Teaching in practice: a qualitative factor analysis of community-based teaching

How does the introduction of a new year three GP curriculum affect future commitment to teach? An evaluation using a realist approach

In western countries, there is a trend towards increasing amounts of undergraduate medical education being delivered in General Practice (GP). However, many medical schools report difficulties with the recruitment and retainment of GP clinical teachers. Newcastle University recently introduced a new year three GP curriculum, involving an increased quantity of community-based teaching and changes to the responsibilities of GP clinical teachers. We sought to explore and explain how this curricular change affects the future teaching commitment of year three GP clinical teachers. We adopted a realist approach. We firstly developed a candidate theory of how the new curriculum may affect future teaching commitment. Data collection and analysis then involved interviews of 10 GP teachers to refine this theory and produce a final Programme Theory. The results suggest that different teachers are affected in different ways, influenced by practice and individual contexts. Some parts of the new curriculum tend to reduce future teaching commitment, whereas other aspects tend to increase commitment. Mechanisms include changes to autonomy and sense of value. The results allow medical schools to better understand how GP teacher retention can be facilitated during curricular change. We make numerous recommendations, including advocating a team-based approach to teaching, paying attention to teacher autonomy, and considering patient contact in relation to generalist, primary care-orientated medicine as a core component of GP teaching.

Understanding impacts of accreditation on medical teachers and students: A systematic review and meta-ethnography

PURPOSE

Accreditation is widely used by medical schools around the word to evaluate their curricula and educational processes, although its impacts on those involved in the 'frontline' of medical education receive little attention. This study systematically identified and synthesised qualitative studies that have explored medical teachers' and students' experiences of accreditation.

METHODS

Four databases (Pubmed, EMBASE, ERIC, and PsychINFO) were searched for relevant published articles. Synthesis was performed using meta-ethnography.

RESULTS

Eighteen articles were included in the final synthesis with 1017 individual participants from 10 countries. Findings were categorised into four domains, including navigating power differentials, evaluating credibility, influencing medical programmes, and culture and behaviour. The synthesis demonstrates divergent views on the value of accreditation in medical schools from students and staff including both positive and negative impacts on medical education programmes and stakeholders.

CONCLUSIONS

Although accreditation is perceived to have many benefits, it also has a number of unintended consequences, including on staff morale, student-teacher relationships, and teacher workloads. Medical teachers also have a number of concerns about the credibility of accreditation standards, assessors, and processes. Regulators and policymakers should consider the views of teachers and students as they seek to improve current accreditation practices.

Selecting, training and assessing new general practice community teachers in UK medical schools

BACKGROUND

Standards for undergraduate medical education in the UK, published in Tomorrow's Doctors, include the criterion 'everyone involved in educating medical students will be appropriately selected, trained, supported and appraised'.

AIMS

To establish how new general practice (GP) community teachers of medical students are selected, initially trained and assessed by UK medical schools and establish the extent to which Tomorrow's Doctors standards are being met.

METHOD

A mixed-methods study with questionnaire data collected from 24 lead GPs at UK medical schools, 23 new GP teachers from two medical schools plus a semi-structured telephone interview with two GP leads. Quantitative data were analysed descriptively and qualitative data were analysed informed by framework analysis.

RESULTS

GP teachers' selection is non-standardised. One hundred per cent of GP leads provide initial training courses for new GP teachers; 50% are mandatory. The content and length of courses varies. All GP leads use student feedback to assess teaching, but other required methods (peer review and patient feedback) are not universally used.

CONCLUSIONS

To meet General Medical Council standards, medical schools need to include equality and diversity in initial training and use more than one method to assess new GP teachers. Wider debate about the selection, training and assessment of new GP teachers is needed to agree minimum standards.

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-centred GP ambassadors: Perceptions of experienced clinical tutors in general practice undergraduate training

OBJECTIVE

To explore experienced general practitioner (GP) tutor perceptions of a skilled GP tutor of medical students.

DESIGN

Interview study based on focus groups.

SETTING

Twenty GPs experienced in tutoring medical students at primary health care centres in two Swedish regions were interviewed.

METHOD

Four focus-group interviews were analysed using qualitative content analysis.

SUBJECTS

Twenty GP tutors, median age 50, specifically selected according to age, gender, and location participated in two focus groups in Gothenburg and Malmö, respectively.

MAIN OUTCOME MEASURES

Meaning units in the texts were extracted, coded and condensed into categories and themes.

