Hospital-based versus community-based clinical education: comparing performances and course evaluations by students in their second-year pediatrics rotation

Assessing the Learning Environment Perception Among Medical Students at a Tertiary Referral Hospital in Saudi Arabia

Objective

To assess the perception of medical students at Alfaisal University College of Medicine (AUCOM) of their learning environment at a referral-based tertiary hospital in Riyadh, Saudi Arabia.

Methods

The validated Dundee Ready Educational Environment Measure (DREEM) questionnaire was administered to all year 4 and year 5 students during the academic year 2020-2021. Scores were analyzed using the descriptors provided by the questionnaire developers and compared across different students' cohorts using SPSS.

Results

The overall DREEM score was 120.45/200, which can be described as a "more positive than negative environment", indicating a positive perception with a potential for improvement. All domain scores were on the positive side except the "students' social self-perception" which had a score indicating a problematic area. Female students had a statistically significant more positive score in the domain "students' perception of learning" than male students. Scores for individual questions were persistently on the positive side except for eight questions that pointed to problematic areas in the curriculum. When compared between student cohorts, five questions had statistically significant difference in scores between students in both academic years, but only two of those had scores indicating concerning areas.

Conclusion

Referral-based tertiary hospitals can be perceived positively by students as a learning environment in undergraduate medical education. We identified some areas of concern in our curriculum to be targeted by future research.

General Surgery Residents' Perception of Feedback: We Can Do Better

BACKGROUND

Feedback (FB) regarding perioperative care is essential in general surgery residents' (GSRs) training. We hypothesized that FB would be distributed unevenly across preoperative (PrO), intraoperative (IO), and postoperative (PO) continuum of the perioperative period. We aimed to compare results between university- and community-hospital settings planning to institute structured, formalized FB in a large health care system operating multiple surgery residency programs in departments that are linked strategically.

METHODS

Quantitative, cross-sectional, Likert scale anonymous surveys were distributed to all GSRs (categorical and preliminary; university: community 1:2). Twenty-five questions considered frequency and perceived quality of FB in PrO, IO, and PO settings. Data were tabulated using REDCap and analyzed in Microsoft Excel using the Mann-Whitney U test, with α = 0.05. Comparisons were made between university- and community-hospital settings, between junior (Post-Graduate Year (PGY) 1-3) and senior (PGY 4-5) GSRs, and by gender.

RESULTS

Among 115 GSRs surveyed, 83 (72%) responded. Whereas 93% reported receiving some FB within the past year, 46% reported receiving FB ≤ 20% of the time. A majority (58%) found FB to be helpful ≥ 80% of the time. Among GSRs, 77%, 24%, and 64% reported receiving PrO, IO, or PO FB ≤ 20% of the time, respectively, but 52% also believed that FB was lacking in all 3 areas. Most GSRs wanted designated time for PrO planning FB (82%) and PO FB (87%), respectively. Thirty-six percent of GSRs reported that senior/chief (i.e., PGY-4/PGY-5 GSRs) took them through cases ≥40% of the time; notably,78% reported that FB from senior/chief GSRs was equally or more valuable than FB from attending surgeons. A majority (78%) reported that attending surgeons stated explicitly when they were providing FB only ≤20% of the time. GSRs at the community hospital campuses reported receiving a higher likelihood of "any" FB, IO FB, and PO FB (p < 0.05). Most GSRs surveyed preferred a structured format and designated times for debriefing and evaluation of performance. Subanalyses of gender and GSR level of training showed no differences.

CONCLUSIONS

FB during GSR training varies across the perioperative continuum of care. Community programs seem to do better than University Programs. More work need to be done to elucidate why differences exist between the frequency of FB at University and Community programs. Further, data show particularly low FB outside of the operating room. Ideally, according to respondents, FB would be provided in a structured format and at designated times for debriefing and evaluation of performance, which poses a challenge considering the temporal dynamism of general surgery services.

