The contribution of general practice to medical education: expectations and fulfilment

The aim of this study was to discover what students expected to learn during their fourth-year general practice attachment, to compare this with their GP tutors' expectations and to determine the extent to which the students' expectations were fulfilled. Questionnaires were used to gather this information; students completed them on the first and last days of the 4-week attachment and tutors shortly after the attachment. Students and their tutors had the highest expectations of the course in helping to raise awareness of the psychological and social aspects of ill health and develop clinical decision-making and management skills. At the end of the course students thought that they had gained most in these areas. Both students and tutors had lower expectations of the course helping to develop physical examination and practical skills and to improve knowledge in certain clinical areas. These were also rated lowest in terms of fulfillment. This study was carried out at a time when it is being suggested that more undergraduate teaching should take place in general practice and that this could include the teaching of practical skills and clinical subjects traditionally associated with hospital-based teaching. The results suggest that the expectations of students and GP tutors would need to be modified, as well as extra resources provided, if there is to be a shift in teaching towards the community.     

Hopes and concerns of a first-year medical school class

Summary. To assess the hopes and concerns of first-year medical students, the 1991 Oregon Health Sciences University (OHSU) Medical School class was surveyed during orientation. Using qualitative research methods, student responses were grouped into general categories. The most common ‘hopes’ were to provide personal care and develop relationships with patients, to attain self-fulfilment, and to enjoy the personal challenge and variety of medicine. Common ‘concerns’ were family issues, outside intervention into medicine, and loss of self. The hopes and concerns of this class revolve primarily around personal issues, rather than issues relating to their local community or to society. This information may be useful in student counselling and curriculum development. Further research is necessary to evaluate changes in this class's attitudes over time. The methodology of this study may be useful in the evaluation of the attitudes of subsequent first-year medical school classes at OHSU, and at other institutions.     

Independent learning among general practice trainees: an initial survey

Self-directed learning is a natural way for adults to learn. Vocational training for general practice is a preparation for unsupervised clinical work that will be supported, in the main, by continuing medical education. This study uses the Self-Directed Learning Readiness Scale to investigate factors influencing readiness for such learning among a sample of general practice trainees. Three principal factors emerged from analysis: enjoyment and enthusiasm for learning; a positive self-concept as a learner and a factor suggesting the possibility of a 'reproducing' orientation to learning. These factors may reflect approaches to learning in general rather than these adopted for professional learning, but offer helpful pointers for the development of both vocational training and of continuing medical education.     

Multiple choice question tests in physiology: a preliminary attempt to apply the minimum pass level§

Summary. At the mid-term test in Part I Physiology at the University of Zagreb the students (n= 280) were graded by our standard pass level (SPL) arbitrarily set at 54% correct answers (SPL = 0.54). The test consisted of 50 items of the one best answer type. Items were selected from the pool by one examiner to conform, by his judgement, to the predetermined SPL. Post hoc the minimum pass level (MPL) was assessed independently by eight examiners and an MPL value of 0.60 for the whole test was obtained. The original Nedelsky scale was used in assessment of MPL but for statistical analysis the data was expressed as log(1/MPL) to linearize the scale of measurements and to reduce the variances. The data showed a large difference between examiners in their assessment of MPL. Nevertheless, the average log(1/MPL) value of individual items showed a significant negative linear relationship with the item difficulty indices as calculated from student's answers, indicating that despite the large heterogenity in assessment the average item log(1/MPL) may be acceptable as a reasonable prediction of item difficulty. Finally, ‘subtests’ were formed from the whole test by grouping items according to their log(1/MPL) value. The passing rate at these subtests was found to be identical despite the fact that they considerably differed in their MPL values. Therefore, the MPL value seems to be useful in setting objective standards for the decision of pass or fail, even when the MPL was assessed in a very heterogenous way.     

Medical students' attitudes to and knowledge of the aged

Summary. It is a fact that, with the increase in life expectancy, an increasing proportion of the population will consist of elderly people in future years, particularly those over 85 years of age ( Bromley 1988 ). The provision of care for the aged is an important aspect of undergraduate medical training ( Gale & Livesley 1975 ; Steele 1987 ). However, it is essential to realize that if medical practitioners do turn their attention more towards the elderly, their knowledge about the aged and their attitudes towards them are of vital importance. Moreover, studying medical students' attitudes and knowledge would be valuable for the training and education of future practitioners.     

