Learning medicine in the communityBMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6976.343 (Published 11 February 1995) Cite this as: BMJ 1995;310:343
- Jenny Field,
- Ann-Louise Kinmonth
Learners should be where the patients are
“Medical Education is a reflection of medical practice; it is not the education that will change the practitioners, but reformed practice that will redesign medical education.”1 George Silver, professor of epidemiology and public health at Yale, wrote in 1983, reflecting on repeated and ineffective attempts over the years to improve medical care through education. We are now undergoing just such a reformation in the delivery of health care. Patients in hospital are likely to be very sick indeed or admitted briefly for minimally invasive surgery or investigation. Much of the natural course of those chronic disorders that put the greatest burden on our society can now be best observed outside hospital. Students based in the community can follow up patients over longer periods than before and, by accompanying these patients when they go into hospital, can see secondary care in an appropriate context.
The General Medical Council recently recommended that medical students should gain more experience in outpatient clinics, general practice, and community health services.2 Pioneering steps have already been taken by King's medical firm in the community,3 the Cambridge community based clinical course,4 and the preregistration house officer rotation in general practice organised by Lisson Grove Health Centre and St Mary's Hospital in London.5 This week's journal contains accounts of how the Cambridge approach provided Mandy Wharton with “a rich environment in which to anchor … teaching of disease, health, and clinical skills” (p 407)4 and how house officers in general practice gain insight into primary care services and receive substantially more teaching and clinical time than hospital colleagues (p 369).6 If these initiatives are so satisfactory why is the move to community based learning of medicine so slow? This problem and suggested solutions are explored in Widening the Horizons of Medical Education, recently published by the King's Fund.3
In the report researchers from King's College, London, explore the implications of transferring a substantial amount of undergraduate medical education into the community. They advocate managing educational change by consultation, and describe how they carried out this consultation in and around King's College Hospital. They report the views of patients, general practitioners, students, and other interested parties. Patients and carers wanted to participate in the teaching of medical students; and general practitioners were also enthusiastic but saw the need for protected time, training, and support; students were initially anxious about potential isolation, breaking with tradition, and the quality of teaching but became more positive when they considered the implications of learning in the community. The authors say that “telling is selling”; discussion with interested groups tended to increase support.
One important barrier to any change of site for medical education is the cumbersome funding system, whereby the complex funding provided jointly by the Department of Health and the Higher Education Funding Council is divorced from educational accountability, which is itself unclear. In addition, the provision of the service increment for teaching and research is governed by rules that do not allow the increment to be transferred outside the hospital system. At present the Department of Health (through the family health services authorities) provides small fees for the teaching of undergraduates in general practice but makes no formal provision for the supervision of house officers. The report from King's College recommends that medical education should be both funded and monitored for quality by the Higher Education Funding Council. Medical schools would allocate funds to the various sites where students learn.
Two further proposals should be considered. Firstly, teachers need training to develop their abilities. This is a task already taken seriously in the education of postgraduate trainees in general practice, and without it consistently high quality teaching is unlikely to be maintained in any context.7 Because formal training in educational skills has been largely absent in hospital settings, reorganisation of the present funding system might not cover staff development and new ways to teach teachers might have to be devised.
Secondly, teaching and research in the community requires an infrastructure, including space, administration, and information technology. Teachers and researchers in general practice need an ability to appraise evidence from scientific research and clinical examination. Because they share these needs and research is likely to be more effective when clinicians and researchers share priorities and values,8 closer links between clinical teachers, researchers, and clinicians should also pay dividends in the development of primary care. One way of doing this would be to set up academic practices with an additional partner to reduce service loads and contracts to provide both teaching and research.9 This would also help to prevent the potential isolation of students outside a hospital base but would again require funding additional to that proposed at King's College.
In all these developments there is a risk that primary care departments may be seen as competing with hospital specialties and basic sciences for both curricular time and funding. It is vital that all change is underpinned by a clear educational philosophy related to the aims of the overall curriculum. Hospital specialists also serve the community, but their views were not sought in the King's College project. Examples of good teaching in the present curriculum and house officer posts should not be lost but reinforced. Combined staff development sessions, such as those reported at King's College, could both reduce any tension and improve the confidence of staff working outside the hospital setting. Finally, all change must be carefully evaluated. Evidence based education is as important as evidence based medical practice.
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