Students' perceptions of the relative advantages and disadvantages of community-based and hospital-based teaching: a qualitative study

AIMS: To obtain the perceptions of first-year clinical medical students of the relative advantages and disadvantages of community-based and hospital-based clinical teaching. METHODS: A qualitative study. A purposive sample of first-year clinical medical students who had experienced both community-based and hospital-based teaching was invited to participate in individual semistructured interviews or focus groups. Interviews and focus groups were audiotaped and transcribed to facilitate content analysis of the data. A total of 24 students participated in individual interviews and a further 18 took part in focus groups. RESULTS: Respondents identified advantages and disadvantages specific to teaching in each setting. Chief advantages of hospital-based learning were perceived to include learning about specialties and the management of acute conditions, and gaining experience of procedures and investigations. Community-based learning was perceived as particularly appropriate for learning about psychosocial issues in medicine, for increasing students' awareness of patient autonomy and for improving communication skills. In addition, aspects of organization and of teaching methods employed by community tutors, although not site-specific, were viewed as conducive to a positive educational experience. Students perceived some areas, such as clinical skills acquisition, to be equally well learned in either setting. DISCUSSION: As community-based teaching forms a greater proportion of the undergraduate medical experience, medical educators must find ways of determining the specific advantages that community and hospital settings can contribute to undergraduate learning and of using these resources effectively to develop comprehensive and integrated curricula. Innovations in teaching methods may also be necessary to provide an effective educational experience and promote active learning.     

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.     

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.     

Variation in medical students'' approaches to diagnosis: a basis for initiating conceptual change among teachers and students

OBJECTIVES: This study examines Finnish medical students' approaches to diagnosis and investigates further how medical teachers can use information about variation in their students' approaches to diagnosis to foster teaching in medical school. DESIGN: The medical students responded to the Conceptions and Experiences of Diagnosis Inventory (CEDI). SETTING: Faculty of Medicine, University of Helsinki. SUBJECTS: Ninety medical students in their clinical years and eight clinical teachers from the same Faculty of Medicine. RESULTS: The 11 subscales of the CEDI formed two contrasting factors: the first reflecting variation in 'non-virtuously' labelled, and the second in 'virtuously' labelled, aspects of diagnosis. CONCLUSIONS: Cluster analyses revealed subgroup characteristics of students' diagnostic processes that are of potential benefit to both students and teachers. Teacher interviews indicated that, for students, the CEDI may act as a self-assessment tool to help develop their diagnostic and metacognitive skills. For teachers, the CEDI was seen to offer important information about their students' conceptions of diagnosis and diagnostic skills.     

Successful teaching in evidence-based medicine

OBJECTIVES: Several published articles have described the importance of exposing medical trainees to the 'new paradigm' of evidence-based medicine (EBM). Recognizing this, we sought to develop and objectively evaluate a mini-course in EBM for third-year medical students. DESIGN: We developed a mini-course consisting of four sessions in which students learn to derive sequentially focused questions, search MEDLINE, review articles critically and apply information from the literature to specific clinical questions. To evaluate the teaching intervention, we performed a controlled educational study. Students at the intervention site (n=34) attended the EBM mini-course, while students at the control site (n=26) received more 'traditional' didactic teaching on various clinical topics. Intervention and control students were surveyed immediately before and after the mini-course to assess changes in reading and literature searching skills, as well as a tendency to use the literature to answer clinical questions. SETTING: Boston University School of Medicine. SUBJECTS: Third-year medical students. RESULTS: The intervention was associated with significant changes in students' self-assessed skills and attitudes. MEDLINE and critical appraisal skills increased significantly in the intervention group relative to the control group (significance of between group differences: P=0.002 for MEDLINE and P=0.0002 for critical appraisal), as did students' tendency to use MEDLINE and original research articles to solve clinical problems (significance of between group differences: P=0.002 and P=0.0008, respectively). CONCLUSIONS: We conclude that this brief teaching intervention in EBM has had a positive impact on student skills and attitudes at our medical school. We believe that the key elements of this intervention are (1) active student involvement, (2), clinical relevance of exercises and (3) integrated teaching targeting each of the component skills of EBM.     

