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

The Impact of an Undergraduate Community-Based Medical Education Program in a Japanese Urban City

INTRODUCTION

 With an aging global population posing healthcare challenges, especially in community healthcare, training professionals for community healthcare remains a global educational challenge, including in Japan. While previous research shows increased student interest in community healthcare through practical experiences, the focus has primarily been on rural areas, leaving a gap in understanding urban-based community medical education. This study aimed to evaluate the impact of urban community-based medical education on students' understanding and attitudes toward community healthcare.

METHODS

 This study was conducted at Kyushu University in Fukuoka City, the sixth-largest city in Japan. For fifth-grade medical students, a community-based medical education program is mandatory, with a one-week schedule that includes orientation, one day in a clinic, and three days in a community hospital. The program aimed to expose students to various healthcare settings, emphasizing outpatient care, inpatient management, home health care, home nursing, and rehabilitation. A self-administered questionnaire referencing the Model Core Curriculum for medical education was administered immediately before and after the program, and the differences in students' perceptions were assessed using the Student's t-test.

RESULTS

 Findings from 188 students completing both pre- and post-program questionnaires revealed significant improvements in perceptions of students' knowledge and skills related to community healthcare. After the training, there was a noteworthy positive shift in attitudes toward community healthcare and increased interest in primary care physicians as a career choice. Although students maintained a preference for urban areas, there was a notable inclination towards rural settings. The study highlights the program's success in enhancing students' understanding and positive attitudes toward community healthcare within an urban context. It challenges prior notions regarding work-life balance and urban-rural preferences in career choices.

CONCLUSIONS

 Urban community-based medical education significantly improved students' perceptions and attitudes toward community healthcare. It offers valuable insights for curriculum planners, emphasizing the need for continued research into sustained effects and broader applicability.

Perceptions and Attitudes toward Community Health and Interprofessional Education in Students with and without an Additional Community Medicine-Focused Program

The Rural Medical Education (RMED) Program at the University of Illinois College of Medicine Rockford campus, and part of the National Center for Rural Health Professions, strives to recruit students from rural areas, who, after completing residency, return to rural Illinois as primary care physicians. RMED students meet monthly to learn about the community and public health in rural communities. Furthermore, they complete a 16-week rural preceptorship during their fourth year. During the fourth year of medical school, all RMED students, as well as the students following the regular curriculum, are asked to complete a survey, related to the understanding of medical students' views of community and interprofessional education. We aimed to identify how the community-based curriculum affects the students' understanding and appreciation of community as they go into rural health practice. The results showed that students in the RMED Program are more aware of the community they are part of, as well as being more interested in becoming part of their community. RMED students reported a statistically significantly higher rating of feeling appreciated and accepted by their community and rated their confidence in their abilities in the community statistically significantly higher. Interestingly, RMED students were not more likely to be more familiar with several health professions and programs within their community, compared to non-RMED students. Results comparing self-rated capabilities for RMED students within the community both before and after adding components of an interprofessional education curriculum showed no statistically significant changes. These results support previous research, while also providing more support for the development of successful interprofessional education courses.

Patient-centred orientation of students from different healthcare disciplines, their understanding of the concept and factors influencing their development as patient-centred professionals: a mixed methods study

BACKGROUND

A patient-centred approach to care is increasingly the mandate for healthcare delivery. There is a need to explore how health professional students develop patient-centred attributes. This study aims to understand the extent of patient-centred orientations of health professional students, their perceptions and factors influencing their adoption of the approach.

METHODS

The study used a cross-sectional, parallel mixed methods design combining a survey using the Patient-Practitioner Orientation Scale (PPOS) followed by focus groups with medical, nursing, physiotherapy and speech and language therapy students. Data included students' age, gender, programme, and placements experienced. Pearson's chi squared and the non-parametric equivalent Kruskal-Wallis H test were done to test for differences in demographics for appropriate variables. One-way ANOVA or Welch test was done to explore differences in PPOS scores. Regression analysis was done to test the influence of the demographic variables on PPOS scores. Data from focus groups were coded, categorised and organised under themes appropriate to the research aims.

RESULTS

Of the 211 complete responses, significant differences were observed between medical and physiotherapy students in total PPOS scores, (MD -8.11 [95% CI -12.02 - 4.20] p = 0.000), Caring component (MD -4.44 [95% CI - 6.69, - 2.19] p = 0.000) and Sharing component (MD -3.67 [95% CI -6.12 -1.22] p = 0.001). The programme in which students were enrolled i.e. Medicine and SALT were the only indicators of higher PPOS total scores (F = 4.6 Df 10,69; p = 7.396e-06) and caring scores (F = 2.164 Df 10, 69 p = 0.022). Focus groups revealed that students perceived patient-centredness as holistic yet individualised care through establishing a partnership with patient. They identified that their student status, placement pressures, placement characteristics especially mentoring influenced their development of patient-centred attributes.

CONCLUSION

This study highlights the fact that the pressures of training in the National Health Service affects the development of students' patient-centred orientation. There is a need for further work to explore aspects related to mentor training, for the development of patient-centred attributes, in a curricular framework structured on students' needs from this study.

