General Practice Clerkship Research Articles

Medical students’ clinical performance in general practice – Triangulating assessments from patients, teachers and students

Background: Formative assessment of medical students' clinical performance during general practice clerkship is necessary to learn consultation skills.Aims: Our aim was to triangulate feedback using patient questionnaires, written self-assessment and teachers' observation-based assessment, and to describe the content of this feedback.Method: We developed StudentPEP, a 15-item version of EUROPEP, a tool for measuring patients' evaluation of quality in general practice. The teacher and student forms consisted of five StudentPEP-items and open-ended questions asking for approval and improvement needed on four aspects. Quantitative scores were analyzed statistically. Free-text comments were analyzed and categorized into ‘specific and concrete’ versus ‘general and unspecific’.Results: One hundred seventy-three students returned data from 2643 consultations. Mean patients' scores for 15 items were 4.3–4.8 on a five-point Likert scale. Mean teacher scores were 4.4 on five items, while students' mean self-assessments were 3.6–3.8. In an analysis of 380 consultations, students were more specific and concrete in their self-evaluation compared with teachers (p < 0.01).Conclusion: Patients scored students' performance high compared with students' self-assessments. Teachers' scores were in accordance with patients' scores. Teachers' written evaluations of students were often general. There is a potential for improving teachers' feedback in terms of more specific and concrete comments.

‘Can you take a student this morning?’ Maximising effective teaching by practice nurses

Little is known about the contribution nurses make to medical student learning. This study set out to explore the nature of practice nurse teaching during the general practice clerkship and to investigate ways in which the teacher and learner (the practice nurse and the medical student) can be best supported to maximise learning. Mixed focus groups were conducted with general practitioner educational supervisors and practice nurses. Further focus groups were conducted with students on completion of clerkships. There is wide variation in the delivery, organisation and expectations of practice nurse teaching. Although there is some evidence of a passive learning experience, the learning dynamic and the student-nurse relationship are regarded highly. Time spent with practice nurses is an important part of the clerkship in general practice. The nature of the practice nurse-medical student relationship differs from that of the educational supervisor-medical student relationship and can be built upon to maximise learning during the clerkship. The experience for the practice nurse, medical student and supervisor can be enhanced through formal preparation for delivering teaching.

Student evaluation of a primary care clerkship: quality assurance and identification of potential for improvement

BackgroundIn Germany, like many other countries, general practice clerkships have only recently become mandatory during medical education. The biggest challenges for the organisation of such clerkships are achieving a minimum level of standardisation, and developing and maintaining a system of quality assurance. The aim of this study is to assess the instructional quality in teaching practices using a benchmark system.MethodsBefore commencing, students anonymously assessed the importance of core aspects of the mandatory primary care clerkship. After the clerkship, they evaluated learning opportunities and teaching performance. Based on this data, a benchmark system was developed to identify areas of strength and weakness for all practices as well as individual teaching practices.ResultsA total of 695 students evaluated 97 general practices belonging to a teaching network. Prior to the clerkship, most students considered recognition of frequent diseases (85%) and communication skills (65%) the most important learning goals. After the clerkship, nearly 90% of students confirmed that the general practitioner (GP) was good or excellent at teaching these two goals but only two-thirds thought the GP's teaching performance good or excellent in preventive medicine and screening. In an exemplary analysis, we identified the 2 best and the 2 worst practices that consistently received scores far above or below average, respectively.ConclusionWe were able to identify areas of weakness in teaching and identified specific GPs who did not meet the students' needs and expectations. This evaluation seems to be a useful quality assurance tool to identify the potential for improvement and faculty development.

Shortage in general practice despite the feminisation of the medical workforce: a seeming paradox? A cohort study

BackgroundFemale medical students often prefer primary care specialties, while male students appear to be attracted to hospital specialties. Notwithstanding the steady feminisation of medicine, in many countries there are still difficulties in recruiting trainees for general practice. This seeming paradox raises the question on what specific role gender plays in a specialty choice. The authors looked at the (a) the role of gender in general practice specialty choice of Dutch medical students, (b) the decisive factors in career choice and relation of gender to these, and (c) differences in how male and female students are influenced by the GP clerkship.MethodsA cohort of 206 final year medical students at the Maastricht University, the Netherlands were asked to complete a questionnaire focusing on career preferences before and after a 12-week general practice clerkship and at graduation, a couple of months later.ResultsGender was significantly related to willingness to become a GP in bivariate analysis. Adding variables in multivariate analysis made this effect disappear. While females expressed overall higher preference for general practice than males, after the GP clerkship likelihood of choosing general practice increased with 38% among male and 22% among female students. After graduation, interest in general practice had dropped, mainly among females. Attitudes predicting a GP career choice were: extrinsic career motivation before the clerkship, and the content of GP work (patient contacts, treatments) and motivation to work with chronic and palliative patients after the clerkship.ConclusionGender 'as such' appeared not to be a distinctive predictor of specialty choice. It is students' attitudes towards GP work and preferred patient category that determine the career choice in general practice. However, more male students were positively influenced by the GP clerkship than female students. The motivating effect of the clerkship is not long lasting. Especially female graduates change their interest in favour of other specialties, which may explain why eventually few students choose general practice. It might be worthwhile to reinforce an initial preference for general practice by motivational guidance throughout the whole period of clerkships.

