British lournal of Medical Edrrcarion. 1975, 9, 42-48
Development and evaluation of teaching course in general practice J. H. BARBER’ and E. T. HARALDSSQN Woodside Health Centre, Barr Street, Glasgow Key words
GENERAL PRACTICE/ ‘edUC *EDUCATION, MEDICAL. UNDERGRADUATE CURRlCULUM SCOTLAND TEACHING CALLS QUESTIONNAIRES PHYSICIAN-PATIENT RELATlONS EDUCATIONAL MEASUREMENT HOUSE
A formal teaching course in general practice
was first introduced in the University of Glasgow in October 1972. Each fifth year student had six afternoon sessions with a general practitioner tutor, and these teaching sessions were prepared in advance and were related to a syllabus and to specific objectives. This course was evaluated by questionnaires given to students and tutors and by a multiple choice question paper which was answered by a control group of sixth year students in addition to those who had received teaching. The question paper also included some questions relating to topics which had been excluded from the teaching course. The development and evaluation of this course have been described in detail (Barber, 1973). In the academic year 1973/74, the main emphasis of the teaching in general practice was continued in the fifth year. Several other varied areas of teaching have been developed and there is now an input of teaching in general practice for selected groups of students in all the four clinical years. This paper describes the further development and evaluation of the teaching course given to fifth year students.
Administration The main lessons learned from the fifth year course of the academic session 1972/73 were that six afternoon sessions over two terms were thought to be insufficient by both students and ‘Requests for reprints to Professor J . H. Barber. Woodside Health Centre, Barr Street. Glasyow G10 7LR. 32
tutors; that the arrangement by which each student group had one teaching session every three weeks made the course disjointed and prevented continuity of teaching; that the students preferred to see patients in their own homes rather than in consulting rooms; that they wished to have a more active participation in the learning situation, and that the size of each group should be restricted to four students. This number was thought to be neither too large nor too small but one which encouraged discussion between the students about the patients and the problems that they had seen. These lessons were incorporated into the course for the academic year 1973/74. The group size was restricted as far as was possible to four students and each group was given a maximum of eight afternoons of teaching. As in the previous year, the only time that was available for teaching was the one afternoon each week that the student was free of other classes. The fifth year was divided into two main groups, one of which was given teaching during the Martinmas (Winter) term and the other during the Candlemas (Spring) term. This allowed eight weekly sessions during the Martinmas term and seven during Candlemas: the reduction during the spring term was necessary to avoid the last two or three weeks of term when the students were preparing for professional and class examinations. As in the previous year, attendance registers were kept by the tutors. All the general practitioners who had been involved in the previous year’s teaching continued as tutors during the session 1973/74,
Development and evaluation of teaching course in general practice
and as the number and frequency of teaching sessions had been increased, the number of tutors involved rose from 26 in 1972 to 31 in 1973. Teaching Method One of the controversial aspects of the first teaching course had been that the patients shown to students were selected and that the teaching sessions were prepared in advance and were held in time set aside from normal practice work. This approach proved successful and was continued during 1973/ 74. During the previous year, many of the tutors had overestimated the number of patients that could be shown to the students during a two-and-a-halfhour session, and there was a feeIing that two or three patients was the optimum number that should be shown to students in one afternoon. The students clearly preferred to see patients at home and, consequently, a greater emphasis was put on this aspect. Student participation in the sessions was improved by allowing them to see the patient without the tutor being present, and by asking the students later to present their patients to the group as a whole. This method was not adhered to strictly - individual tutors decided when it would be likely to be of most value to their group and included this method as often as they thought advisable. In general, however, the pattern was for the students to spend approximately one and a half hours with two or three patients in their homes, thereafter returning to the surgery for a discussion period of about one hour.
Teaching Content As in the previous year, objectives were de-
fined and a syllabus was drawn up for the guidance of tutors. Four main objectives were stated (Table 1) and the tutors were asked to select patients who would illustrate one or Table 1. Objectives of course ~
~.
~
enable the, student to see ‘diagnosis’ and management’ In physical, psychological, and ?ocial terms 2. To show the student conditions not frequently ceen in hospital, which are responsible for a considerable degree of morbidity 3. To demonstrate what is involved in the long-term c x e of chronic ill-health 4. To demonstrate the application of team care to ill-health in the communitv I.
