The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand

CONTEXT: Cultural factors in health and illness, and an awareness of community health needs analysis, are important issues for medical education. Both have received relatively little recognition in the medical education literature. This paper describes the development of an educational attachment to remote predominantly Maori rural communities in New Zealand. The twin purposes of the programme were to encourage students to adopt broad public health approaches in assessing the health needs of defined communities, and to increase their awareness of the importance of cultural issues. METHODS: During a one week attachment, 51 students from the Wellington School of Medicine were hosted in six small communities in the East Cape region of New Zealand. Students gained an insight into the health needs of the communities and were encouraged to challenge their own attitudes, assumptions and thinking regarding the determinants of health and the importance of cultural factors in health and illness. The programme included both health needs assessment and cultural immersion. Students made visits with primary health care professionals and were also introduced to Maori history and cultural protocol, and participated in diverse activities ranging from the preparation of traditional medicines to performing their own songs in concert. CONCLUSIONS: The students evaluated the course extremely highly. Attachments of this sort provide an opportunity for students to appreciate how cultural values have an impact on health care, and how they also make the teaching and learning of topics such as community health needs analysis an enjoyable and dynamic experience.     

Attitudes towards community medicine: a comparison of students from traditional and community-oriented medical schools

OBJECTIVE: To compare the attitudes towards community medicine of first and final year students from two Australian medical schools. METHOD: In 1995, medical students from Newcastle University (a problem-based, community-oriented curriculum) and Adelaide University (a more traditional lecture-based curriculum) were asked to complete the Attitudes to Community Medicine questionnaire. This is a valid and reliable 35 item survey assessing six key domains of community medicine. The two medical schools differ in their methods of selection and curriculum delivery, and also in curriculum content. RESULTS: Response rates averaged 95% for first year and 81% for final year students. Students selected into both medical schools were found to have positive attitudes with respect to most aspects of community medicine. However, those entering Newcastle had more positive attitudes toward community medicine overall than their Adelaide counterparts. They also scored more positively on subscales relating to holistic care and evaluation of health care interventions. Students who were older and female scored more positively on some subscales, but correction for age and gender did not change the conclusions about medical school differences. CONCLUSION: This study suggests that selection criteria, and probably curriculum style and emphasis, have an influence on the attitudes that medical students possess and later develop toward community medicine.     

Two models of primary health care training

Summary. In 1991, the Fiji School of Medicine restructured the training of its medical students, dividing the 7-year course into two phases. Students now undertake a 3-year community-oriented primary care practitioners course, after which they may elect to continue practice in a primary health care role, or to undertake further hospital-based training to complete their medical degree. The course responds to the health needs of the South Pacific, and the local patterns of morbidity and mortality, rather than measuring itself against the curricular demands of its more developed neighbours, Australia and New Zealand. At the same time, the Tropical Health Program of the University of Queensland Medical School responded to demands from the Aboriginal and Torres Strait Islander community to develop primary health care training at degree level. This was intended to complement other strategies undertaken by the Aboriginal and Torres Strait Islander Studies Unit such as the recruitment and support of indigenous students through mainstream health professional education. There was a need to address health priorities that are very different to those of the Australian population as a whole, as well as the sociopolitical and cultural context as it affects both students themselves and health issues in their communities. Both institutions have chosen problem-based teaching/learning as appropriate to their courses, and content is also similar, though with emphases that reflect the differing contexts. The two courses are examples of innovative responses by centres with university medical faculties to specific issues in health education.     

