1997, a decision was made by the Department of Surgery at the University of Adelaide to proceed with optional rural surgical attachments in 1998. Subjects: The survey was distributed to the 125 members of the 1997 fifth year medical student group. Results: A total of 92 questionnaires were returned giving a response rate of 75%. Thirty‐nine students ranked a rural term in their top half of preferences, while a further 18 indicated that they would go to a rural centre if they had to. Conclusion: Despite having little warning of the impending changes to their surgical curriculum, the majority of students who responded to the questionnaire stated that they would be willing to venture to the country locations. Before planning significant changes to an established curriculum, the student group should be consulted to gauge their opinion. What is already known: Within the medical literature, studies have been performed with regard to student opinions regarding postgraduate internships in rural locations, but to our knowledge, this survey represents the first study into student opinion with particular reference to rural surgical attachments prior to their commencement within a medical school curriculum. What this study adds: As a result of this study, it can now be concluded that a considerable amount of interest exists within the student population to undertake rural surgical rotations.     

What's in store for medical students? Awareness and utilization of expert nutrition guidelines among medical school preceptors

BACKGROUND: Instruction of physicians and other health professionals in medical nutrition sciences is among the expert recommendations to promote population health and reduce risks for cancer and other major causes of morbidity and mortality in the population. However, formal training in nutrition in United States medical schools is still lacking compared to the gains in basic and applied medical nutrition sciences. We sought to understand the awareness and current utilization of expert nutrition recommendations and practice guidelines among medical student faculty preceptors. METHODS: We surveyed the teaching faculty who precept for first-, second-, and third-year medical students in two required courses at Boston University. The instrument queried preceptor awareness and current utilization of expert nutrition recommendations, nutritional management practice guidelines, as well as faculty-student interactions regarding patient nutritional education and counseling. RESULTS: Of 187 faculty surveyed, 139 (74%) responded. Faculty reported using 2.3 expert guideline sources (N = 111; SD = 1.8; range = 0-8) but 83% had considered only one or no sources or did not remember what guidelines they had used. Eighty-four percent of preceptors expected students to routinely discuss nutritional practices with patients and/or their families; however, less than half of preceptors routinely provided feedback to students on patient nutritional education or counseling strategies. CONCLUSION: Our findings suggest gaps in faculty awareness and utilization of expert nutrition recommendations and practice guidelines relating to cancer and other chronic disease-risk reduction and population health promotion, underscoring the need for improvements in faculty and medical student training in basic and applied medical nutrition sciences.     

Expectations and opinions of pregnant women about medical students being involved in care at the time of delivery

Information was collected from pregnant women about their knowledge of and previous experience with medical students; their opinions towards medical students being involved at the time of delivery and the socio-economic and religious influences on these. The format of the study was a self-administered questionnaire survey. The setting was a teaching hospital in the UK. In total, 118 pregnant women aged between 15 and 46 years, with a gestational age of 18–42 weeks were surveyed. Factors which significantly influenced acceptance of medical students were found to be previous number of children ( P  = <0·001) and religious beliefs of the pregnant women ( P  = 0·002). Only 51·4% of antenatal women knew that a `medical student' is a doctor in training and most assumed that the role of the student at the time of delivery required very few clinical skills. Only 13·6% knew that medical students could deliver a baby under supervision. Of the 118 subjects, 95·4% thought that student participation at the time of delivery was a worthwhile learning experience; however, only 74·6% were actually willing for a student to be involved. In conclusion, pregnant women appear to have made their decisions about medical student participation by balancing personal needs with a sense of responsibility to help in the education of others. The results suggest that patients need more information about medical students, including an explanation of the term `medical student' and an outline of the role they play during the intrapartum period.     

