Medical Education, 1976, 10, 255-259
A comparative study of teachers’ attitudes in the teaching of undergraduate medical students R. HARVARD DAVIS
AND
N . C. H . STOTT
The General Practice Unit, Welsh National School of Medicine
an increasing number of medical schools have established departments of general practice in a number of countries. If these departments are to continue to be viable it must be clear that they have an unique albeit complementary role in the education of the undergraduate medical student. It follows that it should be possible to demonstrate that the staff of departments of general practice do in fact teach relevant aspects of medicine that are not usually covered by the staff of other departments. This is an assumption that is by no means generally accepted. The study reported here was designed to help answer this question by examining whether there were any differences in the approach to teaching by the staff of departments of medicine, surgery and general practice in the medical schools of the United Kingdom and Eire. It also provides information about the way in which the clinical case history is used as a teaching tool.
Summary Senior staff of the departments of medicine, surgery and general practice in each medical school in the United Kingdom were asked to annotate the same case studies which had been prepared by medical students. Analysis of the annotations showed that general practitioners demanded much greater consideration by the student of the patient, his family and his environment, whereas physicians and surgeons tended to be more disease orientated. Nevertheless, expectations and attitudes of teachers in similar departments are remarkably diverse and this highlighted the potential role of the case study as an educational tool for staff and students alike. Many departments need to clarify the difference between undergraduate and postgraduate teaching objectives.
Key words : *EDUCATION, MEDICAL, UNDERGRADU*ATTITUDE OF HEALTH PERSONNEL; *TEACHING; Method GENERALPRACTICE/edUC; SURGERY/edUC; GREAT In the Department of Surgery and in the General BRITAIN ; IRELAND Practice Unit of the Welsh National School of Medicine, medical students are required to produce The Royal Commission on Medical Education (1968) a written case history of one of the patients that they recommended that ‘medical students should be given have clerked. These case histories are commented some insight into general practice, not as a prelimiupon by a member of the staff of each department nary to training for a career in that field, but as an and in the General Practice Unit are also used as a educational experience whose purpose is to give basis for small group discussion. Three case histories every student some understanding of problems which were selected from the material available. All three are of major importance themselves and should not patients would have concerned their family doctor. be thought of as variants or minor subdivisions of the The following are brief summaries of each of the problems raised in hospital practice’. In recent years case histories : ATE;
Case history A. A 25-year-old postman with a 6 year history of Crohn’s disease who had had a surgical resection
Correspondence (including requests for copies of the case histories): Dr R. Harvard Davis, The General Practice Unit, Welsh National School of Medicine, The Health Centre, Llanedeyrn, Cardiff.
255
R. Harvard Davis and N . C. H . Stott
256
of the ileum 3 years previously and was presenting with symptoms suggestive of a malabsorption syndrome. Case history B. A 40-year-old housewife who had had a mastectomy followed by radiotherapy for carcinoma of the breast 9 months previously and who now presented with evidence of bony metastases. Case history C . A 50-year-old civil servant with a past history of rheumatic fever who presented with cardiac failure and mitral valve disease. Each of the case histories was written up in a traditional format and included sections on the history of the presenting complaint, a systems review, past medical history, social history, family history, results of examination, diagnostic assessment or problem list, details of investigation and finally a section in which the student discussed those aspects of the case which he thought were important. A copy of Case histories A and C was sent to the head of each department of medicine in every medical school in the United Kingdom and Eire. A copy of Case histories A and B to the head of each department of surgery, and a copy of all three case histories was sent to the head of each of the seventeen departments of general practice. A covering letter was enclosed requesting the head of the department to ask a senior member of his teaching staff to assume that one of their students had prepared the case history and to annotate it in such a way that they thought would help the student to learn from the experience. The letter also asked those that did this not to discuss the case with their colleagues. One hundred and eighty-three case histories were sent out.
