Teaching of primary health care in practice: a model using local health centres in undergraduate medical education

In Finland primary health care has a long historical background. The local communities, the state and the church have at various times and places been responsible for primary health care during the last few centuries. In 1972, a major reform took place when a new Primary Health Care Act came into force. In the same year two new medical faculties, at Kuopio and Tampere Universities, began to educate undergraduate medical students. In both of these new medical schools special attention was focused on the teaching of primary health care. Today practical teaching, which takes place at a primary health care centre, forms an important part of medical education at Kuopio University. This teaching of undergraduate students is part of the regular duties of general practitioners and public health nurses in the primary health care centres of eastern Finland that have agreed to collaborate in the teaching programme. The main principles are presented for the teaching programme in primary health care at the University of Kuopio.     

Cardiology patient simulator and computer-assisted instruction technologies in bedside teaching

The design and uses of an innovative technology-based approach which addresses critical problems with bedside teaching during ward rounds in the current health care situation are described. A cardiology patient simulator (HARVEY) and an accompanying computer-based interactive laserdisk system provide medical students, house officers and other health professionals with the opportunity to encounter a wide variety of clinical problems for learning and assessment. A group of cardiologists and medical educators from a consortium of US medical schools has guided the development and formal assessment of the entire system over the past 10 years. The system and simulator can be configured and programmed to provide appropriate heart sounds, laboratory data, and test results upon request; hands-on experience to practise examination skills is also available. The system, whole or in part, can be used in a variety of instructional modes from self-instruction to demonstration teaching, and from self-assessment to the final clinical examination. The system's effectiveness for teaching medical clerks is summarized, as is its use in providing continuing education for primary care doctors in rural practice.     

Attachment theory in health care: the influence of relationship style on medical students' specialty choice

INTRODUCTION: Converging sources suggest that patient-provider relationships in primary care are generally of greater intensity and duration than those in non-primary care specialties. In this study, we hypothesised that Year 2 medical students whose close relationships were characterised by security and flexibility would be more likely than students who were less comfortable in close relationships to plan to pursue primary over non-primary care postgraduate training. METHODS: We determined the relationship styles and demographic characteristics of 144 Year 2 medical students. We also gathered information regarding their predicted choices of postgraduate training, which were clustered into primary or non-primary care categories. We compared student choices with respect to their interpersonal relationship styles based on attachment theory. RESULTS: Prevalences of attachment styles were similar to those found in the general population, with 56% of students rating themselves as having a secure relationship style. Students with a secure style were more likely to choose primary care (61%) over non-primary care compared to those whose styles were characterised by self-reliance, support-seeking or caution (41% chose primary care). Compared to those with a secure relationship style, students with a cautious style [OR = 5.9 (1.9, 18.7)] and students with a self-reliant style [OR = 2.4 (0.96, 5.9)] were more likely to choose non-primary over primary care, after controlling for gender. CONCLUSIONS: Assessing relationship styles using attachment theory is a potentially useful way to understand and counsel medical students about specialty choice.     

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.     

The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand

CONTEXT: Cultural factors in health and illness, and an awareness of community health needs analysis, are important issues for medical education. Both have received relatively little recognition in the medical education literature. This paper describes the development of an educational attachment to remote predominantly Maori rural communities in New Zealand. The twin purposes of the programme were to encourage students to adopt broad public health approaches in assessing the health needs of defined communities, and to increase their awareness of the importance of cultural issues. METHODS: During a one week attachment, 51 students from the Wellington School of Medicine were hosted in six small communities in the East Cape region of New Zealand. Students gained an insight into the health needs of the communities and were encouraged to challenge their own attitudes, assumptions and thinking regarding the determinants of health and the importance of cultural factors in health and illness. The programme included both health needs assessment and cultural immersion. Students made visits with primary health care professionals and were also introduced to Maori history and cultural protocol, and participated in diverse activities ranging from the preparation of traditional medicines to performing their own songs in concert. CONCLUSIONS: The students evaluated the course extremely highly. Attachments of this sort provide an opportunity for students to appreciate how cultural values have an impact on health care, and how they also make the teaching and learning of topics such as community health needs analysis an enjoyable and dynamic experience.     

Animals for teaching purposes: medical students' attitude

Animal rights movements have increased the scope and intensity of their activities over the past decade. While it is generally assumed that doctors and other members of the health care professions favour the use of animals for science, few data are available. Student protests in various medical schools against use of animals in teaching laboratories indicated further need for objective data. A questionnaire about attitudes to the use of animals for teaching purposes was distributed to all the medical students at the Ben-Gurion University of the Negev, present during classes on a given day. All students present (200) returned the questionnaire (70% of the student body). Also queried were attitudes towards related subjects. A high percentage of medical students surveyed had significant reservations about animal experimentation for teaching purposes and about the preferential priority for human life over that of animals. These attitudes, if confirmed, have serious implications for educators both in the health fields and otherwise.     