Patient-centered medical education: A proposed definition

Multiple papers have been presented to define patient-centered care, with regulatory bodies such as the General Medical Council mapping this in their professional standards. Educational institutions clearly value instilling appreciation of patient-centredness in medical training, and attempts have been made to make medical education more patient-centered in practice. Such attempts are often limited to expert patients sharing personal stories, and public involvement in teaching. Despite the drive towards patient-centered care and medical education, there has been no attempt to formally define what patient-centered medical education is and what it means to medical educators globally. This paper proposes a definition of patient-centered medical education that is about the patients, with the patients, and for the patients, to ensure current and future doctors remain sensitive to all of the needs of the people they care for. This should be considered at both the micro and macro community levels.

A case-based medical curriculum for the 21st century: The use of innovative approaches in designing and developing a case on mental health

The introduction of case-based learning (CBL) by the School of Medicine at Cardiff University has encouraged innovation in medical teaching and learning. During years one and two of the modernized MBBCh program, students complete 17 cases as part of the newly developed C21 curriculum that emphasizes a patient-oriented and student-centered approach to learning. The mental health case, which is presented in year 2, incorporates a number of novel teaching resources that aim to enhance the students' learning experience and to further reinforce the patient-oriented and community-based philosophy of C21. These include the use of fictionalized video diaries, virtual patient cases, e-learning workbooks, an interactive practical session, and community placements. Novel teaching methods and resources were evaluated by students in terms of effectiveness and value as learning resources through the administration of a structured mixed questionnaire. The results revealed that students valued the inclusion of these resources, which they evaluated as having contributed to their understanding of the subject area. Furthermore, the case was found to have had an impact on student interest in psychiatry as a specialty as well as a career choice. The positive student evaluation of this case supports the innovations in teaching delivery inspired by C21.

The impact of socially-accountable health professional education: A systematic review of the literature

This literature review describes the impact of health professional schools with a social accountability mandate by identifying characteristics of medical education found to impact positively on medical students, health workforce, and health outcomes of disadvantaged communities. A critical appraisal tool was used to identify the strengths and weaknesses of the published articles. Data are presented as a narrative synthesis due to the variety of methodologies in the studies, and characterized using a logic model. Health professional schools aiming to improve health outcomes for their disadvantaged local communities described collaborative partnerships with communities, equitable selection criteria, and community-engaged placements in underserved areas as positively impacting the learning and attitudes of students. Students of socially accountable schools were more likely to stay in rural areas and serve disadvantaged communities, and were often more skilled than students from more traditional schools to meet the needs of underserved communities. However, published literature on the impact of socially accountable health professional education on communities and health outcomes is limited, with only one study investigating health outcomes. The findings of this literature review guide schools on the inputs likely to maximize their socially accountability outputs and increase their impact on students, local health workforce and local communities.

Medical students' feedback regarding their clinical learning environment in primary healthcare: a qualitative study

BACKGROUND

An increasing part of medical students' learning takes place in primary healthcare (PHC) but little is known about how the students perceive PHC as a clinical learning environment. This study aimed to explore medical students' perceptions of the clinical learning environment in PHC and how these vary with stage of education.

METHODS

Free-text course evaluation comments from students in nine different semesters during spring 2014 were analysed using qualitative content analysis. The students had placements in PHC from the first semester, progressing through the whole 5.5 year medical programme, and this was their main clinical training environment during the final 11^th semester.

RESULTS

In total, 800 students (56%) agreed to participate in the study and 437 of these (54%) provided comments. Two overall themes were identified: the supervisor was the central factor that determined the meaningfulness of the placement at all stages of the education, and basic prerequisites for perceived clinical learning were to have an active role in an authentic clinical context and to be trusted to work independently with patients. The three main categories found under these themes were: i) the perceived relationship with the supervisor; ii) the perceived journey to become a doctor; and iii) the perceived structure and culture.

CONCLUSION

The supervisor's role was perceived as central at all stages of the education but the focus changed for other aspects, related to the students' professional development. The need for trust and independence in patient work increased towards the end of the education.

Teaching diversity to medical undergraduates: Curriculum development, delivery and assessment. AMEE GUIDE No. 103

The aim of this Guide is to support teacher with the responsibility of designing, delivering and/or assessing diversity education. Although, the focus is on medical education, the guidance is relevant to all healthcare professionals. The Guide begins by providing an overview of the definitions used and the principles that underpin the teaching of diversity as advocated by Diversity and Medicine in Health (DIMAH). Following an outline of these principles we highlight the difference between equality and diversity education. The Guide then covers diversity education throughout the educational process from the philosophical stance of educators and how this influences the approaches used through to curriculum development, delivery and assessment. Appendices contain practical examples from across the UK, covering lesson plans and specific exercises to deliver teaching. Although, diversity education remains variable and fragmented there is now some momentum to ensure that the principles of good educational practice are applied to diversity education. The nature of this topic means that there are a range of different professions and medical disciplines involved which leads to a great necessity for greater collaboration and sharing of effective practice.

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.

Comparison of students' encountered diseases and available diseases at clerkship sites by exploratory multivariate analysis: Are encountered diseases predictable?

BACKGROUND

Students in clerkship are expected to gain clinical expertise by interacting with real patients in clinical situations. Monitoring and predicting the students' encounter diseases (EDs) is important for providing an optimal experience. EDs should be compared with the available diseases (ADs) at the clerkship site and with the required diseases described in some guidelines for the clinical curriculum.

AIMS

To explore the differences in ADs as learning resources among different types of clerkship sites and to investigate discrepancies between EDs and ADs.