Results The overall response rate to our request for annotated case histories was low (Table 1). Some respondents had reservations about the value of the exercise but five heads of departments (four of surgery and one of medicine) actually refused to collaborate in the study and their expressed reasons for this rejection are illustrated by the following extracts from their letters. ‘I do not wish in any way to be obstructive. I am perturbed by the increasing number of requests of this sort in which I and senior members of this department are asked to do various tasks to assist in some wide ranging review being carried out by other departments. I am sure you will understand when I say that I feel that those of us at the receiving end of these requests have a right to be selective and I have reluctantly come to the conclusion that I would rather not take part in this particular exercise.’ ‘I feel I am not competent to deal with this matter and return the document herewith.’ ‘Thank you very much for involving me in your survey of teaching attitudes. Although you ask for anonymous contributions, I thought I should explain why I have not made any comments. It is my impression that to critically comment would be invalid and in each case I would wish to discuss at length, on a personal basis rather than by annotation.’ These extracts reveal several reasons for refusal which were also stated in other letters: a feeling that the departmental head is too busy to co-operate in the proposed study, and/or a refusal to consider the matter at all, and/or a belief that the ‘case history’ can only be usefully criticized or discussed by the clinician who knows the patient well. Eighty senior clinical teachers annoted the case histories and many were clearly enthusiastic about the exercise. The respondents varied in the way that they annotated the case histories but the comments could be divided into four broad categories.
TABLE I . The number of case histories circulated to the departments of medicine, surgery and general practice
No. of departments which Department
No. of departments No. of heads of departments circulated who refused to collaborate (figures in parentheses (figures in parentheses show show number of number of case histories case histories) rejected)
Medicine Surgery General practice
33 33 17
Total
83 (183)
(66) (66) (51)
returned one or more case histories (figures in parentheses show per cent of departments circulated)
Case histories returned (figures in parentheses show per cent of case histories circulated)
20 (61)
4 (8) (0)
15 (45) 13 (77)
31 (47) 23 (35) 26 (51)
5 (10)
48 (58)
80
1
(2)
~
(44)
Attitudes in undergraduate teaching
(a) Those that drew attention to something that was missing. For example: ‘More details of the presenting symptoms would be helpful, i.e. nature of pain, duration, etc.’. ‘Too sketchy home situation, attitude to illness etc., all need expansion. Could be relevant to diagnosis and therapy.’ (b) Those that provided information for the student. For example: ‘If he has mitral regurgitation as well then (valve) replacement is indicated. It is important to discover the relative contributions made by each defect by catheter studies if surgery is contemplated.’ ‘But remember that digoxin is excreted exclusively by the kidney. Check renal function before prescribing it.’ (c) Those that were framed as a question and required the student to pursue the subject. For example: ‘Can you by next week associate absent knee and ankle jerks with CCF and consumption of 21 pints a week? ‘Where do systemic emboli come from and when are patients at special risk and what can be done to prevent their occurrence? (d) Those that referred to the standard of English and the format in which the study had been written. For example: ‘Presenting complaint. This does not appear to be the correct heading here. It is not followed by the “presenting complaint” but by a narration which is a “potted case history”.’ The majority of the annotations made in the text of the case histories were of the first type drawing attention to something which the teacher thought was missing. We counted the numbers of this type of annotation, which occurred in each section of the TABLE 2.
257
case histories. Clearly these figures cannot be subjected to statistical analysis because they are based only upon a self selected sample of all teachers. Moreover, the number of annotations made by any one teacher does not necessarily measure their value to the student. Nevertheless, major consistent differences are likely to reflect the importance which teachers place upon the different parts of the case history provided this is also confirmed by the general impression conveyed by the annotations. Table 2 details the percentage of the case histories in which one or more items were identified as missing by teachers in departments of medicine, general practice and surgery. The table shows that whilst many teachers in all departments made comments about each section, more than 80% of physicians identified information to be missing in the ‘History of presenting complaint’ and ‘Examination’ sections, whereas general practitioners and surgeons were less critical in these sections. The table shows that the trend is different in the ‘social history’ where 70% of general practitioners identified missing items whereas physicians (42%) and surgeons (9%) were much less critical. There is a similar but less impressive trend in the family history section. Table 3 allows these differences to be examined for each individual case study. Again the most consistent substantial difference between the departments is seen in the social history section in which missing information was identified by less than 10% of surgeons; by between 37% and 47% of physicians, but by 6 4 8 3 % of general practitioners. These objective trends were supported by a very clear general impression that practitioners tend to teach from a broad background of social and family information, whereas fewer hospital doctors adopt this approach. For example, a general practitioner commenting on the housewife with disseminated
Percentage of case histories with one or more items identified as missing by teachers in deuartments of medicine. eeneral oractice and sureerv
Data missing from:
Medicine (%) (31 cases)
General practice (%) (26 cases)
Surgery (%) (23 cases)
History of presenting complaint Systems enquiry Past medical history Social history Family history Examination Diagnosis or problem list Investigation Discussion
