Community hospitals and general practice: extended attachments for medical students

The first year experience of an innovative experiment in undergraduate medical education is described. The study investigated the educational effectiveness of prolonged clinical attachments for medical undergraduates in community hospital-based general practice. It has also assessed the ability of students to take some responsibility for their own learning in a clinically challenging environment. A retrospective evaluation of the experience obtained during the 3 month attachments for a self-selected group of fourth year Dundee medical school undergraduates was made. These undergraduates were placed in 10 mainly rural Scottish general practices with attached community hospitals providing a wide spectrum of inpatient and outpatient medical and surgical care. Students were assessed on the satisfactory completion of a portfolio of learning experiences and a practical clinical skills list. They were also required to submit a clinical project based on some aspect of their work during the attachment. The initial results showed a high degree of student and tutor satisfaction with the attachments. The assessment of all 10 of the students' educational achievements in their attachment were regarded as satisfactory and two were assessed as outstanding. Tutor assessment confirmed the validity of the initiative. Prolonged attachments in community hospital-based general practice for medical undergraduates have proved educationally valid and popular with both students and tutors. The development and dissemination of this model on a wider scale has resource issues which require to be addressed.     

The clinical and educational experiences of pre-registration house officers in general practice

AIMS: To describe aspects of the clinical experience and educational supervision gained by pre-registration house officers (PRHOs) in general practice, and to relate these to the current General Medical Council (GMC) aims for general clinical training in general practice. DESIGN: Qualitative evaluation, part of which involved semistructured interviews with 12 PRHOs who were experiencing a general practice rotation. Interviews were conducted at the beginning and the end of the pre-registration year, and following return to hospital work after completion of the general practice placement. SETTINGS: Three teaching hospitals, two district general hospitals and six general practices in south-east England. PARTICIPANTS: 12 PRHOs who were involved in rotations incorporating a general practice placement. RESULTS: To varying degrees, the GMC aims for training in general practice were met for all the participants. All PRHOs recognized the value of the clinical experience and educational supervision they received in general practice. They particularly valued aspects such as having an individual training programme based on their own needs, and the interlinking of theory and practice, which aided learning. Most felt that having responsibility for their own patients acted as an important incentive for learning, and in general, PRHOs appreciated having the time to learn which general practice allowed. CONCLUSIONS: For the majority of PRHOs, the time spent in general practice was seen as a positive clinical and educational experience. In a variety of ways, the general practice placement encouraged PRHOs to develop the self-directed learning skills seen as essential to the lifelong learning advocated by the GMC. A number of recommendations are made to help improve the integration of the hospital and general practice components of these rotations.     

A written test as an alternative to performance testing

Performance tests are logistically complex and time consuming. To reach adequate reliability long tests are imperative. Additionally, they are very difficult to adapt to the individual learning paths of students, which is necessary in problem-based learning. This study investigates a written alternative to performance-based tests. A Knowledge Test of Skills (KTS) was developed and administered to 380 subjects of various educational levels, including both first-year students and recently graduated doctors. By comparing KTS scores with scores on performance tests strong convergent validity was demonstrated. The KTS failed discriminant validity when compared with a general medical knowledge test. Also the identification of sub-tests discriminating between behavioural and cognitive aspects was not successful. This was due to the interdependence of the constructs measured. The KTS was able to demonstrate differences in ability level and showed subtle changes in response patterns over items, indicating construct validity. It was concluded that the KTS is a valid instrument for predicting performance scores and could very well be applied as supplementary information to performance testing. The relative ease of construction and efficiency makes the KTS a suitable substitute instrument for research purposes. The study also showed that in higher ability levels the concepts which were meant to be measured were highly related, giving evidence to the general factor theory of competence. However, it appeared that this general factor was originally non-existent in first-year students and that these competencies integrate as the educational process develops.     

Approaches to experiential learning, course delivery and validation in medicine. A background document

Educational models and approaches change over time in their dominance and use, offering a wide selection to educational planners and teachers. This paper discusses aspects of experiential learning, distance learning, learning contracts, portfolios, reflection, appraisal, assessment and validation of education. It offers triggers to further thought and enables the analysis of current educational practice.     