RESULTS

Three main themes emerged: "Professional as GP and ambassador to general practice", "Committed and student-centred educator", and "Coordinator of the learning environment".

CONCLUSION

Experienced GP tutors describe their skills as a clinical tutor as complex and diversified. A strong professional identity within general practice is vital and GP tutors describe themselves as ambassadors to general practice, essential to the process of recruiting a new generation of general practitioners. Leaders of clinical education and health care planners must understand the complexity in a clinical tutor's assignment and provide adequate support, time, and resources in order to facilitate a sustainable tutorship and a good learning environment, which could also improve the necessary recruitment of future GPs.

Rewards, costs and challenges: the general practitioner's experience of teaching medical students

CONTEXT

Medical student attachments in general practices play an important role in undergraduate medical education internationally. The recruitment by universities of new teaching practices or an increase in the teaching commitment of existing practices will be necessary to address rising medical student numbers. General practitioners (GPs) are likely to weigh the perceived rewards of practice-based teaching against the perceived costs and challenges in deciding whether to accept a student placement and how to teach. These aspects of the 'lived experience' of the GP-teacher have not been adequately investigated.

OBJECTIVES

This study aims to enhance understanding of the GP clinical teacher experience in order to inform strategies for the recruitment, retention, training and support of teaching general practices.

METHODS

Sixty GP clinical teachers in Brisbane-based urban teaching general practices were interviewed individually face-to-face by the principal investigator, using a semi-structured interview plan. Representativeness was ensured through quota sampling. The interview data were analysed thematically by two of the investigators independently, following member checking of interview transcripts.

RESULTS

The results demonstrate a number of key inter-related perceived rewards, costs and challenges of teaching, including intellectual stimulation, cognitive fatigue and student characteristics.

CONCLUSIONS

The findings extend reports in the previous literature by offering a richer description of current GP-teacher experience. Participants identified teaching rewards in a manner largely consistent with previous research, with the exception of enhanced practice morale and teamwork. Findings confirm that reduced productivity and increased time pressures remain key perceived negative impacts of teaching, but also reveal a number of other important costs and challenges. They emphasise the diversity of GP experience and practice cultures, and the need for teaching to enhance both GP and patient perceptions of consultation quality without increasing the load on the GP-teacher. Recruitment and retention strategies should promote the rewards of teaching, and teacher training should respond to the costs and challenges of practice-based teaching, and facilitate the growth of GPs in their role as clinical educators.

Demonstrating the value of longitudinal integrated placements to general practice preceptors

CONTEXT

This paper aims to consider why general practitioners (GPs) teach, in particular by defining the longitudinal supervisory relationships between rural clinician-preceptors and students.

METHODS

A total of 41 individual semi-structured interviews were conducted with GPs, practice managers and students. All interviews were audiotaped, transcribed and analysed for emergent themes.

RESULTS

In this study preceptors identified many ways in which precepting added value to their roles. However, themes relating to the doctor-student relationship were central to GP preceptors' experiences. These developed in chronological order and resulted in changes in the triangular relationship between doctor, patient and student in the consultation.

DISCUSSION

Interpretive findings identify that the motivators for precepting represent a group of constantly changing interconnected factors that contribute to the defining of preceptors as central members of their professional community of practice. This critical finding challenges the simplistic organisational concept that universities can recruit and retain GPs by offering increased rewards. This paper introduces four clinical preceptor models, which involve the roles of, respectively: the student-observer; the teacher-healer; the doctor-orchestrator, and the doctor-advisor. Symbiosis between student learning and patient care was found to occur in the doctor-orchestrator model.

CONCLUSIONS

The evolution of doctor-student relationships in long-term student placements explains how students become more useful over the academic year and sheds light on how GPs are changed through precepting as part of the complex process by which they come to recognise themselves as central members of the rural generalist community.

Lessons learnt from comprehensive evaluation of community-based education in Uganda: a proposal for an ideal model community-based education for health professional training institutions

BACKGROUND

Community-based education (CBE) can provide contextual learning that addresses manpower scarcity by enabling trainees acquire requisite experiences, competence, confidence and values. In Uganda, many health professional training institutions conduct some form of community-based education (CBE). However, there is scanty information on the nature of the training: whether a curriculum exists (objectives, intended outcomes, content, implementation strategy), administration and constraints faced. The objective was to make a comprehensive assessment of CBE as implemented by Ugandan health professional training institutions to document the nature of CBE conducted and propose an ideal model with minimum requirements for health professional training institutions in Uganda.