Medical students' experiences with and perceptions of chronic illness prior to medical school

Summary. Concerns have been expressed about the failure of the medical curriculum to address the health-care needs of the chronically ill. It has been shown in the literature that medical students develop cynicism and negative feelings towards chronic illness as they progress through their training, perhaps as a result of the attitudes and frustrations of their teachers. What has been inadequately addressed are the experiences with and perceptions about chronic illness that medical students have before entering medical school. Some recommendations are made for curriculum changes based on the findings reported.     

Students' written reports as an essential part of a casebased learning programme in anatomy

Summary. This paper reports on second-year medical students' views and performance on the written reports for the cases that were studied in a case-based learning programme in anatomy at the University of Otago in 1988. The mean marks for the reports for the three main categories of student entry are presented. Differential performance on the written reports relative to the case-based component of the examination held at the end of the year has been determined for each student in the class and ranked in order. The proportions of students falling in the top and bottom quartiles for the class are given. The data taken together indicate that with an intensive programme of case-based learning in 1988, optimal performance in the written reports was reached at an early stage by the graduates whereas the two undergraduate categories improved their performance towards the end of the programme.     

Experiences with a method for obtaining feedback on a medical curriculum undergoing change

Summary. Successful innovation and change in the way medical students are prepared are notoriously difficult. The relationship between the administrative structures of the medical school and its teaching hospitals, other responsibilities of its teachers and administrators, and the intricacies of the curriculum as a system of interrelated components, mean that any real change has wide repercussions. An opportunity for evaluation of a curriculum undergoing change was presented at the University of New South Wales, when the Faculty of Medicine introduced a new 6-year medical curriculum in 1988. The change was made to address a number of problems experienced with the old 5-year curriculum. The Course Evaluation Committee was in a unique position to conduct an ongoing evaluation of the new curriculum, year by year, as it was being introduced. A method for obtaining feedback from both staff and students on a medical curriculum undergoing change, is described. While some sample results are presented, the paper concentrates on the advantages and disadvantages of, and our experiences with, this method. Advantages include the specificity and timing of the information collected, and the high response rate. One disadvantage was the repeated use of the same cohort of students. Some staff still perceived the evaluation process as a threat, or were sceptical about the value and validity of student feedback. Whether staff acknowledged ownership of the new curriculum also affected the use of feedback.     

Active and problem-based learning: two years'' experience in physiology at the Medical School of the University of Barcelona

Traditional educational methods are used in most medical schools. The introduction of new methods including active and problem-solving learning in traditional medical schools is difficult. The aims of this experiment were: (1) to introduce a self-learning system with a problem-solving approach in physiology; (2) to promote active student participation; (3) to introduce early clinical exposure; (4) to evaluate the response of the students to this experiment; and (5) to evaluate the feasibility and usefulness of a self-learning and problem-solving approach in only one discipline. Our experience has shown that it is possible to change the learning system in a traditional medical school, with good acceptance by the students and with a high level of satisfaction on the part of the teachers.     

Choosing a career in general practice: the influence of medical schools

Summary. This paper reviews the literature on career choice to investigate the undergraduate influences on the preference of Australian graduates for a career in general practice. Although isolation of influencing factors is difficult, admission criteria and undergraduate curricula may influence career preference. As the institutional environment of medical schools is weighted towards scientific research and specialized medicine, medical students may be socialized into choosing non-generalist careers. Medical schools should consider broadening selection criteria and curriculum exposure to produce graduates with a broad range of career interests.     

The development and evaluation of Basic Epidemiology: Student''s Text

This paper describes the development and evaluation of a World Health Organization book Basic Epidemiology: Student's Text. This book was a response to a need identified by members of the WHO Global Environmental Epidemiology network. A draft was commented on by members of the Network and then at an editorial meeting. Two thousand copies of a pre-publication version were prepared and this version was formally evaluated by 13 teachers of introductory courses of epidemiology and less formally by members of the Epidemiology Network. A high response was received to the evaluation questionnaires; 45% of the students rated the test overall as 'very useful' and another 54% as 'useful'; many useful comments were received and were incorporated into the final version which will be published by WHO in 1993.     

