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.     

Medical faculty as humanistic physicians and teachers: the perceptions of students at innovative and traditional medical schools

BACKGROUND AND OBJECTIVES: The training of caring physicians represents an important goal of medical education. Little is known however, on whether medical faculty constitute good role models for teaching humanistic skills to medical students. In this study, we examined to what extent medical students at innovative and traditional schools perceived their teachers as humanistic physicians and teachers. We also explored whether pre-clinical and clinical students shared the same perceptions. METHODS: A mail survey was conducted in Canada of all second-year students and senior clerks at one innovative medical school (problem-based learning (PBL), patient-centred, community-oriented) and three traditional medical schools. Students were asked to what extent they agreed or disagreed that the majority of their teachers behaved as humanistic physicians and teachers; 10 statements were used. Overall, 65% of the 1039 students returned the questionnaire. RESULTS: Over 25% of second-year students and 40% of senior clerks did not agree that their teachers behaved as humanistic caregivers with patients or were good role models in teaching the doctor-patient relationship. More than half of second-year students and senior clerks did not agree that their teachers valued human contact with them or were supportive of students who had difficulties. There were few differences in the way medical students at innovative and traditional schools perceived their teachers' humanistic qualities. At the pre-clinical level however, there were more students from the innovative school than from the traditional schools (around 60% vs. 40%, P < 0.005) who agreed that their teachers valued human contact with them and were supportive of students. CONCLUSION: Our results indicate that the PBL curriculum fosters better teacher-student relationships during the pre-clinical years. They also suggest that an unacceptably large number of medical students are taught by physicians who seem to lack compassion and caring in their interactions with patients. This study questions the adequacy of medical faculty as role models for the acquisition of caring competence by medical students.     

Structured packs for independent learning: a comparison of learning outcome and acceptability with conventional teaching

OBJECTIVES: The GMC recommends that students become independent learners, while tutor time is an increasingly precious resource. A set of structured learning materials requiring students to undertake and reflect on practical tasks in five learning areas was developed. DESIGN: The study used a randomized control trial to evaluate the effectiveness of using these structured learning materials in place of conventional teaching for 228 third-year undergraduate students and 55 teachers, on both hospital and community based medical and general practice firms. Evaluation involved assessing student performance on an examination question and a writing task, together with a student and tutor satisfaction questionnaire. SETTING: King's College School of Medicine and Dentistry, London. SUBJECTS: Third-year medical (first-year clinical) undergraduates. RESULTS: No significant difference in learning outcome was found for students on community- and hospital-based medical and general practice firms between students who had used the structured materials and those who had had conventional teaching on the same topic. The packs were acceptable to tutors and students. CONCLUSIONS: Such resources represent a mid-point between formal didactic teaching and self-directed learning. They may be particularly suitable for promoting independent learning for students on traditional medical courses. They offer an appropriate way to cover certain topics in the clinical curriculum and help to protect tutor time for topics which cannot be effectively taught in other ways.     

Medical teachers' concerns about the clinical teaching context

INTRODUCTION: Despite several unique aspects of the medical teacher's role compared to other teachers in higher education, there has been little research in this area. In particular there have been few studies which have explored teachers' perspectives on their role. This study aimed to elicit teachers' perceptions of the teaching environment in a single medical school at a time of curriculum change. METHODS: As part of an ethnographic study to explore the culture of the school, 22 teachers took part in in-depth, semi-structured interviews to ascertain their views and experiences of teaching. Additional data were collected through participant observation of curriculum meetings, and informal data collection. The data were analysed using a grounded approach, which resulted in over 200 analytic codes being assigned, which were later grouped into six main themes. RESULTS: The strongest themes to emerge were teachers' concerns about the students, the infrastructure for teaching and their relationship with the medical school. These included concerns about the lack of student clerking activity, insufficient monitoring of students, poor support or recognition of teaching and a perceived lack of inclusion in the medical school. DISCUSSION: The structure and culture within the medical school and associated hospital trust appeared to offer little support for doctors in their teaching role. This suggested that teaching was not highly valued. Teachers were preoccupied with the practical issues of teaching, leaving little time to consider more fundamental educational issues. These findings have implications for the quality of teaching and implementation of curricular change.     

