New century, new challenges for community based medical education.

Abstract

Throughout the world, especially in developing countries where secondary care is less important, there are many ‘community orientated medical schools’ where the curriculum is defined with regard to the priority health needs and resources within the community.1 In the United Kingdom (UK) and in other developed countries, however, the dominance of hospital over community-based medicine has been a traditional aspect of medical education.2 This situation has been criticised by many commentators.3 For example in 1985, Julian Tudor Hart wrote that ‘The core curriculum for all doctors should be primary care: this should be taught where it is carried out, within communities’.4 The most influential call to medical schools to increase the amount of community-based teaching has been the 1993 version of the General Medical Council's report Tomorrow's Doctors.5 This thrust is re-emphasised in the 2002 version which states: ‘Clinical education must reflect the changing patterns of healthcare and provide experience in a variety of environments including hospitals, general practices and community medical services’.6 Against this background, the recent report New Century, New Challenges7 prepared by a working group of the heads of university departments of general practice and primary care in UK medical schools, is timely and important. It records that educational activities involving general practitioners now comprise an average of 9% of undergraduate medical curricula in the UK. About 3900 general practices in the UK, about one third of the total, are currently involved in the delivery of undergraduate medical education. It is estimated that 1000 additional practices need to be recruited to meet the demands of planned increases in the numbers of medical students within new and expanded UK medical schools. An increasing proportion of community-based medical education in the UK is concerned not with teaching general practice, but with the delivery of the core medical curriculum including communication skills, clinical skills, family projects and early community and clinical experience.5 In some medical schools, GP tutors are also involved in educational activities involving ethical issues, evidence-based medicine and interprofessional education. General practitioners are particularly suited to such teaching for several reasons. As medical generalists, they have a broad range of clinical experience from which to draw. They are also used to small group processes in medical education involving, for example, the use of reflection as a key component of experiential learning. Most of all, however, almost all GP tutors have personal experience, via vocational training for general practice, of a professional approach to medical education, in which activities are planned, tutors are trained and outcomes are reviewed as part of a continuous process of course development. Developments in general practice-based medical education reflect not only a shift in the geographical base of teaching, they also involve a re-definition of the role of clinical tutors, covering educational activities in a wide range of areas and applying a professional approach to the educational process. Such teaching is usually highly evaluated by medical students. At a time when medical student numbers are increasing in the UK, and it is increasingly difficult to deliver undergraduate medical education in teaching hospitals, it seems highly desirable, necessary and likely that the current trend of increasing the community-based element of undergraduate medical education will continue. An important part of this development should be closer links between clinical tutors in primary and secondary care, breaking down traditional structures and embodying the principles of continuity, communication and co-operation that are increasingly the hallmarks of high quality clinical care. Although momentum, enthusiasm and a professional approach to medical education are valuable attributes of community-based medical education, they are insufficient to sustain current trends. Academic centres of general practice and primary care currently only receive about 5% of the SIFT/ ACT budgets provided by the UK National Health Service to meet the service costs of undergraduate medical education in general practice.7 They receive even smaller proportions of the university consumable, administrative and academic salary budgets for undergraduate medical curricula. Further increases in community-based medical education will need a fairer share of undergraduate teaching resources.