43
more of these objectives. The syllabus for teaching differed from that which had been used in the previous year: in the 1972173 course, the syllabus had listed medical conditions grouped under each of the stated objectives. In the revised syllabus (Table 2) a list of medical conditions and situations was given which would relate to four main age groups the child, the young adult, the middle-aged, and the elderly - and this was included as a guide for the tutors. The majority of students’ Table 2. List of medical conditions and diseases ~~~~
~
Session I Childhood Enuresis Recurrent otitis media with possible deafness and a school problem Asthma Asthma/eczerna syndrome Epilepsy Mental subnormality--e.g. mongolism Behavioural disorders Obesity Diabetes The handicapped child Session 2 Eearly adult life Dyspepsia Asthma Employment hazards Diabetes Disseminated sclerosis Psychosomatic presentations Anxiety and neurotic illness Rheumatoid arthritis Pregnancy with medical or social complications Headache Psychosexual problems The unsupported mother Sessions 4 and 5 Middle aditll-life Angina Chronic bronchitis Diabetes Post-mycocardial infarction Disseminated sclerosis Alcoholism Rlieiimatoid arrhritis Obesity Sessions 6, 7 . and 8 The elderly Stroke Senile or pre-senile dementia Social deprivation Mirltiple organic and social complaints Cardiac failure Depression Osteoarthritis Other situations The problem family Inadequate personality The range of accommodation for the elderly patient Special clinics, e.g. schools o r sheltered workshops for the physically o r mentally handicapped The elderly patient living on his own with poor social conditions
44
I. H . Barber arid E . T.Haraldssoti
groups followed a progression from youth to old age over the eight-week course, but of more importance, the patients who were selected were those who would illustrate the objectives chosen. The nature of the teaching method meant that there was some restriction on the patients who could be involved. It was not thought justifiable to ask patients to stay away from school or from work for the students’ visit, and this inevitably lead to the preschool child, the housewife, and the elderly, being the groups of patients most frequently selected. There was a natural tendency, backed up by intention, to show patients with complicated medical complaints or multiple problems. If a patient with rheumatoid arthritis was to be shown to students as an illustration of the involvement of the primary care team in the long-term care of chronic disease, it was thought that there would be more benefit to the student if the patient selected had a significant degree of disability or if there were other and varied problems present in addition to the organic disease. Before setting out to see the patient, the students were given a brief resumt of the patient’s current and major medical problem. He was allowed to examine the patient if it was thought that this was necessary, but it was stressed that the important aspects were the preparation of a problem list, the history of the development of each problem, and the steps which could be taken in the overall management of the patient. The students were encouraged to think in terms of problems and to present a problem list for each patient that they saw: this list formed the basis for a group discussion at the end of each teaching session. At the end of the course each student had thus seen between 16 and 24 different patients each of whom had been selected for their potential as a learning situation for the student, and had spent between 30 and 45 minutes taking a history and, on occasions, examining each patient.
Evaluetion The 1972173 course had been evaluated by the use of a multiple choice question paper and by questionnaires answered by both students and tutors. The objective evaluation
had shown that the students scored significantly higher marks in the questions relating to topics which had been included in their teaching course than in questions on topics which had been excluded. No difference was found in the marks obtained by the fifth year and by a control group of final (sixth) year students. Though the question paper had been constructed, as far as was possible, in such a way as to reflect medical care in the context of general practice, there was doubt as to whether this type of question was suited to the teaching which was given. In the academic session 1973/74, an attempt was again made to evaluate the course in both objective and subjective terms. The multiple choice question paper was replaced by a ‘modified essay question paper’ and the student questionnaire was identical to one of those used in the previous year. The modified essay question - MEQ - was developed by the Royal College of General Practitioners and is used in the examination for membership of the College. The question is based on a factual case history and sub-questions are directed at several areas such as the recall of factual information, the diagnostic probabilities, the attitude and sensitivity of the student to practice situations, and the overall management of the patient. Once it is prepared, the MEQ is answered by a group of examiners who have had no previous personal knowledge of the situation described in the question. The examiners’ answers form the basis for a marking and scoring system in which there may be several correct answers to any individual part of the question. The scoring given to each alternative answer reflects the views of the author of the question on the relative ‘correctness’ of the answer (Report from Board of Censors of the Royal College of General Practitioners, 1971). The MEQ was the method chosen to evaluate the fifth year course of teaching in the academic year 1973/74. Three MEQs were constructed from clinical situations known to the author. The subquestions were divided into two main groups - those that were primarily factual and that, it was thought. should be within the competence of any fifth year student to answer correctly, and those that were more situational and attitudinal and
DL,velopment rind evaliiotiot~ of teaching coiirse in genertrl pructice
should reflect the content of teaching which was to be given in the general practice course. The questions were answered by a group of six tutors and an answer sheet with a scoring system was constructed. At the end of the Martinmas term 1973, the fifth year students who had completed their teaching course (84 students) sat the three MEQs. The question papers were marked according to the answer scoring sheet, and the marks were subdivided into two groups - ‘factual’ and ‘attitudinal’. At the beginning of the Candlemas term (1974), a random one in three sample of the other half of the fifth year sat the same question paper and represented the control group. These question papers were corrected with the same answer scoring sheet and, again, the marks were subdivided into ‘factual’ and ‘attitudinal’. It was thought possible that bias might have been introduced into the marking of the two sets of question papers as the authors had known which papers were from the control group and which were from students who had completed their teaching. A random sample of 20 papers from each group was then chosen and re-marked in such a way that the authors did not know from which group the question papers had come or the marks that had been previously given to these papers. For the purpose of analysis it was assumed that the ‘factual’ marks represented knowledge derived from the students’ normal clinical teaching. and that the ‘attitudinal’ marks represented the results of the teaching course in general practice. A questionnaire was given to the students at the end of each of the two terms. The students were asked to score the various activities of the course in which they had been involved and to add any further opinions or comments that they might wish to express (Table 3). The questionnaires, together with the attendance registers, were expected to indicate the students’ subjective opinion of the course. Results The MEQ paper was answered by 84 students at the end of the teaching course in the Martinmas term, 1973, and by 27 students at the
45
start of their teaching course in the Candlemas term of 1974. The comparison between the randomly selected 20 papers from each group is given in Table 4. Table 3. Questionnaire Last year I asked all fifth year students for their opinion and assessment of the teaching course in general practice. The comments and criticisms made were of considerable value in planning this course, and I would be most grateful if you would complete this questionnaire. Please score the activities you have been involved in and cross out any you did not have.