Curriculum assessment for prevention topics and the population perspective

BACKGROUND: According to the Association of American Medical College's (AAMC) Senior Questionnaire, medical students spend an inadequate amount of time learning about health promotion, disease prevention, and the population health perspective. OBJECTIVE: Determine the health promotion/disease prevention (HPDP) content of the medical school curriculum at the University of Kansas School of Medicine, using an inventory of knowledge and skills in HPDP and using physician education objectives from Healthy People 2000. METHODS: A 121-item survey to evaluate curriculum content was developed. All course directors evaluated their course by using this instrument. An average of three medical students used this instrument to assess each curriculum lecture and every clinical clerkship day in the required medical school curriculum. A teaching session was defined as spending a minimum of 3-5 minutes teaching an HPDP topic. RESULTS: Of 21 required courses in the medical school curriculum, 11 accounted for the 393 teaching sessions in HPDP. Seventy-five percent (293 sessions) of these dealt with clinical prevention. Quantitative methods received 40 sessions, whereas the health services organization and delivery and the community dimensions of medical practice received 37 and 23 sessions, respectively. Course directors and students disagreed significantly in which HPDP topics were taught in the curriculum. CONCLUSIONS: Clinical prevention was fairly well covered in the medical school curriculum. Quantitative methods, health services organization and delivery, and community dimensions of medical practice were poorly covered. This assessment was used to substantially improve the curriculum. To track and improve curriculum content in all courses, course directors need to know more precise details about the content of their courses, so this detail can be used to better evaluate the overall curriculum.     

" 'Just think of TB and Asians', that's all I ever hear": medical learners' views about training to work in an ethnically diverse society

The case for being able to respond effectively to cultural and ethnic diversity in health care is attracting increasing debate in medical education. However research exploring the perspectives of learners is lacking. AIMS: We sought medical learners' perceptions and their perceived training needs in relation to cultural and ethnic diversity in health care. METHODS: A series of nine focus group interviews was conducted with 55 medical learners, including undergraduate students in a UK medical school and a group of postgraduate general practitioners in training. Interview data were analysed using qualitative methods. RESULTS: Participants had a broad but superficial awareness of multicultural issues. This focused upon "difference" with students emphasizing their need to acquire knowledge of different beliefs and practices. Current teaching was perceived as inadequate and limited largely to ethnic patterns of disease. Most felt a need for greater training. They regarded development of particular communication skills, such as working with interpreters as helpful. Beyond avoiding stereotyping, learners rarely identified reflecting upon their attitudes or the issue of racism as important. Students anticipated a range of potential problems for further training, but sought learning that was relevant, practically oriented and stimulating. CONCLUSIONS: The study points to learners' experience of inadequate training but suggests a willingness to learn more. The possible predominance of a "difference" perspective might drive a narrow focus upon learning cultural knowledge at the expense of promoting a balance with self-reflection upon attitudes and developing generic skills. Educators might heed learners' views about how they should be taught successfully.     

Extending community involvement in the medical curriculum: lessons from a case study

OBJECTIVES: Recent reports have stressed the importance of developing medical students' understanding of primary and community care and their ability to work in health-care teams. DESIGN: An innovative 3-year project aimed to achieve this understanding by broadening the range of health-care professionals and community organizations contributing to the medical curriculum. SETTING: King's College School of Medicine, London. SUBJECTS: Undergraduate medical students. RESULTS: Through partnerships with three local community health care trusts, non-medical health care disciplines in the teaching hospital and a range of voluntary and statutory services, students have been introduced to a broader spectrum of care. This has taken place both within the core curriculum and through the development of special study modules. CONCLUSIONS: Involving teachers and organizations which have not traditionally contributed to medical education raises philosophical issues around the aims and rationale of their involvement and practical issues such as gaining curriculum time, recruiting suitable teachers and gaining credibility for the courses. We analyse the benefits and difficulties inherent in broadening the curriculum in this way and assess the lessons our experience provides for the future expansion of such learning, both locally and nationally.     

Challenges to rural medical education: a student perspective

ABSTRACT: The key feature of the Greater Murray Clinical School model is the attachment of students to patients. Students follow their patients through the health care system, in contrast to the standard approach where students are attached to doctors or speciality based clinical units. The patient/student coupling occurs at the primary care level, which mostly but not exclusively will occur in the GP's office. Students anchor their knowledge by seeing the natural progression of common illnesses, the impact of behavioural aspects on health and disease, and by experiencing continuity of care. Along their path they develop good problem solving skills and learn to understand the health care system they will become part of. The main obstacle in teaching a medical undergraduate curriculum in a rural setting is that large geographical distances separate students, teachers and resources. Consequently, information technology will play an important role in terms of delivery of the GMCS curriculum. Moreover, there is potential for flow-on benefits to the community following integration of new information technology into the local health infrastructure.     

