CeMENT: evaluation of a regional development programme integrating hospital and general practice clinical teaching for medical undergraduates. The Community-Based Medical Education in North Thames

OBJECTIVES: To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates. DESIGN: A multifaceted approach employing quantitative and qualitative techniques. SETTING: All medical schools in North Thames Region. SUBJECTS: Students, GP tutors and hospital specialists. RESULTS: The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess. CONCLUSIONS: This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project's key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure.     

Hostile teaching hospitals and friendly district general hospitals: final year students' views on clinical attachment locations

Context The NHS Plan has indicated the need to increase the number of doctors in the NHS. To accommodate the substantial increase in student numbers in Birmingham, clinical teaching will need to expand from its traditional base within established teaching hospitals (THs) to district general hospitals (DGHs). Previous studies elsewhere have suggested the experience of students who undertake clinical attachments in DGHs is different from that of students attached to THs. We sought to investigate whether such differences exist in the West Midlands region and to explore the opportunities and problems such differences may present to educators and students alike. Methods A questionnaire‐based survey of the TH and DGH experiences of all medical students in their final year (2000/01) of undergraduate training at the University of Birmingham Medical School was carried out. Results A total of 80% of students responded. Respondents indicated that both the identification of learning objectives and the provision of teaching to meet such objectives were likely to occur in TH and DGH settings equally. However, other differences emerged, suggesting that DGHs offer a friendlier and more supportive learning environment, with greater opportunities for the acquisition of hands‐on practical experience. Conclusions At present, the popularity of DGHs derives from the attitudes of staff and the opportunities for hands‐on experience. However, as student numbers increase, DGHs may be required to take on additional teaching commitments. Will DGHs be able to retain their existing educational characteristics or will they take on those associated with established THs?     

The teaching of communication skills in United Kingdom medical schools

A survey was carried out of the teaching of communication skills in medical schools in the United Kingdom during the academic year 1989/90. Comparison with previous surveys shows a considerable development over the last 10 years. Departments of psychiatry and general practice continue to play a major part in such teaching. There was wide variation in educational objectives and in the curricular time available. Concern is expressed about the methods of assessment and the degree of integration between departments. Future plans and the perceived barriers are reported and the implications discussed.     

A survey of medical undergraduate community-based teaching: taking undergraduate teaching into the community

Summary: Summary. This article summarizes the findings of a survey investigating the extent to which medical schools in the United Kingdom have developed community-based undergraduate teaching: the types of courses being run and their content; whether they are being evaluated; and how the students are assessed. Courses have been categorized under four main headings: (1) based in general practice, for teaching about general practice as a clinical specialty or using practice patients for teaching general medicine and basic clinical skills; (2) community-oriented, led by GP or community tutors; (3) specialist teaching led by hospital consultants; and (4) agency-based teaching. Twenty-eight schools responded to a written request for information and details of 83 courses were received.     

Linking general practices to the medical schools: qualitative issues

The University Linked Practices (ULP) programme links general practices involved in undergraduate medical education with computer services provided through the school of medicine and dentistry. In-depth interviews were conducted with 26 staff involved in teaching undergraduate medical students in 15 general practices across east London and Essex. The interview schedule focused on the use of the computer, IT experience and training needs and the use of the computer network as a resource in undergraduate teaching. It is important to work with curriculum planners to ensure that computers are fully integrated into new courses.     

Students conducting consultations in general practice and the acceptability to patients

OBJECTIVES: The General Medical Council has recommended that medical students should gain more experience in general practice. The study set out to determine patients' reactions to consultations conducted by a medical student alone prior to seeing their GP. DESIGN: A random sample of patients attending general practice surgeries in the Oxford area completed a questionnaire following consultation with a medical student. SETTING: Six general practice teaching surgeries. SUBJECTS: Fifth-year medical students. RESULTS: Of 130 responders 98% experienced no disadvantage in seeing the student; 35% considered that there were advantages in seeing the student; 98% said that they would be prepared to consult with a student again; 85% expressed no concerns about the gender of the student. CONCLUSIONS: The results of this study are very reassuring concerning the acceptability to patients of consulting with medical students and are more favourable than those reported for studies of students being present in consultations by GPs.     