87 55 65 42 26 84 36 13 49
62 63 58 70 43 62 20 48 70
53 22 31 9 9 66 13 41 66
R . Harvard Davis and N . C. H . Stotl
258 TABLE 3.
Number of case histories with one or more items identified as missing by teachers in departments of medicine, surgery and general practice
History of presenting complaint Systems enquiry Past medical history Social history Family history Problem list Examination Investigation Discussion
15 10
13
6 2 8
15 0 4
GP n=9 %
94 62
8 5
81 31
6 6 4
12 50 94 0
25
3
Surgery n=12 %
89
5
56 61 61 44
3
33 78
1 5 5 6 7
Case study A
Case study B
Case study C Medicine n=16 %
18
7
1 2 0
10 1 8
breast carcinoma (Case history B) said :
‘You have given a full and lucid account of the disease, its pathology and its treatment (surgical and non-surgical) and thus far-well done! But if we look at your presentation from the point of view of “whole person medicine” (which is what this part of your course is all about) then you have told me virtually nothing about the patient, the family or the medical management. Can you answer the following: The Patient. What has she been told and how much does she understand concerning her present condition? How does she see the future -what are her fears, her weaknesses and her strengths in the coming trial ahead? Can she continue to lead her normal life? The Family. What have they been told? Have they accepted what has been done and do they look for more from orthodox medicine? Will they turn in desperation to other forms of he1p-e.g. fringe medicine, etc.? Management. What further arrangements (if any) need to be made to ensure Mrs M.G.’s further progress is as smooth as possible? What has the family doctor been told?’ Another practitioner commenting on the same case said: ‘I would rather hear more about the impact of her condition upon her and the family and less about what others have written and said. Tell me what conclusions you draw from the literature and of the localized application to the good lady. What do you think it means to a woman of 40,and to her husband and family, to have a malignant growth of the breast? This appears to be more a
32 25 58 8 17 0 83 58 67
GP n=ll %
4 3
36 21
1 64 7 6 4 2 18 0
0
7
64 45 45
5 5
Medicine n=15 % 12
80 41 1 4 1 1 4 1 6 4 0
7
3 II
4 11
20 13 21 73
Surgery n=ll %
GP n=6 %
1 2 0 1
64
4
61
18 0
3
0 3
0 21
5 4
45
2
36 13
2 5
50 33 83 83 33 33 33 83
8
9
2 5 5 2
treatise on malignant disease of the breast and less of a report on a young woman with malignant disease.’ A minority of teachers from departments of medicine and surgery also took up this point but less directly, for example: ‘What about the disaster in quality of life that this story may represent for the patient?’ ‘Did you talk to the patient at all? Your history seems to be a review of the notes’-‘A case history is about the patient’s experience, not a textbook.’ ‘This is a good history of a very typical case from the point of view of a hospital doctor. N.B. I would have liked a discussion of her future care from the viewpoint of the family doctor, e.g. supportive treatment for herself and family, problems of home care and finally terminal care’.
The expectations of different teachers were clearly remarkably variable. For example, comments from two physicians about the same case (Case history A) varied from ‘very good’ and ‘excellent case study on Crohns’ to ‘too long, tedious and book-like’ and ‘History badly put together, physical had glaring omissions’. Likewise, a surgeon who commented about the discussion of Case history B wrote ‘a good rCsume of a subject but we expect a full essay on current status of treatment of breast carcinoma and your references are too selective.’ Whereas another surgeon felt that far too much had been written and he stressed the importance of patient orientation and problem definition rather than a disease focus. Discussion
The design of this study was dependent upon the assumption that clinical teachers would be interested to know whether their own annotations of a case
Attitudes in undergraduate teaching history would be similar or complementary to clinicians of similar seniority and that clinical teachers would regard the case history (or ‘initial patient work up’) as a method of clinical communication used so widely in clinical medicine that it should be of some value to clinicians without personal knowledge of the patient. This was true for only 61.4% of those departments whose members actually received case histories (Table I), and means that the results cannot be used to draw conclusions about the country as a whole. Other comparable studies are not available and we believe that some tentative but nevertheless interesting implications are revealed by the comments of some of those who refused to collaborate and by the analysis of the annotated case histories of the large number of senior clinical teachers who did collaborate. The attitudes of those heads of departments who wrote to us to say why they were not prepared to collaborate, revealed either a low priority for this kind of research or an unwillingness to look upon the patient record as an important tool for clinical communication, and hence a potential teaching method. This is disturbing in an era of shared care because the doctors ability to record information in a format which communicates readily with his peers will become more and more important to efficient and effective patient care. The accuracy of the clinical information recorded by a student can only be audited by a doctor who knows the patient well, but the completeness, knowledge, attitudes, logic, structure and legibility of the record can be judged by any competent clinician and, indeed, this study showed it to be true. The respondents in this study are clearly not representative of the thirty-three medical schools in the United Kingdom but forty-eight departments and nearly eighty senior clinical teachers have annotated case histories for our analysis. The difference between the three groups of teachers which was most consistent and substantial was the amount of interest shown in the social and family history. The same conclusions emerged whether analysis was with all three cases together (Table 2), by individual cases (Table 3) or from a consideration of the detailed