Does a socially-accountable curriculum transform health professional students into competent, work-ready graduates? A cross-sectional study of three medical schools across three countries

Background: Socially-accountable health professional education (SAHPE) is committed to achieving health equity through training health-workers to meet local health needs and serve disadvantaged populations. This research assesses the biomedical and socially-accountable competencies and work-readiness of first year graduates from socially-accountable medical schools in Australia, the United States and Sudan.Method: A self-administered survey to hospital and community health facility staff closely associated with the training and/or supervision of first year medical graduates from three SAHPE medical schools.Main outcome measure: Likert scale ratings of key competencies of SAHPE graduates (as a group) employed as first-year doctors, compared to first year doctors from other medical schools in that country (as a group).Findings: Supervisors rated medical graduates from the 3 SAHPE schools highly for socially-accountable competencies ('communication skills', 'teamwork', 'professionalism', 'work-readiness', 'commitment to practise in rural communities', 'commitment to practise with underserved ethnic and cultural populations'), as well as 'overall performance' and 'overall clinical skills'.Interpretation: These findings suggest SAHPE medical graduates are well regarded by their immediate hospital supervisors, and SAHPE can produce a medical workforce as competent as from more traditional medical schools, but with greater commitment to health equity, working with underserved populations, and addressing local health needs.

Ranking Programs: Medical Student Strategies

BACKGROUND

Selecting a training program is one of the most challenging choices an applicant to the Match has to make.

DISCUSSION

To make an informed decision, applicants should do a comprehensive research and carefully plan their upcoming steps. Factors that might influence the applicants' decision include geography, program reputation, specific areas of academic focus, subspecialty interests, university-versus community-based training, length of training and interest in combined programs. Such information can be gathered from published material, websites, and personal advice (from faculty, residents and advisors). This process is time-consuming and stressful.

CONCLUSION

Therefore, in this article we elaborate on the above to facilitate this process for applicants.

The impact of socially-accountable, community-engaged medical education on graduates in the Central Philippines: Implications for the global rural medical workforce

INTRODUCTION

Developing and retaining a high quality medical workforce, especially within low-resource countries has been a world-wide challenge exacerbated by a lack of medical schools, the maldistribution of doctors towards urban practice, health system inequities, and training doctors in tertiary centers rather than in rural communities.

AIM

To describe the impact of socially-accountable health professional education on graduates; specifically: their motivation towards community-based service, preparation for addressing local priority health issues, career choices, and practice location.

METHODS

Cross-sectional survey of graduates from two medical schools in the Philippines: the University of Manila-School of Health Sciences (SHS-Palo) and a medical school with a more conventional curriculum.

RESULTS

SHS-Palo graduates had significantly (p < 0.05) more positive attitudes to community service. SHS-Palo graduates were also more likely to work in rural and remote areas (p < 0.001) either at district or provincial hospitals (p = 0.032) or in rural government health services (p < 0.001) as Municipal or Public Health Officers (p < 0.001). Graduates also stayed longer in both their first medical position (p = 0.028) and their current position (p < 0.001).

CONCLUSIONS

SHS-Palo medical graduates fulfilled a key aim of their socially-accountable institution to develop a health professional workforce willing and able, and have a commitment to work in underserved rural communties.

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.

Ophthalmology Teaching-Learning in Undergraduate Classes: Roadblocks and The Remedies

The curriculum needs to run apace with the changing morbidity pattern and social needs. Teaching methodology requires constant evolution. With a static curriculum and teaching methods undergraduate ophthalmology proves difficult for many students. This article briefly analyses the ophthalmology curriculum, highlights the problems of teaching and offers some solutions.

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

Background:

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

Materials and Methods:

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

Results:

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

Discussion:

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

Real patient learning integrated in a preclinical block musculoskeletal disorders. Does it make a difference?