Does teacher thinking match teaching practice? A study of basic science teachers

OBJECTIVE: To obtain an understanding of basic science medical teachers' conceptions of learning and their ideas for facilitation of learning. METHODS: Teaching staff at a biomedical centre (n = 62) were asked to describe their definitions of learning, their suggestions for how to solve an applied educational problem and their intended activities when teaching students. The research was carried out using a questionnaire consisting of open-ended and fixed-choice questions. RESULTS: Although 1 in 4 teachers endorsed constructivist conceptions of learning, only 1 in 8 actually reported using activating teaching strategies. Conceptions of learning did not co-vary with teaching practice. CONCLUSIONS: The assumption that conceptions of learning and teaching practice are aligned was challenged. The current questionnaire could be used as an intervention tool for educational development to map whether or not there is a match between teachers' conceptions and their practice.     

A comparison of the educational opportunities on junior medical attachments in general practice and in a teaching hospital: a questionnaire survey

OBJECTIVES: To obtain students' perceptions of the educational quality of the general internal medicine teaching overall and to determine whether specific learning objectives were better addressed in general practice or in hospital. DESIGN: The survey was carried out after a 10 week block of general internal medicine, consisting of five weeks taught in general practice and five weeks taught in a teaching hospital. Students were randomly allocated to start in either general practice or hospital. The outcome measure was a questionnaire survey of students perceptions' of their learning on the two halves of the block. Each student completed the same questionnaire twice: once after their hospital experience and once after their general practice experience. Statistical Analysis was carried out using the SPSS package for Windows 3.1. Group means were calculated for each response, and the mean differences for each student's responses for the two learning environments were analysed using t-tests for paired samples. SETTING: Royal Free and University College Medical School at University College London. SUBJECTS: The study population was the entire annual intake (n = 225) of students into the first clinical year at one UK medical school. RESULTS: Students perceived they learnt more about history taking and physical examination in the community, whereas they learnt more about writing up their clerkings, keeping progress notes and disease management in hospital. CONCLUSIONS: The community and hospital environments appear to have different strengths for the teaching of medical students. These data support judicious transfer of clinical skills teaching from teaching hospitals into general practice, when the circumstances achieved here can be duplicated. However, some aspects of the clinical attachment, particularly record keeping and disease management, are probably better taught in hospital at present.     

Formative assessment of the consultation performance of medical students in the setting of general practice using a modified version of the leicester assessment package

OBJECTIVE: To evaluate the use of a modified version of the Leicester Assessment Package (LAP) in the formative assessment of the consultation performance of medical students with particular reference to validity, inter-assessor reliability, acceptability, feasibility and educational impact. DESIGN: 180 third and fourth year Leicester medical students were directly observed consulting with six general practice patients and independently assessed by a pair of assessors. A total of 70 practice and 16 departmental assessors took part. Performance scores were subjected to generalizability analysis and students' views of the assessment were gathered by questionnaire. RESULTS: Four of the five categories of consultation performance (Interviewing and history taking, Patient management, Problem solving and Behaviour and relationship with patients) were assessed in over 99% of consultations and Physical examination was assessed in 94%. Seventy-six percent of assessors reported that the case mix was 'satisfactory' and 20% that it was 'borderline'; 85% of students believed it to have been satisfactory. Generalizability analysis indicates that two independent assessors assessing the performance of students across six consultations would achieve a reliability of 0.94 in making pass or fail decisions. Ninety-eight percent of students perceived that their particular strengths and weaknesses were correctly identified, 99% that they were given specific advice on how to improve their performance and 98% believed that the feedback they had received would have long-term benefit. CONCLUSIONS: The modified version of the LAP is valid, reliable and feasible in formative assessment of the consultation performance of medical students. Furthermore, almost all students found the process fair and believed it was likely to lead to improvements in their consultation performance. This approach may also be applicable to regulatory assessment as it accurately identifies students at the pass/fail margin.     