METHOD

A retrospective observational study used secondary data from government statistics to compare ADs of various types of observable clerkship sites by biplot analyses, which allowed multivariate comparisons. EDs collected from logbooks during clerkships at a university hospital were also compared with ADs across sites.

RESULTS

The distributions of ADs differed according to institutional type, and EDs at Kyushu University Hospital were similar to the ADs for the category of hospitals in which it was placed.

CONCLUSION

EDs at a clerkship site may be predictable to some extent by analysing the site's distribution of ADs, but further study is needed. Biplot is useful for visualising these types of statistical similarity.

Developing a patient focussed professional identity: an exploratory investigation of medical students' encounters with patient partnership in learning

Patient encounters are central to the provision of learning opportunities for medical students and their development as medical professionals. The primary aim of the study reported in this paper was to discover how partnering medical students with patients with chronic illness in undergraduate learning influenced the development of a patient centred professional identity and professionalism. An exploratory interpretive research design was used to address the research aim within a patient partner program (P3). Three qualitative data collection methods were used: (1) focus groups (2) extended response questionnaire and (3) semi-structured interviews. Data were coded and analysed thematically. The professional identity of medical students is constructed along traditional lines in the preclinical years. Patient-partnership offers a disruption to this development by way of an intersection with patients with chronic illness which potentially allows meaningful construction of what a patient-centred identity should be. This point of reflection provides an opportunity to engage at a higher level in medical identity development and professionalism. The findings discussed in this paper further stimulate the patient-centred agenda by understanding the conflict associated with the student-patient nexus in medical education and its potential for building professionalism and a patient-centred professional identity. To continue the drive for a patient-centred professional identity there must be ongoing engagement with patients in medical education, preferably commencing early in a student's journey so that it becomes the expected norm. This study has highlighted that a true patient-centred emphasis is being encountered too late in their socialisation process.

The current provision of community-based teaching in UK medical schools: an online survey and systematic review

OBJECTIVE

To evaluate the current provision and outcome of community-based education (CBE) in UK medical schools.

DESIGN AND DATA SOURCES

An online survey of UK medical school websites and course prospectuses and a systematic review of articles from PubMed and Web of Science were conducted. Articles in the systematic review were assessed using Rossi, Lipsey and Freeman's approach to programme evaluation.

STUDY SELECTION

Publications from November 1998 to 2013 containing information related to community teaching in undergraduate medical courses were included.

RESULTS

Out of the 32 undergraduate UK medical schools, one was excluded due to the lack of course specifications available online. Analysis of the remaining 31 medical schools showed that a variety of CBE models are utilised in medical schools across the UK. Twenty-eight medical schools (90.3%) provide CBE in some form by the end of the first year of undergraduate training, and 29 medical schools (93.5%) by the end of the second year. From the 1378 references identified, 29 papers met the inclusion criteria for assessment. It was found that CBE mostly provided advantages to students as well as other participants, including GP tutors and patients. However, there were a few concerns regarding the lack of GP tutors' knowledge in specialty areas, the negative impact that CBE may have on the delivery of health service in education settings and the cost of CBE.

CONCLUSIONS

Despite the wide variations in implementation, community teaching was found to be mostly beneficial. To ensure the relevance of CBE for 'Tomorrow's Doctors', a national framework should be established, and solutions sought to reduce the impact of the challenges within CBE.

STRENGTHS AND LIMITATIONS OF THIS STUDY

This is the first study to review how community-based education is currently provided throughout Medical Schools in the UK. The use of Rossi, Lipsey and Freeman's method of programme evaluation means that the literature was analysed in a consistent and comprehensive way. However, a weakness is that data from the online survey was obtained from online medical school prospectuses. This means the data may be incomplete or out of date. Data in the literature review may also be skewed by publication bias.

Communities’ views, attitudes and recommendations on community-based education of undergraduate Health Sciences students in South Africa: A qualitative study

Background

Medical and Health Sciences students in South Africa undertake community-based education (CBE). Health professionals based at host sites are jointly responsible for training of these students in conjunction with university staff. This study explored the communities’ views, attitudes and recommendations regarding CBE undertaken by these students, in order to improve the quality of community support for these programmes.

Method

A qualitative descriptive study was conducted at CBE placement sites of students from the Faculties of Health Sciences of the University of Limpopo (UL), University of KwaZulu-Natal (UKZN) and University of the Western Cape (UWC) during 2010 and 2011. Focus group discussions were held with site facilitators, community leaders and patients, and interviews were audio recorded, transcribed and translated into English where necessary. Data were analysed using NVivo (version 9).

Findings

CBE was seen to benefit communities, students and host institutions as there was perceived improvement of service delivery, better referral to hospitals and reduction of workloads on site staff. CBE was also seen as having potential for recruiting professionals who have better orientation to the area, and for motivating school pupils for a career in health sciences. Students acquired practical skills and gained confidence and experience. Challenges included poor communication between universities and host sites, burden of student teaching on site facilitators, cultural and religious sensitivity of students and language barriers.

Conclusion

The study revealed that communities have an important role to play in the CBE of future health care professionals. CBE activities could be better organised and managed through formalised partnerships.

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.

General practitioners as supervisors in postgraduate clinical education: an integrative review

CONTEXT

General practice supervisors are said to serve as the cornerstones of general practice postgraduate education and therefore it is important to clearly define their roles and what makes them effective. The commonly used definition of a supervisor is not primarily based on general practice and does not cover aspects predicted to be important according to work-based learning theory.

