Acquisition of basic clinical skills in the general practice setting

Is there a role for GPs in teaching neurology to medical students? A qualitative evaluation

INTRODUCTION

The purpose of this study was to evaluate whether GPs can support medical students in learning basic neurology in the context of a traditional hospital neurology attachment.

METHOD

This was a qualitative evaluation using routinely collected data from stakeholders, consisting of qualitative data in the form of student evaluation questionnaires, course documentation and correspondence from faculty staff.

RESULTS

The addition of GP teaching to the programme increased availability of patients with neurological problems accessible to students and provided a safe, supportive environment for students to learn their fundamental clinical skills. Students gained valuable insights into the impact of neurological disease from the perspective of patients, their families and carers. GP teaching of neurology was well regarded by students. Some GP tutors felt they lacked adequate experience to teach more technical aspects of neurology, and some students shared this concern. Concepts of professional boundaries between generalists and specialists were not observed, but GP teaching was perceived to be 'other' or outside normal medical school activity.

CONCLUSIONS

General practitioners can successfully facilitate students' access to patients with neurological disease and employ their generalist to enhance neurological learning. Some GPs were initially uncomfortable with teaching skills such as detailed neurological physical examination.

A BEME systematic review of UK undergraduate medical education in the general practice setting: BEME Guide No. 32

BACKGROUND

General practice is increasingly used as a learning environment in undergraduate medical education in the UK.

AIM

The aim of this project was to identify, summarise and synthesise research about undergraduate medical education in general practice in the UK.

METHODS

We systematically identified studies of undergraduate medical education within a general practice setting in the UK from 1990 onwards. All papers were summarised in a descriptive report and categorised into two in-depth syntheses: a quantitative and a qualitative in-depth review.

RESULTS

169 papers were identified, representing research from 26 UK medical schools. The in-depth review of quantitative papers (n = 7) showed that medical students learned clinical skills as well or better in general practice settings. Students receive more teaching, and clerk and examine more patients in the general practice setting than in hospital. Patient satisfaction and enablement are similar whether a student is present or not in a consultation, however, patients experience lower relational empathy. Two main thematic groups emerged from the qualitative in-depth review (n = 10): the interpersonal interactions within the teaching consultation and the socio-cultural spaces of learning which shape these interactions. The GP has a role as a broker of the interactions between patients and students. General practice is a socio-cultural and developmental learning space for students, who need to negotiate the competing cultures between hospital and general practice. Lastly, patients are transient members of the learning community, and their role requires careful facilitation.

CONCLUSIONS

General practice is as good, if not better, than hospital delivery of teaching of clinical skills. Our meta-ethnography has produced rich understandings of the complex relationships shaping possibilities for student and patient active participation in learning.

Student perceptions of GP teachers' role in community-based undergraduate surgical education: a qualitative study

Objectives

To evaluate medical students' perceptions of a new community-based surgical module being delivered as part of a third-year clinical methods teaching (CMT) course at Imperial College, London.

Design

A qualitative study using focus group interviews with medical students who had recently completed the surgical module. Focus group discussions were recorded, transcribed and analysed to identify key categories that reflected the positive and negative aspects of the student's perspectives.

Setting

Imperial College, London

Participants

Two groups of fourth-year medical students were invited to participate in the focus groups. The first group consisted of seven students from the surgery and Anaesthesia BSc course. The second group consisted of a random sample of five students from other BSc courses at Imperial College.

Main Outcome Measures

These were not defined pre-study as the purpose of the study was to obtain student perceptions of the surgical module. Facilitators were given guide questions to aid consistency and prompted discussion where required using an inductive approach to the topics discussed by the students.

Results

Student opinions of surgical teaching delivered in the community compared favourably with the surgical teaching delivered in hospitals. Students identified the key benefits as: having protected time to learn, regular access to suitable patients, and teaching that was more learner-centred. Challenges identified by students included the GPs' lack of specialist knowledge and teaching that was dictated by individual interests rather than the syllabus.

Conclusions

Community-based teaching has been widely used to deliver teaching traditionally taught in hospital settings. However, surgical skills are still taught largely by surgical specialists within hospitals. Our study suggests that students are receptive to GPs teaching surgical topics in the community and perceive GPs as competent teachers. This study suggests that there may be benefits in delivering traditional surgical modules in community settings. Providing training for teachers may be a key factor in ensuring quality of surgical teaching for all students.

