Short-term outcomes and long-term impact of a programme in medical education for medical students

Objectives  There is growing appreciation of the value of early preparation of future medical educators. Staff development programmes, conferences and workshops pertaining to the training of educators may be crucial to the pursuit of a school's larger educational mission to educate students, doctors and scholars and to provide comprehensive knowledge, research, patient care and service. This study examined the efficacy of a 1-week educational intervention aimed at preparing medical students to become effective doctor educators by building skills early in their careers. The study asked whether participation in a 5-day teacher training programme led to increased knowledge of instructional methods, more favourable attitudes towards teaching, and the integration of structured instructional design methods in a student-developed teaching project.
Methods  A mixed methods research design was employed with quantitative data captured through pre- and post-test inventories, qualitative components captured through written comments, and a 2-year post-intervention survey. Quantitative analyses included pre-/post-intervention repeated measures with calculated effect sizes. Qualitative analysis was conducted using constant comparative methods.
Results  Subjects demonstrated improved content knowledge and more positive attitudes towards motivation, teaching confidence, teacher roles, varied pedagogy, and use of assessment, instructional planning, and evaluation. Subjects were able to incorporate the programme's teaching theory and methods into their teaching projects and assessment of peers' and others' teaching in their own institutions 2 years post-training.
Conclusions  This study demonstrates that a well-designed programme for teacher preparation can be pedagogically effective for training medical students to become better educators and that this learning can be incorporated into long-term practice.     

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

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

Teaching school health to undergraduate medical students

This paper describes a teaching programme for final- (sixth-) year undergraduate medical students during their 10-week term in child health. Students attend schools on two occasions and are actively involved in the physical, educational and emotional assessment of children. The advantages of the programme include active participation by the students, contact with children in a less threatening environment, learning new skills in the assessment of children, and knowledge of common screening procedures. Student evaluation of the programme has been positive.     

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.     

Language background, proficiency in English, and selection for language development

With a diverse language background profile in an Australian medical student population, teaching interventions are necessary for students whose English language proficiency is not adequate for the study of medicine. This paper describes the screening of written and aural English language proficiency in 143 first year undergraduate students using a standardized instrument. Students identified as experiencing language difficulties were subsequently assessed by interview and allocated to faculty-based Language Development Programme. Students with the greatest need for language support participated in a full 2 year programme. Those requiring less assistance were offered more limited support in the form of specific modules within the programme. Students allocated to the full programme were significantly weaker in language proficiency compared to those offered specific modules and those not offered a placement. The information gathered during the structured interview is valuable in establishing for medical educators specific areas in which language-related teaching for students who require it can be directed. Future research is required to evaluate the effectiveness of faculty-based language interventions in terms of improvement in language proficiency over time and the effect of any improvements in language proficiency on academic and clinical performance.     

The earlier,the better: the effect of early community contact on the attitudes of medical students to older people

BACKGROUND: Early clinical contact for medical students is an important curricular innovation. We wished to determine if early contact with older people in the second year of a more vertically integrated medical undergraduate programme influenced attitudes to older people and if any effect was synergistic with the effect of an existing fourth year course. SUBJECTS: Second and fourth-year medical students. METHODS: We used a modified version of the Rosencranz-McNevin semantic differential on ageing to assess attitudes of medical students before and after a one-week early community contact week. Some second-year students were followed into fourth year and the effect on their attitudes of a health care of the elderly course was measured. We compared these data with attitude scores from an earlier cohort of students who had undertaken the fourth-year but not the second-year component. RESULTS: Contact with older people during second-year had a significantly favourable effect on attitudes to older people, especially for students who saw older people in the community rather than in rest homes. The attitudes towards older people of students who had undertaken a fourth-year clinical health care of the elderly attachment were significantly better on two of three subscales than those of fourth-year students who had not seen older people during their second year. CONCLUSION: Contact with older people early in a medical student's training, and within a more vertically integrated programme, has a positive effect on attitudes to older people. This effect may be synergistic with contact later in training.     

An innovative examination ending the medical curriculum

There has been increasing interest in curriculum innovation in many medical schools. The pedagogic principles for learning and for assessment should be congruent. Changing the curriculum and pedagogic principles for medical education implies that the examinations should also be adapted to the new principles. At the Faculty of Health Sciences, Linköping University, we use a student-oriented programme with problem-based learning, early patient contact, multiprofessional integrated education, and integration between basic science and clinical medicine and between traditional medical subjects. We also encourage the students to adopt a scientific attitude from the very beginning. To assess the students at the conclusion of the medical curriculum, we have developed a new form for the final examination containing measurements of clinical ability based on a videotaped patient consultation, an assessment of the student's performance and presentation of a scientific project, the student's analysis of a published scientific paper and an extensive oral examination based on the students' own scientific papers. Our experience, including results from questionnaires to students and teachers, is that the method is suitable for a final examination and assesses qualities that we previously were not able to assess.     