S c d e of Valire 0 No value 1 Little value 2 Some value 3 Considerable value Patients seen in the surgery
}worth
not worth doing
Patients seen in homes Group discussion after seeing patients Visits to old people Visits to industry Other activities (specify)
Comments on t h e course
doing
0 17
0
0 17
n
0”
Table 4. ‘%actual
questions’ Mean SD
‘ Attiludinal qrrestio ns‘ Mean SP
5th year students 85:L li 7176 11 5th year controls 78‘:: 13 59:A I1 t-test 0.1 >P>0.05 t-test 0~002>P>0~001
Student Attendance Out of a total possible of 672 attendances, 633 (94%) were recorded for students who had completed their teaching in the Martinmas term. In the Candlemas term (1974) most of the tutors reduced the length of the course from eight afternoons to seven, to avoid examinations at the end of the term, and some groups were further reduced to six sessions due to the mid-term university holiday. The total possible attendances in the Candlemas term were 572, and 470 attendances were recorded ( 8 2 % ) . Over the two terms, and thus
J . H . Barber and E . T . Haruldsson
46
over the whole of the fifth year class, the attendance rate was 88%.
Questionnaire At the end of each term the students were invited to complete a questionnaire and, as it was anonymous, they were free to make any comments they wished. There was a total of 170 students in the year and 118 questionnaires were completed (69% of the students). The mean score given to each activity is shown in Table 5 . Table 5. No. of stirdenis
Mean score
Score f o r 1972173
93 118
2.0 2.7
2.5 29
118 104 21
2.5 2.6 2.0
2.6 2.4 2.5
Patients seen in the surgery Patients seen at home Group discussion after seeing patients Visits to old people Visits to industry
2-Some 3-GOOd
value \. valuej
worth doing
Of the 118 questionnaires completed, 109 (92%) included additional comments. These broadly fell into four main groups, and, in many instances, students gave a thorough appraisal and constructive comments about the course. The four main groups of comments are shown in Table 6. Table 6. Analysis of additional comments O /O /
Comments
‘Favourable’ ‘Suggest sitting-in at surgery’ ‘Course should be earlier in curriculum’ ‘Course of little value’
No. of (?A of I09 students questionnaires)
96
88
16
14
9 7
8 6
As expected, the students’ comments were very variable. but on the whole it was noticeable that students in the Candlemas term gave broader and more constructive comments on the course than the students in the Martinmas term. This difference may reflect the students’
hostility towards the examination paper which was given to all students in the Martinmas term but to only 28 in the Candlemas term. A number of students commented on an ‘eye-opening’ effect from seeing people in poor housing and social conditions. Those who had been shown model lodging-houses were clearly very concerned. Many students commented favourably on the value of a primary health care team consisting of a doctor, health visitor, district nurse, and social worker, but as some tutors did not have attached health visitors or social workers, it was not possible to show team care to all students. Discussion This course of teaching for fifth year students had one apparent major disadvantage: it made use of the students’ free afternoons. This will continue to be the pattern until 1976, after which date there is time specifically allocated for this teaching in the fourth year of the new five-year curriculum. The course appeared to be popular with the students, and this was reflected by the high attendance rate (88%). Attendance can be influenced by many factors, including the subject being taught and the quality of the teaching, but when the course uses the students’ own free time, the attendance rate becomes a sensitive barometer of student reaction. With this in mind, it is of less importance that 30% of the students did not return questionnaires. Those that were completed were helpful and will influence the pattern of the course in the next academic session. The two main comments showed that the students were more receptive to seeing patients at home rather than in the surgery, and that the group discussion which occupied the last hour of each afternoon was popular - indeed several students commented that it was essential. By selecting the patients that were seen, by allowing the students to take an active part in the learning situation, and by stressing the preparation of complete problem lists, the students were encouraged to think in terms of ‘wholeperson’ medicine, and to appreciate the complexity of some patients problems. If the social environment were of importance in the management of the patient, these conditions were obvious for the student to see. If there were
Deve!opmenr and evaluariotr of teaching coiirse in grnrrd prcrcricr