Patients' attitudes towards medical students in a teaching family practice: a sri lankan experience

Background:

Faculty of Medicine, University of Kelaniya, Sri Lanka conducts a one month under graduate training programme during their fourth year at the University family practice centre. Students get training in history taking, clinical examination, patient management and practice management during this attachment. This study was conducted to look at the patients’ attitude towards student participation during consultation.

Materials and Methods:

This was a descriptive cross sectional study. All the patients who were 16 years and above during a 2 month period were included in the study. Structured questionnaire was administered by demonstrators following a consultation where students were present. Their demographic data, number of consultations with student participation and questions related to presence of students at various stages of the consultation were asked.

Results:

Total of 85 patients took part in the study and 81.3% of them were females. 88.8% were of the opinion that they benefited by the interaction with medical students while 93.8% thought students understood their problems. 26.3% patients preferred a medical student of the same sex during consultation while 71.3 had not expressed any opinion in this regard. Only 3.8% and 5% wanted the doctor alone during history taking and examination respectively. Almost every patient was happy that they could help the undergraduate training.

Discussion:

As expected results of the study showed that patients were willing to take part in undergraduate training without any reservation. These results are compatible with the previous studies done in the western world and data is not available form either Sri Lanka or other Asian countries.

Clinical exposure during clinical method attachments in general practice

BACKGROUND

There has been a significant decline in medical students' clinical experience in hospitals. Hospital-based teaching is struggling to provide medical students with sufficient experience of the common health problems of our industrialized ageing society. Hence, general practice has become an important locus for medical education. Published evidence, however, that students can access appropriate clinical experience in general practice is sparse.

OBJECTIVE

To determine students' clinical exposure during clinical and method attachments based in general practice at two medical schools. EDUCATIONAL INITIATIVE: Students were attached to general practice tutors to learn clinical method in internal medicine.

METHOD

General practice tutors from two medical schools collected data on age, gender, diagnoses, symptoms and signs of the patients they invited to teaching sessions.

RESULTS

The frequency of diagnoses, symptoms and signs seen by medical students are recorded. Students mostly saw patients with chronic illnesses; the commonest diagnoses were ischaemic heart disease and angina.

DISCUSSION

Our study has recorded the largest published database of clinical diagnoses, symptoms and signs encountered by students learning clinical method in general practice. It shows that students obtained a wealth of experience with patients with common chronic diseases. Students must also learn in the hospital setting, to experience the presentation of acute illness. The combination of teaching in these two settings is likely to provide the most effective technique to ensure that students encounter the common, acute and chronic conditions that affect patients in the 21st century.

What do students actually do on an internal medicine clerkship? A log diary study

BACKGROUND

There are limited data on the amount of time students spend on teaching and learning while on internal medicine clerkships, and existing data suggest a wide international variation. Community-based teaching of internal medicine is now widespread; but its strengths and weaknesses compared to traditional hospital based teaching are still unclear.

AIM

To determine the proportion of time students spend on different activities on an internal medicine clerkship, and to determine whether this differs in general practice and in hospital. In addition we aimed to determine students' views on the educational value and enjoyment of various activities.

METHODS

Prospective completion of log diaries recording student activities. Each student was asked to complete the diary for two separate weeks of their internal medicine clerkship: one week of general practice-based teaching and one week of hospital-based teaching.

RESULTS

The response rate was 68% (88/130). Students spent approximately 5.5 h per day on teaching and learning activities in both environments, with more time (50 min vs. 30 min, P = 0.007) on unsupervised interaction with patients in hospital than in general practice, and more time (53 min vs. 21 min, P < 0.001) undergoingassessment in general practice than in hospital. Standard deviations were wide, demonstrating the heterogeneous nature of the data. Students perceived supervised interaction with patients and teaching by doctors as the most educational activities in both environments, but found it even more educationally valuable and enjoyable in general practice than in hospital (mean score for educational value: 4.27 in general practice, 3.88 in hospital, P = 0.048; mean score for enjoyment 4.13 in general practice, 3.66 in hospital, P = 0.03).

