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.     

Trends in the number and administrative characteristics of medical school health promotion programmes

Over the course of almost 10 years, 1988-97, there has been a significant decline in the number of United States and Canadian medical schools offering health promotion programmes for students. All efforts should be made to enhance the overall health and well-being of medical students and to increase the number of health promotion programmes for them.     

Retention of interviewing skills learned by first-year medical students: a longitudinal study

A pilot interviewing course was offered as an elective to first-year medical students in the spring of 1985. A quasi-experimental pre-test/post-test control group demonstrated that students who took the course exhibited a significant increase in interviewing skills. Subjects, 15 in the experimental group and 11 in the control group, were assessed in each of the following 3 years. Data consisted of five 10-minute videotaped interviews with real or stimulated patients for each subject and subject's responses on a degree of confidence, familiarity and anxiety scale. Interviews were rated on 43 behaviours by two independent coders with a 90% simple agreement. The experimental group did not maintain their scores on interviewing skills and both groups showed a significant decline in nine skills comprising empathy. The only significant difference between the groups in fourth year was on the degree of confidence experienced. While interviewing skills can be learned they decline in the clinical years as students learn medical problem-solving. If medical students are to graduate with their original empathy intact, a follow-up course in fourth year is indicated.     

An international survey of medical school programmes on nuclear war

Many medical organizations have acknowledged the responsibility of doctors to educate health professionals and the public about the medical, social and ecological consequences of nuclear war. Medical schools have begun the development of programmes on these topics. A total of 1130 medical schools in thirty-one countries were surveyed about their presentation of nuclear-war-related subject matter. Eighty-three (49%) of the 168 schools that responded indicated that they offered an activity on medical aspects of nuclear war. Thirty-two per cent of the programmes consisted of one or more hours in an existing required course. Twelve per cent offered an elective course solely concerned with nuclear war. Although only 15% of the schools responded many of the replies indicated interest in learning more about the programmes of other schools and inquired if curriculum or teaching materials were available. Through the survey it was learned that textbooks and other learning resources have been prepared. Survey information suggests that knowledge of nuclear weapons effects is associated with a reluctance to countenance nuclear war.     

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.     

Introducing medical students to medical informatics

Summary. Medical informatics ( MI ) has been introduced to medical students in several countries. Before outlining a course plan it was necessary to conduct a survey on students' computer literacy. A questionnaire was designed for students, focusing on knowledge and previous computer experience. The questions reproduced a similar questionnaire submitted to medical students from North Carolina University in Chapel Hill ( NCU ). From the results it is clear that although almost 80% of students used computers, less than 30% used general purpose applications, and utilization of computer-aided search of databases or use in the laboratory was exceptional. Men reported more computer experience than women in each area investigated by our questionnaire but this did not appear to be related to academic performance, age or course. Our main objectives when planning an MI course were to give students a general overview of the medical applications of computers and instruct them in the use of computers in future medical practice. As our medical school uses both Apple Macintosh and IBM compatibles, we decided to provide students with basic knowledge of both. The programme was structured with a mix of theoretico-practical lectures and personalized practical sessions in the computer laboratory. As well as providing a basic overview of medical informatics, the course and computer laboratory were intended to encourage other areas of medicine to incorporate the computer into their teaching programmes.     

The lessons of deafness: deafness awareness and communication skills training with medical students

This paper describes a 1-day course on deafness awareness and communication skills with fourth-year medical undergraduates and summarizes their evaluation of the course. Deaf people commonly experience major communication difficulties with doctors. This course gives students an awareness of deafness (and of the insights deaf people can give to an understanding of communication)--the lessons of deafness--and challenges some critical assumptions in medical practice. Students are given personal experience of deafness and of the consequent powerlessness and loss of self-confidence, while also learning new communication skills which they then apply in a role-play consultation with a deaf patient. Systematic evaluation has been built into the programme and student opinion has been unanimously enthusiastic.     

Mental health in the community

Medical education needs to reflect the rapid development of community-based health care, particularly in the area of mental health. 'Mental health in the community' is a week-long collaborative course organized through the Department of General Practice at Liverpool University for first-year clinical medical students. It aims to introduce them to the range of mental health problems that exists in the community and the resources available to deal with them; to improve their counselling skills and to reduce their anxiety about mental health, both their own and other people's. The paper describes the wide variety of teaching methods and visits which are offered during the week. The course is evaluated using the method developed by Stake. Although there are some problems with student participation, 'Mental health in the community' has a significant positive overall effect on students' knowledge and anxiety levels with regard to mental health. It is making a contribution to the reorientation of medical education in Liverpool.     

Psychiatric training for family doctors: what do GP registrars want and can a brief course provide this?

