Health care reform as perceived by first year medical students

Our study objective was to evaluate the attitudes of first year medical students toward the health care system using a self administered questionnaire to all first year medical students at the medical schools in the University of California system. Of 631 students surveyed, 94% comleted the instrument. Students were asked about their attitudes toward and familiarity with concepts in health services, access to care, and managed care. Our findings indicated that most students were unfamiliar with concepts related to health services. Students were concerned about access to care; sixty-six percent of students favor a national health insurance plan. A majority of students supported allowing patients access to the current health care system regardless of the cost or utility of a medical test or procedure. Thirty-nine percent felt that rationing health care in any form (transplants, access to the intensive care unit, etc.) is contrary to the way medicine should be practiced. 72% felt that practicing physicians had a major responsibility to help reduce health care costs. When asked about specific changes intended to control health costs, students identified reform of medical malpractice system (63%) and increased spending on preventive health (60%) as the two proposals most likely to be effective. Students generally held negative attitudes toward managed care organizations; only 10% would chose to receive their care in HMOs. We conclude that first year medical students generally have little understanding of the health care system. Despite this, they hold strong opinions about access to care, managed care organizations and strategies intended to reduce health care spending. It is up to medical educators to find creative methods of introducing these content areas into an already bulging curriculum.Funds for this study were generously provided by the L.K. Whittier Foundation. Samuel A. Skootsky's salary was in part supported by Southern California Edison.     

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

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

First year medical students' perceptions of stress and support: a comparison between reformed and traditional track curricula

BACKGROUND: The authors hypothesised that medical schools need to support their students by identifying the challenges inherent in the demanding study of medicine, especially during the transitional phase at the beginning of study. Therefore, a study was conducted to evaluate Year 1 students' perceptions on how well 2 different programmes--a reformed and a traditional programme--helped students make a good start to their studies. DESIGN: Cross-sectional survey. METHOD AND PARTICIPANTS: A questionnaire was distributed to Year 1 medical students on reformed (RT) and traditional track (TT) curricula. Its 5 subscales measured perceived stress and support. RESULT: A total of 155 students (70% of the year group) responded. Significant differences between groups appeared in 4 of the 5 subscales. Students on the RT felt more supported than students on the TT in terms of study conditions, social support at university, perceptions of their own attitudes and competencies, and living conditions. No differences in perceptions of social support outside university were apparent. CONCLUSION: Key aspects that were perceived as supportive included good contact with fellow students and teachers, high quality of courses, and a curriculum that fulfilled students' expectations and made sense to them. In identifying particular features that led to the positive judgement of the RT, the authors hypothesised that the following aspects were crucial: the specific orientation unit in the first 2 weeks, the problem-based learning workshop, the coursebooks and extracurricular social activities.     

Do conventional and innovative medical schools recruit different students?

A mail questionnaire was used to survey the social and demographic characteristics, educational background, attitudinal profiles and expected career choice of 243 first-year students enrolled in three US medical schools. The aim was to determine whether different types of schools selected different types of students. Two schools were considered as conventional whereas one school was considered as innovative both in its admission policies and in its curriculum which emphasizes a biopsychosocial approach to health care. The survey achieved an 84% response rate. The results showed no difference in students' career expectations. Students recruited in the innovative school, however, differed from students recruited in the conventional schools with regard to their social and demographic characteristics, educational background and attitudinal profiles. This study suggests that as some medical schools are innovating in their curriculum and admission policies, new types of medical students are entering medicine. Implications of these results are discussed.     

Attitudes of medical students to old people: a cross-national comparative study

Medical students' attitudes to the elderly were compared at the start and finish of a 5-week clinical attachment in health care of the elderly at the Christchurch School of Medicine. The study investigated students in their first clinical year (fourth year of their medical course) over five terms using a questionnaire employing a Rosencranz-McNevin semantic differential scale to measure general attitudes to old age and a Likert scale to measure attitudes to medical care. A question was also asked about career preferences. There was significant improvement in attitudes measured by both scales (Rosencranz-McNevin P less than 0.001, Likert P less than 0.001). Students also showed an increase in interest in health care of the elderly as a career choice. When compared with two cohorts of students from Nottingham Medical School, attitudes were significantly better in the Christchurch group at the commencement of the run. Students at both schools showed an improvement in knowledge but this was more marked for Christchurch students.     