psychiatric overlays to the organic complaint, these became apparent from the patient’s behaviour and from the interfamily relation that the student observed. Wherever possible a group of four students was divided into pairs, each of which saw each of the patients selected. Every student was then able to contribute to, and to derive benefit from, the group discussion that followed. An outstanding feature of almost every group was the relaxed friendly atmosphere and relation which grew up between students and tutor. This was in part because of the small size of the group, to the frequency with which it met, and to the way in which the tutor had prepared both the content and the objective of each teaching session. By limiting the number of patients shown, the students were given adequate time to see the patient and to discuss the problems in detail. This would not have been possible if the tutors had not set aside time for teaching out of their normal practice work. The patient’s problem sheet formed the basis for a discussion of the physical, psychological, and social problems that had been identified, and this could extend from a consideration of the management of the individual patient to the causation, the natural history, and the treatment of such problems in a practice or population context. The tutors showed considerable skill in the patients that they selected, in taking the students who initially were very disease orientated gradually through increasingly complex situations, and in occasionally showing the students patients to whose problems there were no solutions. On occasions, the students were shown a patient who had presented with some acute condition during that day and were thus able to see the earliest stage of illness. This aspect of medicine in general practice was, however, not positively included in this course as it is at present the central feature of pilot schemes that are being run for third and fourth year students. As formal teaching in general practice has only been established at Glasgow University for two years, it was sometimes difficult for the individual student to see how his fifth year course fitted into the more extended teaching that is being planned. On purpose,
47
each new area of teaching is being treated initially as a pilot scheme and will only be offered to all students if methods of evaluation are developed and can show that the teaching is of value. The fifth year course is essentially an in-depth and prepared course, and other areas such as the initial presentation of illness, the interpretation of the undifferentiated symptom, and the follow-up of patients after discharge from hospital, are being tackled in each of the other clinical years, and in collaboration with the clinical departments of medicine, paediatrics, geriatrics, and psychological medicine. The full-time attachment of a student to a general practitioner is at present available only as an elective attachment. At present this is offered to fifth year students in the Easter vacation: in 1973, 30% of the students took this elective; in 1974 this figure rose to 45%. However encouraging the subjective qucstionnaires prove to be, it is of greater encouragement to find that there is objective and statistical proof of some educational value from the course. The MEQs as described and used by the Royal College of General Practitioners need to be adapted for undergraduate use, but it seems clear that as a method of assessment in the primary care situation it has advantages over both the multiple choice and traditional essay questions. The preparation of an answer and scoring sheet based on answers given by tutors, ensures that there is a degree of standardization in the marking of the students’ papers. This, in turn, enables a statistical comparison to be made between one group who have completed the teaching course and another group who have not. The results obtained in the MEQs given to the fifth year students are clearly significant in the area reflecting the teaching that was given in general practice. This analysis of a teaching course shows only that it was attractive to the students and that it had some apparent educational value. Much more requires to be done - to define more precisely the aspects of medicine in general practice that should be taught and to improve the way in which the teaching is given. There is a need also to determine how this fifth year course relates to the other teaching in general practice that is being attempted.
48
J . H . Barber and E. T . Haroldsson
Medicine in general practice is a wide and varying subject - it is a continuing challenge to identify what and how much should be taught to the undergraduate, how the teaching should interrelate with that of other clinical disciplines, and at what stage or stages of the curriculum it should be introduced.
summary The further development of a teaching course in general practice medicine for fifth year students at Glasgow University is described. Lessons learnt from a Drevious experimental course have been applied: eight afternoon sessions of a structured nature and related to prescribed objectives and a syllabus were given to small groups of students. Questionnaires showed that the in-depth study of selected patients in their own homes, with student involvement in the preparation of problem lists for group discussion were thought by the
students to be valuable. An objective assessment of the course using the modified essay question technique showed an improvement in factual clinical knowledge (P > 0.05) and more importantly in areas relating to the general practice content of the teaching (P > 0,001). The authors wish to record their thanks to the general practitioner tutors and to Professor Keith Hodgkin (the Sir Harry Jephcott visiting Professor in General Practice) for the help and encouragement they have given in the teaching and evaluation of this course.
References Barber, J. H. (1973). A teaching course in general practice. British loirrnul of Medical Editcution, 7 , 165-173.
Board of Censors of the Royal College of General Practitioners (1971). Journal of fhr Royal College of General Prucrifioners, 21, 313.