Basic clinical skills: don't leave teaching to the teaching hospitals

OBJECTIVE: To compare student perception of teaching in general practice (GP), district general hospitals (DGHs) and teaching hospitals (THs) and their examination results. SETTING: The medical school at Queen's University, Belfast. SUBJECTS AND METHODS: A total of 161 medical and 34 dental students completed an objective structured clinical examination and questionnaire at the end of their second semester of basic skills teaching. They scored the course for teaching style, educational value and enjoyment. Teaching attributes of the tutors were similarly recorded. Students were also asked to quantify how time was used and to comment on the course. INTERVENTIONS: A new programme for teaching first- and second-year students basic clinical skills in the community. RESULTS: Teaching in GP and DGHs was reported to be more educational and enjoyable than in the TH. In GP most time was spent being lectured, in DGHs most time was spent with the patient, and in THs, waiting for the tutor. General practitioners and doctors in DGHs were more likely to model positive teaching attitudes such as showing interest in students and providing feedback. The most common complaints related to insufficient time spent with patients in GP and poor tutor preparation in THs. All teaching sites achieved similar examination results. CONCLUSION: Clinical skills can be taught to medical students early in their curriculum using GP tutors. Student preference was strongly for being taught by GPs rather than in THs. Simple steps such as prior preparation and the locating of a suitable patient could markedly improve student experience both in GP and in hospitals.     

The short-term stability of student ratings of instruction in medical school

The purpose of this study was to assess the degree of consistency in student ratings of teacher effectiveness during the first year of medical school. Student ratings of teaching effectiveness represent a commonly used source of information that enters into the academic decision-making process. In medical school, student evaluations often represent a major source of information that is used in promotion and tenure decisions. It is essential that the precision of such ratings be ascertained so that decision-makers will know how much confidence to place in this source of information on teaching effectiveness. In this study, each member of a first-year medical school class was randomly assigned a two-digit identification number at the beginning of the spring semester, 1986. As the semester progressed students were asked to evaluate each full-time teacher in three major courses. Multiple instructors were utilized in each course (n = 10). Each teacher was evaluated immediately after lectures during the first (T1) and second (T2) halves of the course. Students evaluated the teacher a third time (T3) as part of the end-of-semester overall course evaluation. The teachers were evaluated on a short eight-item Likert-type scale that identified several key indicators of effective teaching. Students attached their anonymous identification numbers to individual ratings so that their responses could be matched in the analysis. The results indicate that medical students are only moderately consistent in the extent to which they evaluate teachers. This inconsistency varied by course and by instructors within courses.(ABSTRACT TRUNCATED AT 250 WORDS)     

Training, job demands and mental health of pre-registration house officers

OBJECTIVES: This study aims to explore pre-registration house officer (PRHO) perceptions of work role, job requirements and mental health, in order to enhance work role preparation by means of identifying potential areas for curriculum development. DESIGN: Phase 1 took place 6 weeks before completion of the pre-registration year. A total of 56 PRHOs completed questionnaires which included a diary of activities, recorded daily over a 2-week period (ward rounds, on-call, audit, administration, continuing medical education, etc.), items relating to perceived occupational control, and the Maslach Burnout Inventory. In phase 2, in the final 2 weeks of the preregistration year, 36% (n=18) of phase 1 participants were randomly selected for interview. SETTING: Three hospitals in the North-west of England. RESULTS: The average working week was 56 h, with 10% working in excess of this figure. The average weekly proportion of time spent on organized continuing medical education was 5%. Routine administrative tasks took up one-fifth of PRHO time and were perceived as lacking in training or educational elements. Of the PRHOs, 52% (n=29) desired further advice/training on the technical and management aspects of the job. Additional training was required on topics such as chest drains, delegation and time management. PRHOs felt this should be given prior to commencement of the pre-registration year. In terms of mental health, 25% (n=14) were experiencing burnout. Occupational control was external; many individuals perceived events as often occurring outside individual control. CONCLUSIONS: These findings have implications for the undergraduate curriculum and support General Medical Council recommendations for curriculum reform. It is suggested that organizational skills such as managing responsibility/delegation and additional training in practical procedures should be an integral part of the medical undergraduate curriculum.     