CONCLUSIONS

Students greatly value interactions with patients, perceiving these as both educational and enjoyable. Curriculum planners must continue to place patient-based learning at the centre of undergraduate medical education. The heterogeneity of the data suggests that individual students have very different experiences, despite apparently similar timetables.

Early patient contact in primary care: a new challenge

BACKGROUND

The Medical School of Lund University, Sweden, has introduced an early patient contact course, including training in communication and examination skills. The course runs parallel with theoretical subjects during the students' first two-and-a-half years. General practitioner (GP) participation is gradually increasing, and in the last half-year of the course GPs in all health centres in the area are involved. Little is known about the GPs' interest, competence and time for this new task.

AIM

To describe the GPs' attitudes towards teaching and the rewards and problems they experience.

SUBJECTS

30 GPs teaching third-year medical students.

METHOD

Semistructured interview study. Data analysis by a method described by Malterud.

RESULTS

The attitude towards teaching was mostly positive and the teachers were confident about teaching examination procedure. Among rewards of teaching, improved quality of clinical practice was the main theme, but imparting knowledge to others, contact with enthusiastic students, and gains in self-esteem were also mentioned. Problems with teaching were mostly due to external factors such as lack of time and space, but concern about a negative effect on patient care was also recognized. Educational objectives of the course were not completely accepted. GPs were not fully aware about what to expect from the students, with subsequent problems concerning how to assess students' performance and how to give effective feedback.

CONCLUSIONS

The teaching of junior medical students is maintained by the GPs' enthusiasm for teaching. However, teacher training is required and the crucial issues of time and space have to be considered.

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.

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.

Students' perceptions of the relative advantages and disadvantages of community-based and hospital-based teaching: a qualitative study

AIMS

To obtain the perceptions of first-year clinical medical students of the relative advantages and disadvantages of community-based and hospital-based clinical teaching.

METHODS

A qualitative study. A purposive sample of first-year clinical medical students who had experienced both community-based and hospital-based teaching was invited to participate in individual semistructured interviews or focus groups. Interviews and focus groups were audiotaped and transcribed to facilitate content analysis of the data. A total of 24 students participated in individual interviews and a further 18 took part in focus groups.

RESULTS

Respondents identified advantages and disadvantages specific to teaching in each setting. Chief advantages of hospital-based learning were perceived to include learning about specialties and the management of acute conditions, and gaining experience of procedures and investigations. Community-based learning was perceived as particularly appropriate for learning about psychosocial issues in medicine, for increasing students' awareness of patient autonomy and for improving communication skills. In addition, aspects of organization and of teaching methods employed by community tutors, although not site-specific, were viewed as conducive to a positive educational experience. Students perceived some areas, such as clinical skills acquisition, to be equally well learned in either setting.

DISCUSSION

As community-based teaching forms a greater proportion of the undergraduate medical experience, medical educators must find ways of determining the specific advantages that community and hospital settings can contribute to undergraduate learning and of using these resources effectively to develop comprehensive and integrated curricula. Innovations in teaching methods may also be necessary to provide an effective educational experience and promote active learning.

Influence on general practitioners of teaching undergraduates: qualitative study of London general practitioner teachers

OBJECTIVE

To examine the perceived effect of teaching clinical skills and associated teacher training programmes on general practitioners' morale and clinical practice.

DESIGN

Qualitative semistructured interview study.

SETTING

General practices throughout north London.

SUBJECTS

30 general practitioners who taught clinical skills were asked about the effect of teaching and teacher training on their morale, confidence in clinical and teaching skills, and clinical practice.

RESULTS

The main theme was a positive effect on morale. Within teacher training this was attributed to developing peer and professional support; improved teaching skills; and revision of clinical knowledge and skills. Within teaching this was attributed to a broadening of horizons; contact with enthusiastic students; increased time with patients; improved clinical practice; improved teaching skills; and an improved image of the practice. Problems with teaching were due to external factors such as lack of time and space and anxieties about adequacy of clinical cover while teaching.

CONCLUSION

Teaching clinical skills can have a positive effect on the morale of general practitioner teachers as a result of contact with students and peers, as long as logistic and funding issues are adequately dealt with.