259
content of the annotations. General practitioners are far more likely to demand from the student a specific and considered account of the impact of the disease/ problem on the patient and their family than are their hospital colleagues. This supports views already widely held in medical circles (R.C.M.E. 1968) and suggests that departments of general practice have a role in undergraduate education which is complimentary to that of other departments in a medical school. This is not surprising because the teaching role of any department must clearly be related to the content of the clinical material available and the evolution of the modern hospital and especially the modern teaching hospital makes it increasingly difficult to demonstrate some aspects of clinical work to students in a meaningful way. Many other possible inferences could be drawn from Tables 1 and 2 but the differences are either too small or too inconsistent when considered in the individual case histories to merit conclusions. The variability of teachers working within the same department and annotating the same case history is not surprising in view of the wide range of special interests of teachers. What is more surprising, however, is that this variability extended to the expectations of different teachers. For example, gross differences in the overall assessment of a case history by two physicians (Case A) and two surgeons (Case B) were described in the results. This suggests that teachers may approach the exercise from totally different premises or with opposing objectives. The method we have used in this study could be used to provide teachers with feedback in regard to their teaching and hopefully this would stimulate the formulation by different departments of educational objectives for undergraduate teaching. This becomes more important as teachers become more specialized and as the amount of medical knowledge and skills expands.
Acknowledgment
We are grateful to all those who so generously gave of their time in making this study possible.
A comparative study of teachers’ attitudes in the teaching of undergraduate medical students R. HARVARD DAVIS
AND
N . C. H . STOTT
The General Practice Unit, Welsh National School of Medicine
an increasing number of medical schools have established departments of general practice in a number of countries. If these departments are to continue to be viable it must be clear that they have an unique albeit complementary role in the education of the undergraduate medical student. It follows that it should be possible to demonstrate that the staff of departments of general practice do in fact teach relevant aspects of medicine that are not usually covered by the staff of other departments. This is an assumption that is by no means generally accepted. The study reported here was designed to help answer this question by examining whether there were any differences in the approach to teaching by the staff of departments of medicine, surgery and general practice in the medical schools of the United Kingdom and Eire. It also provides information about the way in which the clinical case history is used as a teaching tool.
Summary Senior staff of the departments of medicine, surgery and general practice in each medical school in the United Kingdom were asked to annotate the same case studies which had been prepared by medical students. Analysis of the annotations showed that general practitioners demanded much greater consideration by the student of the patient, his family and his environment, whereas physicians and surgeons tended to be more disease orientated. Nevertheless, expectations and attitudes of teachers in similar departments are remarkably diverse and this highlighted the potential role of the case study as an educational tool for staff and students alike. Many departments need to clarify the difference between undergraduate and postgraduate teaching objectives.
Key words : *EDUCATION, MEDICAL, UNDERGRADU*ATTITUDE OF HEALTH PERSONNEL; *TEACHING; Method GENERALPRACTICE/edUC; SURGERY/edUC; GREAT In the Department of Surgery and in the General BRITAIN ; IRELAND Practice Unit of the Welsh National School of Medicine, medical students are required to produce The Royal Commission on Medical Education (1968) a written case history of one of the patients that they recommended that ‘medical students should be given have clerked. These case histories are commented some insight into general practice, not as a prelimiupon by a member of the staff of each department nary to training for a career in that field, but as an and in the General Practice Unit are also used as a educational experience whose purpose is to give basis for small group discussion. Three case histories every student some understanding of problems which were selected from the material available. All three are of major importance themselves and should not patients would have concerned their family doctor. be thought of as variants or minor subdivisions of the The following are brief summaries of each of the problems raised in hospital practice’. In recent years case histories : ATE;
Case history A. A 25-year-old postman with a 6 year history of Crohn’s disease who had had a surgical resection
Correspondence (including requests for copies of the case histories): Dr R. Harvard Davis, The General Practice Unit, Welsh National School of Medicine, The Health Centre, Llanedeyrn, Cardiff.
