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.     

Does formal approval of educational courses guarantee quality?

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

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

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

Teaching anatomy without cadavers

BACKGROUND: Anatomy learning is generally seen as essential to medicine, and exposure to cadavers is generally seen as essential to anatomy learning around the world. Few voices dissenting from these propositions can be identified. AIMS: This paper aims to consider arguments relating to the use of cadavers in anatomy teaching, and to describe the rationale behind the decision of a new UK medical school not to use cadaveric material. DISCUSSION: First, the background to use of cadavers in anatomy learning is explored, and some general educational principles are explored. Next, arguments for the use of human cadaveric material are summarised. Then, possible arguments against use of cadavers, including educational principles as well as costs, hazards and practicality, are considered. These are much less well explored in the existing literature. Next, the rationale behind the decision of a new UK medical school not to use cadaveric material is indicated, and the programme of anatomy teaching to be employed in the absence of the use of human remains is described. Curriculum design and development, and evaluation procedures, are briefly described. Issues surrounding pathology training by autopsy, and postgraduate training in surgical anatomy, are not addressed in this paper. FUTURE DIRECTIONS: Evidence relating to the effect on medical learning by students not exposed to cadavers is scant, and plainly opportunities will now arise through our programme to gather such evidence. We anticipate that this discussion paper will contribute to an ongoing debate, in which virtually all previous papers on this topic have concluded that use of cadavers is essential to medical learning.     

The new Dundee medical curriculum: a whole that is greater than the sum of the parts

The medical undergraduate curriculum at the University of Dundee has evolved in response to changing needs. The new curriculum, introduced in 1995, combines idealism and pragmatism. Underpinning it is the concept that the curriculum is an educational programme where the whole is greater than the sum of the parts. The concepts contributing to this are: the spiral nature of the curriculum, with its three interlocking phases; a body-system-based approach, with themes running through the curriculum, providing a focus for the students' learning; a core curriculum with special study modules or options; the educational strategies adopted, including elements of problem-based and community-based learning and approaches to teaching and learning that encourage the students to take more responsibility for their own learning; an approach to assessment which emphasizes the overall objectives of the course; an organization and management of the curriculum; and an allocation of resources designed to support the educational philosophy.     

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

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

Teaching the consultant teachers: identifying the core content

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

Problems for problem-based learning: a comparative study of documents

In medical education the problem-based approach to learning can be considered as the most significant educational innovation in the past two decades. This paper examines the ways and extent to which health problems have been designed for implementation of problem-based curriculum. Content analysis of curriculum documents of three problem-based schools was carried out in a systematic way from identification of unit of analysis, categorization, sampling, data analysis and interpretation. The comparative study revealed common areas in curriculum organization, arrangement of problems in stages, problem selection criteria, and basic concepts in the early stages of the curriculum. About one-third of the health problems were found to be similar in the schools compared. However, there was no uniformity in the sequence of organ-systems or the health problems. This study provides a framework for the development of problem-based curriculum in three stages with essential concepts identified for the first stage. Criteria for a balanced selection of problems and problem design features which affect the quality of health problems have been identified. These findings could be of value for those who are in the process of developing or revising a problem-based curriculum.     

Promoting professional knowledge, experiential learning and critical thinking for medical students

It has been recognized internationally that undergraduate medical education must adapt to changing needs, as illustrated by the Tomorrow's Doctors recommendations from the General Medical Council. This paper aims to relate contemporary educational theory to under-graduate medical educational requirements, specifically highlighting conditions (e.g. experiential learning) for: professional knowledge acquisition; critical thinking, problem-solving and clinical problem-solving; and lifelong professional learning. Furthermore, problem-based learning (PBL) is highlighted as potentially providing such conditions. There are lessons from contemporary educational theory for the reform of undergraduate medical education. These include valuing prior knowledge and experience; promoting learner responsibility through facilitating rather than directing learning; encouraging learners to test out and apply new knowledge, and using small-group work to foster explicitly the elusive skills of critical thinking and reflection. Contemporary educational theory contributes valuable insights, but cannot dictate the ultimate 'mix'; at best it provides some principles for reflective analysis of the learning experiences created for tomorrow's doctors.     

Family attachments and medical sociology: a valuable partnership for student learning

This paper reports association within a curriculum of a theoretical programme in medical sociology for undergraduate medical students with a practical family attachment. These two components constitute the 'sociology' element of a course in behavioural science, and have equal weight for assessment purposes. Recognition of, on one hand, the mutuality of the two elements, and on the other, their similar but distinct theoretical underpinnings, suggests that such an association has the benefit of retaining the individual contributions of each component to student learning, while enabling theoretical and practical components to inform each other. Both are administered from the Department of General Practice of the University of Sheffield, UK. The consequences of such an educational provision are discussed.     

Health promotion and disease prevention: integration into a medical school curriculum

Summary: Many authorities have identified deficiencies in the education of medical students in health promotion and disease prevention. This report describes an attempt to address this problem through the longitudinal integration of health promotion and disease prevention into several major courses in the student curriculum at Harvard Medical School. We used adult learning theory to develop the curricular approach, and designed educational experiences to match the professional development of the student at different phases of medical education. Primary, secondary, and tertiary prevention were particularly germane for students in the first, second, and third years, respectively. During clerkships in the third and fourth years, especially those with a focus on ambulatory patients, students built upon earlier experiences to integrate health promotion and disease prevention into clinical practice. By unifying the teaching of disease prevention with several major required courses, we aimed to create an environment in which students could experience their learning about disease prevention in the same manner that we aspired to have them practise it: integrated throughout clinical medicine.     