CONTEXT: About 40% of British General Practitioners (GPs) train formally in a psychiatric post as part of their general practice training, but such training may not fully meet the needs of future GPs. A specific course in psychiatry for family doctors has run in Manchester for more than a decade. METHOD: Semi-structured interviews conducted with GP registrars before attending the Manchester course in psychiatry with questionnaire follow-up afterwards to ascertain (a) the training 'wants' of GP registrars and (b) whether the course was providing them. RESULTS: GP registrars most frequently wanted training in communication skills, how to access the resources that are available to GPs, the detection of psychiatric illness, drug treatment and the management of aggression. The course was successful in satisfying the first three but failed in the last two. There was trend for those who attended Manchester Medical School, which scored significantly higher on number of topics covered at undergraduate level, to perceive a greater need for training than those who attended other medical schools. However, there was no evidence to link self-perception of greater need with having already worked in general practice during postgraduate training. CONCLUSIONS: More attention needs to be paid to how to address the specific mental health skills training requirements of GP registrars both within the attachment in psychiatry and during the practice year. Preliminary research is required to devise teaching packages before they are entirely satisfactory for GP education.     

Early introduction of clinical skills teaching in a medical curriculum--factors affecting students' learning

OBJECTIVE: To evaluate the effects of the early introduction of clinical skills teaching on students' learning following an overhaul of the curriculum of a traditional Asian medical school. METHODS: Randomly selected medical students in Year I and II were invited to participate in 30 focus group interviews while all students were asked to assist with the questionnaire survey. Most students were contacted personally to help them understand the objectives of the study. Confidentiality was emphasised and a non-faculty interviewer was recruited for the interviews. RESULTS: Two hundred and eight of Year I/Year II students attended the lunchtime focus group interviews (response rate=86.7%) while 252 (73.5%) students returned the questionnaire. The majority of them (87%) agreed or strongly agreed that it was good to introduce clinical skills in the early years of the curriculum. They reflected that the course enhanced their learning interest and made them feel like doctors. They also made many constructive suggestions on how the course could be improved during the interactive focus group interviews so that the negative effects could be minimised. CONCLUSION: It is useful to introduce clinical skills in the early years of a medical curriculum. A comprehensive course evaluation, using both quantitative and qualitative methods, helps to collect useful information on how the course can be improved.     

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.     

An appraisal of medical students' reflection-in-learning

INTRODUCTION: How do students reflect as they strive for some control of learning early in their clinical activities? The purpose of this study was to examine the reflection-in-learning profile of medical students as they started their clinical apprenticeship. METHODS: A measure of reflection-in-learning was used to appraise the level and direction of change of reflection in relation to a course experience. The study involved 103 medical students of both sexes who were beginning clinical activities. Assessments of self-regulation of learning, of the meaningfulness of the learning experience, and of diagnostic thinking were also obtained. RESULTS: The results showed that 81% of the students had an increase in scores for reflection-in-learning between the beginning and the end of a course. At the end of the course, the level of reflection-in-learning was significantly associated with self-perceived competence for self-regulated learning and with the meaningfulness of the learning experience. In the following term, students who had high reflection-in-learning scores at the end of the course had higher grade-point averages and greater self-reported diagnostic ability in comparison with those with low scores. CONCLUSIONS: There was some evidence of an improved quality of reflection as the students strive for some control of learning. Overall, the findings support the idea that a greater effort at reflection is associated with a more positive learning experience. They also suggest that reflection-in-learning is related to readiness for self-regulation of learning and may be conducive to enhanced diagnostic ability. In conclusion, measuring reflection-in-learning may be a useful tool in the appraisal of medical students' learning profiles.     

Barriers to breaking bad news among medical and surgical residents

Communicating "bad news" to patients and their families can be difficult for physicians. OBJECTIVE: This qualitative study aimed to examine residents' perceptions of barriers to delivering bad news to patients and their family members. DESIGN: Two focus groups consisting of first- and second-year medical and surgical residents were conducted to explore residents' perceptions of the bad news delivery process. The grounded theory approach was used to identify common themes and concepts, which included: (1) guidelines to delivering bad news, (2) obstacles to delivering bad news and (3) residents' needs. SETTING: McMaster University, Hamilton, Ontario, Canada. SUBJECTS: First- and second-year residents. RESULTS: Residents were able to identify several guidelines important to communicating the bad news to patients and their family members. However, residents also discussed the barriers that prevented these guidelines from being implemented in day-to-day practice. Specifically, lack of emotional support from health professionals, available time as well as their own personal fears about the delivery process prevented them from being effective in their roles. Residents relayed the need for increased focus on communication skills and frequent feedback with specific emphasis on the delivery of bad news. The residents in our study also stressed the importance of processing their own feelings regarding the delivery process with staff. CONCLUSIONS: Although most residents realize important guidelines in the delivery of bad news, their own fears, a general lack of supervisory support and time constraints form barriers to their effective interaction with patients.     