The impact of clerkships on students’ specialty preferences: what do undergraduates learn for their profession?

Clinical experiences and gender have been shown to influence medical students' specialty choices. It remains unclear, however, which aspects of experiences make students favour some specialties and reject others. This study aimed to clarify the effects of clerkships on specialty choice and to identify explanatory factors. We carried out a longitudinal cohort study to collect data on career preferences and attitudes towards future careers among 3 cohorts of students before and after clerkships in surgery (n = 200), internal medicine (n = 277) and general practice (n = 184). Regression analyses were performed to identify the determinants of career choice and the role of gender. Exposure to clinical settings encourages students to opt for a career in the corresponding specialty. Men were more stimulated than women by the general practice clerkship. Gender had no clear role as a predictor of career preference. The major predictor of career choice in all 3 specialties was positive evaluation of work-intrinsic factors. A preference for working with acute patients and technology-oriented work, prestige orientation and insignificance of a controllable lifestyle were determinants of a preference for surgery. Students with a preference for general practice had almost opposite preferences. Those who chose internal medicine favoured a controllable lifestyle. Factors other than gender appear to drive specialty decisions. Work content, type of patients and lifestyle options play major roles. Consequently, along with teaching about the practice of medicine, the matching of specialty preferences with reality is an essential outcome of clerkships.

Exploring students' perceptions on the use of significant event analysis, as part of a portfolio assessment process in general practice, as a tool for learning how to use reflection in learning

BackgroundPortfolio learning enables students to collect evidence of their learning. Component tasks making up a portfolio can be devised that relate directly to intended learning outcomes. Reflective tasks can stimulate students to recognise their own learning needs.Assessment of portfolios using a rating scale relating to intended learning outcomes offers high content validity.This study evaluated a reflective portfolio used during a final-year attachment in general practice (family medicine). Students were asked to evaluate the portfolio (which used significant event analysis as a basis for reflection) as a learning tool. The validity and reliability of the portfolio as an assessment tool were also measured.Methods81 final-year medical students completed reflective significant event analyses as part of a portfolio created during a three-week attachment (clerkship) in general practice (family medicine). As well as two reflective significant event analyses each portfolio contained an audit and a health needs assessment.Portfolios were marked three times; by the student's GP teacher, the course organiser and by another teacher in the university department of general practice. Inter-rater reliability between pairs of markers was calculated. A questionnaire enabled the students' experience of portfolio learning to be determined.ResultsBenefits to learning from reflective learning were limited. Students said that they thought more about the patients they wrote up in significant event analyses but information as to the nature and effect of this was not forthcoming.Moderate inter-rater reliability (Spearman's Rho .65) was found between pairs of departmental raters dealing with larger numbers (20 – 60) of portfolios. Inter-rater reliability of marking involving GP tutors who only marked 1 – 3 portfolios was very low.Students rated highly their mentoring relationship with their GP teacher but found the portfolio tasks time-consuming.ConclusionThe inter-rater reliability observed in this study should be viewed alongside the high validity afforded by the authenticity of the learning tasks (compared with a sample of a student's learning taken by an exam question). Validity is enhanced by the rating scale which directly connects the grade given with intended learning outcomes.The moderate inter-rater reliability may be increased if a portfolio is completed over a longer period of time and contains more component pieces of work.The questionnaire used in this study only accessed limited information about the effect of reflection on students' learning. Qualitative methods of evaluation would determine the students experience in greater depth. It would be useful to evaluate the effects of reflective learning after students have had more time to get used to this unfamiliar method of learning and to overcome any problems in understanding the task.