Career preference and choice of practice locations by Saudi medical students

Summary. The identification of career preference and intended practice location of medical students may provide a useful contribution to the projections and distribution of doctors across different specialties in the country. Information for this study was obtained from a survey of medical students in the final years at King Saud University College of Medicine in Saudi Arabia. This included demographic characteristics, career choice, training location, qualification in view and intended practice locations. The majority (61.2%) intended to specialize and subsequently practise in the major disciplines of medicine, surgery, paediatrics and obstetrics. Twenty-eight per cent were not sure of their future career choice. Only a few (3.5%) chose primary care and none chose pathology or anaesthesia. More men chose medicine, paediatrics and surgery, but more women chose obstetrics and primary care. The majority (81.2%) would like to have foreign certificates, but all the Saudis would subsequently practice in Saudi Arabia and mainly in large cities. The implications of this career pattern and practise locations are discussed with recommendations for health planners and medical schools.     

Teaching of musculoskeletal medicine: a survey of general practitioners and deans

Summary. A survey was conducted of all general practitioners on the Family Health Service Authority List in Wiltshire and of the deans of all medical schools in the United Kingdom. The results are presented. The findings indicate that the teaching of musculoskeletal medicine is not adequate.     

Residents' perceptions of their teachers: facilitative behaviour and the learning value of rotations

Summary. Despite changes in modern medicine the role of the clinical teacher remains central to medical residents' education and rotations continue to be their dominant educational context. Residents have strong positive feelings for clinical teachers who are perceived as interested in teaching and for those rotations that provide a balance of educational opportunities and patient care responsibilities. Research in residency education has focused on teacher behaviours used to teach medical residents clinical information or patient care skills but has neglected teacher behaviours used to facilitate effective learning relationships with residents. To explore the impact of clinical teachers' use of facilitative behaviours on residents' educational experience, we use concepts stemming from the psychologist Carl Rogers' work previously shown to be associated with positive learning outcomes — empathy, unconditional positive regard, and congruence. These constructs are measured by the use of the four scales of the Barrett-Lennard Relationship Inventory (BLRI) — level of regard, unconditionality of regard, congruence and empathy. Our study measures the correlation between residents' perceptions of clinical teachers' use of facilitative behaviours and residents' evaluation of the learning value of rotations. Thirty-three residents completed the BLRI on a different clinical teacher for each of six monthly rotations. A total of 158 surveys were returned. There were strong positive correlations between three of the BLRI variables and residents' perception of the learning value of rotations. Potential uses of these findings are discussed.     

A skills programme for preclinical medical students

An education programme in which preclinical medical students are introduced to common procedural skills is described. This programme is presented by a multidisciplinary health care team using short lectures, demonstrations, mannequin practice, and, in selected instances, practice on class-mate volunteers. The programme was evaluated by the students immediately following the presentation and for one class during their clinical activities one year later. The students' support for this programme was generally enthusiastic and remained undiminished upon reflection 12 months later.     

An unwelcome visitor? The opinions of mothers involved in a community-based undergraduate teaching project

Summary. This paper describes the family case study, a community-based project for Cardiff medical students involving them in self-directed learning. A comparison is made (using self-administered questionnaires) between the opinions of mothers and students who participated in the 1990/91 project. The results indicate that mothers recruited to the study tended to come from the middle classes and be in stable relationships. The vast majority found participation in the study to be an enjoyable experience. This contrasts sharply with the opinions of students who often expressed concerns about imposing on their families. The study demonstrated that most students were able to pace their self-directed learning by visiting their families on a regular basis. The majority obtained ‘hands-on’ experience of the baby's development and, according to the mothers, improved in competence as a result. The high maternal response rate and the quality of the answers have prompted the authors to consider whether mothers could be more involved in teaching and assessment of medical students in the future.     

Medical student abuse: perceptions and experience

Summary. A questionnaire containing 18 vignettes of common clinical educational situations with potentially abusive treatment of medical students and a 10-item attitude assessment about abusive behaviour were administered to the first-and fourth-year medical students at a mid-west US university medical school. The first- and fourth-year groups did not differ significantly on perceived abusiveness of most of the vignettes, although several of the individual vignettes were perceived significantly differently by the two groups. As hypothesized, the fourth-year students had experienced such situations more frequently. Attitudes towards abusive behaviour did not differ between the two groups. The authors contrast teaching interactions perceived as educationally useful and not abusive with those seen as abusive and not useful and offer explanations for the differences observed. Finally, the possible implications of the results for medical education are discussed.