255
R. Harvard Davis and N . C. H . Stott
256
of the ileum 3 years previously and was presenting with symptoms suggestive of a malabsorption syndrome. Case history B. A 40-year-old housewife who had had a mastectomy followed by radiotherapy for carcinoma of the breast 9 months previously and who now presented with evidence of bony metastases. Case history C . A 50-year-old civil servant with a past history of rheumatic fever who presented with cardiac failure and mitral valve disease. Each of the case histories was written up in a traditional format and included sections on the history of the presenting complaint, a systems review, past medical history, social history, family history, results of examination, diagnostic assessment or problem list, details of investigation and finally a section in which the student discussed those aspects of the case which he thought were important. A copy of Case histories A and C was sent to the head of each department of medicine in every medical school in the United Kingdom and Eire. A copy of Case histories A and B to the head of each department of surgery, and a copy of all three case histories was sent to the head of each of the seventeen departments of general practice. A covering letter was enclosed requesting the head of the department to ask a senior member of his teaching staff to assume that one of their students had prepared the case history and to annotate it in such a way that they thought would help the student to learn from the experience. The letter also asked those that did this not to discuss the case with their colleagues. One hundred and eighty-three case histories were sent out.
Results The overall response rate to our request for annotated case histories was low (Table 1). Some respondents had reservations about the value of the exercise but five heads of departments (four of surgery and one of medicine) actually refused to collaborate in the study and their expressed reasons for this rejection are illustrated by the following extracts from their letters. ‘I do not wish in any way to be obstructive. I am perturbed by the increasing number of requests of this sort in which I and senior members of this department are asked to do various tasks to assist in some wide ranging review being carried out by other departments. I am sure you will understand when I say that I feel that those of us at the receiving end of these requests have a right to be selective and I have reluctantly come to the conclusion that I would rather not take part in this particular exercise.’ ‘I feel I am not competent to deal with this matter and return the document herewith.’ ‘Thank you very much for involving me in your survey of teaching attitudes. Although you ask for anonymous contributions, I thought I should explain why I have not made any comments. It is my impression that to critically comment would be invalid and in each case I would wish to discuss at length, on a personal basis rather than by annotation.’ These extracts reveal several reasons for refusal which were also stated in other letters: a feeling that the departmental head is too busy to co-operate in the proposed study, and/or a refusal to consider the matter at all, and/or a belief that the ‘case history’ can only be usefully criticized or discussed by the clinician who knows the patient well. Eighty senior clinical teachers annoted the case histories and many were clearly enthusiastic about the exercise. The respondents varied in the way that they annotated the case histories but the comments could be divided into four broad categories.
TABLE I . The number of case histories circulated to the departments of medicine, surgery and general practice
No. of departments which Department
No. of departments No. of heads of departments circulated who refused to collaborate (figures in parentheses (figures in parentheses show show number of number of case histories case histories) rejected)
Medicine Surgery General practice
33 33 17
Total
83 (183)
(66) (66) (51)
returned one or more case histories (figures in parentheses show per cent of departments circulated)
Case histories returned (figures in parentheses show per cent of case histories circulated)
20 (61)
4 (8) (0)
15 (45) 13 (77)
31 (47) 23 (35) 26 (51)
5 (10)
48 (58)
80
1
(2)
~
(44)
Attitudes in undergraduate teaching
(a) Those that drew attention to something that was missing. For example: ‘More details of the presenting symptoms would be helpful, i.e. nature of pain, duration, etc.’. ‘Too sketchy home situation, attitude to illness etc., all need expansion. Could be relevant to diagnosis and therapy.’ (b) Those that provided information for the student. For example: ‘If he has mitral regurgitation as well then (valve) replacement is indicated. It is important to discover the relative contributions made by each defect by catheter studies if surgery is contemplated.’ ‘But remember that digoxin is excreted exclusively by the kidney. Check renal function before prescribing it.’ (c) Those that were framed as a question and required the student to pursue the subject. For example: ‘Can you by next week associate absent knee and ankle jerks with CCF and consumption of 21 pints a week? ‘Where do systemic emboli come from and when are patients at special risk and what can be done to prevent their occurrence? (d) Those that referred to the standard of English and the format in which the study had been written. For example: ‘Presenting complaint. This does not appear to be the correct heading here. It is not followed by the “presenting complaint” but by a narration which is a “potted case history”.’ The majority of the annotations made in the text of the case histories were of the first type drawing attention to something which the teacher thought was missing. We counted the numbers of this type of annotation, which occurred in each section of the TABLE 2.