METHODS

We searched for papers published between 1991 and 2011 inclusive, categorised them according to whether they provided empirical evidence, descriptions or recommendations, open-coded the empirical evidence, and used the resulting coding scheme as an analytic framework within which to present a narrative summary of findings.

RESULTS

Recommendations and descriptions far outweighed empirical evidence, which showed how supervisors intertwined clinical and educational activities and formed educational alliances with resident doctors that provided a foundation for learning. Residents needed a balance of challenge, usually provided by patients, and support, provided by supervisors. Supervisors established learning environments, assessed residents' learning needs, facilitated learning, monitored the content and process of learning and the well-being of residents, and summarised learning in ways that turned 'know that' into 'know how'.

CONCLUSIONS

General practice must be expert in ensuring patients are well cared for 'by proxy' and in giving residents just the right amount of support they need to face the challenges posed by those patients. As general practice responds to contemporary clinical demands and rising numbers of undergraduate medical students, it is essential that the ability of general practice supervisors to develop and sustain supportive supervisory relationships with residents is preserved.

Beyond the ward and waiting room: a community-based non-clinical placement programme for Australian medical students

BACKGROUND

Placement programmes are essential to medical education but almost invariably take place in clinical settings, even when community based. Australia's Monash University, however, has included in its core MBBS curriculum a non-clinical placement for second-year students, the Community Based Practice (CBP) programme. This involves partnerships with community organisations that are mostly non-medical. The programme includes a health promotion (HP) component where students respond to a HP or support need nominated by their placement organisation. Though inspired by community-based medical education (CBME) programmes in England and South Australia's Flinders University, its non-clinical focus represents a creative development in Australian medical education.

METHODS

This article describes the programme, explores its place within CBME and outlines the results of its analysis of student responses using SPSS and NVivo.

RESULTS

The evidence showed development of students' communication skills; increased understanding and appreciation of the mainly non-medical health support infrastructure in local communities; increased understanding of HP and community health support at the local level; and contributions to the placement organisations through small-scale research or health support projects.

CONCLUSION

Placement programmes such as this can significantly contribute to medical education, especially in supporting health in local communities and understanding the needs of the marginalised.

Patient-centredness from education to practice: the 'lived' impact of communication skills training

BACKGROUND

Although communication skills training (CST) enhances patient-centred skills and attitudes, the literature indicates a problematic transfer of these from education into practice.

AIM

We explored 'lived' experiences of medical students and doctors to gain a better understanding of the impact of CST on patient-centredness in the transition to real practice.

METHODS

From a phenomenological perspective, we conducted 15 interviews and 11 focus groups with 4-9 participants/group (n = 67) at two universities and carried out constant comparative analysis.

RESULTS

The gap between education and practice is the central phenomenon. Although CST raises students' communication awareness and self-efficacy in an 'ideal' context, this paradoxically seems to jeopardize their ability to bridge the gulf. In addition, CST does not come to grips with students' attitudes. However, CST appears to be successful in equipping students with long-lasting 'handles'. Yet students need more support to mould the provided 'ideal' models into their own unique style of context-specific patient-centred behaviour. This implies: raising students' awareness of own attitudes and communication styles, offering a more realistic training ground, integrating CST with clinical experience and translating the primary-care-rooted concept of patient-centredness into various specialization contexts.

CONCLUSION

CST could raise its impact by supporting students' recycling processes towards a personal style of context-sensitive patient-centredness.

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.

Help, I'm losing patient-centredness! Experiences of medical students and their teachers

OBJECTIVES

Despite all educational efforts, the literature shows an ongoing decline in patient-centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient-centredness in order to gain a better understanding of the factors that determine its development.

METHODS

We conducted 11 focus groups on the subject of learning and teaching about patient-centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the 'sensitising concepts' provided by the Attitude-Social Influence-Self-Efficacy (ASE) model.

RESULTS

Although students express positive attitudes towards patient-centredness and acquire patient-centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today's challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient-centred skills. However, when students lack self-efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non-patient-centred role models and are overwhelmed by powerful experiences, they lose their patient-centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self-awareness and self-care are important qualities of the central phenomenon of the 'doctor-as-person', which is identified as a missing concept in the ASE model. The student-supervisor relationship is found to be key to learning patient-centredness and has several functions: it facilitates the direct transmission of patient-centred skills, knowledge and attitudes; it provides social support of students' patient-centred behaviour; it provides support of the 'student-as-person'; it mirrors patient-centredness by being student-centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student-centred education and guidance be offered, self-awareness be fostered and more opportunities to encounter patients be created, including more time in general practice.

CONCLUSIONS

Supportive student-doctor relationships, student-centred education and guidance that addresses the needs of the doctor-as-person are central to the development of patient-centredness. Medical education requires patient-centred, self-caring and self-aware role models.

Patient-centred attitudes among medical students: gender and work experience in health care make a difference

BACKGROUND

Previous studies of medical students' patient-centred attitudes show a decline across undergraduate education and overall higher scores for female students.

AIM

To assess undergraduate students' patient-centred attitudes at various stages of education and to explore possible associations between attitudes and age, gender and work experience in health care.

METHODS

In autumn 2005, medical students in Gothenburg (n = 797) were asked to answer Patient-Practitioner Orientation Scale (PPOS), a validated instrument exploring attitudes towards the doctor-patient relationship. Data including gender, age, current term and students' work experience in health care were collected.