Teaching clinical skills to new medical students: the Oman experience

The College of Medicine at the Sultan Qaboos University (SQU) in Oman took up the challenge of moving away from a didactic emphasis in the teaching of family and community health by actively involving students in health care, requiring some clinical skills, as early as possible. This paper describes the experience of the Department of Family and Community Health at SQU of the feasibility of training first-year medical students in the measurement of blood pressure within a few days. Our experience showed that proper training before starting field-work can teach clinical skills to students who have had no prior exposure to medical subjects. There was a strong correlation between the measurements of blood pressure of 638 individuals by the students and the supervisors. This experience at SQU has encouraged us to implement the idea of family- and community-based clinical exposure for every class. Teaching of clinical skills is feasible in the field for new entrants, provided there is adequate orientation beforehand and skilled supervision of the students in small groups.     

Survey of the teaching of disability and rehabilitation to medical undergraduates in the UK

The objective of the following survey was to attempt to establish to what extent the undergraduates in medical schools in the UK were being exposed to structured teaching of disability and rehabilitation (i.e. seminars, lectures, group discussions). A questionnaire and covering letter were sent to 25 medical schools exploring how the teaching was performed and whether it utilized the active involvement of disabled people and/or their carers. It also attempted to ascertain the degree of interdisciplinary teaching occurring. Results showed that rheumatology, general practice and geriatrics were predominantly responsible for this teaching, with little structured teaching in ENT and ophthalmology. Five schools (25%) reported back that no structured teaching was occurring in any department. As expected, there was a larger proportion of positive responses on opportunistic teaching (ward rounds, outpatients). Additional invited comments on the questionnaire revealed a variety of innovative activities taking place in different medical schools. It is recognized that a questionnaire of this nature has limitations; nevertheless, it did reveal gaps in the teaching of disability and rehabilitation, with several responses indicating that excess pressure on the curriculum from other subjects left little or no space at the present time. Our survey suggests that disability and rehabilitation are given insufficient emphasis in undergraduate teaching. In particular, more active involvement of patients and their carers should be encouraged. The small proportion of schools which teach rehabilitation as a defined specialty no doubt reflects the inadequate academic structure at present in this field.     

A comparison of the educational opportunities on junior medical attachments in general practice and in a teaching hospital: a questionnaire survey

OBJECTIVES: To obtain students' perceptions of the educational quality of the general internal medicine teaching overall and to determine whether specific learning objectives were better addressed in general practice or in hospital. DESIGN: The survey was carried out after a 10 week block of general internal medicine, consisting of five weeks taught in general practice and five weeks taught in a teaching hospital. Students were randomly allocated to start in either general practice or hospital. The outcome measure was a questionnaire survey of students perceptions' of their learning on the two halves of the block. Each student completed the same questionnaire twice: once after their hospital experience and once after their general practice experience. Statistical Analysis was carried out using the SPSS package for Windows 3.1. Group means were calculated for each response, and the mean differences for each student's responses for the two learning environments were analysed using t-tests for paired samples. SETTING: Royal Free and University College Medical School at University College London. SUBJECTS: The study population was the entire annual intake (n = 225) of students into the first clinical year at one UK medical school. RESULTS: Students perceived they learnt more about history taking and physical examination in the community, whereas they learnt more about writing up their clerkings, keeping progress notes and disease management in hospital. CONCLUSIONS: The community and hospital environments appear to have different strengths for the teaching of medical students. These data support judicious transfer of clinical skills teaching from teaching hospitals into general practice, when the circumstances achieved here can be duplicated. However, some aspects of the clinical attachment, particularly record keeping and disease management, are probably better taught in hospital at present.     

Teaching consultation skills: a survey of general practice trainers

BACKGROUND: Consultation skills are vitally important in general practice (GP), and now form part of the summative assessment of GP registrars in the UK. GP trainers need to be skilled in teaching consultation skills, and also need the time and resources to ensure that their registrars are competent in consultation skills. AIMS: To describe the teaching methods used by GP trainers in one deanery, the frequency of teaching of consultation skills, the problems encountered and the training that GP trainers have themselves received both in consultation skills and how to teach them. METHOD: Postal questionnaire survey of all the 164 trainers in the Yorkshire Deanery. RESULTS: Replies were received from 129 trainers (response rate 79%) of which 123 could be analysed. Of these trainers, 45 (37%) trainers taught consultation skills fewer than five times a year, 45 (37%) five to 10 times, and 14 (11%) more than 10 times a year. A total of 24 trainers reported problems with teaching consultation skills, most commonly lack of time, technical difficulties, and unreceptive registrars, and 97 (79%) trainers had had some postgraduate training in consultation skills with 112 (91%) reporting some form of teacher training. CONCLUSION: There is considerable variation in the reported frequency of teaching consultation skills, the models used, and the preparation of trainers for teaching, despite a systematic approach to teacher training in the Yorkshire Deanery.     

