Health education poster: a teaching model for clinical medical students

Summary. The teaching of health education or health promotion to medical students is often difficult because they have little experience on which to base their learning. They have limited clinical knowledge and in particular their awareness of the value of and the opportunities for health promotion in general practice is limited. The problem-oriented teaching method described here attempts to make the subject interesting and relevant by asking students, while in their practice attachments, to identify areas of need for health promotion or health education and then to prepare a poster, with supportive background and research, to satisfy that need for display in their given practice.     

Primary care education for the new NHS: a discussion paper

CONTEXT: The White Paper, The New NHS: Modern, Dependable, once again heralds change and new expectations of primary care in the UK. OBJECTIVES: This discussion paper aims to encourage reflection on the implications for primary care teams of current governmental strategy, and to address the pivotal role which education can play in equipping practitioners for their roles. KEY AREAS: The paper examines the opportunities and threats for primary care in the new NHS developments, the strengths and weaknesses of the role that education currently plays in primary care, and how recent innovations might be used to give a more holistic approach to the needs of practitioners. The challenges for clinical governance of lay engagement and ethical decision making are seen as two crucial outcomes for an educational strategy which must be practice-led, and must interface individual practitioner education with the needs of the team and the community as a whole. I draw on a range of policy documents and educational literature to alert the reader to the different choices which can be made when thinking about appropriate educational models and methods; and offer a detailed structure for a practical educational strategy that may effectively unite theory and practice. The key elements are a three-tier link between practices, primary care groups, and district-level resources for all educational and training activity, and the aim of continuing multiprofessional development which will underpin the new NHS.     

Information Management and Technology (IM&T): training provision in postgraduate medical education

Information Management and Technology (IM&T) is assuming a greater role within the modern NHS and there is an increasing need for members of the medical, and other health care, professions to receive appropriate training and education in these areas. Over half the Postgraduate Deans, Regional Advisers in General Practice and the Medical Royal Colleges have made a conscious decision to supply training in IM&T-related areas. These courses are open to a wide range of health care professionals. However, the number of reported places is not adequate for the large number of people who require the training. Less than half the organizations employed staff with a remit to provide training but over half provided courses in collaboration with educational establishments. As the medical undergraduate curriculum changes and incorporates training in computer skills, the links between the postgraduate institutions and medical schools must be fostered and developed. This will lead to increasing opportunities for health professionals both in the range of subjects and the number of places available.     

Academic careers in general practice: scientific requirements in Europe

This paper, based on a survey of all 25 council members of the European Academy of Teachers in General Practice (EURACT), describes requirements for scientific qualification in general practice. The career tracks for becoming a professor are different throughout Europe and the criteria to enter a research programme or to start a doctorate are diverse. Three models of academic careers have emerged: (1) career development following no formalised path (e.g. in Israel); (2) a ‘liberal’ model requiring a thesis (e.g. in Denmark, the Netherlands and the UK); (3) a formal procedure (habilitation) which requires completed vocational training, a number of high-quality research publications, some years of teaching experience, and a successful thesis (e.g. in Croatia, Germany, Hungary). In most European countries, research doctorates with an MD or PhD degree usually precede an appointment as professor of general practice. Although strengthening the scientific base of general practice is necessary to improve the reputation of the discipline, a liberal model for entry into an academic career may offer the best opportunities to combine academic work with primary care for general practitioners (GPs) in European countries.     

What happens to medical students who complete an honours year in public health and epidemiology?

BACKGROUND: Around one-third of medical students in the UK take an intercalated honours degree in addition to their basic undergraduate course. The honours year has been reported to have a major influence on subsequent career choice; honours students show greater interest in research and laboratory medicine careers and less in general practice and public health.1,2 AIMS: To examine the career choice of Nottingham medical students who completed an honours year in public health and epidemiology (including general practice). METHODS: Postal questionnaire and telephone follow-up of a cohort of 266 students who entered the honours year in Public Health and Epidemiology between 1973 and 1993. RESULTS: Career information was available on 203 students; 78% (195) of those are currently employed in medicine. 44% were working in general practice (expected 40-45%) and 8% in public health medicine (expected 2%). Overall 19% (expected 4-11%) had chosen academic careers including nine of the 15 choosing an academic career in public health. The majority (60%) reported that the honours year had influenced their career choice, while 55% reported that the year had increased their likelihood of choosing an academic career. CONCLUSIONS: The honours year does encourage entry into academic and research careers in general and the type of honours year department strongly influences the subsequent choice of specialty.     