Teaching medical students about over-the-counter medications

OBJECTIVES: Over-the-counter (OTC) medications account for over half of US drug expenses but have received little attention in medical school education. This pilot study evaluated student attitudes and knowledge in connection with a new curriculum in an ambulatory teaching clinic. DESIGN: Learning objectives were developed for six categories of OTC medications and students taught each other under the direction of a clinical pharmacist and family physician. Learning was undertaken in small groups and a site visit to a pharmacy was included. A 25-question test of knowledge was administered before and 6 months after the project, and student attitudes were assessed. SETTING: The sessions were taught as part of a longitudinal family medicine clerkship at an ambulatory care teaching clinic, Rockford, Illinois, USA. SUBJECTS: Twenty third-year medical students took the pre-test and attended the educational sessions; 19 completed the post-test and 16 completed the attitudinal survey. RESULTS: The mean pre-test score of 49% improved to 67% on the post-test (p<0.001). On the survey, 94% found the material useful and 88% liked the small group learning, but only 60% felt the pharmacy trip was worthwhile. CONCLUSION: In this study, medical students found teaching about OTC medications to be useful and showed significant improvement on a fund of knowledge test.     

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.     

The essential role of the student in curriculum planning

Medical school curricula are planned, written and organized by academic and clinical staff within medical schools. While these medical educators may well be experts in their given field, they lack first-hand experience of what it is to be a medical student in 1995. For a medical curriculum to be an effective means of learning for today's students, it must be written with a knowledge of their priorities, needs and abilities. The way in which this can be best achieved is by the inclusion of current students in all stages of designing a new curriculum.
In my second year of medicine at Flinders University, I became involved in planning for the new Graduate Entry curriculum. In the role of student advocate, I have found I am able to offer teaching staff a unique perspective, the student perspective , on various issues.
Students, through experience from their own education, are able to give advice on student resources and facilities and are in a favourable position to judge other aspects of curricula, such as the balance and relevance of course content and assessment. Students need to realize the valuable insight they have to offer their faculties and the way in which this can benefit future students. It is by actively seeking student involvement and using their input, that faculties will be able to create a consumer-friendly curriculum.     

The McMaster philosophy: a student''s perspective on implementation

The author visited McMaster Medical School as a fourth-year medical student in 1984 and took part in a 12-week unit 3 course. The present investigation on implementation of the educational principles of the MD programme was performed as an elective. A sample of 30 students out of 100 unit 3 all completed a questionnaire. Only 5 of 18 student groups used the 'cold', i.e. unprepared, approach to problem-solving during tutorials and 15 of 30 practised self-learning related to the last problem. The others spent most time on general reading. From unit 1 to unit 3 a declining number of groups used peer evaluation (less than 50%) and evaluation of groups (greater than 50%). The students felt that the performance of tutors should be improved. Most students attended lectures. It is suggested that tutor and group function may benefit from releasing the tutor from grading students. Despite its implementation problems, the author found the McMaster approach to education more beneficial than that of his own traditional school.     