Although musculoskeletal disorders are the most common reason for general practitioner visits, training did not keep pace. Implementation of learning from patients with rheumatologic disorders linked together with the teaching of theoretical knowledge in the preclinical medical education might be an important step forward in the improvement of quality of care for these patients. The Leiden Medical School curriculum has implemented two non-obligatory real patient learning (RPL) practicals integrated within the preclinical block musculoskeletal disorders. This study investigates the educational effectiveness of the practicals, the expectations students have of RPL, and students’ satisfaction. Participants’ grades on the end-of-block test served as the test results of the educational effectiveness of the practicals and were compared with those of the non-participants. Qualitative data was collected by means of questionnaires generated by focus groups. The participants in practicals scored significantly higher at the end-of-block test. The expected effects of the contact with real patients concerned positive effects on cognition and skills. ‘Contextualizing of the theory’, ‘better memorizing of clinical pictures’, and ‘understanding of the impact of the disease’ were the most frequently mentioned effects of the practicals. Overall, the participants were (very) enthusiastic about this educational format. The RPL practicals integrated within a preclinical block musculoskeletal disorders are a valuable addition to the Leiden medical curriculum. This relatively limited intervention exhibits a strong effect on students’ performance in tests. Future research should be directed towards the long-term effects of this intervention.

Performance of clinical clerks doing paediatric rotations in a community hospital versus a university hospital

INTRODUCTION

Most clinical clerks (third-year medical students) do their paediatric rotation at the IWK Health Centre, the Dalhousie University-affiliated tertiary care paediatric institution in Halifax, Nova Scotia. Due to limited space, some clerks are sent to community hospitals in the provinces of New Brunswick and Prince Edward Island. These community hospitals are different in terms of the academic environment and the availability of paediatric subspecialty services.

OBJECTIVE

To compare performance of clinical clerks doing paediatric rotations in community hospitals (group I) with those in a university hospital (group II).

METHODS

The end-of-rotation test scores on the 45 single correct answer multiple choice questions and the three 15 min objective structured clinical examinations in group I (n=54) and group II (n=124) for two consecutive academic years were studied. The end-of-rotation comments by the clerks in group I were examined to assess the quality of their experience.

RESULTS

For the two academic years, the cumulative mean +/- SD scores for multiple choice questions and objective structured clinical examinations were 82.82+/-7.47 and 70.82+/-11.37, respectively, in group I compared with 83.03+/-7.74 and 69.02+/-11.23 in group II. There were no significant differences in the results between the two groups. No difference in results was seen when the scores were analyzed separately for each of the academic years. The clerks in group I rated their experience as positive.

CONCLUSIONS

Clerks doing paediatric rotations in community hospitals perform as well and receive similar educational benefits as those at university hospitals. Community hospitals can provide a quality experience for paediatric clerkship training.

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.

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review

REVIEW DATE

Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research.

SEARCH STRATEGY

Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology.

CRITERIA

DEFINITIONS

EXPERIENCE

Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included.

EXCLUSIONS

Not empirical; not early; post-basic; simulated rather than 'authentic' experience.

DATA COLLECTION

Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation.

HEADLINE RESULTS

A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention.

CONCLUSIONS

Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Early practical experience and the social responsiveness of clinical education: systematic review

OBJECTIVES

To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence.

DESIGN

A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001.

DATA SOURCES

Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration.

SELECTION OF STUDIES

All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication.

RESULTS

Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations.

CONCLUSION

Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Trends in North American medical education

Medical education in the United States of America (USA), and worldwide, is increasingly concentrating on the process and outcome of the educational experience. The first efforts to substantially improve medical education in the USA resulted in the Flexner Report in the early 1900s. The release of this report led to significant advancements in the quality of curriculum content. However, in the past few decades there has been increasing realization that delivery of content will not, by itself, assure the development of excellent physicians. As a result, there has been an increasing emphasis on the process, and, most recently, the outcome, of medical education. Process movements have examined the context and methods for teaching and learning. The problem-based learning movement is perhaps the most widely-known example of process trends. The latest trends in USA medical education focus on the outcomes of the learning process. At the forefront of this movement is the American Council on Graduate Medical Education (ACGME), which accredits all USA post-graduate training programs. Recently, the ACGME has defined a set of six core clinical competencies that all graduates must demonstrate. A second emerging trend is inter-professional education. Increasingly, healthcare is provided by inter-professional healthcare team, and students must be competent to function effectively in this setting. Many academic health centers are developing joint curricula to address this need. Medical education has evolved from a primary focus on content to an emphasis on process of teaching and learning, and will increasingly concentrate on educational outcomes.