Dermatology examination performance: wide variation between different teaching centres

Summary: Summary. Three hundred and one clinical medical students in four universities took the same 50 question MCQ dermatology examination after their dermatology teaching. In one centre, half the students had had additional teaching; these students performed better (mean score 47.5%, n = 29) than those who had no extra teaching (mean score 40.9%, n = 29). In another centre, the students' mean score improved from 24.1 (SD = 6.7) before to 41.6 (SD = 7) ( n = 46, P < 0.001) after their dermatology teaching. The different subject areas covered by the examination were analysed separately. In the lowest scoring centre (mean score 34.0, SD = 9.4) the students scored lowest in 9 of the 14 subject areas. In the highest scoring centre (mean score 47.5, SD = 9.9) students scored highest in 7 of these 14 subject areas. This study enabled questions of high discriminatory value to be identified for future use. The use of the same examination in different centres provides feedback for the centres concerning strengths and weaknesses of their teaching.     

Context-bound communication skills training: development of a new method

OBJECTIVES: To examine how communication skills training might be integrated into everyday clinical practice in a manner that is acceptable to clinicians. DESIGN: General practitioners from 3 group practices agreed to take part, in turn, in a study of how to manage difficult consultations about antibiotic prescribing for acute respiratory infections. This provided the opportunity to conduct communication skills training in which lessons learned from one practice were taken into the next. SETTING: United Kingdom general practices. SUBJECTS: Three groups of general practitioners. FINDINGS: Difficulties with the acceptability of a traditional off-site workshop approach, using role play as the main teaching method, led to the development of a new training method (context-bound training), which proved to be practical and acceptable to experienced clinicians. The main features of the method were the delivery of training in the clinicians' place of work, and the transformation of their reported difficult cases into scenarios which they then encountered with a standardized simulated patient before and after brief seminars. Everyday clinical experience was kept in the foreground and 'communication skills' in the background. CONCLUSIONS: The method is acceptable to clinicians and adaptable to a range of clinical situations. It offers potential for improving the communication skills of clinicians both in hospital and primary care settings.     

Quality of clinical supervision as perceived by attending doctors in university and district teaching hospitals

CONTEXT: Attending doctors (ADs) play important roles in the supervision of specialist registrars. Little is known, however, about how they perceive the quality of their supervision in different teaching settings. We decided to investigate whether there is any difference in how ADs perceive the quality of their supervision in university teaching hospital (UTH) and district teaching hospital (DTH) settings. METHODS: We used a standardised questionnaire to investigate the quality of supervision as perceived by ADs. Fifteen items reflecting good teaching ability were measured on a 5-point Likert scale (1-5: never-always). We investigated for factors that influenced the perceived quality of supervision using Likert scale items (1-5: totally disagree-totally agree) and open-ended questionnaires. RESULTS: A total of 83 ADs (UTH: 51; DTH: 32) were eligible to participate in the survey. Of these, 43 (52%) returned the questionnaire (UTH: 25; DTH: 18). There was no difference in the overall mean of the 15 items between the UTH (3.67, standard deviation [SD] 0.35) and DTH (3.73, SD 0.31) ADs. Attending doctors in the DTH group rated themselves better at 'teaching technical skills' (mean 3.50, SD 0.70), compared with their UTH counterparts (mean 3.0, SD 0.76) (P = 0.03). Analysis of variance of the overall means revealed no significant difference between the different hospital settings. CONCLUSIONS: The results suggest that teaching hospital environments do not influence how ADs perceive the quality of their supervision. Lack of time for teaching was perceived as responsible for poor supervision. Other factors found to influence AD perceptions of good supervision included effective teaching skills, communication skills and provision of feedback.     

Health education poster: a teaching model for clinical medical students

Summary. The teaching of health education or health promotion to medical students is often difficult because they have little experience on which to base their learning. They have limited clinical knowledge and in particular their awareness of the value of and the opportunities for health promotion in general practice is limited. The problem-oriented teaching method described here attempts to make the subject interesting and relevant by asking students, while in their practice attachments, to identify areas of need for health promotion or health education and then to prepare a poster, with supportive background and research, to satisfy that need for display in their given practice.     