Complementary and alternative medicine (CAM) in the undergraduate medical curriculum: the Southampton experience

OBJECTIVE: We describe the planning, development and evaluation of a special study module (SSM) on Complementary and Alternative Medicine (CAM) as part of the Southampton Medical School undergraduate curriculum. AIM: To address how the module was received by students, the themes that emerged, the effect on student attitudes to CAM and how the teaching aims developed into learning objectives. METHOD: Student feedback questionnaires and regular teaching staff meetings over a period of 3 years. RESULTS: The course resulted in a significant change in student attitudes to CAM and was well received by the students. It offered a reflective insight into conventional medicine. We have developed and validated core teaching objectives. CONCLUSIONS: We hope that our well validated and well received core teaching objectives will provide a broadly applicable base for those who wish to run similar courses.     

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.     

Return to basic sciences after clinical experience in undergraduate medical training

As part of the restructured undergraduate medical curriculum at McGill Medical School, a return to basic sciences was introduced in the students' final year. This follows the completion of the formal portion of their undergraduate clinical education. This paper describes this unique return to the basic science programme including the rationale behind the change and the effects of this programme on student learning, and student attitudes towards the programme. Final-year medical students in 1978 and 1981 were tested on educational and attitudinal variables. Data were collected using achievement tests, questionnaires and interviews. The findings of the study indicated that the major objectives of the programme, which were to facilitate student learning in greater depth and to integrate basic sciences with clinical knowledge, were achieved. The programme was enthusiastically received by the students in 1978 and also in 1981, indicating the outcome of the return to the basic science programme to be more than a 'Hawthorne effect' as suspected in 1978. The concept of a return to basic science is recommended for consideration by medical faculties.     

The attitudes of 'tomorrow's doctors' towards mental illness and psychiatry: changes during the final undergraduate year

AIMS: To compare the efficacy of two teaching styles, didactic teaching and problem based learning, in producing enduring change in final-year medical students' attitudes towards psychiatry and mental illness. METHOD: A 1-year follow-up questionnaire survey of two groups of medical students taught psychiatry in their fourth-year training by two different methods. One-year follow-up scores were compared with pre-attachment and post-attachment scores in the fourth year. RESULTS: 70 (68%) students completed both questionnaires at follow-up. The follow-up scores were significantly lower compared with both the fourth-year pre-attachment and post-attachment scores, suggesting that the positive change in attitudes following psychiatric training in the fourth year significantly decayed during the final year. The two teaching methods did not differ in the magnitude of this reduction. CONCLUSIONS: The positive change that occurs in medical students' attitude towards psychiatry, psychiatrists and mental illness after their fourth-year psychiatric training is transient and decays over the final year.     

Use of an outcomes research collaborative training curriculum to enhance entry-level dietitians' and established professionals' self-reported understanding of research

This project pilot tests a unique outcomes research training curriculum that prepares entry-level dietitians (goal 1) and provides established dietetics professionals with the resources to successfully execute an outcomes research plan (goal 2). The learning objectives for each goal were met via lectures and assignments in two courses, one taught in the fall and one in the winter semester of the second (senior) year of the Coordinated Program at the University of Missouri. At their respective healthcare facilities, registered dietitian (RD) preceptors along with the students progressed through all stages of the research process, from proposal development to data presentation. At the completion of the process, a questionnaire was administered to students and preceptors to evaluate the curriculum. Fourteen of the 15 possible student respondents and four of the five possible RD preceptors returned their questionnaires. Salient findings as well as actions to be taken in subsequent course offerings include: (a) clarify expectations, (b) limit geographical distance, (c) increase in-class time, (d) limit project scope, (e) add more statistics training/practice, (f) introduce outcomes research earlier, (g) preceptors' participation was positive. This endeavor allowed us to acquire the information and experience required to make outcomes research training a more significant component of dietetics education.     