Teaching the consultant teachers: identifying the core content

OBJECTIVES: To determine the key themes for teaching hospital consultants how to teach. DESIGN: 1. In-depth interviews with a total of 19 experts, consultants and junior doctors to identify key topics. 2. Literature review from 1969 to obtain the main themes from the medical educational literature. 3. Analysis of the main themes in 11 'Teaching the teachers' courses. 4. Triangulation of interview data, literature themes and teaching courses content to generate 15 criteria for a questionnaire. 5. Questionnaire study to 593 senior and junior hospital doctors. SETTING: Hospitals in the West Midlands Region in England. SUBJECTS: Consultants and junior hospital doctors. RESULTS: Overall, 441 doctors replied (74% response rate). The top five themes were giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee's learning needs. Results showed no statistically significant differences in the order of themes for all groups analysed, including seniority, gender, specialty, origin by medical school and consultants of different ages. CONCLUSIONS: Consultants need teaching in these topics. There are implications for funding and providing these courses for postgraduate deans, Royal Colleges and universities. Further research is needed to evaluate whether such an initiative does produce better teaching and learning, and a better educational climate in hospitals.     

Does formal approval of educational courses guarantee quality?

OBJECTIVES: To assess whether organizers of continuing medical education for general practitioners used principles of adult learning when designing their meetings. DESIGN: A questionnaire study of organizers of approved educational meetings for general medical practitioners (GPs). SETTING: South East Scotland. SUBJECTS: Organizers of educational meetings. RESULTS: Organizers often failed to use principles of adult learning in the construction of their meetings. Organizers with prior training in medical education were, however, significantly more likely to adopt these principles. CONCLUSIONS: Given concern about the quality of educational meetings as assessed by their educational impact, formal approval is not an indicator of quality. Postgraduate bodies should use explicit criteria both in the development and approval of continuing educational meetings.     

Portfolio learning in general practice vocational training – does it work?

Reflective learning has been widely addressed as an important learning mechanism in the educational literature. The creation of portfolios has been seen as a mechanism to promote this, though there has been little exploration of the place of a portfolio in general practice training. This study examined the introduction of a model of a portfolio learning strategy into one training region. The model had been developed by previous pilot work. The study explored the model in terms of its usefulness in general practice training and its relationship to reflective learning. An educational facilitator was used to support this introduction. Workshops and written material were developed to disseminate and refine ideas generated in the pilot study. This was followed by visits to trainer/general practice registrar (GPR) pairs over a 2-year period. These visits included semistructured interviews, which were tape-recorded and analysed using qualitative methods. Additional written resources, video and audio material as well as new workshops were designed with the researched participants in order to promote the development of the concepts of portfolio learning. Sixty interviews were carried out over a 2-year period with 44 pairs of trainers and GPRs. This included a total of 27 trainers and 44 registrars. Eighteen pairs were interviewed twice. Two focus groups were used at the end of the project. Portfolios have a place to play in general practice vocational training. They act as a bridge between hospital and general practice. They can be used to develop a learner-centred curriculum, explore difficult emotive concerns and facilitate feedback. They do not suit all learning styles. Their use is determined by a cost–benefit analysis described in this study.     

The Hampshire Depression Project: development and piloting of clinical practice guidelines and education about depression in primary health care

This paper describes the development and piloting of a comprehensive educational programme about recognition and management of depressive illness in primary care. Full evaluation of the effectiveness of the programme is currently underway in a randomized controlled trial, the Hampshire Depression Project (HDP), involving 56 general practices. The programme consists of clinical practice guidelines, practice-based seminars and follow-up sessions. Each part of the programme has been designed to be flexible, clinically oriented and relevant to all members of the multidisciplinary primary care team. The pilot study established the need for a systematic approach to the access of practices and practice teams, and the organization and process of the seminars. Application of this approach was associated with excellent attendance in the main programme.     

Portfolios in continuing medical education – effective and efficient?