Training Hungarian primary health care teachers: the relevance of a UK postgraduate course for health educators

OBJECTIVES: This study constituted a formative evaluation of the relevance of the MSc course to the needs of Hungarian primary health care educators. DESIGN: A qualitative, naturalistic approach using in-depth interviews was used to construct the meaning of the experience of the MSc for the Hungarian participants. Interviews were triangulated using observation and documentary analysis. SETTING: The University of Exeter's Institute of General Practice. SUBJECTS: Eight Hungarian primary health care professionals. RESULTS: The evaluation data revealed that the attitude of the Hungarian students to their role as medical educators had been substantially changed by exposure to western models of adult education. There were a number of 'clashes of expectation' between the Hungarian students and the course staff in relation to the course requirements. Reconciliation of these differing expectations required a sequence of ongoing adjustments to the course content and delivery. CONCLUSIONS: Existing postgraduate courses for health educators can accommodate the needs of medical teachers from countries who are developing their primary health care education systems. Successful accommodation is facilitated by ensuring an adequate preparation in relation to language fluency, academic requirements of the course, familiarization with modern approaches to adult education as well as with the local health care delivery system.     

Teaching of medical ethics: implications for an integrated curriculum

This paper reports on an investigation into the teaching of medical ethics and related areas in the medical undergraduate course at the University of Queensland. The project was designed in the context of a major curriculum change to replace the current 6 year course by an integrated, problem-based, 4 year graduate medical course, which began in 1997. A survey of clinical students, observations of clinical teaching sessions, and interviews with clinical teachers were conducted. Data obtained have contributed to curriculum development and will provide a baseline for comparison and evaluation of the graduate course in this field. A view of integrated ethics teaching is advanced in the light of the data obtained.     

Library use and academic achievement among medical students

Many factors play a part in determining the performance of students in examinations, but the extent to which students use library facilities does not appear to have been recently considered as a factor, in medicine or in any other academic subject. In this study, the number of books borrowed from the library by undergraduate medical students was used as a simple measure of library use, and significant differences in book-borrowing levels were found between students in different years of the medical course, students from different regions of the world, and men and women students. In the first year of the course, students who borrowed most also performed best in their end-of-year examinations, and this association was only partly explained by regional differences. No such association was found among final-year students, suggesting different study habits and different assessment criteria in the clinical years of the course.     

An assessment of academic performance and personality

This study examines whether personality profiles, using personality factors, or clusters of personality factors, are associated with academic success. One hundred and forty medical students of the University of Wales College of Medicine were invited to complete a personality questionnaire (Cattell 16 PF) as they sat their final examinations in June 1988. A total of 129 usable forms were obtained. The students were divided into four groups dependent on their academic performance, which had been monitored throughout the course. The majority (62%) had no academic problems, but 16 (12%) students had serious difficulties, which entailed delaying qualification by at least 6 months. There was no relationship between the scores obtained for the students' first attempt at A-level and their subsequent medical school academic performance. However, students who obtained a degree either before or during their medical course were significantly less likely to have academic problems. Academic success was not associated with any of Cattell's personality factors. This was true of previously reported groups of factors associated with the poor student performance, and regardless of first or second order factors. We conclude that this personality profile is unlikely to be helpful in selecting future intakes of medical students, although a prospective study would be required for a definite answer to this question.     

The use of focus group interviews in Asian medical education evaluative research

OBJECTIVE: To evaluate the use of focus group interviews in Asian medical education evaluative research. METHODS: Randomly selected medical students were invited to participate in 30 focus group interviews to provide in-depth data about the effect on their learning of the introduction of early clinical skills. Efforts were made to meet all the students to help them understand the objectives of the focus group. Confidentiality was emphasised and a non-faculty interviewer was recruited for the interviews. RESULTS: The students considered the use of focus groups to be a more meaningful way of collecting students' opinions than other methods, for example structured questionnaire, because it allowed an interactive discussion. They also felt that having an independent non-faculty interview moderator had encouraged them to express their opinions more candidly during the interviews. CONCLUSION: The use of focus group interviews among Asian medical students for evaluative research is practical and efficient.     

Microfiches as an aid to teaching histology

A set of six colour microfiches and an atlas of black-and-white prints of the photomicrographs used in the microfiches have been prepared by the author and have been used for teaching an Histology course to medical students for 4 years. Student reaction to them and their use has been gauged by voluntary questionnaires. Of students who responded, 78% found the microfiches made the course easier for them; 76% like the microfiches because they can use them for home study; 77% find them useful for class discussion; 62% like them because of their colour reproduction. A small group of fifteen students, who failed the Histology course the year prior to the introduction of microfiches and subsequently repeated the course, felt they could revise better with the help of the microfiches. Also they felt the course was clearer. Comparison of the examination results of the students for the 4 years preceding the introduction of microfiches with those of the 4 years since, shows an improvement in mean percentage achieved together with a decrease in the standard deviation (s.d.).