Clinical clerkships: students can structure their own learning

In clinical clerkships, student learning is often unstructured and diverse. Even when curriculum objectives are explicit, they are seldom used by students to guide their learning. Student-determined learning objectives may help students to structure their learning. This study aimed to assess whether students can use this method to meet widely differing learning needs within the general practice clerkship and considered the relationship of student objectives to overall curriculum objectives. Students allocated a 5-week clerkship in general practice from April 2000 to April 2001 were required to set and meet personal learning objectives within a supportive learning environment. They recorded the strategies they used, how well objectives were met and which curriculum objectives they met. Objectives were categorised using a hierarchical system. A total of 143 (85%) students recorded 1549 objectives. Four categories accounted for 1092 (70%) of objectives: Consultation Skills; Study of Diseases; Practical Procedures, and Therapeutics. Otherwise the range of objectives set was wide, encompassing all curriculum objectives. A total of 1043 objectives were rated as satisfactorily or highly satisfactorily met and 185 (12%) were not met at all. Strategies that students used to meet objectives included clinical experience with doctors but also with practice-based nurses. Students were able to use student-determined learning objectives to meet a diverse range of learning needs within the general practice clerkship. The objectives set reflected the breadth of curriculum objectives. This method allows students to address gaps in their knowledge in a clerkship where teaching is largely based on opportunistic contact.

The introduction of a ten-week general practice clerkship in the United Arab Emirates

Clerkships in general practice have become established in medical curricula around the world. The reorganization of the clinical course at the United Arab Emirates University Faculty of Medicine and Health Sciences was an opportunity to design and introduce a new 10-week clerkship in general practice. This article reports the aims, structure and educational processes of the clerkship including the student assessment methods adopted. Early student feedback on the clerkship is positive.

Does a brief clerkship change Hong Kong medical students' ideas about general practice?

This study examines the impact on students of a brief general practice clerkship, during a curriculum that is otherwise almost entirely hospital-based and in a practice environment that often does not encourage good primary care. 15 focus group discussions were held with a total of 110 students, as part of an action research project. Student responses were audiotaped, transcribed and then analysed for recurrent themes. General Practice Unit, University of Hong Kong. Medical students There was evidence of pre-existing negative stereotypes of general practice, but in many cases these were dispelled by the relationships students developed during their attachment to general practitioners in the community. In an overcrowded curriculum, students ration their time and energy, focusing their learning pragmatically on subjects that have a high profile during examinations. Even in healthcare and medical school systems that are specialist-dominated, and in which the circumstances of practice do not always encourage high standards of care, the general practice clerkship can allow students to gain an understanding of the importance of primary care, and of the significance of the general practitioner's role in the healthcare system.

Educational objectives and requirements of an undergraduate clerkship in general practice. The outcome of a consensus procedure.

The main aim of this study was to reach consensus between students, faculty and general practice teachers on the educational objectives and requirements of the clerkship in general practice. The consensus procedure consisted of four steps and all active general practice teachers (n = 116) were asked to participate in the study. We identified 189 educational objectives: 127 complaints (problems, symptoms, syndromes), 29 clinical skills and 37 objectives concerning the theoretical dimensions of general practice. Educational requirements crystallized to 16 essential preconditions of a teaching practice and 35 didactic activities to be performed by the general practice teachers. These consensus results will be used to structure the medical curriculum and as guidelines for the educational process during the clerkship.

Changes in students' perceptions of clinical teaching as a result of general-practice clerkships.

This study investigated whether a 3-week clerkship for third-year medical students in general-practice doctors' offices changed the students' perceptions of clinical teaching. The Preceptor Evaluation Questionnaire was administered to 138 junior medical students before and after their clerkships. The result of the study indicated that the clerkship had a positive effect on the students' perceptions. This finding was not related to their experiences in other clerkships nor to the grades they received for the clerkship. The results indicate that the teaching relationship established between student and family doctor significantly affects students' perceptions of aspects of effective clinical teaching.

A factor analytic study of teaching in off-campus general practice clerkships.

The Preceptor-evaluation questionnaire (PEQ) was developed at the University of Mississippi Medical Center to evaluate the clinical teaching behavior of general practice doctors in private practice who have one or more third-year medical students per year in their offices for a required general practice clerkship. The PEQ was designed to provide feedback to these doctors and the sponsoring department in an effort to improve teaching in this setting. Developed from the input of family practice doctors who have supervised students in their offices and from a review of related literature, the instrument was given to students to determine the level of importance they attributed to each teaching characteristic. A principle components factor analysis and subsequent varimax rotation produced six significant teaching factors in this setting. These six factors were: (1) demonstrates a humanistic orientation toward patients and staff; (2) demonstrates a humanistic orientation toward student; (3) provides opportunity for practice; (4) motivates and stimulates student's thinking; (5)communicates effectively with student; and (6) demonstrates comfort and confidence in the roles of doctor and teacher. The factor relating to the humanistic orientation toward student has not appeared as a separate factor in other studies of clinical teaching. This may be due to the unique aspects of the relationship between student and doctor in this setting which may not occur in other settings. The PEQ and similar reliable and valid instruments can provide valuable information for the doctors in these off-campus teaching situations as well as provide useful programme planning information for the sponsoring academic departments. This information may also be valuable for off-campus residency training.