RESULTS

Of 797 students 600 (75%) answered the questionnaire. No decrease of students' PPOS score across the curriculum was observed. PPOS scores from female students were higher compared to males (p < 0.0001) and female scores were significantly higher in the later terms compared with earlier (p = 0.0011). Female students had more experience from working in health care (p = 0.0023). Extended work experience was associated with higher PPOS only among females (p = 0.0031).

CONCLUSION

No decline of students' patient-centred attitudes may indicate an ongoing shift. Gender differences in patient-centred attitudes were reproduced. Work experience in health care presents a new gender difference. These gender differences should be considered when training patient-centred attitudes and skills.

Medical students' and facilitators' experiences of an Early Professional Contact course: active and motivated students, strained facilitators

BACKGROUND

Today, medical students are introduced to patient contact, communication skills, and clinical examination in the preclinical years of the curriculum with the purpose of gaining clinical experience. These courses are often evaluated from the student perspective. Reports with an additional emphasis on the facilitator perspective are scarce. According to constructive alignment, an influential concept from research in higher education, the learning climate between students and teachers is also of great importance. In this paper, we approach the learning climate by studying both students' and facilitators' course experiences.In 2001, a new "Early Professional Contact" longitudinal strand through term 1-4, was introduced at the Sahlgrenska Academy, University of Gothenburg, Sweden. General practitioners and hospital specialists were facilitators.The aim of this study was to assess and analyse students' and clinical facilitators' experiences of the Early Professional Contact course and to illuminate facilitators' working conditions.

METHODS

Inspired by a Swedish adaptation of the Course Experience Questionnaire, an Early Professional Contact Questionnaire was constructed. In 2003, on the completion of the first longitudinal strand, a student and facilitator version was distributed to 86 students and 21 facilitators. In the analysis, both Chi-square and the Mann-Whitney tests were used.

RESULTS

Sixty students (70%) and 15 facilitators (71%) completed the questionnaire. Both students and facilitators were satisfied with the course. Students reported gaining iiration for their future work as doctors along with increased confidence in meeting patients. They also reported increased motivation for biomedical studies. Differences in attitudes between facilitators and students were found. Facilitators experienced a greater workload, less reasonable demands and less support, than students.

CONCLUSION

In this project, a new Early Professional Contact course was analysed from both student and facilitator perspectives. The students experienced the course as providing them with a valuable introduction to the physician's professional role in clinical practice. In contrast, course facilitators often experienced a heavy workload and lack of support, despite thorough preparatory education. A possible conflict between the clinical facilitator's task as educator and member of the workplace is suggested. More research is needed on how doctors combine their professional tasks with work as facilitators.

Attitudes towards the doctor-patient relationship: a prospective study in an Asian medical school

CONTEXT

Patient-centredness is an accepted guiding principle for health system reform, patient care and medical education. Although these attitudes are strongly linked with cultural values, few studies have examined attitudes towards patient-centredness in a cross-cultural setting.

OBJECTIVES

This prospective study evaluated attitudes towards patient-centredness in a cohort of Asian medical students and examined changes in these attitudes in the same students on completion of their junior clinical clerkships.

METHODS

The study was conducted in a cohort of 228 medical students entering Year 3 in medical school. The Patient-Practitioner Orientation Scale (PPOS), a validated instrument which scores an individual's level of patient-centredness, was used.

RESULTS

Being female and having personal experience of continuing care were significantly associated with higher scores. Students in the USA were previously reported to have similar 'caring' but higher 'sharing' scores on the same scale. At the end of the junior clinical clerkship, there were improvements in the 'caring' subscale, but no change or a reduction in 'sharing'. Students who did not have previous personal experience with continuing care experienced a greater increase in overall PPOS score.

CONCLUSIONS

When compared with students in the USA, the students in our study appear to have a lower propensity to view the doctor-patient relationship as a partnership. This may be a reflection of differences in cultural norms and expectations of doctor-patient interaction in different societies. Our finding that attitudes towards patient-centredness did not decline over the course of the year, which contrasts with findings of other studies, may be attributed to various factors and warrants further study.

Ethnic stereotypes and the underachievement of UK medical students from ethnic minorities: qualitative study

OBJECTIVE

To explore ethnic stereotypes of UK medical students in the context of academic underachievement of medical students from ethnic minorities.

DESIGN

Qualitative study using semistructured one to one interviews and focus groups.

SETTING

A London medical school.

PARTICIPANTS

27 year 3 medical students and 25 clinical teachers, purposively sampled for ethnicity and sex.

METHODS

Data were analysed using the theory of stereotype threat (a psychological phenomenon thought to negatively affect the performance of people from ethnic minorities in educational contexts) and the constant comparative method.

RESULTS

Participants believed the student-teacher relationship was vital for clinical learning. Teachers had strong perceptions about "good" clinical students (interactive, keen, respectful), and some described being aggressive towards students whom they perceived as quiet, unmotivated, and unwilling. Students had equally strong perceptions about "good" clinical teachers (encouraging, interested, interactive, non-aggressive). Students and teachers had concordant and well developed perceptions of the "typical" Asian clinical medical student who was considered over-reliant on books, poor at communicating with patients, too quiet during clinical teaching sessions, and unmotivated owing to being pushed into studying medicine by ambitious parents. Stereotypes of the "typical" white student were less well developed: autonomous, confident, and outgoing team player. Direct discrimination was not reported.