Medical students in ENT outpatient clinics: appointment times, patient satisfaction and student satisfaction

OBJECTIVES: Outpatient clinics are increasingly important in medical education. The effect of students on clinic times and patient satisfaction, as well as their own satisfaction, were studied. DESIGN: A prospective, non-randomized, controlled study using adult patient questionnaires, medical student questionnaires and clinic time sheets. SETTING: Two teaching hospital ENT clinics. SUBJECTS: Medical students and adult patients. RESULTS: Three hundred and twenty-five patient questionnaires were collected (77% response), including 135 student encounters. Students did not affect appointment durations (19 min +/- 0.48 (standard error)) except at centre B (35 min +/- 1.1, P < 0.0001) where patient numbers were cut for teaching. Patient satisfaction, generally high, was not affected by students, appointment duration or gender of doctor or patient. It was slightly higher in the lower social classes (rs = 0.20, P = 0. 003) and older patients (rs = 0.17, P = 0.002). Student acceptability scores were not affected by student numbers (up to four), social class or time spent alone with students. They were higher if time was spent alone with the doctor (75.3% +/- 4.9) than not (63.0% +/- 1.8, P = 0.024). Thirty-six per cent of patients preferred to have a student present; only 9% preferred not. Student satisfaction was higher at centre B (73.7% +/- 2.3) where appointments were longer and students spent more time alone with patients than centre A (64.3% +/- 2.3, P = 0.0052). CONCLUSIONS: Clinic appointments are not necessarily longer in the presence of students. When students have the chance to see patients alone during longer consultations, student satisfaction is higher. Patient satisfaction, generally high, is not altered by the presence of students, but patients given time alone with their doctor are more accepting of students. These findings have resource implications for the planning of NHS clinics in teaching hospitals.     

Medical students' evaluation of tutors in a group-learning curriculum

This study focused on students' evaluation of tutors' effectiveness during an academic term, using a nineteen-item questionnaire. The study took place within an integrated problem-solving medical course. Four major factors in the tutor's behaviour were identified as having importance in the rating process: the ability to care for students, a knowledge of course structure and teaching staff philosophy, the ability to encourage independent thinking in students and a knowledge of the specific medical problems being studied. Further analysis suggested that students distinguish between good and bad tutors, those in different medical strands and with differing status. In general, the findings complement those dealing with student evaluation of lectures and to some extent, patient satisfaction with doctors.     

Attitudes of medical students to medical ethics in their curriculum

One hundred and one students at different levels of their medical education were surveyed as to their views about inclusion of medical ethics in their curriculum. The results showed that 88% of the students feel that medical ethics has a place in their curriculum, and 84% rated medical ethics to be of High to Critical Importance to good medical care. They tended to read infrequently about medical ethics, which they would like integrated at all levels of the curriculum, particularly the clinical years. The more senior students were less sensitive to ethical issues. The students mentioned only dramatic issues in their accounts of encounters with cases involving ethical issues. It is felt that a wide gap is left in the education of these students if medical ethics is not included in a positive way in their curriculum.     

Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school

OBJECTIVE: To explore attitudes among National Health Service consultants responsible for delivering basic clinical teaching to medical students. DESIGN: Postal questionnaire. SUBJECTS AND SETTING: A total of 308 acute hospital trust consultants working in 4 'new' and 4 'established' teaching hospitals in the West Midlands metropolitan area, and involved in the delivery of clinical teaching to Year 3 medical students at the University of Birmingham Medical School during 2002-03. MAIN OUTCOME MEASURE(S): The questionnaire explored contractual requirements, actual teaching commitments and perceptions of medical students' knowledge and attitudes. Responses from doctors and surgeons and from respondents working in established and new teaching hospitals were compared. RESULTS: A total of 249 responses were received (response rate 80.8%). Although many consultants enjoy teaching students, their enjoyment and their ability to deliver high standards of teaching are compromised by time and resource constraints. For many the situation is aggravated by the perceived inappropriate organisation of the clinical teaching curriculum and the inadequate preparation of students for clinical practice. Linking these themes is the overarching perception among teachers that neither service nor educational establishments afford teaching the levels of recognition and reward associated with clinical work or research. CONCLUSION: To overcome barriers to teaching requires more reciprocal links between hospital staff and medical schools, opportunities for consultants to understand and to comment on curricular and timetable developments, and, perhaps most importantly, recognition (in contractual, financial, managerial and personal terms) of the importance of undergraduate teaching in the competing triad of service, research and education.     