Audit in general practice: educating medical students

This paper describes the third stage in the evolution of methods of teaching on audit in general practice at the Department of General Practice, University of Glasgow. The authors asked the final year students to develop, carry out and submit a written report on an audit project devised by themselves, after briefing and with continued support. Every student asked was successful in producing a report and the standard was generally very high, although only two students completed the audit cycle in the 4 week period. More than half the students (51.7%) found the project valuable or very valuable. As many as 90.6% understood audit better or much better after doing the project and 83.4% thought that the project should continue to be part of the GP attachment. Seventy-eight per cent of the GP tutors thought that teaching audit to undergraduates in general practice was valuable or very valuable, 64.4% reported that the audit had been of benefit to their practice, and 89.9% thought that audit should continue to be part of the GP attachment. This method of teaching students about audit was the most successful of three methods tried. It has produced benefits both for students and for the general practices to which they were attached, ultimately producing benefits for patients.     

The need for teaching in medical audit: a survey in one medical school

Summary: Summary. A questionnaire survey was carried out among senior clinical teachers at Newcastle upon Tyne Medical School, UK about their current practice and attitudes toward the teaching of medical audit in the undergraduate curriculum. A response rate of 88% was achieved. Less than a fifth of respondents provided such teaching, but the majority were in favour of seeing the topic introduced. A variety of teaching methods were used, and feedback from students was generally favourable. A number of concerns were expressed, including the problem of curriculum overload, the timing of the teaching, and the need to ensure that the learning was experiential with a minimum of theoretical teaching. Those who were in favour of introducing such teaching, or who were unsure, were also concerned about pressures on curricular time, but some felt in addition that the topic was more appropriately a postgraduate one. A short attitude scale demonstrated a skew towards favourable attitudes among the whole group. The implications of the survey for teaching about audit and quality are discussed.     

What can students learn from studying medicine in literature?

OBJECTIVE: To identify what students can learn from studying medicine and literature as part of a final-year special study module in general practice. METHOD: The project reports and evaluation forms completed by all eight students who had chosen to study medicine and literature as part of their special study module in general practice at Nottingham University Medical School were analysed qualitatively. RESULTS: Students said that they gained a greater understanding of the patient's experience of illness, as a result of the texts they had read. They learned how illness can affect family or friends of the patient and about the psychological impact of physical illness. Most students thought their future care of patients would be influenced by what they had learned. Studying medicine in literature during a clinical attachment allowed students to draw comparisons between literature and their clinical experience. DISCUSSION: This study is based on a small number of students who chose to study medicine in literature. The results may not be generalizable to all medical students and not all students may be receptive to this method of learning. However, we recommend that students who are interested should be given the opportunity to study medicine in literature during their clinical years. This can enable them to reflect on their clinical experience and can provide a more profound understanding of the consequences of illness for the patient and their family.     

Undergraduate medical students’ exposure to clinical ethics: a challenge to the development of professional behaviours?

CONTEXT: The objective of this research was to explore medical students' experience of challenges to their ethical knowledge and understanding in clinical practice, and to investigate their need and preference for support when faced with such challenges. METHODS: We carried out a cross-sectional survey using web-based and paper questionnaires. Questions were designed using examples of ethical challenges identified in the previous literature. The study involved 3 UK university medical schools. All incorporate ethics teaching programmes in problem-based learning curricula. Participants were 732 (30% of total) senior undergraduate medical students learning within the clinical environment. RESULTS: Students regularly experienced situations in clinical teaching settings that challenged their ethical values. Despite self-reports of good levels of confidence in their knowledge of ethical principles, medical students reported low levels of confidence in their ability to address these challenges, and perceived a need for additional support from clinical teachers. CONCLUSIONS: Complex and ethically challenging situations occur commonly in medical education. Many students feel that they do not currently access sufficient support from staff to address these. Clinical teachers were identified as the most relevant providers of guidance. The nature of medicine and its delivery makes it highly likely that medical students will come into contact with ethically challenging situations. Appropriate educational provision therefore requires medical educators to be equipped with the knowledge and the skills to engage with students' ethical concerns.     