CONCLUSIONS

Asian clinical medical students may be more likely than white students to be perceived stereotypically and negatively, which may reduce their learning by jeopardising their relationships with teachers. The existence of a negative stereotype about their group also raises the possibility that underperformance of medical students from ethnic minorities may be partly due to stereotype threat. It is recommended that clinical teachers be given opportunities and training to encourage them to get to know their students as individuals and thus foster positive educational relationships with them.

Students learning from patients: let's get real in medical education

Medical students must be prepared for working in inter-professional and multi-disciplinary clinical teams centred on a patient's care pathway. While there has been a good deal of rhetoric surrounding patient-centred medical education, there has been little attempt to conceptualise such a practice beyond the level of describing education of communication skills and empathy within a broad 'professionalism' framework. Paradoxically, while aiming to strengthen patient-student interactions, this approach tends to refocus on the role modelling of the physician, and opportunities for potentially deep collaborative working relationships between students and patients are missed. A radical overhaul of conventional doctor-led medical education may be necessary, that also challenges the orthodoxies of individualistic student-centred approaches, leading to an authentic patient-centred model that shifts the locus of learning from the relationship between doctor as educator and student to the relationship between patient and student, with expert doctor as resource. Drawing on contemporary poststructuralist theory of text and identity construction, and on innovative models of work-based learning, the potential quality of relationship between student and patient is articulated in terms of collaborative knowledge production, involving close reading with the patient as text, through dialogue. Here, a medical 'education' displaces traditional forms of medical 'training' that typically involve individual information reproduction. Students may, paradoxically, improve clinical acumen through consideration of silences, gaps, and contradictions in patients as texts, rather than treating communication as transparent. Such paradoxical effects have been systematically occluded or denied in traditional medical education.

Evaluation of a clinical attachment in Primary Health Care as a component of undergraduate medical education

INTRODUCTION

It seems that there is a trend in undergraduate medical education towards including clinical attachments in primary health care (PHC) worldwide. The benefits of such initiatives are already well described. The aim of this study was to evaluate the effect of a clinical attachment in undergraduate medical students in a European country with an odd medical educational system that essentially lacks any kind of academic PHC departments.

METHODS

The study was undertaken during 2005-2007. A non-mandatory 1-week clinical attachment in PHC/general practice was organized in an urban PHC unit by general practitioners with educational experience in collaboration with the Department of Physiology of the local medical school. The participants were a prospective cohort of medical students in the 2nd year of undergraduate studies. All participating students sat a pre-defined clinical exam which consisted of multiple choice questions, mini case papers and an objective-structured clinical examination before and after the attachment. In addition, the students rated the whole process.

RESULTS

The response ratio was 77.06%. The mean score on objective structured clinical examination of participants increased from 30.70/100 to 62.28/100 (p < 0.001). The students' impression of the study was rather positive (4.39/5).

DISCUSSION

The educational intervention of including a clinical attachment in an undergraduate curriculum seems to have encouraging results, considering the peculiarity of inexistence of academic departments of PHC or General Practice in the national medical schools and the inexperience of students regarding similar concepts.

Early student-patient contacts in general practice: an approach based on educational principles

BACKGROUND

Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students' learning processes.

AIMS

To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility.

METHOD

Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme.

RESULTS

Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients,transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible.

CONCLUSION

In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in general practice based on educational principles.

A survey of UK medical schools' arrangements for early patient contact

BACKGROUND

Many U.K. medical schools have patient contact in the first two years of the undergraduate course.

AIM

To compare the purposes and organization of early patient contact in UK medical schools and to relate these arrangements to the schools' curricular objectives.

METHODS

A telephone survey of lead educators in UK medical schools. Categories of contact were plotted against phases of the course to discern patterns of organisation.

RESULTS

The quantity of contact varies considerably (four to 65 days). There is a pattern, with learning objectives around the social context of health and illness preceding skills based work and integrated clinical knowledge for practice coming later. Schools fall into three categories: close adherence to the preclinical/clinical split, with limited early contact acting as an introduction to social aspects of health; provision of substantial patient contact to maximize the integration of knowledge and skills; and transitional, with limited clinical goals. General practice provides between one third and one half of early patient contact.

CONCLUSIONS

Arrangements meet the objectives set by each school and reflect differing educational philosophies. Change is toward more early contact. There appears to be no national guidance which supports a minimum quantity of patient contact or specific educational purpose in the early years of U.K. basic medical training.

Brazilian medical students' attitudes towards patient-centered care

BACKGROUND

The doctor-patient relationship is essential to medical care (Engel 1980; Balint 1984), however, medical schools focus mainly on biomedical subjects and don't give the necessary attention to communication skills, humanistic attitudes, and professional values (Haidet et al. 2001, 2002).

METHODS

Attitudes of medical students towards the doctor-patient relationship have been examined and the Patient-Practitioner Orientation Scale (PPOS) has been used to measure students' and practitioners' patient-centered beliefs, first in USA (Haidet et al. 2002), and then in several other countries (Choi & Moon 2005; Tsimtsiou et al. 2005; Shankar et al. 2006). This study aimed to examine the attitudes of Brazilian medical students towards the doctor-patient relationship by using the PPOS. The scale was translated into Portuguese and was administered to approximately 800 students in their first, fifth, seventh, ninth, tenth and twelfth semesters of medical school along with a socio-demographic questionnaire.

