Medical students in general practice: students' learning experiences and perspectives from supervisors and patients

During the last decades considerably more of medical students’ clinical training has shifted into general practice. The aim of this thesis was to study medical students’ learning experiences in general practice, work-based assessment, and the perspectives of GP supervisors and patients. Results Senior students’ learning in a portfolio pilot was mainly on patient-centred communication, clinical reasoning and professional development. Junior students appreciated contact with good role models. Long-term use of a work-based assessment tool for senior students significantly increased the proportion of specific goals and feedback to students, supervisors’ stringency of the assessment, and their satisfaction with the tool. The work-based assessment and the portfolio assessment had acceptable reliability, validity and educational impact. GPs were highly motivated teachers and took pride in their discipline. In their teaching of junior students, their main reward was improved quality of own work. Their predominant problem was lack of time for teaching, but relationship to patients and provision of feedback were other concerns. Teacher training was required. The vast majority of patients were satisfied with both senior and junior student encounters, even though caution was recommended when patients attend for sensitive matters. Patients perceived their teaching role mainly as facilitators of students’ development of professional skills

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

Objective. To explore experienced general practitioner (GP) tutor perceptions of a skilled GP tutor of medical students. Design. Interview study based on focus groups. Setting. Twenty GPs experienced in tutoring medical students at primary health care centres in two Swedish regions were interviewed. Method. Four focus-group interviews were analysed using qualitative content analysis. Subjects. Twenty GP tutors, median age 50, specifically selected according to age, gender, and location participated in two focus groups in Gothenburg and Malmo, respectively. Main outcome measures. Meaning units in the texts were extracted, coded and condensed into categories and themes. Results. Three main themes emerged: "Professional as GP and ambassador to general practice", "Committed and student-centred educator", and "Coordinator of the learning environment". Conclusion. Experienced GP tutors describe their skills as a clinical tutor as complex and diversified. A strong professional identity within general practice is vital and GP tutors describe themselves as ambassadors to general practice, essential to the process of recruiting a new generation of general practitioners. Leaders of clinical education and health care planners must understand the complexity in a clinical tutor's assignment and provide adequate support, time, and resources in order to facilitate a sustainable tutorship and a good learning environment, which could also improve the necessary recruitment of future GPs

Patients consulting with students in general practice: Survey of patients' satisfaction and their role in teaching.

Background: General practice is a common setting for medical students' clinical training. However, little is known about patients' views on consulting with senior students. Aims: To investigate patients' attitudes to consultations conducted by senior students alone, before patients saw their GP; and to enquire into patients' perception of their teaching role. Method: Adult patients attending 50 health centres in Sweden completed a questionnaire directly after their consultation with a fifth-year medical student and their GP. Results were analysed quantitatively and qualitatively. Results: The questionnaire was completed by 495 patients, and 92% were satisfied with their consultation. Reasons were personal gain as well as altruism. Almost all patients were prepared to consult with a student again, however in a third of cases conditional on the nature of their presenting complaints. Emotional problems and intimate examinations could cause reluctance. Patients' conception of their teaching role supported previous research: patients as "facilitators of students" development of professional skills and as "experts" or "exemplars" of their condition. An additional theme, patients as "part of a real context", emerged. Conclusions: Patients in general practice have a positive view towards consulting with senior students. Even unprepared patients see themselves as contributors to teaching, and their capacity in this respect is probably under-utilized

Students' reflections in a portfolio pilot: Highlighting professional issues.

Background: Portfolios are highlighted as potential assessment tools for professional competence. Although students' self-reflections are considered to be central in the portfolio, the content of reflections in practice-based portfolios is seldom analysed. Aim: To investigate whether students' reflections include sufficient dimensions of professional competence, notwithstanding a standardized portfolio format, and to evaluate students' satisfaction with the portfolio. Methods: Thirty-five voluntary final-year medical students piloted a standardized portfolio in a general practice (GP) attachment at Lund University, Sweden. Students' portfolio reflections were based upon documentary evidence from practice, and aimed to demonstrate students' learning. The reflections were qualitatively analysed, using a framework approach. Students' evaluations of the portfolio were subjected to quantitative and qualitative analysis. Results: Among professional issues, an integration of cognitive, affective and practical dimensions in clinical practice was provided by students' reflections. The findings suggested an emphasis on affective issues, particularly on self-awareness of feelings, attitudes and concerns. In addition, ethical problems, clinical reasoning strategies and future communication skills training were subjects of several reflective commentaries. Students' reflections on their consultation skills demonstrated their endeavour to achieve structure in the medical interview by negotiation of an agenda for the consultation, keeping the interview on track, and using internal summarizing. The importance of active listening and exploration of patient's perspective was also emphasized. In students' case summaries, illustrating characteristic attributes of GP, the dominating theme was 'patient-centred care', including the patient-doctor relationship, holistic modelling and longitudinal continuity. Students were satisfied with the portfolio, but improved instructions were needed. Conclusions: A standardized portfolio in a defined course with a limited timeframe provided ample opportunities for reflections on professional issues. Support by mentors and a final examiner interview contributed to the success of the portfolio with students. The interview also allowed students to deepen their reflections and to receive feedback

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

Structured feedback to undergraduate medical students: 3 years' experience of an assessment tool.

Background: There is a paucity of research on the effects of interactive feedback methods and sustained assessment strategies in formative assessment of students in the workplace. Aims: To investigate the outcome of long-term use of an assessment tool. Methods: Retrospective analysis of summarised assessment tools from 3 years of 464 final-year students in general practice. Quantitative data were analysed using non-parametric tests and a multi-level approach. Qualitative data were subjected to content analysis. Results: Students' main deficiencies in the consultation were in the domains of working diagnoses and management plans; however, supervisors emphasised goals of patient-centred communication and structure of the medical interview. As a group, students underestimated their clinical performance, compared to supervisors' judgement. Most students were supplied with specific goals, 58% with specific follow-up feedback. The majority of students and supervisors were satisfied with the assessment strategy. Long-term experience with the tool significantly increased the proportion of specific goals and feedback to students, supervisors' stringency of the assessment, and their satisfaction with the tool. Conclusions: The summarised assessment strategy proved feasible and acceptable with students and supervisors in a continuous attachment with assigned personal supervisors. However, there was room for improvement in supervisors' provision of specific follow-up feedback

Samverkan lärare-­studenter nyckeln till lyckad förändring

Vår utgångspunkt är den nya kursen »Individ och samhälle« på den reformerade läkarutbildningens avslutande termin. Som lärare betonar vi vikten av att kompetensmål, arbetsformer och examination hänger samman på ett klart och tydligt sätt, så att de studerande styrs rätt i sitt lärande. Som studerande lyfter vi fram förutsättningarna för en aktiv studerandemedverkan: att involveras medan möjlighet till påverkan ännu finns, att bli väl insatta i de aktuella frågorna och, inte minst, att bli tagna på allvar. Nu återstår att se om de fina planerna håller måttet i den pedagogiska vardagen, också på lite längre sikt