Evaluation of undergraduate medical education in Finnish community-oriented and traditional medical faculties: a 10-year follow-up

OBJECTIVES: This study focused on Finnish physicians' views of their undergraduate medical education. Differences between traditional and community-oriented medical faculties were examined and changes which had taken place during a 10-year follow-up period were also assessed. METHODS: The study was based on data retrieved from a postal survey made among Finnish physicians in 1998. The study population consisted of all doctors who graduated between 1987 and 1996 (n=4926); those born on odd-numbered days were selected for this study (n=2492). A postal questionnaire and two reminders were sent to those selected, and 1822 questionnaires were returned, giving a response rate of 73.1%. RESULTS: Physicians who graduated from the community-oriented faculties were more satisfied with their undergraduate medical education when compared with their colleagues graduating from traditional faculties. There were some differences between the universities with respect to education for hospital work. The teaching of primary health care, however, was clearly more effective in community-oriented faculties. The proportion of graduates who were satisfied with their primary care education was over 70% in community-oriented faculties, whereas in the traditional faculties it was only 35-45%. CONCLUSIONS: According to graduates, the community-oriented medical school curriculum better meets the needs of practising physicians than that in traditional faculties. In curriculum reforms, more emphasis should be placed on comprehensive medical education, which includes both primary and secondary health care.     

Changing the attitudes of `tomorrow's doctors' towards mental illness and psychiatry: a comparison of two teaching methods

The General Medical Council's document ` Tomorrow ' s Doctors ' (1993, GMC, London) recommended major changes in the undergraduate curricula of UK medical schools. In Nottingham, the fourth-year psychiatric attachment became shorter in duration, and interactive, problem-oriented, workshop-based learning replaced lectures. We compared the efficacy of this new teaching style in changing medical students' attitudes towards psychiatry and mental illness with that of old-style, didactic, lecture-based teaching. On the first and last days of their psychiatric attachment, 110 fourth-year medical students (45 old curriculum; 65 new curriculum) completed two self-administered attitudinal measures: the Attitude to Psychiatry Questionnaire (ATP-30) and the Attitude to Mental Illness Questionnaire (AMI). We found that students had favourable attitudes towards psychiatry and mental illness before the attachment. These attitudes became more positive after the attachment in students from both curricula, with no significant difference between the groups and no gender difference. Students found patient contact rewarding, become more accepting of community care, and had greater appreciation of the therapeutic potential of psychiatric interventions. The interactive, student-centred, problem-oriented teaching of the shortened new curriculum appeared as effective in changing medical students' attitudes as a longer attachment with traditional teaching.     

Ruralising medical curricula: the importance of context in problem design

ABSTRACT: The establishment of a new medical school in northern Australia, with its focus on preparing graduates to understand the health care needs of the regional population, has raised an interesting issue in problem design for teaching and assessing in an integrated curriculum. This issue is the extent to which the clinical content of a teaching or assessment problem should consider more subtle contextual issues that help to define the different roles played by rural practitioners, rather than what might be regarded as appropriate for 'generic' medical education. This brief paper provides example case studies that highlight the challenge facing curriculum designers developing programs for rural clinical schools.     

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.     

Medical students' evaluation of a teaching session in occupational medicine: the value of a workplace visit

BACKGROUND: Undergraduate teaching in occupational medicine in UK medical schools is in decline. We developed a teaching programme for the new curriculum at our medical school, and then used student evaluation to tailor it to students' perceived learning needs. AIMS: To examine medical students' perception of a teaching session in occupational medicine after changes made in the light of earlier student evaluation, and in particular their views on the inclusion of a workplace visit. METHODS: Questionnaire evaluation feedback completed immediately after teaching sessions, triangulated with a student focus group session conducted by an external facilitator to explore what students valued most and least and why. Comparison of student evaluations before and after changes introduced in the light of student evaluations. RESULTS: Students' perception of the usefulness and relevance of the session significantly improved after the changes. Students consistently identified the use of case scenarios as helpful but demonstrated a dichotomy of opinion about the value of a workplace visit. Overall, students valued the brevity of the session that resulted from removing the workplace visit. CONCLUSIONS: It is possible to enhance students' perception of the value of a teaching session by modifying the session in the light of student-based evaluation.     