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.     

Indian student doctors'' attitudes towards primary health care, poverty and related issues

An attempt is made to study the attitudes of student physicians towards primary health care, poverty, and related social issues in India. The sample consisted of 464 men and 228 women final-year medical students (a total of 692) from 11 medical colleges in India. An open-ended questionnaire was used. Content analysis was performed on the responses. There were no statistically significant differences between the responses of the students belonging to different socio-economic groups. There were some differences in the responses of the men and women students, especially on the question of poverty and related social issues. The data presented here show that the student physicians do not have a clear understanding of the primary health care approach, or about the social issues that influence health. This study underlines the need for exposing student physicians to the essential aspects of poverty and its impact on health and the importance of the primary health care approach for providing health care to disadvantaged groups.     

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.     

Clinical experience of medical students in primary care: use of an electronic log in monitoring experience and in guiding education in the Cambridge Community Based Clinical Course

OBJECTIVES: The amount of medical student teaching in the community has increased markedly recently, but uncertainties remain about whether there is sufficient clinical material to meet students' learning needs and, if so, how best to monitor the experience and ensure that students are benefiting from it. DESIGN: On the Cambridge Community Based Clinical Course, a 15-month attachment in primary care, the students used hand-held computers to monitor their clinical experience as it developed. SETTING: The General Practice and Primary Care Research Unit, Cambridge, UK. SUBJECTS: Medical students. RESULTS: Thirteen students recorded 8140 contacts over 4 years. Contacts recorded by students over 15 months varied between 256 and 1153. Eight specialities each contributed more than 5% of total experience. These were general medicine, 26.9% (range 23.8%-36. 6%), obstetrics and gynaecology, 11.3% (range 7.2%-17.1%), orthopaedics and rheumatology, 11.3% (range 3.7%-15.2%), paediatrics, 10.7% (range 4.1%-19.8%), ENT, 7.4% (range 3.3%-10.2%), dermatology, 7.1% (range 4%-10.1%), psychiatry, 6.4% (range 5%-9.7%) and general surgery, 6.4% (range 1.1%-9.9%). CONCLUSIONS: The results show that it is possible to get a broad and varied exposure to clinical problems on a long-term community-based course. However, as a consequence of the opportunistic way in which clinical experience is obtained on a community attachment, individual students often had gaps in their experience. The logs provided a means for identifying these gaps so that action could be taken to address them. The logs themselves proved to be a practical and feasible way to record student experience as it unfolded.     

Teaching medical students about family planning: experiences from a primary health care course in Lagos, Nigeria

In 1979, the College of Medicine, Lagos, Nigeria embarked on a new curriculum, which places more emphasis on primary health care in line with the needs of the country. This paper discusses one aspect of the primary health care course, family planning, which involves teaching a practical subject to a large number of students within a relatively short period of time and with limited patient contact. It is hoped that some of the ideas discussed can be of use to other medical teachers faced with similar dilemmas.     

A programme in undergraduate geriatric education: the Beer Sheva experiment

The Beer Sheva medical school was started in 1974 with the objective of training primary care doctors to meet the health needs of the Negev region of Israel. This paper describes a programme developed at Beer Sheva to prepare students to deal with the health-related problems of the elderly. Students begin their contact with the elderly in their first year (early clinical teaching programme) and continue this exposure in varying degrees during the 6 year curriculum. A preliminary study has shown that there is a trend for students to commence their studies with positive attitudes toward the elderly. The early clinical teaching programme which emphasizes interviewing skills, knowledge about ageing and community services that relate to the aged, reinforces the student's sensitivity to geriatric issues. In order to maintain the student's interest in working with the elderly, it is apparent that it will be necessary to educate both hospital and community-based physicians to provide positive role models for students.     

General practice based teaching exchanges in Europe. Experiences from the EU Socrates programme 'primary health care'

This paper reviews the experience of international exchange of medical students for general practice. The experience is based on the EU Socrates programme 'Primary Health Care' that offers, since 1992, clinical attachments and research electives in primary care. This programme involves 11 university departments of general practice/primary care in eight countries: Austria - Vienna; Belgium - Gent; Germany Düsseldorf; Italy - Monza, Udine; Netherlands Nijmegen; Slovenia - Ljubljana; Sweden - G?teborg; and the UK - Edinburgh, Imperial College London and Nottingham. More than 150 students have taken part in the programme, most in the last four years. For clinical attachment communication to patients is essential, and students should be able to speak the language of the host university. A research elective in primary care is less demanding and requires students' ability to communicate in English. Despite marked differences in health care structure in the countries involved, it is quite possible to provide a valuable teaching environment in general practice, and the experience gained by students in the exchanges more than equals that what they would gain at home. The added value is in experiencing the influence of another health care system and of working in another academic primary care centre. A substantial number of research electives have been published in international peer reviewed scientific journals with the student as first (occasionally second) author and staff members of the student's host and home university as co-authors. A further benefit of the exchange programme lies in the transfer teaching innovations between universities.     