Translating learning principles into practice: a new strategy for learning clinical skills

AIM: There are data to suggest that medical school may not adequately prepare doctors for practice and that there are deficiencies in undergraduate teaching of skills in history taking, physical examination, diagnosis and management (clinical skills). There is a need to re-evaluate methods by which we can teach clinical skills effectively. This aim of this review was to describe the literature concerning the important principles underpinning effective clinical learning. Subsequently a structured learning tool and teaching process was developed in order to support these principles. METHOD: The principles of effective clinical learning were derived after a search of the medical education and relevant behavioural science literature. Consequently, a structured learning tool and teaching process was developed in order to potentiate the translation of these principles into practice for medical school training in clinical skills. RESULTS: Ten principles were derived from the 68 articles referred to in this review. These were: making active decisions, an individual focus to learning, gaining experience, feedback to the learner, reciprocal learning, holistic care, relevant learning, feasibility, cost efficiency and mentoring. A process for history taking, physical examination and management plan was developed for medical students which incorporated these principles. CONCLUSION: Relevant literature can provide the foundations for teaching and learning methods in medical education. We plan to trial this method and evaluate the impact on student learning outcomes.     

Preliminary evaluation of "interpreter" role plays in teaching communication skills to medical undergraduates

RATIONALE AND OBJECTIVES: Multiculturalism presents linguistic obstacles to health care provision. We explored the early introduction of "interpreter" role-play exercises in teaching medical undergraduates communication skills. The interpreter role creates a natural barrier in communication providing an active prompt for recognizing learning needs in this area. METHODS: Bilingual Cantonese first-year medical students (n=160) were randomly allocated to either "Observer" or "Interpreter" role plays at a small-group introductory communication skills workshop using a quasi experimental design, counterbalanced across tutors. Students assessed their own skill competence before and, together with their perceptions of the different role plays' effectiveness, again after the workshop, using an anonymous 16 item Likert-type scale, analysed using ANOVA and MANOVA. RESULTS: Students' assessments of their skills improved significantly following the workshop (F=73.19 [1,156], P=0.0009). Students in the observer group reported greater changes in their scores following the workshop than did students in the interpreter group (F=4.84 [1,156], P=0.029), largely due to improvement in perceived skill (F=4.38 [1,156], P=0.038) rather than perceived programme effectiveness (F=3.13 [1,156], P > 0.05). Subsequent MANOVA indicated no main effect of observer/interpreter conditions, indicating these differences could be attributed to chance alone (F=1.41 [16 141], P > 0.05). CONCLUSION: The workshop positively influenced students' perceived communication skills, but the "Interpreter" role was less effective than the "Observer" role in achieving this. Future studies should examine whether interpreter role plays introduced later in the medical programme are beneficial.     

Some problems in teaching clinical decision-making

Evaluation of a number of courses in clinical decision-making (CDM) indicates that there are well-defined problems in teaching this subject. This paper describes some of the difficulties and proposes appropriate remedies. Problems in teaching undergraduates are different from those in the postgraduate years. Three areas where the principles of CDM are particularly useful to undergraduates relate to the structuring of clinical problems, clarifying the place of value judgements and developing new concepts regarding test ordering, particularly the importance of false positive rates and the overwhelming power of prior probabilities. In postgraduate teaching the most important areas relate to the origin of probability and of utility estimates. The complexity of decision analysis also needs critical comment. Two remedies are suggested which will help course developers when faced with these problems. Firstly, the early introduction of concepts regarding sensitivity analysis, making it clear that with the aid of CDM we are able to deal with a wide range of probability estimates, precision rarely being required in clinical medicine. Secondly, the availability of educational support systems will help expert clinicians teach CDM concepts within their own field.     

An audit of clinical teaching in paediatric surgery to interns and surgical registrars

OBJECTIVES: The study aimed to assess the knowledge increment in paediatric surgery of interns (pre-registration) after a 1-month period of training and of registrars after a 6-month rotation. A comparison of the knowledge base of interns from different universities was included. DESIGN: A standard questionnaire was completed by all interns and registrars on the first day of their appointment and again at the end of rotation. Knowledge increment was assessed for each student and each question. SETTING: King Edward VIII Hospital, Durban, South Africa. SUBJECTS: Interns (equivalent to pre-registration house officers) and registrars (registered practitioners) undergoing general surgical training. RESULTS: Both registrars and interns improved their test scores after their training period. However, satisfactory exit scores were achieved by interns in only 72% of questions. CONCLUSIONS: This study forms the basis for assessing future educational strategies and has identified areas of teaching weakness which can be remedied. The reduction in exposure of interns to clinical paediatric surgery must be balanced by more efficient use of teaching time.     

Teaching clinical skills to medical students: the use of simulated patients and videotaping in general practice

This paper describes the use of simulated patients in a problem-based teaching programme designed to develop the clinical skills of medical students during a 5-week course in general practice in the University of Leicester. The logistics of training and the advantages of using simulated patients are discussed. Simulated patients are practicable and acceptable in a United Kingdom medical school, and the reaction of students to their use is favourable.