Teaching the teachers--a needs assessment of tutors for a new clinical skills course

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.

Early patient contact in primary care: a new challenge

BACKGROUND

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

AIM

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

SUBJECTS

30 GPs teaching third-year medical students.

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

CONTEXT

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

In response to Tomorrow's Doctors, the use of primary care as a teaching base has been extended in many medical curricula. Previous reports have largely been speculative, looking at the theoretical possibilities and concerns of general practitioner teachers; in order to validate such studies, it is now important to evaluate the experience of those actually engaged in new teaching opportunities. In addition, curriculum developers need to go beyond descriptive studies to weight the factors which may help or hinder new teaching.

AIM

The aim of this qualitative study was to use the context of a substantive increase in community-based teaching to evaluate the perspective of key general practice tutors on factors related to recruitment and retention, impact and outcomes, curriculum delivery, training and support, and quality assurance of the course.

METHODS

Data were collected by written questionnaires to a sample of 45 general practitioners, plus semi-structured interviews with 15 general practitioners (33% of total sample). The data were purposively analysed to seek key factors, which were weighted by 'force field' analysis to show the balance of positive and negative factors.

RESULTS

The data demonstrate important factors which may facilitate or impair community-based teaching at the levels of tutor, student, practice, and academic context.

DISCUSSION

A 'cycle of satisfaction' is described, where personal motivation, shared team responsibility for teaching, and an enhanced professional self-image may all be crucial interdependent contributors. Suggestions are drawn from the data on key elements of effective academic support and possible practical quality indicators.

Measuring instructional quality in community-orientated medical education: looking into the black box

OBJECTIVES

Decentralizing medical education to community settings has raised issues of instructional quality. The need to evaluate community-based instruction accents the need to adopt a systems perspective, moving beyond factors known to comprise general clinical teaching effectiveness to include factors that focus on instruction as a process. Application of evaluation models using traditional input-output analysis can be flawed. This approach--dubbed the 'black box'--typically examines inputs and outputs, but often ignores throughputs.

DESIGN

In this article we open the black box, using theory to examine the underlying processes that define community-based medical education. We first describe the components and processes of an instructional model that is framed by the philosophy of quality and grounded in experiential learning theory. Without examining the critical processes at work inside the black box - i.e. how students come to acquire clinical knowledge and how behaviours are influenced - it is difficult to assess which programme features contribute to success. Tensions created by the absence of consensus on the outcomes of instruction and the challenge of developing adequate measures are highlighted.

SETTING

State University of New York at Buffalo.

SUBJECTS

Clinician-teachers, learners and patients in the environment.

RESULTS AND CONCLUSIONS

We conclude with describing a tool for evaluating community-based instruction that is guided by the context of our model.