257
case histories. Clearly these figures cannot be subjected to statistical analysis because they are based only upon a self selected sample of all teachers. Moreover, the number of annotations made by any one teacher does not necessarily measure their value to the student. Nevertheless, major consistent differences are likely to reflect the importance which teachers place upon the different parts of the case history provided this is also confirmed by the general impression conveyed by the annotations. Table 2 details the percentage of the case histories in which one or more items were identified as missing by teachers in departments of medicine, general practice and surgery. The table shows that whilst many teachers in all departments made comments about each section, more than 80% of physicians identified information to be missing in the ‘History of presenting complaint’ and ‘Examination’ sections, whereas general practitioners and surgeons were less critical in these sections. The table shows that the trend is different in the ‘social history’ where 70% of general practitioners identified missing items whereas physicians (42%) and surgeons (9%) were much less critical. There is a similar but less impressive trend in the family history section. Table 3 allows these differences to be examined for each individual case study. Again the most consistent substantial difference between the departments is seen in the social history section in which missing information was identified by less than 10% of surgeons; by between 37% and 47% of physicians, but by 6 4 8 3 % of general practitioners. These objective trends were supported by a very clear general impression that practitioners tend to teach from a broad background of social and family information, whereas fewer hospital doctors adopt this approach. For example, a general practitioner commenting on the housewife with disseminated
Percentage of case histories with one or more items identified as missing by teachers in deuartments of medicine. eeneral oractice and sureerv
Data missing from:
Medicine (%) (31 cases)
General practice (%) (26 cases)
Surgery (%) (23 cases)
History of presenting complaint Systems enquiry Past medical history Social history Family history Examination Diagnosis or problem list Investigation Discussion
87 55 65 42 26 84 36 13 49
62 63 58 70 43 62 20 48 70
53 22 31 9 9 66 13 41 66
R . Harvard Davis and N . C. H . Stotl
258 TABLE 3.
Number of case histories with one or more items identified as missing by teachers in departments of medicine, surgery and general practice
History of presenting complaint Systems enquiry Past medical history Social history Family history Problem list Examination Investigation Discussion
15 10
13
6 2 8
15 0 4
GP n=9 %
94 62
8 5
81 31
6 6 4
12 50 94 0
25
3
Surgery n=12 %
89
5
56 61 61 44
3
33 78
1 5 5 6 7
Case study A
Case study B
Case study C Medicine n=16 %
18
7
1 2 0
10 1 8
breast carcinoma (Case history B) said :
‘You have given a full and lucid account of the disease, its pathology and its treatment (surgical and non-surgical) and thus far-well done! But if we look at your presentation from the point of view of “whole person medicine” (which is what this part of your course is all about) then you have told me virtually nothing about the patient, the family or the medical management. Can you answer the following: The Patient. What has she been told and how much does she understand concerning her present condition? How does she see the future -what are her fears, her weaknesses and her strengths in the coming trial ahead? Can she continue to lead her normal life? The Family. What have they been told? Have they accepted what has been done and do they look for more from orthodox medicine? Will they turn in desperation to other forms of he1p-e.g. fringe medicine, etc.? Management. What further arrangements (if any) need to be made to ensure Mrs M.G.’s further progress is as smooth as possible? What has the family doctor been told?’ Another practitioner commenting on the same case said: ‘I would rather hear more about the impact of her condition upon her and the family and less about what others have written and said. Tell me what conclusions you draw from the literature and of the localized application to the good lady. What do you think it means to a woman of 40,and to her husband and family, to have a malignant growth of the breast? This appears to be more a
32 25 58 8 17 0 83 58 67
GP n=ll %
4 3
36 21
1 64 7 6 4 2 18 0
0
7
64 45 45
5 5
Medicine n=15 % 12
80 41 1 4 1 1 4 1 6 4 0
7
3 II
4 11
20 13 21 73
Surgery n=ll %
GP n=6 %
1 2 0 1
64
4
61
18 0
3
0 3
0 21
5 4
45
2
36 13
2 5
50 33 83 83 33 33 33 83
8
9
2 5 5 2
treatise on malignant disease of the breast and less of a report on a young woman with malignant disease.’ A minority of teachers from departments of medicine and surgery also took up this point but less directly, for example: ‘What about the disaster in quality of life that this story may represent for the patient?’ ‘Did you talk to the patient at all? Your history seems to be a review of the notes’-‘A case history is about the patient’s experience, not a textbook.’ ‘This is a good history of a very typical case from the point of view of a hospital doctor. N.B. I would have liked a discussion of her future care from the viewpoint of the family doctor, e.g. supportive treatment for herself and family, problems of home care and finally terminal care’.