The emergency medicine rotation: a unique experience for medical students

The objective of this study was to determine if an Emergency Medicine (EM) rotation for medical students offers a unique educational opportunity, and to document those experiences. Thirty-three medical students at one teaching hospital recorded in a computer database information about their patient encounters during EM and Internal Medicine (IM) rotations. Data collected included the types of patients seen, the level of participation in patient care and decision making, and procedures performed. A total of 2740 patient encounters were recorded, 1564 EM and 1176 IM. Students on EM rotations were more likely than students on IM rotations to be involved in the initial evaluation (93.1% vs. 47.0%, respectively), diagnosis (93.5% vs. 44.7%, respectively), and decision making (93.3% vs. 43.5%, respectively); they were also more likely to perform procedures (31.7% vs. 8.5%, respectively). There were significant differences in the patient populations and disease processes encountered on the two rotations as well.

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

AIMS

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

METHODS

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

RESULTS

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

DISCUSSION

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

Standardized patient assessment of ambulatory clerks: effect of timing and order of the clerkship

BACKGROUND

A standardized patient examination may assess unique learning in an ambulatory clerkship but, as with written tests, may be affected by student maturation.

PURPOSE

To explore the effect of timing and order of a medicine ambulatory clerkship on student performance of a standardized patient examination (SPE).

METHODS

All students rotating through an ambulatory medicine clerkship in 1 academic year completed an SPE designed to reflect specific learning objectives of the clerkship as well as nonclerkship case content. Students were grouped according to prior inpatient clerkship experience.

RESULTS

When compared to students with only ambulatory experience, students with both inpatient and ambulatory experiences in internal medicine did not perform better on the ambulatory cases of the SPE but did perform better on nonclerkship cases. Performance on the SPE was not affected by month of training. At completion of the inpatient clerkship, students with prior ambulatory experience did not perform better than students with inpatient-only experience on the National Board of Medical Examiners Medicine Subject Examination.

CONCLUSIONS

The SPE is an appropriate assessment tool for the ambulatory clerkship when case content is linked to learning objectives of the clerkship. Unlike other knowledge-based assessments, the SPE is not affected by student maturation.

Teaching doctors about the eye: trends in the education of medical students and primary care residents

Ophthalmologists play a relatively peripheral role in medical student and resident education. A review of the evolution, funding, and administration of medical education in the United States lends insight into why this is so. The author reviews the current status of education in ophthalmology for medical students and residents; the development of an ophthalmology curriculum; alternatives to the traditional medical school curriculum and how these have been incorporated into ophthalmic education; and the effect of new trends in medical education and pressures created by health care reform on the education of medical students and residents. The role of ophthalmologists in the general practice of medicine and in teaching doctors about the eye is discussed. Finally, the opportunity that the current climate presents for ophthalmologists to define their role in health care through education is considered.

Orienting medical education to community need: a review

The literature on community-oriented medical education is reviewed. In response to major changes in the origin, expression and place of management of much illness, many medical schools are turning their attention increasingly to the community from whence to derive their curriculum and wherein to effect their teaching. The traditional hospital base of teaching is eroding, necessitating new, innovative approaches to medical education. Becoming community-oriented, or using community-based learning, offers potential benefits for the schools, the students, and the public. The experience of others demonstrates the necessity of enlisting community representatives as partners in the process of change. Institutional barriers are significant and careful planning is needed to overcome them.