Community-oriented medical education in Glasgow: developing a community diagnosis exercise

OBJECTIVES: Recent NHS changes have included an increasing emphasis on primary care settings, and hence community needs assessment. This has led to suggestions that medical education should become more community-oriented if today's medical students are to become effective medical practitioners. Recent curriculum reforms in a number of medical schools frequently involve a more student-centred approach, which encourages students to learn by intellectual discovery and critical thinking. We describe one such exercise in community diagnosis that has been developed in Glasgow's new undergraduate medical curriculum. DESIGN: The exercise has been developed as three teaching sessions, each with specific learning objectives. The first session explores the strengths and weaknesses of routine statistics, and reveals the lack of information regarding individual's and community's health and health care needs. The second session is a community-based rapid participatory appraisal arranged by general practitioners. Students interview patients, carers, and local key informants and health care professionals about their perceptions of health and health needs. In the final campus-based session, students combine and present their findings. Development included two pilot exercises involving detailed evaluation. SETTING: University of Glasgow. SUBJECTS: Medical students. RESULTS: Students valued the contrasting perspectives and information provided by different sources. After completing the three sessions, most students and tutors considered it an interesting, enjoyable and educational experience. CONCLUSIONS: This innovative community-oriented teaching programme gave students some insight into how health, morbidity and mortality are measured, why these might vary between different communities, and how different community members' perspectives might differ regarding perceived health and social needs.     

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 essential role of the student in curriculum planning

Medical school curricula are planned, written and organized by academic and clinical staff within medical schools. While these medical educators may well be experts in their given field, they lack first-hand experience of what it is to be a medical student in 1995. For a medical curriculum to be an effective means of learning for today's students, it must be written with a knowledge of their priorities, needs and abilities. The way in which this can be best achieved is by the inclusion of current students in all stages of designing a new curriculum.
In my second year of medicine at Flinders University, I became involved in planning for the new Graduate Entry curriculum. In the role of student advocate, I have found I am able to offer teaching staff a unique perspective, the student perspective , on various issues.
Students, through experience from their own education, are able to give advice on student resources and facilities and are in a favourable position to judge other aspects of curricula, such as the balance and relevance of course content and assessment. Students need to realize the valuable insight they have to offer their faculties and the way in which this can benefit future students. It is by actively seeking student involvement and using their input, that faculties will be able to create a consumer-friendly curriculum.     

Preparation for palliative care: teaching about death,dying and bereavement in UK medical schools 2000-2001

AIM: To examine changes in formal teaching about death, dying and bereavement in undergraduate medical education in UK medical schools. METHODS: A short questionnaire based on one used in 2 previous surveys in 1983 and 1994 was sent to all UK medical schools. FINDINGS: All schools with clinical teaching provided teaching in this area. The amount of such teaching varied widely and appeared in the curriculum in a variety of manners, times and places. Specialists in palliative medicine, general practitioners and nurse specialists were most frequently involved in teaching, with decreased involvement of non-practitioners since 1983. Most schools covered a wide range of topics, with all addressing attitudes towards death and dying and symptom relief in advanced terminal illness. Some schools used terminally ill patients directly in their teaching and most included hospice participation. As the surveys conducted in 1983 and 1994 indicated, many schools do not address the evaluation of palliative care learning. ANALYSIS: Changes in undergraduate medical education, especially in terms of more integrated curricula, mean that for many schools, palliative care teaching is integrated into learning in other areas. This should help students apply their palliative care learning to other contexts. The increase in teaching about the management of physical symptoms that has occurred since the previous surveys seems to reflect the establishment of palliative medicine as a speciality and the current emphases within palliative care practice in the UK. CONCLUSION: The preparation for palliative care work provided for current undergraduate medical students appears to be of a better quality than that provided in 1983.     

