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.     

What anatomy shall we teach medical and dental students in a primary health care curriculum?

The opinions of 142 doctors on the relevance of anatomy to the diagnosis and management of common clinical problems in their current medical and dental practice were analysed. This was in a bid to determine the relevant anatomy course content for the new primary health care oriented medical and dental curriculum of the College of Medicine, University of Lagos. The respondents gave high scores to the relevance of anatomy knowledge to the management of acute abdomen (mean = 3.5), dislocated shoulder (3.3), Colles' fracture (3.2), palmar space abscess (3.2), obstructed labour (3.2), carcinoma of the breast (3.2), ectopic pregnancy (3.1), flail chest (3.1) and upper respiratory obstruction (3.0). They gave minimal scores to helminthiasis (mean = 1.5) common cold and anaemia (1.6), sickle cell disease (1.7), gastroenteritis (1.8), dental abscess (2.0), hypertension (2.2) and asthma (2.2). A basis for selecting relevant anatomy course content is deduced for an undergraduate curriculum in which the responsibilities and competence of the graduates is known. A nationwide extension of the study, especially amongst general practitioners and first-line doctors in rural areas, would be useful for identification of health problems that require little or no knowledge of anatomy and which can be safely managed by lower cadres of health personnel, traditional practitioners and members of the lay community.     

Student-directed problem-based learning in general practice and public health medicine

The development and implementation are described of a new 6-week course in general practice and public health medicine for final-year medical students. This course is based on the principles of student-directed problem-based learning in small groups and makes substantial use of student attachments to local general practices which act as learning resources. Student assessment is by profiles. Course evaluation is by qualitative feedback, and the results of this are presented. The course offers a flexible learning environment in which the aims of its designers and the goals of their students can be achieved.     

Introducing training in primary health care programme management into the curriculum

A short account of the objectives and strategies of Gezira Medical School in relation to community medicine and primary health care is given. The introduction of primary health care programme management into the curriculum is described. Preliminary evaluation of the first course reflected positive results for students' achievement and acceptance. The experience proved the feasibility of integrating health care programme management into the undergraduate curriculum.     

Medical curricula and students'' attitudes towards general and family practice in Mexico

In an exploratory study of the influence of different undergraduate curricula on students' attitudes towards general and family medicine, a questionnaire including a Likert attitude scale was administered to a sample of 1217 first- and fourth-year students at five medical schools with different curricula in Mexico City. The preliminary results suggest that the innovative educational programmes have not apparently had a significant impact on students' attitudes. It is hypothesized that students' perceptions of the job market are stronger in determining their attitudes than the orientation of the curriculum itself. It is also suggested that the differences found among the students of the five schools might have been due to differences in the populations entering them. The instrument developed during the study proved to be sufficiently reliable to warrant further use.     

Family and community health in a new medical school

The planning and implementation of a curriculum for a department of family and community health in a new medical school in a developing country presents special problems. The evolution of the programme at Sultan Qaboos University in the Sultanate of Oman is described and discussed.     

Integrated medical student teaching. A combined course in community medicine, general practice, geriatrie medicine and mental health

In order to provide 'horizontal' integration of related clinical subjects, a combined teaching course in community medicine, general practice, geriatric medicine and mental health has been devised. The course lasts 12 weeks and is divided between joint teaching of topics of common interest and clinical clerkships in individual disciplines. A joint assessment takes place at the end of the course. The course was popular with students who all felt that it covered topics not encountered in other parts of the medical curriculum. A course of this type leads to a better integration of clinical subjects and avoids repetition or omission of topics which are not clearly the responsibility of any individual department.     

Teaching student-centred educational approaches to general practice teachers

Summary. The people responsible for undergraduate medical education are being urged to devise curricula which are more learner centred and community oriented. This has huge implications for teacher training. A project is reported aimed at helping general practice teachers develop learner-centred educational approaches through one-day workshops, themselves arranged on learner-centred lines. An evaluation indicates these workshops met their aim, and seem most useful when participants have an opportunity to practise newly acquired skills as soon afterwards as possible.     

HIV/AIDS workshop for primary health care staff

The purpose of this study was to develop and pilot a workshop to train general practitioners and other primary care workers to become competent in the primary, secondary and tertiary prevention of acquired immunodeficiency syndrome (AIDS). The development of the workshop took place at four venues in the South West Thames Region and involved 41 general practitioners and 33 primary care nurses. Questionnaire evaluation before and immediately after each workshop showed a significant improvement in participants' attitudes towards the prevention and management of human immunodeficiency virus (HIV) infection in general practice. We conclude that a suitably designed workshop can be effective in improving the attitudes of primary health care workers towards AIDS prevention and care.     

