HOW T O . . .
Plan an Off-Campus Clinical Teaching Programme
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
GERALD B. HOLZMAN and WILLIAM S. ABBETT Gerald B. Holzman, MD, is Professor and Vice Chairman, Department of Obstetrics and Gynecology, Medical College of Georgia and William S. Abbett, PH.D,is Assistant Dean, College of Human Medicine, and Assistant Professor, Ojfice of Medical Education Research and Development, Michigan Slate University, East Lansing, Michigan, USA.
Teaching i n non-university hospitals not only supplements university-based educational resources but also provides students with greater opportunities to be involved with cases frequently encountered in actual practice. It also strengthens continuing education of doctors in the community, and can lead to a better understanding of the realities and problems of community health care. Success is partially dependent upon initial planning, which should include setting objectives, adapting them to the educational environment, and choosing a n environment in which they are likely to succeed. Acceptance within the community is dependent upon prior knowledge of the political structure and the involvement of those people who command the respect of the community at large. Teaching should be shared between the university and the community, not just delegated either to the community or assumed totally by the university. Faculty development is crucial initially and on a continuing basis. This article is based on the American system, but is relevant to other situations.
Advantages of Experience i n Non-university Hospitals Although the initial motivation to seek off-campus teaching facilities may have been economic (for example, inability to construct or expand a university hospital), most schools involved in community-based education have found the experience intrinsically rewarding. For example, proponents suggest that training students in community settings provides a more realistic introduction to clinical medicine.* Rather than focusing on the ‘rare clinical case’ normally found in the tertiary care university facility, students in community hospitals have more opportunities to be involved with cases frequently encountered in actual practice. Students also have a chance to observe the importance of other community agencies in the promotion and maintenance of health. The use of community hospitals has served to reinforce the importance of primary care in response to mandates for increased manpower in that area.’ Some Problems
Over the past 20 years, there has been a dramatic increase in the use of community hospitals, that is non-university hospitals, as sites for undergraduate clinical education. Sonic of these hospitals have a long tradition of training house oflicers; others have had no experience whatsoever in the education of medical students or recent graduates. In the United States, many of the schools established since 1960 have turned to the community hospital as the primary setting for their clinical education programmes.’ Other more established colleges of medicine, in response to increasing demands, have also turned to these facilities to supplement university-based educational resources. 46
However, even the proponents of community-based education agree that there are problems inherent in ofl-silt, clinical teaching. Student education may be severely handicapped in sites with limited patient populations, outmoded facilities, and/or inadequate teaching staffs. There is also the problem of ensuring consistency of learning across multiple sites. Indeed, a clerkship offered in one community hospital may be quite different in structure from one given in another facility. Such differences may produce serious discrepancies in what is learned. Finally, there may be problems of commitment and control. In most cases, community hospitals receive only minimal remuneration for hosting a clerkship, and community physicians generally serve as faculty on a Medical Teacher Vol 6 No 2 1984
volunteer basis. Since it may be perceived as peripheral to the central functions of the hospital and medical staff, student education may be given a relatively low priority by hospital administrators and community practitioners. As such, the day-to-day administrative operation of a clerkship (for example, student, faculty, patient, and facility scheduling) can often be problematic.
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
The Experience at Michigan State University Many schools have been successful in dealing with these problems and have developed exceptionally good educational experiences for students in community settings. The College of Human Medicine at Michigan State University, for example, has been involved in community-based education since 1970 and currently conducts undergraduate clinical education in hospitals located in seven Michigan communities. The College has experienced both the benefits and problems associated with a multi-site clinical endeavour. Although this experience has not resulted in the definition of a ‘fool-proof prescription, it has strongly suggested the importance of thoughtful planning as the critical prerequisite for success in community-based education. In the remaining sections of this paper, we outline essential steps in the planning process and offer some practical suggestions to those developing off-site teaching programmes. Setting Objectives The first and most important step in any planning process is determining the objectives or desired outcomes of the programme to be developed. Once established, these will serve to guide subsequent stages of the planning process and will later function as reference points against which success will be measured. The planning objectives should clearly and realistically describe expectations for student learning. They should define the fundamental concepts and skills that students are expected to acquire as a result of a clerkship experience. This alone, however, is not enough to facilitate later planning and evaluation. The planning objective should specify what should be learned, what experiences may be used to enhance learning, and how one will know whether or not the objectives has been met. The objectives should be categorized in some fashion to reflect their relative importance in the education of a medical student. Rather than using a complicated ranking scheme, it is enough simply to classify the objectives into three groups: 0 Absolutely essential. 0 Desirable, though not essential. 0 ‘Extra added attractions’.