General practice in the undergraduate curriculum: 20 interviews with Southampton final-year students

The Primary Medical Care Group at the University of Southampton contributes to the medical curriculum in the first, third and final years. A visiting lecturer from Sweden took the opportunity to interview a sample of 20 final-year students using a qualitative approach. Questioning centered on the impact of the primary care course both in relationship to medicine as a whole and to general practice. It was found that primary medical care was often not seen as a central or integral part of the curriculum but many students acknowledged its important contribution to seeing the patient as a whole and in integrating the various other parts of the curriculum, with significant opportunity for role modelling and informing career choice. A hidden curriculum emerged of attitudes which provided a conflict for some students. Improvements should include clearer dovetailing of primary medical care with other curricular components, limitation of aims with more specific and rigorous assessment and a wide strategy of staff development not confined to those directly involved in general practice attachments.     

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.     

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.     

Does a rural educational experience influence students' likelihood of rural practice? Impact of student background and gender

CONTEXT: The family medicine clerkship at the University of Calgary is a 4-week mandatory rotation in the final year of a 3-year programme. Students are given the opportunity to experience rural practice by training at 1 of several rural practices. OBJECTIVE: To determine whether exposure to a rural educational experience changes students' likelihood of doing a rural locum or rural practice and whether student background and gender are related to these practice plans. METHOD: Clinical clerks from the Classes of 1996-2000, who trained at rural sites, responded to questionnaire items both before and after the rural educational experience. Responses to the questionnaire items and discipline of postgraduate training served as dependent variables. Student background and gender were independent variables. RESULTS: As a result of the rural educational experience all students were more likely to do a rural locum. Compared to their urban-raised peers, students from rural backgrounds reported a significantly greater likelihood of doing a rural locum and practising in a rural community, irrespective of gender or participating in a rural educational experience. There was no relationship between background and career choice. CONCLUSION: A rural educational experience at the undergraduate level increases the stated likelihood of students participating in rural locums and helps to solidify existing rural affiliations. Students with rural backgrounds have a more favourable attitude toward rural practice. This pre-post study provides further support for the preferential admission to medical school of students with rural backgrounds to help alleviate the rural physician shortage.     

The students' view of an innovative undergraduate medical course: the first year at the University of Newcastle,N.S.W.†

An innovative medical course commenced in 1978 in a new medical school at the University of Newcastle. An evaluation of the student response to the first year of this course was carried out. This evaluation aimed to assess how far the students had progressed towards the attainment of the long-term Faculty objectives on which the Newcastle curriculum is based. Students' perceptions of educational innovations were obtained and compared with the Faculty's stated aims. Students felt that they could approach a problem scientifically, in a manner consistent with the Faculty's specified methods. In the area of team work, students had accepted the need for training in team skills as preparation for work after graduation. Students have adapted to the use of objectives, to assessment for competence, and to the marking of one another's papers. These methods had been introduced to facilitate the development of skills necessary for independent and continuing self-education. Patient contact was designated as the greatest strength of the first year. Students expressed concern for patient well-being and the influence of student activities on patients. This indicated that students had progressed some way towards the attainment of the Faculty objective that they should develop an humanitarian approach to patients.     

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.     