A community-based approach to the medical humanities

BACKGROUND: This paper discusses the rationale behind, and an approach to, the development of a graduate level interdisciplinary curriculum in literature and health care that incorporates community-based learning. Such an innovative approach emerges from the recognition that professional training in both health care and humanities programmes often does not model the kinds of collaborative relationships and professional values desired by contemporary health care students, providers and patients. METHOD: Recent trends in literary study and the medical humanities are described, along with the function (and benefits to students) of interdisciplinary classrooms and the role of community-based learning in higher education. The authors discuss their experiences teaching, and offer students' responses to medical humanities courses from which the concept for such a curriculum evolved. The paper offers advice on developing, evaluating and disseminating such a model curriculum for medical, nursing and graduate literature students. PROPOSAL: By linking health care with graduate English literature students, such a course would promote dialogue and understanding among health professionals, enhance student awareness of the effects of illness on patients, their caregivers and families, and encourage student activism and community service. A common set of literary works would provide a shared vocabulary and opportunities for ethical, critical and personal response. Working together in a community-based project, students from different programmes would learn to appreciate alternative professional and lay perspectives on common experiences.     

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.     

Providing early clinical experience in primary care

Undergraduate courses in British medical schools are changing following recommendations from the General Medical Council. Increasing emphasis has been placed on teaching in the community. Nottingham Medical School has pioneered the teaching of basic clinical skills in primary care during the pre-clinical course to help produce an integrated curriculum. This qualitative study evaluated the first two years of the new early clinical experience course at Nottingham by using interviews with 19 students and their GP tutors. Students claimed to have gained confidence in talking to patients, their understanding of the role of the doctor and the importance of the doctor-patient relationship. Students were less confident about examining patients and some reported having had little opportunity to practice examination skills. Half the students thought that the early clinical visits had helped them to understand and be more motivated to learn their basic medical sciences course. The newly recruited GP teachers were highly motivated, very positive about the early clinical teaching and all wanted to continue to teach the pre-clinical students. Difficulties in providing the course included communication with students and staff, organization of student travel and variation in the quality of teaching. However, the Nottingham early clinical experience course has shown that basic clinical skills can be successfully taught to pre-clinical students in primary care.     

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

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

Two models of primary health care training

Summary. In 1991, the Fiji School of Medicine restructured the training of its medical students, dividing the 7-year course into two phases. Students now undertake a 3-year community-oriented primary care practitioners course, after which they may elect to continue practice in a primary health care role, or to undertake further hospital-based training to complete their medical degree. The course responds to the health needs of the South Pacific, and the local patterns of morbidity and mortality, rather than measuring itself against the curricular demands of its more developed neighbours, Australia and New Zealand. At the same time, the Tropical Health Program of the University of Queensland Medical School responded to demands from the Aboriginal and Torres Strait Islander community to develop primary health care training at degree level. This was intended to complement other strategies undertaken by the Aboriginal and Torres Strait Islander Studies Unit such as the recruitment and support of indigenous students through mainstream health professional education. There was a need to address health priorities that are very different to those of the Australian population as a whole, as well as the sociopolitical and cultural context as it affects both students themselves and health issues in their communities. Both institutions have chosen problem-based teaching/learning as appropriate to their courses, and content is also similar, though with emphases that reflect the differing contexts. The two courses are examples of innovative responses by centres with university medical faculties to specific issues in health education.     

The cost of problem-based vs traditional medical education

It is generally accepted that teachers' salaries are a major factor in the cost of medical education. Little is known about the effects of curriculum on teaching time. A comparison of teaching time devoted to each of two different medical education curricula is presented. In a traditional teacher-centered, subject-oriented curriculum, 61% of the total teaching effort expended by twenty-two teachers took place in the absence of students, i.e. in preparation for student contact. Only 39% of the effort devoted by these teachers to medical education took place in the presence of students. In a problem-based, student-centered curriculum which focuses upon small-group tutorial learning and early extended primary care experience in a rural community setting, 72% of the total teaching effort devoted to medical education was spent with students and only 28% was spent in preparation for student contact. Overall, there were no differences in the total amount of teaching time required by each of the two curricular approaches to medical education. There were, however, major differences in how teachers spent their teaching time.