Development and evaluation of teaching course in general practice J. H. BARBER’ and E. T. HARALDSSQN Woodside Health Centre, Barr Street, Glasgow Key words
GENERAL PRACTICE/ ‘edUC *EDUCATION, MEDICAL. UNDERGRADUATE CURRlCULUM SCOTLAND TEACHING CALLS QUESTIONNAIRES PHYSICIAN-PATIENT RELATlONS EDUCATIONAL MEASUREMENT HOUSE
A formal teaching course in general practice
was first introduced in the University of Glasgow in October 1972. Each fifth year student had six afternoon sessions with a general practitioner tutor, and these teaching sessions were prepared in advance and were related to a syllabus and to specific objectives. This course was evaluated by questionnaires given to students and tutors and by a multiple choice question paper which was answered by a control group of sixth year students in addition to those who had received teaching. The question paper also included some questions relating to topics which had been excluded from the teaching course. The development and evaluation of this course have been described in detail (Barber, 1973). In the academic year 1973/74, the main emphasis of the teaching in general practice was continued in the fifth year. Several other varied areas of teaching have been developed and there is now an input of teaching in general practice for selected groups of students in all the four clinical years. This paper describes the further development and evaluation of the teaching course given to fifth year students.
Administration The main lessons learned from the fifth year course of the academic session 1972/73 were that six afternoon sessions over two terms were thought to be insufficient by both students and ‘Requests for reprints to Professor J . H. Barber. Woodside Health Centre, Barr Street. Glasyow G10 7LR. 32
tutors; that the arrangement by which each student group had one teaching session every three weeks made the course disjointed and prevented continuity of teaching; that the students preferred to see patients in their own homes rather than in consulting rooms; that they wished to have a more active participation in the learning situation, and that the size of each group should be restricted to four students. This number was thought to be neither too large nor too small but one which encouraged discussion between the students about the patients and the problems that they had seen. These lessons were incorporated into the course for the academic year 1973/74. The group size was restricted as far as was possible to four students and each group was given a maximum of eight afternoons of teaching. As in the previous year, the only time that was available for teaching was the one afternoon each week that the student was free of other classes. The fifth year was divided into two main groups, one of which was given teaching during the Martinmas (Winter) term and the other during the Candlemas (Spring) term. This allowed eight weekly sessions during the Martinmas term and seven during Candlemas: the reduction during the spring term was necessary to avoid the last two or three weeks of term when the students were preparing for professional and class examinations. As in the previous year, attendance registers were kept by the tutors. All the general practitioners who had been involved in the previous year’s teaching continued as tutors during the session 1973/74,
Development and evaluation of teaching course in general practice
and as the number and frequency of teaching sessions had been increased, the number of tutors involved rose from 26 in 1972 to 31 in 1973. Teaching Method One of the controversial aspects of the first teaching course had been that the patients shown to students were selected and that the teaching sessions were prepared in advance and were held in time set aside from normal practice work. This approach proved successful and was continued during 1973/ 74. During the previous year, many of the tutors had overestimated the number of patients that could be shown to the students during a two-and-a-halfhour session, and there was a feeIing that two or three patients was the optimum number that should be shown to students in one afternoon. The students clearly preferred to see patients at home and, consequently, a greater emphasis was put on this aspect. Student participation in the sessions was improved by allowing them to see the patient without the tutor being present, and by asking the students later to present their patients to the group as a whole. This method was not adhered to strictly - individual tutors decided when it would be likely to be of most value to their group and included this method as often as they thought advisable. In general, however, the pattern was for the students to spend approximately one and a half hours with two or three patients in their homes, thereafter returning to the surgery for a discussion period of about one hour.
Teaching Content As in the previous year, objectives were de-
fined and a syllabus was drawn up for the guidance of tutors. Four main objectives were stated (Table 1) and the tutors were asked to select patients who would illustrate one or Table 1. Objectives of course ~
~.
~
enable the, student to see ‘diagnosis’ and management’ In physical, psychological, and ?ocial terms 2. To show the student conditions not frequently ceen in hospital, which are responsible for a considerable degree of morbidity 3. To demonstrate what is involved in the long-term c x e of chronic ill-health 4. To demonstrate the application of team care to ill-health in the communitv I.