RESULTS

A total of 738 students (>90%) completed data collection. For the entire cohort, female gender (p < 0.000), later semester in medical school (p < 0.000), primary-care specialty choice (p < 0.02) and lower familial income (p < 0.03) were significantly associated with more patient-centered attitudes. Sharing sub-scores, measuring beliefs about power and information between physician and patient, were significantly more patient-centered for twelfth semester male students than for first semester males (p < 0.000), but not for female students. Caring sub-scores, which measure beliefs about attending to patient's emotions and lifestyle, did not change with the years of school. In general, Caring scores were considerably higher than Sharing scores. Total PPOS scores in Brazil are comparable to those found among medical students in the United States, however they are considerably higher than PPOS total scores in Nepal, Greece, and Korea.

CONCLUSIONS

Communication skills and patient care needs to be critically examined by Brazilian teachers and students aiming to change attitudes toward the doctor-patient relationship to be more patient-centered attitudes.

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.

"A memorable consultation": writing reflective accounts articulates students' learning in general practice

OBJECTIVES

To explore and analyse students' learning experiences of a memorable consultation during a final-year attachment in general practice.

SETTING

After a two-week primary care attachment in the undergraduate curriculum, students were invited to write a reflective account of a memorable consultation.

DESIGN

A total of 52 reflective accounts were read and processed according to qualitative content analysis. Credibility of the analysis was validated by two co-authors reading the descriptions separately and trustworthiness was tested at local seminars.

RESULTS

Three main themes emerged. In "The person beyond symptoms" the students recognize the individual properties of a consultation. "Facing complexity" mirrors awareness of changing tracks in problem-solving and strategies of handling unclear conditions. "In search of a professional role" reflects the interest in role modelling and the relation to the supervisor.

CONCLUSION

Involving students in writing reflective accounts appears to stimulate them to articulate practice experiences of the consultation.

Medical students as family-health advocates: Arabian Gulf University experience

BACKGROUND

The Arabian Gulf University is a coeducational Islamic institution in the Kingdom of Bahrain sponsored by the Gulf Cooperative Council. The College of Medicine follows a problem-based curriculum in which science is integrated with professional skills and a community-health programme, comprising of maternal and child health, family studies, and population-health research. The family-studies programme requires all third-year students to complete a wide series of activities under family-physician supervision.

AIM

The aim of the study was to assess the performance of the programme with specific regard to students' family-health advocacy roles.

METHOD

A trained community-health nurse administered a semistructured questionnaire based on family empowerment to 30 families. Themes included health-knowledge gains, positive changes in lifestyle and communication practices, and accessing community resources.

RESULTS

All families reported a gain in relevant health knowledge, and a number of families reported positive changes in lifestyle.

CONCLUSIONS

Students proved to be valuable advocates for families in this programme. Their principal role lay in the uncovering of psychosocial distress, but they were able also to offer practical help in lifestyle behaviour changes, communication, and community-resource use.

Patient contact in the first year of basic medical training--feasible, educational, acceptable?

BACKGROUND

A new UK medical school uses substantial early patient contact in the first 2 years of an integrated 5-year course.

AIMS

To explore the feasibility, educational effectiveness, and acceptability to patients of substantial early patient contact.

METHODS

Mixed-methods case study with data from patients, students, and staff gathered via encounter forms, questionnaires, interviews, and focus groups.

RESULTS

The curriculum model of recruiting a specific patient case-mix to match concurrent theoretical teaching was feasible. Patients were willing to attend specifically to meet students, even if not receiving contemporaneous care. Patient satisfaction with teaching involvement was very high, and most patients were willing to attend further sessions. Although at an early stage of knowledge and skill acquisition, students greatly valued their extensive contact with patients. They perceived it as adding substantially to their learning of clinical medicine, by providing 'real' learning opportunities and linking theory to practice. It was motivating and memorable, and enabled students to meet learning objectives. There was also evidence that it encouraged students to develop a patient-centred approach.

CONCLUSIONS

Early, integrated patient contact was both feasible to organise and acceptable to patients. The curriculum model was perceived by all parties to be educationally effective. The indications are that this model will be sustainable but will need consistent intensive support.

Medical students' attitudes toward patient-centred care: a longitudinal survey

PURPOSE

Patient-centredness should be at the heart of medical education. This longitudinal study aimed to assess possible attitude changes towards patient-centredness in a medical students' cohort as they progressed through the clinical curriculum. It also investigated the possible impact of socio-demographic factors on students' attitudes.

METHODS

The same student cohort was tested on 2 occasions: during their initial exposure to clinical curricula (year 4) and after 2 years, at the end of the clerkship (year 6). Students completed a questionnaire including demographics and the 18-item Patient-Practitioner Orientation Scale (PPOS). PPOS differentiates between patient-centred versus doctor-centred or disease-centred orientation, measuring attitudes along 2 dimensions: 'sharing' and 'caring'.

RESULTS

A total of 483 fully completed questionnaires was returned (response rate 83%). The cohort's attitudes were significantly more doctor-centred at the end of their studies compared to the beginning of their clinical curricula (P < 0.001). However, regarding the caring part of their relationship with patients, they maintained a satisfactory level of patient-centredness. Concerning sharing information, female students were significantly more patient-centred at year 4, with their mean score decreasing at the end of their clerkship. Furthermore, among only female students, having a looser relationship with religion was associated with more patient-centred attitudes.