Patients as teachers: a qualitative study of patients'' views on their role in a community-based undergraduate project

OBJECTIVES: Patients have been used in clinical medical education for many years with, traditionally, a relatively passive role. Following the General Medical Council recommendations for curricular change and the development of more community-based teaching, 'ordinary patients' in the community are increasingly being partnered with undergraduate students for particular projects. Very little research has been undertaken on patients' perceptions of this role. DESIGN: Semi-structured interviews were carried out with 20 people to explore the views of patients taking part in a community-based undergraduate medical student project (the 'patient study') at Newcastle Medical School about their role as teachers of medical students, what they felt they had gained from participating, any problems or concerns and suggestions for change or improvement. SETTING: Newcastle Medical School, UK. SUBJECTS: Second-year medical students. RESULTS: Two major themes emerged. First, patients saw themselves in active roles as teachers: as experts in their medical condition; as exemplars of their condition; and as facilitators of the development of students' professional skills and attitudes. Secondly, patients felt they had benefited from participation, through talking about their problems; learning more about themselves; the satisfaction of helping; and from receiving gifts. In addition, a number of other issues were identified including interpersonal dynamics, gender and ethnic differences, inadequate briefing of participants and whether such community-based patient involvement might, in some situations, be felt to be exploitative. CONCLUSIONS: The study has shown that patients see themselves clearly as having specific contributions to make to medical students' education and training. This has implications for the further development of community-based teaching.     

Factors influencing the communication skills of first-year clinical medical students

The aim of this study was to examine the factors influencing medical students' communication skills. The sample comprised all first-year clinical students. Thirty-two received teaching in communication skills during the year; the remaining 56 did not. Students' career preferences, attitudes towards communication skills and confidence in their ability to communicate with patients were assessed by questionnaire at the beginning and end of the year. At the end of the year each student was videotaped interviewing a simulated patient. Students' communication skills were assessed on the basis of this interview by raters using a standardized rating scale, and by patient questionnaires. While there was some evidence that brief communication skills training improved skills, sex of student was a more significant predictor of level of skill. Students who perceived communication skills as less relevant to medicine and those who were more confident about their own communication skills were more likely to prefer a career in hospital medicine. Students' judgements of their ability to communicate effectively were poor. In the main there was no relationship between confidence and level of skill: where they were related, the association was negative. The benefits from communication skills training might be enhanced by involving hospital doctors in the teaching, and providing students with detailed video feedback on their skills at the outset.     

Early patient contact in primary care: a new challenge

BACKGROUND: The Medical School of Lund University, Sweden, has introduced an early patient contact course, including training in communication and examination skills. The course runs parallel with theoretical subjects during the students' first two-and-a-half years. General practitioner (GP) participation is gradually increasing, and in the last half-year of the course GPs in all health centres in the area are involved. Little is known about the GPs' interest, competence and time for this new task. AIM: To describe the GPs' attitudes towards teaching and the rewards and problems they experience. SUBJECTS: 30 GPs teaching third-year medical students. METHOD: Semistructured interview study. Data analysis by a method described by Malterud. RESULTS: The attitude towards teaching was mostly positive and the teachers were confident about teaching examination procedure. Among rewards of teaching, improved quality of clinical practice was the main theme, but imparting knowledge to others, contact with enthusiastic students, and gains in self-esteem were also mentioned. Problems with teaching were mostly due to external factors such as lack of time and space, but concern about a negative effect on patient care was also recognized. Educational objectives of the course were not completely accepted. GPs were not fully aware about what to expect from the students, with subsequent problems concerning how to assess students' performance and how to give effective feedback. CONCLUSIONS: The teaching of junior medical students is maintained by the GPs' enthusiasm for teaching. However, teacher training is required and the crucial issues of time and space have to be considered.     

Teaching patient wellness to first-year medical students: the impact on future ability to perform the history of present illness

OBJECTIVES: Curriculum innovations to improve clinical skills have been implemented at many American medical schools. A current curricular change at the University of Connecticut School of Medicine involves teaching wellness to students in the first year rather than the more traditional focus on disease processes. It is unknown, however, if focusing on wellness detracts from students' future ability to perform the history of present illness (HPI) which requires students to focus on disease processes. DESIGN: The current study examined this issue by comparing two cohorts' clinical skills (n=156), with one class participating in a traditional curriculum during their first year and the other in a revised curriculum teaching wellness during the first year. Each class was evaluated at the beginning of their second year to determine their level of clinical competence. SETTING: University of Connecticut School of Medicine SUBJECTS: Second-year medical students. RESULTS: Analyses suggested that teaching wellness did not detract from future ability to perform an HPI, and in fact students taught wellness had significantly higher history-taking scores. CONCLUSIONS: Curricular innovations which stress wellness and prevention early in medical education do not detract from and may enhance students' ability to perform the history of present illness later during medical training.     