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.     

Video and qualitative research: analysing medical practice and interaction

CONTEXT: Video has long been recognised as providing an important resource within medical education, particularly, perhaps, for training in primary health care. As a resource for research, and more specifically within qualitative social science studies of medical practice, video has proved less pervasive, despite its obvious advantages. METHODS: In this paper, we sketch an approach to using video to inform the analysis of medical practice and the ways in which health care is accomplished through social interaction and collaboration. Drawing on our own research, we discuss two brief examples: the first involves the use of computing technology in primary health care and the second concerns informal instruction during surgery. The examples illustrate the multimodal character of medical work, how activities are accomplished through the interplay of talk, the visual and the use of material artefacts. They also illustrate the ways in which video provides access to the complex forms of social interaction and collaboration that underpin health care. DISCUSSION: We reflect upon the research opportunities afforded by video and the ways in which video-based studies of interaction can contribute to the practice and practicalities of medicine.     

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.     

Specialty choice and understanding of primary care among Japanese medical students

To assess specialty choice and understanding of primary care among Japanese medical students, all students from seven Japanese medical schools (three public and four private) were surveyed, using a written questionnaire. A total of 3377 students provided data for the study. Of the students surveyed, 89.8% wanted to become clinicians, and 79.3% wanted to have general clinical ability. About half of the respondents, 54.9%, replied that they had some, or great, interest in primary care, but it was found that their understanding of primary care was inadequate. Almost half (56.3%) of the students answered that they had some idea of what a general practitioner did. This proportion was nearly the same through all years of medical school. While 1245 (36.9%) students (most of them in the fifth or sixth year) replied that they had received some clinical training while working in hospitals, only 203 (6.0%) students had worked in private clinics (the sites where most primary care is still provided), and 129 (3.8%) students had experience in providing home visits and home care. An even greater number, 64.3%, replied that they had inadequate information about the career options available to them. The study found that although many Japanese medical students want to obtain broad clinical competence, their understanding of primary care is insufficient. In order to increase the number of primary care providers the system of medical education in Japan must provide primary care doctors to act as role models, and must make available information about postgraduate primary care programmes. These programmes need to be increased, as do rewarding positions for programme graduates.     

Academic training schemes reviewed: implications for the future development of our researchers and educators

CONTEXT: There is an international crisis in academic medicine: numbers of academics are low; there is a split between teaching and research, and career progression is poorly defined. In the UK, academic career pathways have recently been reformed, but there is little readily accessible information on what a high-quality academic training scheme might comprise. METHODS: I conducted a wide review of medical and bio-psychosocial databases, coupled with a search of the grey literature. RESULTS: The review suggests both widespread support for training in research and dissatisfaction with training schemes. Insufficient training time is a major issue. High-quality supervision is crucial, with clear goals and expectations for research fellows. Structured training seems to be helpful, as is financial, administrative and statistical support. However, the vast majority of studies give a broad overview or opinion, or report the superficial results of questionnaire surveys. The focus is on research training; teaching is ignored. CONCLUSIONS: Although there appears to be broad agreement on a number of issues, the literature lacks sufficient depth, and little is known about factors that contribute to effective academic training schemes. Schemes must be studied in depth to determine what makes them successful, in order to ensure the future of teaching and research.     

Learning to value ethnic diversity – what,why and how?

INTRODUCTION: Learning to value ethnic diversity is the appreciation of how variations in culture and background may affect health care. It involves acknowledging and responding to an individual's culture in its broadest sense. This requires learning the skills to negotiate effective communication, a heightened awareness of one's own attitudes, and sensitivity, to issues of stereotyping, prejudice and racism. This paper aims to contribute to debate about some of the key issues that learning to value ethnic diversity creates. CONTEXT: Although some medical training is beginning to prepare doctors to work in an ethnically diverse society, there is a long way to go. Promoting 'valuing ethnic diversity' in curricula raises challenges and the need to manage change, but there are increasing opportunities within the changing context of medical education. Appropriate training can inform attitudes and yield refinement of learners' core skills that are generic and transferable to most health encounters. CURRICULUM DEVELOPMENT: Care must be taken to avoid a narrow focus upon cultural differences alone. Learning should also promote examination of learners' own attitudes and their appreciation of structural influences upon health and health care, such as racism and socio-economic disadvantage. Appropriate training and support for teachers are required and learning must be explicitly linked to assessment and professional accreditation. CONCLUSION: Greater debate about theoretical approaches, and much further experience of developing, implementing and evaluating effective training in this area are needed. Medical educators may need to overcome discomfort in developing such approaches and learn from experience.     