CONCLUSIONS

Increased authoritarianism in graduating students' attitudes emphasises clearly the need for future research and redesigning communication curricula. Furthermore, the influence of gender and relationship with religion on attitudes towards the doctor-patient relationship should be explored further, in order to eliminate disparities in the provision of patient-centred medical care.

Involving practitioners in continuing education needs assessment: use of the nominal group technique

The nominal group technique (NGT) is described. An example of this method is provided. The goal was to identify clinical cases that could be used in a practitioner self-assessment tool. Practitioners in three groups were asked to keep a journal about cases they saw in the two weeks prior to their group discussion, individually provide case ideas within the group, and prioritize the cases individually. The groups provided over 192 case descriptions that can be used in a self-assessment tool for small animal practitioners. The NGT is a valuable tool that can identify and prioritize issues.

Impact of medical students' descriptive evaluations on long-term course development

BACKGROUND

In medical education, feedback from students is helpful in course evaluation. However, the impact of medical students' feedback on long-term course development is seldom reported. In this project we studied the correspondence between medical students' descriptive evaluations and key features of course development over five years.

METHODS

Qualitative content analysis was used. The context was consultation skills courses in the middle of the Göteborg undergraduate curriculum during five years. An analysis of 158 students' descriptive evaluations was brought together with an analysis of key features of course development; learning objectives, course records, protocols from teachers' evaluations and field notes. Credibility of data was tested by two colleagues and by presenting themes at seminars and conferences. Authors' experiences of evaluating the course over many years were also used.

RESULTS

A corresponding pattern was found in students' descriptive evaluations and key features of course development, indicating the impact of students' open-ended feed-back. Support to facilitators and a curriculum reform also contributed. Students' descriptive feedback was both initiating and validating longitudinal course implementation. During five years, students' descriptive evaluations and teachers' course records were crucial sources in a learner-centred knowledge-building process of course development.

CONCLUSION

Students' descriptive evaluations and course records can be seen as important instruments in developing both courses and students' learning. Continuity and endurance in the evaluation process must be emphasized for achieving relevant and useful results.

Isolated rural general practice as the focus for teaching core clinical rotations to pre-registration medical students

BACKGROUND

Earlier studies have successfully demonstrated that medical students can achieve success in core clinical rotations with long term attachments in small groups to rural general / family practices.

METHODS

In this study, three students from a class of 226 volunteered for this 1-year pilot program, conducted by the University of Queensland in 2004, for medical students in the 3rd year of a 4-year graduate entry medical course. Each student was based with a private solo general practitioner in a different rural town between 170 and 270 km from the nearest teaching hospital. Each was in a relatively isolated rural setting, rated 5 or 6 on the RRMA scale (Rural, Remote, Metropolitan Classification: capital city = 1, other metropolitan = 2, large regional city = 3, most remote community = 7). The rural towns had populations respectively of 500, 2000 and 10,000. One practice also had a General Practice registrar. Only one of the locations had doctors in the same town but outside the teaching practice, while all had other doctors within the same area. All 3 supervisors had hospital admitting rights to a hospital within their town. The core clinical rotations of medicine, surgery, mental health, general practice and rural health were primarily conducted within these rural communities, with the student based in their own consulting room at the general practitioner (GP) supervisor's surgery. The primary teacher was the GP supervisor, with additional learning opportunities provided by visiting specialists, teleconferences and university websites. At times, especially during medicine and surgery terms, each student would return to the teaching hospital for additional learning opportunities.

RESULTS

All students successfully completed the year. There were no statistical differences in marks at summative assessment in each of the five core rotations between the students in this pilot and their peers at the metropolitan or rural hospital based clinical schools.

CONCLUSION

The results suggest that isolated rural general practice could provide a more substantial role in medical student education.

Characterizing the patient-centeredness of hidden curricula in medical schools: development and validation of a new measure

PURPOSE

The "hidden curriculum" has a powerful influence in shaping medical students' attitudes and behaviors toward patient care. The purpose of this project was to develop and test a tool (the C(3) Instrument) to help educators characterize and understand the hidden curriculum at their own institutions.

METHOD

In 2000, the authors developed survey items to measure three content areas of the hidden curriculum with respect to patient-centered care. These content areas include role modeling, students' patient-care experiences, and perceived support for students' own patient-centered behaviors. The survey was distributed to third- and fourth-year students at ten medical schools in the United States. Using factor analysis, the authors selected items for the final version of the C(3) Instrument. To examine validity, they compared instrument scores to results of a poll of members of two organizations devoted to teaching patient-centered care.

RESULTS

A total of 890 students completed the survey. The mean age of students was 27 (SD 3). Fifty-two percent of students were women, and 70% were white. Twenty-nine items were selected for the C(3) Instrument, with internal consistency measures ranging from .67 to .93 for instrument subdimensions. In the validation analysis, summary scores for all three content areas of the C(3) Instrument were consistent with results of the poll of patient-centered organizations.

CONCLUSION

Despite some issues that still need to be resolved, the C(3) Instrument proved to be a reliable and valid tool that characterizes a medical school's hidden curriculum with respect to patient-centered care. It can be used to guide educational interventions by addressing the context that exists around formal teaching activities. It also makes possible the study of hidden curricula across multiple medical schools. Further research on the hidden curriculum should be aimed at developing a greater understanding of the dynamics between formal teaching activities and school culture.

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.