INTRODUCTION: A cross over comparison between 'traditional' continuing medical education (CME) activities and portfolio-based learning in general practice is described. METHOD: Thirty-two volunteer general practitioners (GPs) were divided into two cohorts; each cohort spent six months following a 'traditional' route to postgraduate educational accreditation (PGEA) and six months following a portfolio-based learning route supported by three CME tutors. OUTCOME MEASURES: These were the submission of a completed portfolio with evidence of the completion of learning cycles and participants reflections on the educational process. Qualitative and quantitative evaluation data were collected by questionnaire, semi-structured interview, participant observation and review of completed portfolios. RESULTS: The themes identified by GPs as hopes for the portfolios were largely fulfilled and the anxieties generally confounded. The flexibility of the portfolio learning process was particularly important to the participants. The breadth of topics covered by the portfolios was extremely wide and comparison with the submissions for 'traditional' PGEA showed a much smaller spread of learning activities and fewer subjects of study. EFFECTIVENESS: The use of the portfolios of critical incidents and the completion of learning cycles with application to practice provided evidence of the effectiveness of such learning. EFFICIENCY: The mean number of hours spent by GPs preparing the portfolios was 24.5 +/- 12 (SD) which was significantly more than the 15 hours of PGEA awarded. CONCLUSIONS: This study demonstrates that a portfolio-based learning scheme can meet the needs of GPs relevant to their professional practice; it can give learners control over how, what and when they learn and encourage active and peer-supported learning; it can build personal and professional confidence and be thought both valid and reliable by participants. Learning outcomes can also be reliably assessed by PGEA within the context of an individually created learning plan.     

Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical Course

BACKGROUND: Medical students receive increasing amounts of their clinical education in a primary care setting. The educational possibilities of such attachments are still being explored. AIM: To report the evaluation of a small, radical innovation to provide students with a long-term community attachment which integrated with hospital-based education. METHOD: Between 1993 and 1998, 13 medical students completed 15-month attachments with a single general practice in England. The course offered them experience in the major clinical specialties throughout this period. Students were exposed to specialist as well as generalist education in the context of patients with whom they could establish a continuing relationship. The innovation was evaluated by its feasibility, by students' examination results, by analysis of clinical experience, through formal student feedback and by cost. RESULTS: The course was practicable in a particular setting with academic leadership. The students all passed their exams. They had wide, appropriate clinical experience even though the attachment was to a single practice. When they returned to the hospital environment, students did not feel themselves at a disadvantage compared with traditional students. The costs of the course are controversial: placement costs were higher than in the hospital, but those for facilities were lower. CONCLUSION: It is possible to run a course like this successfully. It remains the most radical attempt to share clinical education in the UK between primary and secondary/tertiary care. Further research is required into providing long-term clinical attachments in NHS primary care settings.     

Dissection as a modulator of emotional attitudes and reactions of future health professionals

Context  There is ongoing discussion within the medical education community about dissection as an educational strategy and as a professional training tool in technical and emotional skills training.
Objectives  This study aimed to discover the emotional reactions, attitudes and beliefs of new students faced with human cadaver dissection; to evaluate the changes produced in these variables by the exhibition and practice of dissection; to analyse the level of anxiety students feel when faced with death, and to elucidate the possible relationships between these items.
Methods  The study used a sample of 425 students who were first-time enrolees in a human anatomy course. Three new instruments were designed, with items covering emotional reactions (cognitive, physiological and motor reactions), beliefs and attitudes related to what the student expects to experience or has experienced in dissection. Death anxiety was measured using the Death Anxiety Inventory.
Results  As students gained more experience of dissection, their emotional reactions were reduced and their attitudes and beliefs changed. Statistically significant differences in the level of death anxiety emerged, depending on the perceptions students had of their degree of preparation for dissection, and emotional control and deeper thoughts about life and death during dissection.
Discussion  The practice of anatomy allows the student to learn how to face up to and adapt his or her emotional reactions and attitudes; this gives human cadaver dissection great importance as an educational strategy and as a professional training tool in technical and emotional skills training.     

Skills and attributes of directors of educational programmes

OBJECTIVES: The purpose of this study was to obtain a list of desirable skills and attributes of prospective educational programme directors as judged by potential employers of future directors. DESIGN: An international mail survey was conducted worldwide, using a one-page, open-ended questionnaire. SETTING: University of Illinois at Chicago, USA. SUBJECTS: Deans, department heads and chief executive officers from the various health professions. RESULTS: A total of 139 respondents completed the questionnaire (22. 3% response rate). Responses were remarkably similar across health professions. The nine leading skills were: oral communication skills, interpersonal skills, competent practitioner, educational goal-definition skills, educational design skills, problem-solving and decision-making skills, team worker and building skills, written communication skills and fiscal manager and budgeting skills. The three leading personal attributes were: visionary, flexible and open-minded and trustworthy and value-driven individual. CONCLUSIONS: The complete list of skills and attributes can be used by employers or administrators to build checklist items when hiring or reviewing programme directors or to plan and evaluate training programmes. The importance of leadership compared to managerial responsibilities is discussed as well as the need to train future educational programme directors.     