Low- to high-fidelity simulation – a continuum of medical education?

Context  Changes in medical training and culture have reduced the acceptability of the traditional apprenticeship style training in medicine and influenced the growth of clinical skills training. Simulation is an educational technique that allows interactive, and at times immersive, activity by recreating all or part of a clinical experience without exposing patients to the associated risks. The number and range of commercially available technologies used in simulation for education of health care professionals is growing exponentially. These range from simple part-task training models to highly sophisticated computer driven models.
Aim  This paper will review the range of currently available simulators and the educational processes that underpin simulation training. The use of different levels of simulation in a continuum of training will be discussed. Although simulation is relatively new to medicine, simulators have been used extensively for training and assessment in many other domains, most notably the aviation industry. Some parallels and differences will be highlighted.     

The WISDOM project: training primary care professionals in informatics in a collaborative ''virtual classroom''

OBJECTIVES: The WISDOM project applies Internet technologies to create a virtual classroom in health informatics for primary care professionals. Participants use a facilitated E-mail discussion list supported by a web site which provides on-line resources and an archive of teaching materials. DESIGN: The project took an adult-learning model in which participants identify their learning needs, emphasized using informatics skills in practice, and focused on skills likely to enhance evidence-based practice. The paper describes the project and an evaluation of the first programme which ran in 1997 with 28 participants. Pre- and post-intervention questionnaires were used to assess perceived skills in informatics and evidence-based practice. SETTING: University of Sheffield. SUBJECTS: Primary care professionals. RESULTS: Participants reported statistically significant increases in eight informatics skills. There were no significant changes in evidence-based practice skills. The web-site, seminar programme and discussion list were highly rated as useful in delivering informatics training. CONCLUSIONS: The WISDOM approach is effective for the delivery of informatics training to primary care professionals, and may be used more widely for other subjects and professional groups. There is a need for further research into facilitating virtual classrooms.     

Learning in primary care--a report

A symposium on Learning in Primary Care was held in Cape Town, South Africa, as a pre-conference workshop to the 9th International Ottawa Conference on Medical Education. The aim of this report is to inform medical educationalists of important issues in learning in primary care and to stimulate further debate. Four international speakers gave presentations on their experiences in teaching and learning in primary care. Objective positive outcome measures include acquiring clinical skills equally well in general practice as in hospital, and improved history taking, physical examination and communication skills learning. Students regard the course as an essential requirement for learning and are appreciative of the wider aspect to learning provided by the community, giving a more holistic view of health. A SWOT analysis (strengths, weaknesses, opportunities and threats) of teaching and learning in primary care identified that learning in primary care is of a generalist nature and reality based, but is hampered by a lack of resources. The increased professionalization of teaching in primary care results in better training, cost containment, and improved quality of health care at community level. It is important to focus on turning threats into opportunities. Academic credibility needs to be established by conducting research on learning in primary care and developing the conceptual basis of primary care.     

The place of primary health care in medical education in the United Kingdom: a survey

Primary health care has been held to be the foundation of any rational health system. The principle was fully endorsed by the Alma-Ata Conference in 1978, and has become the main policy of the World Health Organization. Important implications are involved for the education and training of doctors and other health care professions.
An enquiry was conducted by personal interviews of those most responsible for the teaching of primary health care in the United Kingdom, to enquire about the status of primary health care in the curricula of U.K. medical schools, and about the standing of general practice. The enquiry also explored the degree of awareness among medical educators about the Alma-Ata Declaration. The leading representatives of primary health care in the medical schools made it clear that the teaching of primary health care varied greatly in the importance accorded to it and the resources made available for it by medical schools. Almost half the respondents were unaware of the support for greater emphasis on primary health care that had been specified in the Alma-Ata Declaration.     