METHODS

We employed several methods: documentary review of curricula of 22 institutions, so as to assess the nature, purpose, outcomes, and methods of instruction and assessment; site visits to these institutions and their CBE sites, to assess the learning environment (infrastructure and resources); in-depth interviews with key people involved in running CBE at the institutions and community, to evaluate CBE implementation, challenges experienced and perceived solutions.

RESULTS

CBE was perceived differently ranging from a subject, a course, a program or a project. Despite having similar curricula, institutions differ in the administration, implementation and assessment of CBE. Objectives of CBE, the curricula content and implementation strategies differ in similar institutions. On collaborative and social learning, most trainees do not reside in the community, though they work on group projects and write group reports. Lectures and skills demonstrations were the main instruction methods. Assessment involved mainly continuous assessment, oral or written reports and summative examination.

CONCLUSION

This assessment identified deficiencies in the design and implementation of CBE at several health professional training institutions, with major flaws identified in curriculum content, supervision of trainees, inappropriate assessment, trainee welfare, and underutilization of opportunities for contextual and collaborative learning. Since CBE showed potential to benefit the trainees, community and institutions, we propose a model that delivers a minimum package of CBE and overcomes the wide variation in the concept, conduct and implementation of CBE.

Learning in the clinical environment

Clinical learning is central to medical education. Learning theories suggest that it is most effective when students are actively engaged with patient care and receiving timely feedback. Changes in health care delivery mean that learning must take place in a variety of clinical settings. The 'One Minute Preceptor' approach allows teaching to take place in the course of routine delivery of care.

General practice: a leading provider of medical student education in the 21st century?

General practice is well placed to become a major setting for medical student education over the next decade. New models of clinical education are required, to take account of changes in the patient population, disease profile and management strategies. While there has been an increase in general practice-based and other community-based education, there is the potential for further expansion. Evidence for the positive role of general practitioners and general practice in medical education is growing, including the benefits of prevocational training in general practice. If GPs are to assume a major role in community-based education of medical students, there will need to be changes in funding structures and supporting resources, particularly at this time of increasing medical student numbers and workforce shortage and maldistribution.

Training doctors in general practices: A review of the literature

OBJECTIVE

This study was undertaken to assess the evidence of whether new forms of medical training, where substantial training takes place in general practice, will be acceptable to GPs. In particular, we asked the questions: Are GPs willing to act as trainers and supervisors in their practices? Do GPs have the appropriate skills to be trainers? Do practices have the infrastructure and resources to support placements? And, are patients happy to be seen by medical students and General Practice Registrars?

DESIGN

Key Australian and international databases, key Australian journals and key Australian websites were searched for literature on general practice-based training of medical students and General Practice Registrars.

RESULTS

In the international and Australian literature, we found that many GPs consider training medical students and General Practice Registrars to be intrinsically satisfying. They vary in their skills, and most medical schools have made significant investments in training and support activities. Many practices do not have the necessary infrastructure, and investments need to be made if extended placements are to be successful. Many patients are happy to be seen by students and Registrars, but careful thought needs to be given to implementing appropriate models so that students have good learning opportunities, patients are not disadvantaged and general practices can operate efficiently.

CONCLUSION

The success of this new model of clinical placements is dependent on medical schools having a detailed understanding of the needs and expectations of GPs.

The impact of medical students on rural general practitioner preceptors

INTRODUCTION

As universities rely more heavily on rural GPs to precept medical students, the formation of symbiotic partnerships benefiting students, universities and GPs, becomes imperative. In order to develop and consolidate these partnerships universities must understand who their rural GP preceptors are and how precepting impacts on them.

METHODS

A review of the literature was undertaken to determine the significant themes of student impacts from articles where conclusions were clearly based on empirical findings.

RESULTS

Forty-three articles were included in the final review, but only nine specifically looked at impacts on rural GPs. Impacts were categorized into six domains: personal; time; patient care; professional relationships and professional development; business and infrastructure; and recognition and remuneration.

CONCLUSIONS

Literature specifically addressing the impact of precepting on rural GPs is scarce. Further studies are required to evaluate the relationship between the quality of teaching delivered to students, the type and length of student attachments and the likely impacts on rural GPs.

What impact will an increased number of teaching general practices have on patients, doctors and medical students?

BACKGROUND

Recommendations for medical training have seen a growing drive for undergraduate teaching to take place within the community - primarily in the general practice surgery. In light of the ongoing expansion of medical student numbers, many more general practices will be required to participate in undergraduate teaching.

