A review of longitudinal community and hospital placements in medical education: BEME Guide No. 26.

BACKGROUND: Traditionally, clinical learning for medical students consists of short-term and opportunistic encounters with primarily acute-care patients, supervised by an array of clinician preceptors. In response to educational concerns, some medical schools have developed longitudinal placements rather than short-term rotations. Many of these longitudinal placements are also integrated across the core clinical disciplines, are commonly termed longitudinal integrated clerkships (LICs) and often situated in rural locations. This review aimed to explore, analyse and synthesise evidence relating to the effectiveness of longitudinal placements, for medical students in particular to determine which aspects are most critical to successful outcomes. METHOD: Extensive search of the literature resulted in 1679 papers and abstracts being considered, with 53 papers ultimately being included for review. The review group coded these 53 papers according to standard BEME review guidelines. Specific information extracted included: data relating to effectiveness, the location of the study, number of students involved, format, length and description of placement, the learning outcomes, research design, the impact level for evaluation and the main evaluation methods and findings. We applied a realist approach to consider what works well for whom and under what circumstances. FINDINGS: The early LICs were all community-based immersion programs, situated in general practice and predominantly in rural settings. More recent LIC innovations were situated in tertiary-level specialist ambulatory care in urban settings. Not all placements were integrated across medical disciplines but were longitudinal in relation to location, patient base and/or supervision. Twenty-four papers focussed on one of four programs from different viewpoints. Most evaluations were student opinion (survey, interview, focus group) and/or student assessment results. Placements varied from one half day per week for six months through to full time immersion for more than 12 months. The predominant mechanism relating to factors influencing effectiveness was continuity of one or more of: patient care, supervision and mentorship, peer group and location. The success of LICs and participation satisfaction depended on the preparation of both students and clinical supervisors, and the level of support each received from their academic institutions. CONCLUSION: Longitudinal placements, including longitudinal integrated placements, are gaining in popularity as an alternative to traditional block rotations. Although relatively few established LICs currently exist, medical schools may look for ways to incorporate some of the principles of LICs more generally in their clinical education programmes. Further research is required to ascertain the optimum length of time for placements depending on the defined learning outcomes and timing within the programme, which students are most likely to benefit and the effects of context such as location and type of integration.

Re-licensing of general practitioners using the current UK revalidation proposals: a cross sectional study.

Objective To explore the views of general practitioners (GPs) on the feasibility of collecting supporting information for the Royal College of General Practitioners (RCGP) revalidation portfolio and mapping of this evidence to the General Medical Practice framework for proposed UK medical re-licensing. Design Cross sectional study with a questionnaire. Setting One inner city and one mixed urban/rural primary care organisation in the West Midlands, England and one rural primary care organisation in Wales. Participants 51/69 GPs who submitted a revalidation portfolio from November 2009 to February 2010. Results The majority of GPs considered the majority of work based supporting information was feasible to collect within a 5 year revalidation cycle; most concerns were expressed about providing evidence for extended practice, learning credits, and patient satisfaction and colleague feedback surveys (59%, 63%, 72%, and 77%, respectively, of GPs considered it feasible to collect this evidence) due to workload time constraints and lack of automatic access to evidence from others, which differed by GP work role. Two-thirds of participants (65%) stated that the submission of a portfolio of evidence was a feasible component of GP revalidation, reporting reservations on the appropriateness of patient and colleague feedback surveys and extended practice (55%, 57%, and 59% respectively) to provide objective evidence. GPs requested further clarity on the evidence mapping process. Conclusion Overall, GPs reported a positive response to the RCGP revalidation proposals. Concerns were focused on collecting the newer types of supporting information and the ability of GPs non-principals to collect this evidence. GP revalidation training and preparation is required.

An assessment of medical students' experiences of learning about the psychosocial enquiry in their introductory clinical course.