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.     

Academic careers in general practice and primary care

In the past 10 years, significant developments in general practice teaching and research have led to the considerable growth of academic general practice as a discipline. This paper reviews issues relating to these developments, particularly career pathways and training aspects. The need to extend these advances to the broadening arena of primary health care has given further impetus for the development of academic careers. General practice will need to work closely with secondary care, community health, and social services to develop primary health care in its broadest sense, and an evidence base, generated by relevant research and evaluation, must underpin all of this. Structural and funding changes to undergraduate education, postgraduate training and primary care research have created a range of opportunities for general practice clinicians to define career pathways, not formerly available, within multiprofessional and multidisciplinary departments and groups. Education for future general practice and primary care must underpin developments as much as a research base. Relevant masters' degrees and diplomas are now widely available, and extended vocational training and higher professional education will enable general practitioners in their formative years to consider academic opportunities.     

Audit: teaching medical students in general practice

Summary. Audit is being seen as an increasingly important topic for medical students. Many departments of general practice in the UK now incorporate audit as part of their course work. It remains controversial as to whether this is perceived to be worthwhile by the students. Following an introductory seminar final-year medical students at the University of Glasgow were asked to perform a case-note review of 10 randomly chosen diabetic patients for a number of process and outcome measures during their practice attachments. Feedback was given in their final teaching session. 128/153 (84%) students completed an evaluation of the course on their knowledge and attitudes to audit. Unsurprisingly, 39% found the data collection boring or very boring; however, 60% found the feedback session very interesting or interesting. Both the data collection and the feedback were considered relevant by the majority of students (57% and 70% respectively). Students' self-reported knowledge also dramatically increased (P < 0.0001 ).     

A new integrated course in preventive and community medicine

An integrated course in Preventive and Community Medicine was introduced at the Christchurch Clinical School, New Zealand in 1974. Details of the fourth and fifth clinical years as well as the elective studies in the trainee intern (sixth) year are presented. The implications of the topic studies, rotating attachments, preventive medical examinations, preventive medical ward rounds, problem-orientated record studies, simulated disabilities and Clinico-Pathological Conferences are discussed. Some preliminary conclusions are drawn from the evaluation of this course.     

A human sexuality course for Oxford University medical students

A human sexuality course for clinical students in Oxford was held based on the format of similar courses held in the U.S.A. with one-and-a-half days of films and lectures followed by discussion in small groups. The course was largely successful and evaluation of attitudes and knowledge revealed that significant preliminary changes resulted. Students who failed to complete the course had more inhibited attitudes towards sexuality and less sexual information compared with those who attended the whole course. Advice is given to those intending to hold such a course elsewhere, including how more inhibited students, who probably are most in need of such teaching, might be encouraged to participate.     

Competence-based summative assessment of a student-directed course: involvement of key stakeholders

The 5-week module in general practice for final-year students at the University of Sheffield is based on practice attachments and student-directed learning in small groups. This paper describes how the summative assessment process of the module was revised to incorporate the notion of competence-based assessment, and how general practitioner tutors, departmental tutors and students were involved in this revision. The question ‘What are students expected to know and be able to do by the end of the module?’ was answered in terms of a statement of the key purpose of the module and a list of intended learning outcomes. The question ‘How can we find out if students have achieved these outcomes?’ was addressed by developing check-lists of criteria for observed behaviours and for the written products of students' actions.     

General practice in the undergraduate curriculum: 20 interviews with Southampton final-year students

The Primary Medical Care Group at the University of Southampton contributes to the medical curriculum in the first, third and final years. A visiting lecturer from Sweden took the opportunity to interview a sample of 20 final-year students using a qualitative approach. Questioning centered on the impact of the primary care course both in relationship to medicine as a whole and to general practice. It was found that primary medical care was often not seen as a central or integral part of the curriculum but many students acknowledged its important contribution to seeing the patient as a whole and in integrating the various other parts of the curriculum, with significant opportunity for role modelling and informing career choice. A hidden curriculum emerged of attitudes which provided a conflict for some students. Improvements should include clearer dovetailing of primary medical care with other curricular components, limitation of aims with more specific and rigorous assessment and a wide strategy of staff development not confined to those directly involved in general practice attachments.     

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

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

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.     

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.