Medical students' learning needs about setting and maintaining social and sexual boundaries: a report

BACKGROUND: Despite increasing awareness of the potentially harmful consequences of social and sexual relationships between doctors and patients, little assessment has been made of the learning needs of medical students for setting and maintaining social and sexual boundaries in the doctor-patient relationship. AIM: To assess the learning needs of students with regard to issues concerning the setting of professional boundaries. METHODS: The study used a 4-part questionnaire, designed to collect both quantitative and qualitative data from medical students in all 6 years of the medical curriculum at 1 Australian university. RESULTS: A total of 293 students participated (94.5% response rate). The majority of students were ambivalent about the relationship between social and sexual boundary violations and sexual misconduct. A total of 21% of students said that sexual contact with patients might not be inappropriate. Short answers to a series of vignettes demonstrated conservatism on the part of students when faced with dilemmas. Most (87.4%) of the student population surveyed stated that insufficient teaching time had been given to issues concerning social and sexual boundaries. CONCLUSION: If medical schools shun teaching about the violation of social and sexual boundaries in doctor-patient relationships, sexual predators will continue to graduate.     

Comparing health care delivery systems – initiating a student exchange project between Europe and the United States

BACKGROUND: Cross-cultural contact among different health care systems can provide a framework for identifying the strengths and weaknesses of one's own healthcare system. However, such contact has rarely had much impact upon medical education curricula. Despite intense debate on reforming the healthcare delivery systems (HCDS) in Europe and the United States, there is very little formal representation of this interdisciplinary field in our educational programs. DESCRIPTION: To address this problem, a medical student exchange program was conducted in which students developed case studies that produced comparative analyses of HCDS in Germany, Sweden, Denmark and the United States. Each case is intended to highlight critical differences among the systems. EVALUATION: Students and their faculty preceptors completed pre- and post-exchange questionnaires to assess perceived knowledge of the HCDS and the adequacy of time devoted to it in their curricula. Both perceived that too little attention was devoted to this content in their programs. Following the exchange, students described clear increases in perceived knowledge. DISCUSSION: Our common interest in curriculum reform was key to implementing the exchange. The written cases generated by the students are being developed as course material in some of the schools and a conference is planned to disseminate the cases and the implementation strategies for their inclusion in medical curricula.     

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.     

Undergraduate surgical teaching utilizing telemedicine

OBJECTIVES: To evaluate the concept of a new telemedicine orientated educational application by exposing junior medical students to surgical teaching via video-conferencing from the operating theatre and comparing this to the traditional method currently employed, which requires the presence of students in the operating room. To determine student satisfaction with this novel method and identify deficiencies associated with traditional surgical teaching. DESIGN: Students were connected by video-conferencing equipment 2 Mbit/s permanent virtual circuits that provided two-way picture and voice communication. Traditional tutoring involved students attending the operating theatre in set numbers. Video recordings were made during the telemedicine transmission for highlighting important factors relevant to the operative procedure. A questionnaire was used to assess the quality of time spent and information obtained by the students. SETTING: Telemedicine centre and operating theatre, St Mary's Hospital, London. SUBJECTS: Junior clinical students. RESULTS: The median score for surgical teaching utilizing video-conferencing was 9 (scale 0-10) compared to 5 for traditional operating theatre surgical teaching. All 46 (100%) subjects indicated a willingness to return for the telemedicine influenced method of tutoring compared to 65% of students exposed to the conventional method. CONCLUSIONS: Our early experience with telemedicine assisted surgical teaching indicate high acceptance and satisfaction rates by clinical students. Further studies to evaluate the objective gain in knowledge associated with this method is required prior to its implementation in any future medical curriculum.