Medical students' ability to take a meaningful psychosocial history has been shown to decline during clinical training. We postulated that psychosocial histories are given a low priority in busy clinical attachments. The aim of this study was to identify factors that affect how medical students gain skills in psychosocial assessment. A random sample of 37 students filled in a questionnaire before and after their introductory course, and they were asked to keep a logbook of their experiences of teaching about psychosocial history taking. There were 504 teaching experiences recorded of which less than half were positive. Negative experiences often related to poor communication by clinicians. At the end of the course less than half the students felt confident in taking a psychosocial history. To improve doctors' skills in this important area we suggest that teaching in psychosocial history taking should be made explicit, as an integrated part of the overall assessment of a patient.

Introducing community-based teaching of third year medical students: outcomes of a pilot project one year later and implications for managing change.

INTRODUCTION: British undergraduate medical education is undergoing change, including a greater emphasis being placed on community-based teaching. These changes need to be evaluated for their educational outcomes, but there also needs to be a review of the process of introducing change and its subsequent management. THE SETTING: During the academic year 1996/97 a new project was piloted at Leeds University. Fifty-three third year medical students were attached in groups of four to general practitioner tutors in a primary care setting for four days in order to improve consultation skills. There was an emphasis on adopting a patient-centered approach, particularly asking patients about their concerns. METHOD: These students were asked to fill in a questionnaire to determine whether the community-based teaching has made any lasting impression on their attitudes and performance. The response rate was 80%. The students commented that even only four days of community-based teaching had helped them realize the importance of asking about patients' concerns. They also reported beginning to concentrate on psychosocial issues while talking to patients, issues that are often ignored by medical students. The students' comments are contrasted with those of the hospital-based tutors, some of whom have looked less than favorably on the project. DISCUSSION: The introduction of any new learning experience needs to be evaluated both in the short term and in the long term. This study begins to address long-term evaluation and suggests that a brief attachment can be memorable to students and beneficial one year later.

Making and sharing decisions about management with patients: the views and experiences of pre-registration house officers in general practice and hospital.

OBJECTIVES: To explore the views and experiences of pre-registration house officers (PRHOs) in general practice and hospital settings regarding the concept of patient partnership and their experience of involving patients in management decisions. DESIGN: The 12 PRHOs who had graduated from British universities and who were working within the Yorkshire Deanery were interviewed towards the end of their four-month general practice attachments. The interviews were semi-structured and analysed qualitatively. RESULTS: Three major themes emerged. The PRHOs perceived differences in approach between consultations carried out in hospital and primary care settings, with general practitioners being more likely to share information and decisions with patients. As medical students, the PRHOs had little opportunity to practise sharing information and management decisions with patients, and variable experience of this after graduation. On the whole they were favourable to the concept of patient partnership. CONCLUSIONS: Medical students and PRHOs lack training and opportunities to decide on management and discuss this with patients and yet, particularly in general practice settings, they have to practise these skills. The PRHOs had begun to develop strategies to decide how much information to give to patients and to what extent to involve patients in management decisions. This is an area that needs further consideration when planning both undergraduate and postgraduate medical education.

Patient-centred consultations: a comparison of student experience and understanding in two clinical environments.

OBJECTIVES: To explore students' perspectives on doctor-patient communication. DESIGN: We interviewed students in focus groups before and after their placements. In semistructured interviews they were asked about their experiences of learning through clinical contact, with particular emphasis on patient-centred consultations, on the wards and during their community attachment. Students whose clinical skills training remained hospital-based were also interviewed to compare the range of experiences. SETTING: Leeds University. SUBJECTS: Third-year medical students. RESULTS: During hospital training students are rarely introduced, either through teaching or observation, to the idea of patient-centred consultations. In contrast both the principles underpinning and/or the practice of such consultations were routinely encountered during the general practice placement. Students considered the community attachment to have helped them appreciate the value of exploring patients' concerns both in terms of enhancing the patients' overall healthcare experience and promoting effective clinical management. While they considered the nature and purpose of hospital care to be qualitatively different from that conducted in the community, the relevance of adopting a patient-centred approach on the wards was confirmed. CONCLUSIONS: Recommendations for clinical training are made. The relevance and best use of community and hospital-based attachments need to be evaluated further.