Developing service-based teaching in health education for medical students.

In the expanding concern about the social-behavioral aspects of health care in medical education, health education has opportunities for making itself an important part of basic medical training. The need is to actually define a physician's appropriate educational tasks and competencies as a basis for curriculum development in health education which would ideally be integrated into the whole educational program. This case study presents efforts to develop an educational service component at a rural health center which, connected to a major teaching hospital, serves as a learning base for medical students. Through trial and student feedback a program has been developed which includes patient counseling, evaluative home visits, group education sessions, exit interviews, medication counseling, community needs assessment and educational consultation with local school teachers. With this program as a foundation, the goal is to integrate health education learning throughout the rest of the medical curriculum.     

An inter-university community child health clinical placement programme for medical students

BACKGROUND: Inpatient teaching no longer reflects the full spectrum of paediatric practice and community-based programmes with clearly defined aims and evaluation of learning are becoming increasingly important. Competition for community resources poses threats to the delivery of effective community child health learning programmes by individual medical schools. OBJECTIVES: To develop and evaluate a combined inter-university, child-focused, active learning programme in community child health. METHODS: A total of 55 postgraduate-entry medical students from the Flinders University of South Australia and 97 undergraduate-entry University of Adelaide students were placed with 25 community child health agencies and instructed to assess services from a client perspective by tracking one child and family through multiple agency contacts. Following each placement, achievement of specific programme aims was evaluated by students and agency staff using a 7-point Likert scale. RESULTS: Students and agency staff indicated substantial achievement of programme aims. Mean agency ratings were significantly higher than student ratings for three aims: students' experiencing a wider spectrum of health care problems than in teaching hospitals (5.7 +/- 1.5 versus 4.9 +/- 1.6, P < 0.001); the importance of social and environmental factors (5.9 +/- 1.0 versus 5.2 +/- 1.4, P < 0.001), and the importance of coordinating care (6.0 +/- 1.0 versus 5.2 +/- 1.2, P < 0.001). Ratings from undergraduate-entry students differed from those of postgraduate-entry students only with respect to the importance of social and environmental factors (4.8 +/- 1.4 versus 5.7 +/- 1.1, P < 0.001). CONCLUSIONS: The new collaborative Community Child Health Programme substantially achieved learning aims and demonstrated effective integration of postgraduate- and undergraduate-entry medical students from two universities.     

The social contract challenge in medical education

Medical education has been criticized for loss of touch with the health needs of society. A social contract implies that medical schools, their students and teaching staff have certain rights and privileges in return for serving society. Commitment to this important reciprocal relationship makes it necessary to ensure that medical students gain understanding of the basic health needs of the communities they will serve. Health, Illness and the Community (HIC) is a mandatory course in the first and second years of the curriculum at the University of Toronto. Its goal is to provide students with community learning experiences by involving over 300 community agencies as learning sites. The course takes place one half-day per week throughout first and second year. All 177 students initially work with patients in their homes and in public health units and related agencies. Students are then assigned to agencies using health determinants and health promotion strategies. In the second year, each student selects an agency in the community, and carries out for the entire year a major project focused on the interaction of a health problem with a social issue. This educational initiative has been received well by community agencies and patients. Teaching staff have been enthusiastic and students have performed very well. A major obstacle has been the negative attitudes of some students to community-based learning, but these appear to be improving with time. Involving multiple agencies as learning sites is a feasible method for enabling students to learn about community health needs.     

Self-directed learning in population health. a clinically relevant approach for medical students.