What students bring to medical school: attitudes toward health promotion and prevention

INTRODUCTION: Health care providers' positive attitudes toward prevention and health promotion are important in achieving national health care goals. Limited studies of incoming medical students have been conducted that measure predictors of positive attitudes toward health promotion and prevention. METHODS: Data were obtained from a 1993 curriculum evaluation survey of first-year students at five different medical schools in California. Attitudes toward health promotion and prevention were measured using a nine-question Prevention Attitude Scale (PAS). We developed 2 multivariate linear regression models using demographics, education choices, and personal social values and beliefs to predict PAS scores. We also performed bivariate analysis. RESULTS: Five hundred ninety-nine completed surveys were analyzed, with a response rate of 95%. Mean PAS score was 36.47 +/- 3.7 on a 0 to 44 scale. Female gender, Democratic party preference, and a planned specialty choice in preventive medicine or primary care predicted the highest PAS scores on bivariate analysis (p < 0.002). Significant correlation ( p < 0. 001) was shown between PAS scores and 2 additional scales regarding beliefs in associations of social factors and illness and in the importance of caring for the poor. Linear regression model using personal social values and beliefs explained 34% of the variance, as opposed to the demographic model that explained only 9% of the variance. CONCLUSIONS: In the schools studied, participating first-year medical students had moderately positive attitudes toward health promotion and prevention, as measured by PAS scores. In designing curriculum to improve medical students' attitudes toward health promotion and prevention, medical educators may need to consider other personal and social values held by medical students and to address the "political" aspects of health promotion and prevention. Future studies are needed to longitudinally follow medical student attitudes.     

Effect of medical students' ethnicity on their attitudes towards consultation skills and final year examination performance

AIM: The study had two aims. The first aim was to examine the relationship between final year medical students' ethnicity and their attitudes towards consultation skills. The second aim was to investigate the relationship between ethnicity and final year performance. METHOD: A cross-sectional study was undertaken of all final year medical students in 1995 and 1996, both before and after their attachment through the Department of General Practice at Monash University, Australia. A questionnaire was designed to assess students' attitudes (views of importance and confidence) towards consultation skills. Also, records of final year performance were obtained from the University. RESULTS: Five clusters of consultation skills were formed through factor analysis: communication skills, difficult consultations, traditional diagnostic methods, routine management and life threatening conditions. There were no significant differences in students' attitudes towards these consultation skills based on country of birth, language, or student status preattachment. The only significant postattachment difference was that students born in non-Western countries placed a significantly higher importance on communication skills and the traditional diagnostic method than students born in Western countries. There were significant differences in final year performance between students across all three parameters of ethnic diversity. Non-Western born students performed worse than Western born students. Students who preferred using a language other than English also performed worse than those students preferring English. International students performed worse than students with Australian citizenship or permanent residency., CONCLUSIONS: The only significant difference regarding attitudes to consultation skills was that non-Western born students placed significantly greater importance on communication skills and the traditional diagnostic method postattachment than Western born students. No significant differences were found in attitudes preattachment. There were significant differences in performance, with students of ethnic background performing consistently poorer in all the final year assessment parameters analysed.     

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.     

Are professional attitudes related to gender and medical specialty?

OBJECTIVES: The importance of professional attitudes in medical care has long been recognized; however, medical training has not stressed attitude development until recently. In previous studies among medical students, we found that gender and specialty preference are important factors in attitudes. In this study, patient-centredness of trainees in general practice and surgery and of final-year clerks preferring one of these specialties was assessed in one medical school in The Netherlands. The effect of gender, specialty and training level on attitude was investigated. DESIGN: In 1995, attitudes of 37 general practice trainees, 31 surgery trainees and 120 clerks were measured anonymously using questionnaires containing the Doctor-Patient Scale. This attitude scale measures patient-centredness vs. doctor-centredness. Response rates were 78%, 58% and 84%, respectively. SETTING: University of Utrecht. SUBJECTS: Medical students. RESULTS: Attitudes were related to specialty. General practice trainees showed more patient-centredness than surgery trainees. In accordance with previous findings among younger students, no differences were found between final-year clerks and vocational trainees. In contrast to previous studies, gender was not related to patient-centredness. CONCLUSIONS: Professional attitudes, in particular patient-centredness, seem to be related to specialty preference in the final year of graduate medical training and specialty as a career choice. It remains unclear whether professional socialization reinforces existing attitudes or whether existing attitudes result in specialty preference.     

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

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