43
more of these objectives. The syllabus for teaching differed from that which had been used in the previous year: in the 1972173 course, the syllabus had listed medical conditions grouped under each of the stated objectives. In the revised syllabus (Table 2) a list of medical conditions and situations was given which would relate to four main age groups the child, the young adult, the middle-aged, and the elderly - and this was included as a guide for the tutors. The majority of students’ Table 2. List of medical conditions and diseases ~~~~
~
Session I Childhood Enuresis Recurrent otitis media with possible deafness and a school problem Asthma Asthma/eczerna syndrome Epilepsy Mental subnormality--e.g. mongolism Behavioural disorders Obesity Diabetes The handicapped child Session 2 Eearly adult life Dyspepsia Asthma Employment hazards Diabetes Disseminated sclerosis Psychosomatic presentations Anxiety and neurotic illness Rheumatoid arthritis Pregnancy with medical or social complications Headache Psychosexual problems The unsupported mother Sessions 4 and 5 Middle aditll-life Angina Chronic bronchitis Diabetes Post-mycocardial infarction Disseminated sclerosis Alcoholism Rlieiimatoid arrhritis Obesity Sessions 6, 7 . and 8 The elderly Stroke Senile or pre-senile dementia Social deprivation Mirltiple organic and social complaints Cardiac failure Depression Osteoarthritis Other situations The problem family Inadequate personality The range of accommodation for the elderly patient Special clinics, e.g. schools o r sheltered workshops for the physically o r mentally handicapped The elderly patient living on his own with poor social conditions
44
I. H . Barber arid E . T.Haraldssoti
groups followed a progression from youth to old age over the eight-week course, but of more importance, the patients who were selected were those who would illustrate the objectives chosen. The nature of the teaching method meant that there was some restriction on the patients who could be involved. It was not thought justifiable to ask patients to stay away from school or from work for the students’ visit, and this inevitably lead to the preschool child, the housewife, and the elderly, being the groups of patients most frequently selected. There was a natural tendency, backed up by intention, to show patients with complicated medical complaints or multiple problems. If a patient with rheumatoid arthritis was to be shown to students as an illustration of the involvement of the primary care team in the long-term care of chronic disease, it was thought that there would be more benefit to the student if the patient selected had a significant degree of disability or if there were other and varied problems present in addition to the organic disease. Before setting out to see the patient, the students were given a brief resumt of the patient’s current and major medical problem. He was allowed to examine the patient if it was thought that this was necessary, but it was stressed that the important aspects were the preparation of a problem list, the history of the development of each problem, and the steps which could be taken in the overall management of the patient. The students were encouraged to think in terms of problems and to present a problem list for each patient that they saw: this list formed the basis for a group discussion at the end of each teaching session. At the end of the course each student had thus seen between 16 and 24 different patients each of whom had been selected for their potential as a learning situation for the student, and had spent between 30 and 45 minutes taking a history and, on occasions, examining each patient.
Evaluetion The 1972173 course had been evaluated by the use of a multiple choice question paper and by questionnaires answered by both students and tutors. The objective evaluation
had shown that the students scored significantly higher marks in the questions relating to topics which had been included in their teaching course than in questions on topics which had been excluded. No difference was found in the marks obtained by the fifth year and by a control group of final (sixth) year students. Though the question paper had been constructed, as far as was possible, in such a way as to reflect medical care in the context of general practice, there was doubt as to whether this type of question was suited to the teaching which was given. In the academic session 1973/74, an attempt was again made to evaluate the course in both objective and subjective terms. The multiple choice question paper was replaced by a ‘modified essay question paper’ and the student questionnaire was identical to one of those used in the previous year. The modified essay question - MEQ - was developed by the Royal College of General Practitioners and is used in the examination for membership of the College. The question is based on a factual case history and sub-questions are directed at several areas such as the recall of factual information, the diagnostic probabilities, the attitude and sensitivity of the student to practice situations, and the overall management of the patient. Once it is prepared, the MEQ is answered by a group of examiners who have had no previous personal knowledge of the situation described in the question. The examiners’ answers form the basis for a marking and scoring system in which there may be several correct answers to any individual part of the question. The scoring given to each alternative answer reflects the views of the author of the question on the relative ‘correctness’ of the answer (Report from Board of Censors of the Royal College of General Practitioners, 1971). The MEQ was the method chosen to evaluate the fifth year course of teaching in the academic year 1973/74. Three MEQs were constructed from clinical situations known to the author. The subquestions were divided into two main groups - those that were primarily factual and that, it was thought. should be within the competence of any fifth year student to answer correctly, and those that were more situational and attitudinal and
DL,velopment rind evaliiotiot~ of teaching coiirse in genertrl pructice
should reflect the content of teaching which was to be given in the general practice course. The questions were answered by a group of six tutors and an answer sheet with a scoring system was constructed. At the end of the Martinmas term 1973, the fifth year students who had completed their teaching course (84 students) sat the three MEQs. The question papers were marked according to the answer scoring sheet, and the marks were subdivided into two groups - ‘factual’ and ‘attitudinal’. At the beginning of the Candlemas term (1974), a random one in three sample of the other half of the fifth year sat the same question paper and represented the control group. These question papers were corrected with the same answer scoring sheet and, again, the marks were subdivided into ‘factual’ and ‘attitudinal’. It was thought possible that bias might have been introduced into the marking of the two sets of question papers as the authors had known which papers were from the control group and which were from students who had completed their teaching. A random sample of 20 papers from each group was then chosen and re-marked in such a way that the authors did not know from which group the question papers had come or the marks that had been previously given to these papers. For the purpose of analysis it was assumed that the ‘factual’ marks represented knowledge derived from the students’ normal clinical teaching. and that the ‘attitudinal’ marks represented the results of the teaching course in general practice. A questionnaire was given to the students at the end of each of the two terms. The students were asked to score the various activities of the course in which they had been involved and to add any further opinions or comments that they might wish to express (Table 3). The questionnaires, together with the attendance registers, were expected to indicate the students’ subjective opinion of the course. Results The MEQ paper was answered by 84 students at the end of the teaching course in the Martinmas term, 1973, and by 27 students at the
45
start of their teaching course in the Candlemas term of 1974. The comparison between the randomly selected 20 papers from each group is given in Table 4. Table 3. Questionnaire Last year I asked all fifth year students for their opinion and assessment of the teaching course in general practice. The comments and criticisms made were of considerable value in planning this course, and I would be most grateful if you would complete this questionnaire. Please score the activities you have been involved in and cross out any you did not have.