Effective supervision in clinical practice settings: a literature review

CONTEXT: Clinical supervision has a vital role in postgraduate and, to some extent, undergraduate medical education. However it is probably the least investigated, discussed and developed aspect of clinical education. This large-scale, interdisciplinary review of literature addressing supervision is the first from a medical education perspective. PURPOSE: To review the literature on effective supervision in practice settings in order to identify what is known about effective supervision. CONTENT: The empirical basis of the literature is discussed and the literature reviewed to identify understandings and definitions of supervision and its purpose; theoretical models of supervision; availability, structure and content of supervision; effective supervision; skills and qualities of effective supervisors; and supervisor training and its effectiveness. CONCLUSIONS: The evidence only partially answers our original questions and suggests others. The supervision relationship is probably the single most important factor for the effectiveness of supervision, more important than the supervisory methods used. Feedback is essential and must be clear. It is important that the trainee has some control over and input into the supervisory process. Finding sufficient time for supervision can be a problem. Trainee behaviours and attitudes towards supervision require more investigation; some behaviours are detrimental both to patient care and learning. Current supervisory practice in medicine has very little empirical or theoretical basis. This review demonstrates the need for more structured and methodologically sound programmes of research into supervision in practice settings so that detailed models of effective supervision can be developed and thereby inform practice.     

The parallel rural community curriculum: an integrated clinical curriculum based in rural general practice

INTRODUCTION: In an attempt to address the rural medical workforce maldistribution and the concurrent inappropriate caseload at the urban tertiary teaching hospitals, Flinders University and the Riverland Division of General Practice decided to pilot, in 1997, an entire year of undergraduate clinical curriculum in Australian rural general practice. This program is called the Parallel Rural Community Curriculum (PRCC). This paper is a discussion of the aims of the programme; student selection; practice recruitment; curriculum structure, and academic content, together with lessons learnt from the evaluation of the first cohort of students' experience of the course. METHODS: Independent external evaluators undertook a thematic analysis of a series of structured interviews of students and faculty involved in both the PRCC and the traditional curriculum. The mean examination results were determined and a rank order comparison of student academic performance was undertaken. RESULTS: The eight selected volunteer students reported greater access to patients and clinical learning opportunities than their mainstream counterparts and learned clinical decision making in the context of the whole patient, their family, and the available community resources. They identified patients with 'core' clinical conditions and had a longitudinal exposure to common diseases, whereas hospital-based peers had a cross-sectional exposure to highly filtered illness. The PRCC students' academic performance improved in comparison with that of their tertiary hospital peers' and in comparison to their own results in previous years. CONCLUSION: The PRCC curriculum has cut across the traditional clinical discipline boundaries by teaching in an integrated way in rural general practice. It has affirmed the potential role of true generalist physicians in undergraduate medical education.     

Complexity, risk and simulation in learning procedural skills

BACKGROUND: A complex chain of events underpins every clinical intervention, especially those involving invasive procedures. Safety requires high levels of awareness and vigilance. In this paper we propose a structured approach to procedural training, mapping each learner's evolving experience within a matrix of clinical risk and procedural complexity. We use a traffic light analogy to conceptualize a dynamic awareness of prevailing risk and the implications of moving between zones. THE IMPORTANCE OF CONTEXT: We argue that clinical exposure can be consolidated by simulation where appropriate, ensuring that each learner gains the skills for safe care within the increasingly limited time available for training. To be effective, however, such simulation must be realistic, patient-focused, structured and grounded in an authentic clinical context. Challenge comes not only from technical difficulty but also from the need for interpersonal skills and professionalism within clinical encounters. PATIENT FOCUSED SIMULATION: Many existing simulations focus on crises, so clinicians are in a heightened state of expectation that may not reflect their usual practice. We argue that simulation should also reflect commonly occurring non-crisis situations, allowing clinicians to develop an awareness of the complex events that underpin clinical encounters. We describe a patient-focused approach to simulation, using simulated patients and inanimate models within realistic scenarios, to ground experience in authentic clinical practice and bring together the complex elements that underpin clinical events. APPLICATIONS: Although our argument has evolved from surgical practice and operating theatre teams, we believe it can be widely applied to the increasing number of health care professionals who perform clinical interventions.