The expectations of different teachers were clearly remarkably variable. For example, comments from two physicians about the same case (Case history A) varied from ‘very good’ and ‘excellent case study on Crohns’ to ‘too long, tedious and book-like’ and ‘History badly put together, physical had glaring omissions’. Likewise, a surgeon who commented about the discussion of Case history B wrote ‘a good rCsume of a subject but we expect a full essay on current status of treatment of breast carcinoma and your references are too selective.’ Whereas another surgeon felt that far too much had been written and he stressed the importance of patient orientation and problem definition rather than a disease focus. Discussion
The design of this study was dependent upon the assumption that clinical teachers would be interested to know whether their own annotations of a case
Attitudes in undergraduate teaching history would be similar or complementary to clinicians of similar seniority and that clinical teachers would regard the case history (or ‘initial patient work up’) as a method of clinical communication used so widely in clinical medicine that it should be of some value to clinicians without personal knowledge of the patient. This was true for only 61.4% of those departments whose members actually received case histories (Table I), and means that the results cannot be used to draw conclusions about the country as a whole. Other comparable studies are not available and we believe that some tentative but nevertheless interesting implications are revealed by the comments of some of those who refused to collaborate and by the analysis of the annotated case histories of the large number of senior clinical teachers who did collaborate. The attitudes of those heads of departments who wrote to us to say why they were not prepared to collaborate, revealed either a low priority for this kind of research or an unwillingness to look upon the patient record as an important tool for clinical communication, and hence a potential teaching method. This is disturbing in an era of shared care because the doctors ability to record information in a format which communicates readily with his peers will become more and more important to efficient and effective patient care. The accuracy of the clinical information recorded by a student can only be audited by a doctor who knows the patient well, but the completeness, knowledge, attitudes, logic, structure and legibility of the record can be judged by any competent clinician and, indeed, this study showed it to be true. The respondents in this study are clearly not representative of the thirty-three medical schools in the United Kingdom but forty-eight departments and nearly eighty senior clinical teachers have annotated case histories for our analysis. The difference between the three groups of teachers which was most consistent and substantial was the amount of interest shown in the social and family history. The same conclusions emerged whether analysis was with all three cases together (Table 2), by individual cases (Table 3) or from a consideration of the detailed
259
content of the annotations. General practitioners are far more likely to demand from the student a specific and considered account of the impact of the disease/ problem on the patient and their family than are their hospital colleagues. This supports views already widely held in medical circles (R.C.M.E. 1968) and suggests that departments of general practice have a role in undergraduate education which is complimentary to that of other departments in a medical school. This is not surprising because the teaching role of any department must clearly be related to the content of the clinical material available and the evolution of the modern hospital and especially the modern teaching hospital makes it increasingly difficult to demonstrate some aspects of clinical work to students in a meaningful way. Many other possible inferences could be drawn from Tables 1 and 2 but the differences are either too small or too inconsistent when considered in the individual case histories to merit conclusions. The variability of teachers working within the same department and annotating the same case history is not surprising in view of the wide range of special interests of teachers. What is more surprising, however, is that this variability extended to the expectations of different teachers. For example, gross differences in the overall assessment of a case history by two physicians (Case A) and two surgeons (Case B) were described in the results. This suggests that teachers may approach the exercise from totally different premises or with opposing objectives. The method we have used in this study could be used to provide teachers with feedback in regard to their teaching and hopefully this would stimulate the formulation by different departments of educational objectives for undergraduate teaching. This becomes more important as teachers become more specialized and as the amount of medical knowledge and skills expands.
Acknowledgment
We are grateful to all those who so generously gave of their time in making this study possible.