BACKGROUND: In this article, we describe the education model used to integrate population health learning into a new 4-year medical program at the University of Sydney. METHOD: Our two-pronged approach aims to prepare third-year students to integrate population health thinking into their day-to-day clinical reasoning and to equip them with skills to investigate specific population health topics. We provide an example of a student-led, small-group session on health issues for disadvantaged populations, along with an outline of our assessment and evaluation methods. This innovative course illustrates one approach to the challenge of motivating students to bridge the gap between their interest in the medical care of individual patients and the healthcare needs of whole populations. RESULTS/CONCLUSIONS: Students performed adequately in the assessments required for progression to the next year of the program. Students rated the case-based exercises; self-directed learning; on-line and library resources; tutor facilitation; and student-led, small-group sessions as effective methods for learning.     

Health promotion in the medical curriculum

It has been argued that health promotion should be included in the medical curriculum, if medical education is to match the needs and health goals of communities. In spite of the medical profession's awareness of the importance of health promotion, few universities in the UK have introduced a substantive course on the subject. This paper describes the teaching of health promotion in Nottingham Medical School. It identifies the aims and objectives of the course which are amongst others to develop an understanding of: the factors which influence the perception and experience of health and illness; the concepts of health promotion and health education; the scientific basis of health promotion; the relative effectiveness of approaches used; the measurement of health status and health behaviour; and health policy and planning. An innovative element of the teaching involves a community project which gives students experience of health promotion in practice. Evaluation of the impact of the course suggests that students perceive it to be interesting, stimulating and enjoyable, whilst examination and continuous assessment indicate that it has also influenced students' knowledge and understanding of the subject.     

A programme in undergraduate geriatric education: the Beer Sheva experiment

The Beer Sheva medical school was started in 1974 with the objective of training primary care doctors to meet the health needs of the Negev region of Israel. This paper describes a programme developed at Beer Sheva to prepare students to deal with the health-related problems of the elderly. Students begin their contact with the elderly in their first year (early clinical teaching programme) and continue this exposure in varying degrees during the 6 year curriculum. A preliminary study has shown that there is a trend for students to commence their studies with positive attitudes toward the elderly. The early clinical teaching programme which emphasizes interviewing skills, knowledge about ageing and community services that relate to the aged, reinforces the student's sensitivity to geriatric issues. In order to maintain the student's interest in working with the elderly, it is apparent that it will be necessary to educate both hospital and community-based physicians to provide positive role models for students.     

Orienting medical education to community need: a review

The literature on community-oriented medical education is reviewed. In response to major changes in the origin, expression and place of management of much illness, many medical schools are turning their attention increasingly to the community from whence to derive their curriculum and wherein to effect their teaching. The traditional hospital base of teaching is eroding, necessitating new, innovative approaches to medical education. Becoming community-oriented, or using community-based learning, offers potential benefits for the schools, the students, and the public. The experience of others demonstrates the necessity of enlisting community representatives as partners in the process of change. Institutional barriers are significant and careful planning is needed to overcome them.     

Meeting the needs of future physicians: a core curriculum initiative for postgraduate medical education at a Canadian university

In addition to possessing medical expertise, contemporary physicians are expected to be skilled communicators, critical consumers and users of medical research, teachers, collaborators, health care advocates, and managers. A core curriculum is a common set of learning experiences designed to help prepare physicians for these complex roles. PURPOSE: This article describes the design and implementation of one core curriculum, summarizes the feedback received from residents, and shares some of the lessons we are learning as we use feedback to develop our programme. METHOD: The core curriculum described was implemented at a Canadian university which offers 56 residency programmes with a total enrollment of approximately 360 students. The curriculum consisted of 30 sessions organized around four themes: biostatistics and epidemiology; communications and teaching skills; healthcare management, and ethical, medicolegal and lifestyle issues. Each session in the Core Curriculum was evaluated by residents with respect to the timing, quality, and value of the learning experience. In addition, residents participated in focus group discussions of their Core Curriculum experiences. RESULTS: Key findings related to the characteristics of effective core curriculum learning experiences and to the barriers to implementing a core curriculum across programmes. Of particular salience were findings related to explicit issues of attendance and the diverse needs of learners and programmes, and to more implicit issues of communication and managing change. The specific content and format of the Core Curriculum and the results of the evaluation process will be of interest to others considering a core curriculum for postgraduate medical programmes.