Voluntary active euthanasia and doctor-assisted suicide: knowledge and attitudes of Dutch medical students

The objective of the study was to gain insight into the knowledge of and attitudes towards voluntary active euthanasia and doctor-assisted suicide (EEDAS) of Dutch medical students, and to determine whether knowledge and attitudes change after a 1–day informative conference about EDAS. Data were collected by means of two self-administered questionnaires. Questionnaire 1 had to be completed before the start of the conference and questionnaire 2 after the conference. In both questionnaires, students were asked by means of two open-ended questions to define euthanasia and doctor-assisted suicide. They were also asked to indicate which of eight statements met with the requirements for prudent practice. Finally, the students were asked to what extent they agreed or disagreed with each of seven statements about attitudes towards EDAS. To determine if a selection occurred among students who returned both questionnaires, their background characteristics, and knowledge and attitudes towards EDAS were compared with those who returned only the first questionnaire. Forty-seven students returned only the first questionnaire, while both questionnaires were returned by 137 students. No differences were found between students who returned both questionnaires and those who returned only the first questionnaire with regard to age, religion, knowledge of and attitudes towards EDAS. Students' knowledge of the definitions of EDAS and the requirements for prudent practice improved significantly. Students' reactions to the statements on attitudes towards EDAS showed that a large majority had a fairly positive attitude towards EDAS. There was no significant difference before and after the conference. Male students and students with a religion were more opposed to EDAS than female students and students without a religion. The fact that the students' knowledge of EDAS improved after a 1–day conference does not imply sufficient understanding of the issue. Because EDAS is allowed only under strict conditions in the Netherlands, medical students require special training. Only then will they be equipped to deal with requests for EDAS during their future careers.     

The cost of problem-based vs traditional medical education

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.     

Teaching medical students about over-the-counter medications

OBJECTIVES: Over-the-counter (OTC) medications account for over half of US drug expenses but have received little attention in medical school education. This pilot study evaluated student attitudes and knowledge in connection with a new curriculum in an ambulatory teaching clinic. DESIGN: Learning objectives were developed for six categories of OTC medications and students taught each other under the direction of a clinical pharmacist and family physician. Learning was undertaken in small groups and a site visit to a pharmacy was included. A 25-question test of knowledge was administered before and 6 months after the project, and student attitudes were assessed. SETTING: The sessions were taught as part of a longitudinal family medicine clerkship at an ambulatory care teaching clinic, Rockford, Illinois, USA. SUBJECTS: Twenty third-year medical students took the pre-test and attended the educational sessions; 19 completed the post-test and 16 completed the attitudinal survey. RESULTS: The mean pre-test score of 49% improved to 67% on the post-test (p<0.001). On the survey, 94% found the material useful and 88% liked the small group learning, but only 60% felt the pharmacy trip was worthwhile. CONCLUSION: In this study, medical students found teaching about OTC medications to be useful and showed significant improvement on a fund of knowledge test.     

The development and evaluation of an integrated community-based,patient-centred learning activity at the University of Hong Kong

OBJECTIVE: To develop and evaluate the Patient Care Project (PCP), an integrated patient-centred, community-based learning activity, implemented at the University of Hong Kong since 1992. DESIGN: The PCP, a required course in the first 2 preclinical years, is structured into four learning cycles over 9 months. Each cycle consists of a patient interview followed by a debriefing group tutorial. In-depth interviews with the same patient allow students to explore the impact of disease and patients' illness experience, as well as the contribution of the wider determinants of health to their condition. The debriefing tutorial frames empirical observations into theoretical models and its format reinforces habits of problem-based learning. The programme was evaluated using survey questionnaires completed by students, patients and tutors. PARTICIPANTS: 324 first- and second-year medical students. RESULTS: Students, participating patients and tutors all rated the PCP positively in end-of-course evaluations. Specifically, 68% of students commented that the PCP had met all or most of its stated objectives, while there was nearly unanimous agreement among patients that students demonstrated understanding and empathy in the visits and interviews. Tutor appraisal of student performance also indicated the attainment of all stated aims and objectives overall. CONCLUSIONS: The PCP is a valuable contribution to community-based learning and the promotion of the patient-centred clinical method.