Valuing diversity: helping medical students explore their attitudes and beliefs.

The General Medical Council of the United Kingdom has defined a set of standards for doctors dealing with patients, including respecting the diversity of lifestyles and beliefs of patients. These have been incorporated into Personal and Professional Development (PPD) course unit of the undergraduate medical curriculum at Leeds University. The objectives of PPD include helping students understand how age, gender, culture, sexuality and disability affect how events are experienced or perceived. In 2002 seminars were run on valuing diversity to encourage students to develop insight into and reflect on their own attitudes to diversity. The sessions were evaluated and assessed by means of student feedback and as part of a written PPD exercise. Students rated the sessions highly and appeared to learn a great deal about diversity including approaches to communication and breaking down stereotypes. Their evaluation will help to improve the course.

Creative intervention strategies in the management of perinatal loss.

The personal grief experienced by a mother who has lost her child is profound. Coping with the sadness and incomprehensibility of the loss predisposes her to feelings of increased vulnerability and isolation. As the woman externalizes her internal experience of grief, she is better able to manage and deal with the situational crises that surround and emerge from the pregnancy loss. This article presents a number of creative, non-traditional approaches that can be utilized to bring about wholeness and well-being in the mother as she shares her loss story.

Medical students' attitudes towards concordance in medicine taking: exploring the impact of an educational intervention.

BACKGROUND AND OBJECTIVES: Concordance has been suggested as a new way of describing the agreement about medicine taking during the consultation process. The aim is a decision on management agreed on by both doctor and patient. As such it has strong links with shared decision-making and patient partnership. In order to encourage doctors to adopt a concordant model, we need to foster a positive attitude towards the concept. We decided to investigate the attitudes of first and second year medical students towards concordance as a base for further educational interventions. SETTING: The School of Medicine, Leeds University. METHODS: We administered the Leeds Attitude toward Concordance scale (LATCon) to first and second year medical students at the beginning of the academic year, and to the same second year students after they had completed a written exercise relating to concordance. RESULTS: The response rate was over 80% for each group. There was no difference in the attitudes towards concordance of the first years and the second years prior to the intervention. After they had completed the exercise, the second years' attitudes towards concordance improved by a small but significant amount. CONCLUSIONS: A paper-based exercise with questions focusing on concordance and based around cases appears to improve medical students' attitudes towards the concept. This exercise needs to be followed up with skills training and observation of role models in order that the attitudes of the students translate into practice once they are qualified.

First step: report on a pilot course for personal and professional development.

OBJECTIVE: To describe a pilot course in personal and professional development, entitled 'Becoming a doctor: the first step' and our suggestions for what might be incorporated into future courses. SETTING AND CONTEXT: Leeds Medical School begins a new curriculum in September 1999 with a proportion of the first 3 years being devoted to a new module on personal and professional development. This module will include courses involving communication skills, ethics, working in groups and early patient contact through community visits. Some of these topics were piloted in a short course for first-year medical students in 1998. LEARNING METHODS: The course ran for 9 weeks and was largely experiential. The group facilitators came from diverse health and social care backgrounds. A variety of learning methods were used, concentrating on self-reflection, discussion, community visits and information gathering. EVIDENCE FOR EFFECTIVENESS: The views of both facilitators and students were analysed. Students particularly appreciated the community visits and group work. The facilitators were positive about the course overall while suggesting improvements, including their own involvement in future development of the course. CONCLUSIONS: The pilot course has helped us to focus on objectives for the new curriculum and to plan the new course. In particular there is a need for more attention to be given to the involvement of facilitators in course development.