Can general internal medicine be taught in general practice? An evaluation of the University College London model

There is national and international interest in increasing the community-based component of undergraduate medical education, but more research is needed on its potential, practicability and effectiveness. The objective of the study was to examine the feasibility and efficacy of general practitioners teaching basic clinical skills to first year clinical medical students in the community. The structure and methods of evaluation of the programme are described. Evaluation tools included semi-structured interviews of general practitioner tutors; student questionnaires; assessment of student performance; and costs of the programme. The great majority of the students found the programme enjoyable (81 out of 81, 100%) and educational (79 out of 81, 97%). Students' perfomance in the end of rotation Objective Structured Clinical Examination suggested that clinical skills are acquired at least as well in the community as in hospital. Tutors identified the personal benefits of this teaching as development of their own clinical skills and the stimulation of teaching. The programme has been successfully expanded from 24 students to 230 students annually and has demonstrated that community-based teaching can usefully contribute to undergraduate medical education in the area of clinical skills teaching. Key practical issues for schools contemplating similar initiatives are presented.     

Teaching and assessing clinical skills: a competency-based programme in China

The objective of this study was to develop a compentency-based clinical skills teaching and assessment programme in China utilizing modern teaching techniques. Medical teachers from three schools agreed on items for inclusion in the complete physical examination of an asymptomatic adult, an outline for an adult and paediatric history, and important interviewing skills. Lesson plans, performance checklists, and written and videotape training materials were developed. Standardized patients were trained at one school to assist with the teaching at that school and with the assessment at all three schools. A national, a provincial, and a local medical school in China were used. Before beginning the new curriculum for students in their first year of clinical training, baseline data were collected on skills of students at various levels of training in the previous curriculum at all three schools. Although in the previous curriculum there was some improvement in clinical skills among advanced compared to more junior students, performance was lower than expected by staff. One year after implementation of the new curriculum, students were evaluated. These students significantly outperformed their counterparts as well as the more senior level students tested the previous year. This project has established a competency-based teaching and assessment programme in China that allows for rapid improvement in the clinical skills of students. Within a short time, a sophisticated group of medical educators has been formed, who now function as consultants to other educators in their own country. Many aspects of this programme are being adapted throughout China and are applicable to medical schools throughout the world.     

Teaching medicine in general practice: the Guy''s experience

The development of teaching in general practice at Guy's Hospital Medical School is described. Important features of the current programme (a new programme for the United Schools of Guy's and St Thomas' Hospitals will come into effect this year) are the emphasis on learning directly from patients and the active role and responsibility given to clinical students. Students welcome the opportunities to see patients first, to deal with undifferentiated problems, to work with one clinical teacher, to put to use knowledge and skills and to test themselves as clinicians. In these circumstances they gain confidence and display the human qualities required of doctors. An acceptable service to patients, the essential basis for effective clinical teaching, requires the general practitioner teachers devote more of their time to service than to clinical teaching.     

Graduate evaluation of undergraduate teaching programmes in paediatrics

In a new undergraduate teaching course in child health, medical students were encouraged to prepare and present topics to their colleagues. These presentations covered major subjects in paediatric medicine and were supervised by an experienced teacher. Students were then asked to evaluate the programme at the end of their course in child health and after graduation. Evaluation scores for these presentations were high at the end of the course. Spontaneous comments suggested some disadvantages such as poor or too-detailed student presentations. However, some noted the value of personal research. After graduation, more positive comments were made and the majority felt that the course had advantages in the area of personal research, that it was better than or as good as other teaching methods, and that it should be continued in its present format.     

Student perceptions of a new integrated course in clinical methods for medical undergraduates

CONTEXT: In line with recent General Medical Council recommendations a new, 8-week integrated course in clinical methods has been introduced into the undergraduate curriculum at Leicester University. OBJECTIVES: To describe student perceptions of the course and to identify areas for improvement. DESIGN: A questionnaire survey. SETTINGS: These were 50 general practices, three teaching hospitals and the academic Department of General Practice and Primary Health Care. SUBJECTS: A total of 180 third- and fourth-year medical students. RESULTS: The questionnaires were completed by 93% of students. The latter expressed higher satisfaction with practice teaching compared with hospital teaching, on a 5-point scale, with regard to questions on 'teaching content' (4.0 vs. 2.7, P < 0.0001) and 'teaching process' (4.1 vs. 2.7 P < 0.0001), which was reinforced by free text comments. Of the respondents, 92% agreed that their teaching practice had satisfied the required teaching timetable and 87% of students found their departmental tutor enthusiastic and stimulating. CONCLUSION: It is possible to deliver an integrated course in clinical methods, teaching generic clinical skills, in a mix of hospital and practice settings. Nevertheless there were substantial differences in student perceptions of the relative quality and impact of teaching in the two settings. This may be related to the more detailed programme of preparation of practice teachers and the greater extent to which practice teachers were required, and able, to create protected time for the teaching task. These differences should be minimized if hospital teachers undergo similar preparation for the teaching task and have similar levels of protected teaching time.     