Why? What? and How? IT provision for medical students in general practice

OBJECTIVES: The aim of this paper is to discuss the increasing use of computers in undergraduate medical education and explore the why, what and how of providing IT facilities to undergraduate medical students when they are on placement in general practice. Adequate computing facilities are usually available within hospitals and medical schools, however, major changes are taking place in undergraduate education resulting in more teaching being undertaken in the community. Students will therefore need access to comparable facilities whilst in primary care settings in order for their training not to be compromised. SETTING: This paper describes one initiative addressing this need: the University Linked Practices (ULP) project in the Department of General Practice and Primary Care at St. Bartholomew's and the Royal London School of Medicine and Dentistry. DESIGN: We discuss the ways in which computers are currently being used in medical education and discuss some of the merits and drawbacks that are associated with this increasing drive to computerization.     

Educational assessment of general practice experience for psychiatric trainees

Eighteen psychiatric trainees spent 6 months each as general practice trainees. The educational impact of the experience was assessed by a self-assessment questionnaire, a semi-structured interview and a videotaped interview with a psychiatric patient. Each assessment was conducted at baseline and after 12 months. A control group of 14 trainees was recruited from the same rotation. On the self-assessment questionnaire, the study registrars rated their abilities to solve general medical problems significantly improved compared to controls. They had also acquired greater understanding of the limitations of their knowledge and their legal responsibilities towards their patients. The semi-structured interview failed to distinguish between the two groups. Videotapes for rating at baseline and follow-up were available for only 17 of the trainees. Assessment of the tapes used the Maguire Scale and the Interview Behaviour Scale. Neither scale demonstrated any intervention effect. The interviews were all characterized by a preponderance of 'closed psychological' and 'checking-out' questions. It appears that psychiatric trainees' interviewing styles had not been influenced by the experience. This study suggests that psychiatric trainees gain greater confidence in their role as a doctor and greater understanding of the scope and nature of general practice by such an attachment. It is unclear whether or not supplementary interviewing skills had been acquired which were not utilized in the taped interview, which conforms very much to traditional psychiatric examination behaviour. Trainees were reassured that they had increased their knowledge without losing any of their specific professional skills.     

CeMENT: evaluation of a regional development programme integrating hospital and general practice clinical teaching for medical undergraduates. The Community-Based Medical Education in North Thames

OBJECTIVES: To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates. DESIGN: A multifaceted approach employing quantitative and qualitative techniques. SETTING: All medical schools in North Thames Region. SUBJECTS: Students, GP tutors and hospital specialists. RESULTS: The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess. CONCLUSIONS: This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project's key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure.     

Education and training in the senior house officer grade: results from a cohort study of United Kingdom medical graduates

INTRODUCTION: This paper shows the findings from a survey of 439 senior house officers undertaken as part of the British Medical Association cohort study of 1995 medical graduates. The aim of the study was to assess the quality of senior house officer training in the United Kingdom. METHOD: In July 1997 a postal questionnaire was sent to a sample of 545 doctors who graduated from medical school in 1995. Responses were received from 515 (95%). Only those doctors who had worked as a senior house officer in the previous 12 months were included in the analysis (n = 439). RESULTS: Encouraging results are that 69% of the senior house officers surveyed had discussed their progress directly with their consultant, and 24% rated their supervision by their consultant as 'excellent'. Of concern are the findings that 47% of respondents did not receive protected teaching time and 16% were unable to take study leave. DISCUSSION: The study revealed wide variability in the quality of training received by senior house officers in the United Kingdom. Whilst some respondents - notably those in general practice, accident and emergency, paediatrics and psychiatry - had enjoyed a high standard of education and training, it was clear that a minority of posts continue to offer little if any educational value to the post holder. The results point to a need for a more systematic approach to maintaining standards in senior house officer training with greater incentives for under-performing trusts.