Developing a Korean communication skills attitude scale: comparing attitudes between Korea and the West

Objectives  We aimed to develop a Korean version of the Communication Skills Attitude Scale (CSAS) created by Rees et al . in order to elucidate the positive and negative aspects of Korean pre-medical and medical students' attitudes towards communication skills (CS) learning.
Methods  We performed two surveys. In the first of these, 325 pre-medical and medical students completed a translated version of the CSAS. In the second survey, 257 medical students and doctors-in-training answered five open-ended questions to obtain more qualitative data about their attitudes.
Results  Principal component analysis with direct oblimin rotation performed with the data from the first survey produced the following five factors: facilitation of interpersonal skills; doubts about the importance of CS learning in medicine; motivation; negative attitudes towards assessment, and overconfidence. Results from the second survey indicated that facilitation and importance within a medical context were two core attitudinal factors and suggested some modification to the CSAS to improve its fit for Korean pre-medical and medical students.
Conclusions  Using a Korean version of the CSAS (CSAS-K), we determined five factors that revealed a somewhat complex attitude structure among students towards CS learning. The CSAS required some modification, possibly because CS teaching and learning in Korea are in the development stage. Finally, the educational implications of the results are discussed.     

Portfolio-based learning and general practice vocational training

This action research project developed a portfolio-based learning system, based around a 'log diary', with the trainers and general practitioner registrars of one training region in the UK. For those that found benefit from the system, the diary became an important way of holding all the events of a training year together; a way of looking back, in order to view the progress made, and looking forward, to view potential learning needs. Such portfolios were not found to be effective formal assessment mechanisms because the threat of assessment influenced the type of material collected. The enthusiasm of trainers was crucial in encouraging use of the model. The action research process was fundamental in stimulating exploration of ideas on reflective learning. There remains some resistance to the idea of reflective writing, and in this context, portfolios may be one educational tool for use by some, but which may not be universally applicable. Their development and implementation requires considerable local support through facilitation.     

A framework for developing excellence as a clinical educator

The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome-based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.     

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

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

Medical students' perceptions of their educational environment: expected versus actual perceptions

Objective To compare Year 1 medical students' perceptions of their educational environment at the end of Year 1, with their expectations at the beginning of the year using the Dundee Ready Education Environment Measure (DREEM). Methods Year 1 students (n = 130) at the University of East Anglia Medical School were asked to complete the DREEM during their induction week at the beginning of Year 1, thinking about the educational environment they expected to encounter (Expected DREEM), and again as part of a compulsory evaluation at the end of Year 1, thinking about the educational environment they had actually experienced (Actual DREEM). A total of 87 students (66.92% of the starting cohort) completed the DREEM on both occasions and gave permission for their data to be published. Results The Expected DREEM score was 153 out of a maximum of 200, and the Actual DREEM score was 143. Student's expected perceptions of learning and teachers, and their expected academic self- and social self-perceptions were all more positive than their actual perceptions. There was no difference between expected and actual perceptions of atmosphere. Specific aspects of the educational environment showing dissonance were identified. In some areas students' low expectations had been matched by their actual experience. Conclusions Medical students had started Year 1 with expectations about the educational environment that had not been met. However, areas showing dissonance received low item scores on the Actual DREEM and as such would be picked up for remediation, even without information about student expectations.     

An evaluation of introductory courses in environmental health

Introductory courses in environmental health are intended for doctors newly appointed to the emergency duty rotas of the Medical Officer for Environmental Health. Three courses have been held in Bristol between 1984 and 1987. They have been evaluated with a problem management questionnaire completed by 44 of the 47 participants before and after the teaching. Seventy-four per cent (23/31) of a comprehensive list of aspects that could be considered were mentioned by less than 30% of respondents at the beginning of the course and 65% (20/31) of these aspects were mentioned by at least 30% more participants at the end of the course than before it. There were no differences in these patterns between respondents who attended the different courses. The findings support the need and educational worth of such courses, and help to identify learning deficiencies. Problem management questionnaires are useful in their evaluation.     

Use of learning contracts in an office-based primary care clerkship

OBJECTIVES: This paper describes implementation of the learner-centred learning goal within the primary care clerkship at a Midwestern, United States medical school. DESIGN: The learner-centred learning goal exercise was developed to tailor students' educational activities to their personal level of development and to enhance their commitment to life-long learning in medicine. In the learner-centred learning goal exercise, each student records three specific learning goals early in the primary care clerkship. Students record the methods by which they will pursue and document achievement of each goal. Attainment of the learner-centred learning goal is evaluated based on an oral presentation at the end of the clerkship. We compiled presented learning goals along with the corresponding grade. Students' ratings of the learner-centred learning goal exercise were also compiled. Evaluations and ratings were made on a 1-5 Likert scale, where 1 is the best rating and 5 is worst. SETTING: Department of Medicine, Northwestern University Medical School, Chicago, USA. SUBJECTS: One hundred and seventy-seven third- and fourth-year medical students who presented learner-centred learning goals between 1 July 1995 and 30 June 1996. RESULTS: Students rated pursuing their individual learning goals more worthwhile than most clerkship lectures but less worthwhile than the office experience. Several learning goals were chosen by a disproportionate number of students, potentially indicative of some perceived deficiencies elsewhere in the curriculum. Third-year students ranked the learner-centred learning goal exercise more favourably than fourth-year students (2.14 vs. 2. 51, P = 0.03). CONCLUSIONS: The learner-centred learning goal exercise is a feasible and well-received method within our primary care clerkship. Further study is required to determine whether the exercise promotes independent learning after formal medical school education is completed.     

Community hospitals and general practice: extended attachments for medical students

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

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

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