S c d e of Valire 0 No value 1 Little value 2 Some value 3 Considerable value Patients seen in the surgery
}worth
not worth doing
Patients seen in homes Group discussion after seeing patients Visits to old people Visits to industry Other activities (specify)
Comments on t h e course
doing
0 17
0
0 17
n
0”
Table 4. ‘%actual
questions’ Mean SD
‘ Attiludinal qrrestio ns‘ Mean SP
5th year students 85:L li 7176 11 5th year controls 78‘:: 13 59:A I1 t-test 0.1 >P>0.05 t-test 0~002>P>0~001
Student Attendance Out of a total possible of 672 attendances, 633 (94%) were recorded for students who had completed their teaching in the Martinmas term. In the Candlemas term (1974) most of the tutors reduced the length of the course from eight afternoons to seven, to avoid examinations at the end of the term, and some groups were further reduced to six sessions due to the mid-term university holiday. The total possible attendances in the Candlemas term were 572, and 470 attendances were recorded ( 8 2 % ) . Over the two terms, and thus
J . H . Barber and E . T . Haruldsson
46
over the whole of the fifth year class, the attendance rate was 88%.
Questionnaire At the end of each term the students were invited to complete a questionnaire and, as it was anonymous, they were free to make any comments they wished. There was a total of 170 students in the year and 118 questionnaires were completed (69% of the students). The mean score given to each activity is shown in Table 5 . Table 5. No. of stirdenis
Mean score
Score f o r 1972173
93 118
2.0 2.7
2.5 29
118 104 21
2.5 2.6 2.0
2.6 2.4 2.5
Patients seen in the surgery Patients seen at home Group discussion after seeing patients Visits to old people Visits to industry
2-Some 3-GOOd
value \. valuej
worth doing
Of the 118 questionnaires completed, 109 (92%) included additional comments. These broadly fell into four main groups, and, in many instances, students gave a thorough appraisal and constructive comments about the course. The four main groups of comments are shown in Table 6. Table 6. Analysis of additional comments O /O /
Comments
‘Favourable’ ‘Suggest sitting-in at surgery’ ‘Course should be earlier in curriculum’ ‘Course of little value’
No. of (?A of I09 students questionnaires)
96
88
16
14
9 7
8 6
As expected, the students’ comments were very variable. but on the whole it was noticeable that students in the Candlemas term gave broader and more constructive comments on the course than the students in the Martinmas term. This difference may reflect the students’
hostility towards the examination paper which was given to all students in the Martinmas term but to only 28 in the Candlemas term. A number of students commented on an ‘eye-opening’ effect from seeing people in poor housing and social conditions. Those who had been shown model lodging-houses were clearly very concerned. Many students commented favourably on the value of a primary health care team consisting of a doctor, health visitor, district nurse, and social worker, but as some tutors did not have attached health visitors or social workers, it was not possible to show team care to all students. Discussion This course of teaching for fifth year students had one apparent major disadvantage: it made use of the students’ free afternoons. This will continue to be the pattern until 1976, after which date there is time specifically allocated for this teaching in the fourth year of the new five-year curriculum. The course appeared to be popular with the students, and this was reflected by the high attendance rate (88%). Attendance can be influenced by many factors, including the subject being taught and the quality of the teaching, but when the course uses the students’ own free time, the attendance rate becomes a sensitive barometer of student reaction. With this in mind, it is of less importance that 30% of the students did not return questionnaires. Those that were completed were helpful and will influence the pattern of the course in the next academic session. The two main comments showed that the students were more receptive to seeing patients at home rather than in the surgery, and that the group discussion which occupied the last hour of each afternoon was popular - indeed several students commented that it was essential. By selecting the patients that were seen, by allowing the students to take an active part in the learning situation, and by stressing the preparation of complete problem lists, the students were encouraged to think in terms of ‘wholeperson’ medicine, and to appreciate the complexity of some patients problems. If the social environment were of importance in the management of the patient, these conditions were obvious for the student to see. If there were
Deve!opmenr and evaluariotr of teaching coiirse in grnrrd prcrcricr