Teaching primary health care: some lessons from Zimbabwe

A new teaching programme for fourth-year medical students in child health in Harare, Zimbabwe is outlined. A 2-week attachment to a rural district-level hospital is intended to orient the students to primary health care and to the practice of clinical medicine in a low resource environment. The attachment has become popular with students and it is hoped that it will improve attitudes of teaching staff in the medical school towards primary health care.     

Ethics in the clinic: a comparison of two Dutch teaching programmes

This paper compares ethics programmes in clinical education in two medical schools in the Netherlands. Ethics education in the University of Maastricht is case oriented, whereas the emphasis in ethics teaching in the Catholic University of Nijmegen is focused on the methods of ethics and moral reasoning. The general objectives, format and evaluation are discussed. Both programmes assume that in clinical decision-making normative and technical issues are intertwined; if a normative dimension is intrinsic to medical practice itself, students should learn during clinical training how to explicate and evaluate the moral quandaries of their profession. The positive characteristics of the Maastricht programme (student-centred approach, relevant cases, team-teaching of ethicist and clinician), if combined with those of the Nijmegen programme (a coherent theoretical framework and method for case analysis and interpretation), would create a new, powerful model for clinical ethics teaching. In a recent report such a model is advocated for all Dutch medical schools.     

Chronic patients in undergraduate education: didactic value as perceived by students

OBJECTIVES: Medical education should prepare students for future clinical practice. However, this preparation is inadequate for the most prevalent problem in health care: chronic disease. This applies to the continuous aspect of chronic disease. Within the context of a newly developed programme, we investigated what makes a chronic patient interesting in the eyes of medical students, what they learned from a specific programme in which each student had contact with a chronic patient 4 times in 8 months, and what they learned from their patients. METHODS: A total of 240 Year 3 students were enrolled in the programme, 89 of whom filled in questionnaires at both the start and end of the programme. Topics included the characteristics of the ideal and the actual patient, the Ideal Physician Questionnaire, and several questions on the expected and actual amount of knowledge gained from the patient. RESULTS: Students preferred patients who demonstrated clear symptoms and had frequent contacts with health care professionals during the programme to 'well adapted' patients. The perceived knowledge obtained from the patient was less than they had expected at the start of the programme. A didactic gain perceived as low was mainly due to low expectations of gaining knowledge at the start of the programme, a doctor-centred attitude and a high level of discrepancy between the student's ideal patient and the actual patient. CONCLUSIONS: Programmes that aim to present chronic patients to medical students focus on patient selection so that patients who differ only very slightly from healthy persons are eliminated. In addition, realistic information on the types of patients with whom students can expect to have contact may help students appreciate the knowledge to be gained from these patients.     

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.     

Teaching support in the behavioural sciences for non-English speaking background medical undergraduates

INTRODUCTION: This paper reports on a teaching strategy designed to support first year undergraduate medical students from non-English speaking backgrounds in a behavioural science course taught at an Australian university. METHOD: The strategy is described, as is the language profile of students from two successive cohorts who participated in the teaching programme. The effectiveness of the intervention in improving students' academic performance is explored, as gauged by summative assessment and student perceptions. CONCLUSIONS: Findings suggest that students disadvantaged by difficulties with language and/or knowledge of Australian culture were able to perform at least as well as other students on a number of summative criteria. Non-English speaking background students perceived the behavioural science course to be difficult, and indicated that they found the teaching support offered to them to be useful. The methodological difficulties and limitations involved in the evaluation of a teaching programme such as this are discussed and the conclusions that can be validly drawn are considered.     

Medical students'' attitudes to old people and career preference: a comparison of two universities

Medical students' attitudes to old people were compared at broadly similar points in their education at two medical schools, one with a department of health care of the elderly (Nottingham), the other without such a university department (Leeds). The students were tested at both schools before their clinical training in care of the elderly, using a modified Rosencranz-McNevin semantic differential scale to measure general attitudes to old age, and a Likert scale to measure attitudes to medical care. Questions were also asked about career preferences. Both groups of students showed similar general attitudes to ageing. The Nottingham students showed more positive attitudes to care of old people, and this was reflected in career preferences.     

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.     

A conference on ethics for obstetric and gynaecological clerkship students

Integrating the teaching of medical ethics into medical students' clinical education is challenging, given the competing demands on students' time and the need for teaching to be clinically relevant. This paper describes a model programme for incorporating ethics teaching into the obstetrics and gynaecology clerkship for third-year medical students. The programme is taught by two attending teachers and a medical ethicist with experience teaching in the clinical setting of obstetrics and gynaecology. Objective pretests and posttests showed substantial improvement in students' knowledge, and student feedback has been very positive.