AIM

To explore the perceptions of primary care staff on the impact that increasing student numbers will have on them, on their patients and on the students themselves.

DESIGN OF STUDY

Semi-structured interviews.

SETTING

Three general practices presently involved in undergraduate teaching, 3 practices about to become involved in undergraduate teaching and 1 non-teaching practice, all in the Black Country area of the West Midlands.

METHODS

Semi-structured interviews with prearranged prompts were undertaken with a variety of practice staff including general practitioners (GPs), practice managers and practice nurses, as well as administrative and reception staff.

RESULTS

Eleven GPs, 6 practice managers, 4 practice nurses and 6 receptionists/administrators took part in the interviews. Three main themes emerged relating to the effects on students and reflecting attitudes towards the Black Country, the experience of working among deprived populations and issues around access to the new training locations. The majority of interviewees were of the opinion that patients both enjoy taking part in undergraduate teaching and are able to benefit from the process. Positive impacts on practice infrastructure were also elicited, but when asked about the resource implications for the practice of undergraduate teaching, there was a dichotomy of opinion.

CONCLUSION

For many practices, involvement in undergraduate teaching is a double-edged sword.

Professional development in undergraduate medical curricula--the key to the door of a new culture?

CONTEXT

One of the most pressing requirements for contemporary medical education is to develop a framework for theory and practice of professional development which results in the attainment of professional competencies suitably robust for a lifetime's practice. The proposed content of a professional development curriculum may be reasonably straightforward to establish from policy documents and public expectations, but the process of achieving the desired outcomes is more complex, because professional development is largely based on attitudinal learning. Attitudes are at the interface between the personal and public psyche, relying more on individual experience and the accumulated impact of social and cultural interpretations than on propositional knowledge, and are therefore less amenable to factual or didactic teaching.

AIMS

The purpose of this discussion paper is to develop thinking on the conceptual frameworks which need to underpin curriculum decision-making for professional development, especially in undergraduate medical training where models of good practice are less well-established. It brings together work from educational, sociological and psychological perspectives to elucidate the key principles which are most likely to result in acquisition of desirable professional attributes.

IMPLICATIONS

The literature suggests that successful professional development needs to be based on explicit values, which are repeatedly demonstrated in the learning environment, and modelled by senior colleagues and tutors; that the curriculum should incorporate a clear model of emotional as well as cognitive development; should be a major component of summative assessment; and needs to include formative mentorship at all stages of training.

Teaching in partnership: linking a medical school and a community trust

Since 1997, the Croydon and Surrey Downs Community NHS Trust, together with the Department of General Practice and Primary Care at Guy's, King's and St Thomas' School of Medicine, King's College London, has offered a community-based special study module to second year medical students. The module offered an opportunity to learn how people living with a chronic infection, such as HIV/AIDS, cope with their condition while being looked after by a multidisciplinary team in the community. This article describes how interprofessional teaching and supervision between community nurse specialists and medical students, with the involvement of multidisciplinary and community-based teachers, enabled active engagement of students in their learning. We also discuss the learning outcomes for the students and the benefits for the community trust staff in the context of interprofessional teaching.

Patient-centred medicine through student-centred teaching: a student perspective on the key impacts of community- based learning in undergraduate medical education

CONTEXT

The UK General Medical Council has proposed that increased use of community settings is essential to enhancement of medical education. However, such curriculum developments have been directed by educationalists and clinical faculty; there is to date little to show whether student perspectives accord with such expectations.

AIM

To examine student views on whether community-based learning during a UK undergraduate medical education course results in new learning in the areas expected, and to elucidate any process factors which enhance attainment of learning objectives.

METHOD

Nominal group technique, to develop consensus on important learning outcomes and process factors, and questionnaire survey, developed from the views of the nominal groups.

RESULTS

89 students participated (response rate 70% for the nominal groups, and 88% for questionnaire). Students perceived increased learning in many of the areas expected. In particular, students reported significant learning from: witnessing the impact of a longer term and more personal relationship with patients; the visible impact of social environment on health; the importance of dealing with people rather than diseases, and the use of the whole team for care. In addition, they emphasized that tutor, staff and patient enthusiasm for student presence and learning greatly enhanced the student learning experience.

CONCLUSIONS

Community settings appear to achieve the expected attitudinal adaptation of students. The role of the committed tutor and team is seen as pivotal to learning. The conclusions support an increased emphasis in contemporary medical education and related research activity on the key impact of relationships in the learning environment.