psychiatric overlays to the organic complaint, these became apparent from the patient’s behaviour and from the interfamily relation that the student observed. Wherever possible a group of four students was divided into pairs, each of which saw each of the patients selected. Every student was then able to contribute to, and to derive benefit from, the group discussion that followed. An outstanding feature of almost every group was the relaxed friendly atmosphere and relation which grew up between students and tutor. This was in part because of the small size of the group, to the frequency with which it met, and to the way in which the tutor had prepared both the content and the objective of each teaching session. By limiting the number of patients shown, the students were given adequate time to see the patient and to discuss the problems in detail. This would not have been possible if the tutors had not set aside time for teaching out of their normal practice work. The patient’s problem sheet formed the basis for a discussion of the physical, psychological, and social problems that had been identified, and this could extend from a consideration of the management of the individual patient to the causation, the natural history, and the treatment of such problems in a practice or population context. The tutors showed considerable skill in the patients that they selected, in taking the students who initially were very disease orientated gradually through increasingly complex situations, and in occasionally showing the students patients to whose problems there were no solutions. On occasions, the students were shown a patient who had presented with some acute condition during that day and were thus able to see the earliest stage of illness. This aspect of medicine in general practice was, however, not positively included in this course as it is at present the central feature of pilot schemes that are being run for third and fourth year students. As formal teaching in general practice has only been established at Glasgow University for two years, it was sometimes difficult for the individual student to see how his fifth year course fitted into the more extended teaching that is being planned. On purpose,
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each new area of teaching is being treated initially as a pilot scheme and will only be offered to all students if methods of evaluation are developed and can show that the teaching is of value. The fifth year course is essentially an in-depth and prepared course, and other areas such as the initial presentation of illness, the interpretation of the undifferentiated symptom, and the follow-up of patients after discharge from hospital, are being tackled in each of the other clinical years, and in collaboration with the clinical departments of medicine, paediatrics, geriatrics, and psychological medicine. The full-time attachment of a student to a general practitioner is at present available only as an elective attachment. At present this is offered to fifth year students in the Easter vacation: in 1973, 30% of the students took this elective; in 1974 this figure rose to 45%. However encouraging the subjective qucstionnaires prove to be, it is of greater encouragement to find that there is objective and statistical proof of some educational value from the course. The MEQs as described and used by the Royal College of General Practitioners need to be adapted for undergraduate use, but it seems clear that as a method of assessment in the primary care situation it has advantages over both the multiple choice and traditional essay questions. The preparation of an answer and scoring sheet based on answers given by tutors, ensures that there is a degree of standardization in the marking of the students’ papers. This, in turn, enables a statistical comparison to be made between one group who have completed the teaching course and another group who have not. The results obtained in the MEQs given to the fifth year students are clearly significant in the area reflecting the teaching that was given in general practice. This analysis of a teaching course shows only that it was attractive to the students and that it had some apparent educational value. Much more requires to be done - to define more precisely the aspects of medicine in general practice that should be taught and to improve the way in which the teaching is given. There is a need also to determine how this fifth year course relates to the other teaching in general practice that is being attempted.
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J . H . Barber and E. T . Haroldsson
Medicine in general practice is a wide and varying subject - it is a continuing challenge to identify what and how much should be taught to the undergraduate, how the teaching should interrelate with that of other clinical disciplines, and at what stage or stages of the curriculum it should be introduced.
summary The further development of a teaching course in general practice medicine for fifth year students at Glasgow University is described. Lessons learnt from a Drevious experimental course have been applied: eight afternoon sessions of a structured nature and related to prescribed objectives and a syllabus were given to small groups of students. Questionnaires showed that the in-depth study of selected patients in their own homes, with student involvement in the preparation of problem lists for group discussion were thought by the
students to be valuable. An objective assessment of the course using the modified essay question technique showed an improvement in factual clinical knowledge (P > 0.05) and more importantly in areas relating to the general practice content of the teaching (P > 0,001). The authors wish to record their thanks to the general practitioner tutors and to Professor Keith Hodgkin (the Sir Harry Jephcott visiting Professor in General Practice) for the help and encouragement they have given in the teaching and evaluation of this course.
References Barber, J. H. (1973). A teaching course in general practice. British loirrnul of Medical Editcution, 7 , 165-173.
Board of Censors of the Royal College of General Practitioners (1971). Journal of fhr Royal College of General Prucrifioners, 21, 313.