Community family medicine teachers' perceptions of their teaching role

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

Benefiting from clinical experience: the influence of learning style and clinical experience on performance in an undergraduate objective structured clinical examination

OBJECTIVE: To assess the relationship between clinical experience, learning style and performance in an objective structured clinical examination (OSCE) in medical students at the end of their first clinical year. DESIGN: Prospective study of undergraduate students taking an OSCE examination at the end of their first clinical year. SUBJECTS: 194 undergraduate medical students (95 male). MAIN OUTCOME MEASURES: Performance in the OSCE examination, the Entwhistle Learning Style Inventory1 and a composite self-reported score of clinical activity during the students first clinical year. RESULTS: Performance in the OSCE examination was related to well-organized study methods but not to clinical experience. A significant relationship between clinical experience and organized deep-learning styles suggests that knowledge gained from clinical experience is related to learning style. CONCLUSIONS: The relationship between clinical experience and student performance is complex. Well-organized and strategic learning styles appear to influence the benefits of increased clinical exposure. Further work is required to elucidate the most beneficial aspects of clinical teaching.     

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.     

Social issues in medicine: a follow-up comparison of senior-year medical students'' attitudes with contemporaries in non-medical faculties

A comparison of first-year medical students' attitudes to social issues in medicine with attitudes of non-medical first-year students in 1983 found that the medical group was less conservative towards general social issues but more conservative in relation to those areas which closely affect the doctor's role, particularly the place of allied health professions and government intervention in health care. This paper reports a follow-up study of the same groups of students when they had reached senior years in their respective courses. While medical student conservatism on general social issues continues to be no greater than other student groups there is a marked increase in conservatism of attitudes towards government involvement in health care and regulation of costs. Attitudes to allied health professions and preventive care remain unchanged but senior medical students are significantly less likely to recognize social factors as determinants of illness than they were when they commenced the study of medicine. Specific curricular attention to social and behavioural medicine does not appear to counteract the predominantly biomedical perspective students experience in teaching hospitals, the major venue for their clinical education.     

Students' perception of good and bad teaching: report of a critical incident study

Evaluation of teaching by the use of questionnaires to students is now commonplace. If it is to be useful the data obtained must be reliable and valid. One criterion of reliability is the response rate, and a low response rate may indicate low validity, i.e. that the questions asked do not reflect the students' real concerns. In order to inform questionnaire design a critical incident study was undertaken. A 20% random sample of students in each of the 5 years of the course were asked to describe one piece of good teaching and one piece of bad teaching, and say why they were good or bad. There was a 65% response rate, and replies were independently categorized by three people. The factors identified fell into three 'domains': interpersonal behaviour of teachers; planning and preparation; and the ability to run the session well. There was no evidence that teaching which 'played to the gallery' or was very examination-oriented would earn high ratings from students.     

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

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

Contraception: a new practical learning package

BACKGROUND: A new self-directed learning package was developed to assist medical students learn the counselling and practical skills to enable them to communicate with men and women about contraception and related matters. OBJECTIVES: This paper describes the package and the way it was facilitated, the students' ratings of the package and their feedback about the session on the first time it was presented at four teaching hospitals. RESULTS: The students rated the contraception package as average. The reasons given were: no introduction to the contraception session, lack of a trained person to conduct and facilitate the contraception learning session, poor organization at one of the hospitals and too little emphasis on self-assessment. The assumption that the students had a basic hormonal knowledge prior to the contraception sessions was incorrect. DISCUSSION: The results suggest the contraception learning package needs a person with contraceptive knowledge, patient-doctor skills and experience with self-directed learning to be present throughout the 3-hour session and for tools to be available that emphasize self-assessment during the session. OUTCOME: The modifications to be made to the learning package include pairing male and female students, a reduction in duration of the learning stations, an additional learning station relating to hormonal contraception, and inclusion of pregnancy and ovulation testing. These modifications were suggested by the participating students.