These rankings will prove useful later when the objectives are being used as criteria for planning decisions. The clerkship planning objectives initially should be formulated by and reflect the considered judgment of the medical school faculty. Although they will serve to guide decisions made in the planning process, they should not be viewed as inviolate, but must be reviewed continuously Medical Teacher Vol 6 No 2 1984
in the light of the realities of a given community setting. Assessing the Educational Environment The second major step in planning an off-site clerkship involves a careful assessment of potential educational resources available in the community. Information on the nature and adequacy of clinical facilities and existing patient populations should be gathered and assessed in relationship to the defined clerkship objectives. Of critical importance is the availability of private physicians to serve as a volunteer faculty in the proposed clerkship. This should include consideration of the physicians’ existing patient loads as well as their interest in involving students in their practices, primarily in the hospital but also in their private offices if outpatient clinical opportunities are not available within the hospital. Other resources should be considered in determining the appropriateness of the site. For example, if the site is beyond commuting distance from the main campus, it is essential to consider the availability of temporary housing facilities for medical students. If students are required to stay at the site to complete several clerkships, the potential for other facilities and student services should be determined. Among these are the availability of low-cost housing for single and married students, employment opportunities for spouses, medical and psychological services, and recreational facilities. Assessing the Political Structure and Climate Assuming the community resource base is adequate to meet clerkship objectives, the next step in the planning process is to assess the feasibility of implementing the clerkship in the light of the political structure and climate in the medical community. It would be naive to assume that an externally sponsored educational programme could be implemented in a community without becoming involved in .the political affairs of that community. Indeed, the likelihood of successfully implementing and/or maintaining an educational programme in an unsupportive or openly hostile political environment is minimal. Those who try generally find themselves confronted with insurmountable ‘roadblocks’, or are embroiled in timeconsuming political battles which compromise and frustrate the educational process. To avoid this outcome, it is essential to assess carefully the political environment before the community is selected as a teaching site. This assessment should be focussed on obtaining a clear understanding of both the political structure of the medical community and the underlying issues that may tend to motivate local political activity for or against the proposed educational programme. Taking account of 'Hidden ’ Power Structures In attempting to understand the political structure of a given community, it is important to recognize that political power, or the ability to influence community opinion and action, generally does not reside in a single individual. 47
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
It is, of course, easy to identify those individuals who derive their power from the positions they hold in various community health care organizations. Hospital administrators, chiefs of staff, and local medical society officers, h y virtue of the authority of their positions, can significantly influence the medical community. Yet, these individuals alone may not represent fully the complete power structure. Lying beneath the organizational charts, there are often ‘hidden’ power structures, which may be far more influential in controlling community action. Local physicians, for example, who control large numbers of referrals, or the community philanthropist, who selectively donates large sums ‘to promote health care’, may be significant components of this hidden system. There are also individuals who, by virtue of their professional or community standing, can influence both opinions and action. It is essential that the views of all who hold power be ronsidcred in relationship to the educational progratntne. T h e likelihood for success is further increased if rc-presentatives of both the formal and hidden power structures are involved in both the final planning and ongoing operation of‘ the clerkship.
medical school neither wants to control them nor tell them how to practise, and that their patients will be respected. The greatest fear of community physicians is that, with the potential influx of full-time medical school faculty, practice income will decrease. This fear probably is unjustified in distant communities unless the school plans to locate a number of the full-time faculty at the site. In nearby communities, however, the fear may well be justified and will need to be addressed. In cases where conflict is not easily resolved, it is important for the community and medical school leadership to agree on mechanisms (for example, committees, policies) that may effectively respond to specific problems as they arise.
Structuring the Relationship
Ensuring that Motives are Congrucnt
Once a clear understanding of the climate is achieved, consideration must be given to establishing a relationship that clarifies the responsibilities of both the medical school and the community in operating the educational programme. There are at least three models to consider: the ‘contractual model’, the ‘academic model’ and the ‘shared system’.
I n dealing with the community leadership, it is necessary
The Contractual Model
to identify and address in a forthright manner all issues
that tnay affect the successful implementation and operation of the proposed clerkship. As a first step, medical school planners should clearly understand the motives of the community for wanting the educational programme. At the same time, the community should understand the motives of the medical school. In many instances, the motives (for example, a mutual desire to train students in realistic settings or the need to bolster continuing medical education efforts) will be congruent. In other cases, however, the motives may be in conflict. The medical school, for example, may see the establishment of a residency programme as one of its long-term goals, while the community may want no part of such a programme. Overcoming the Fears o j Community Prac&i&ioners Thc concerns and fears of community practitioners, whether justified or not, may also form the basis for conflict. In tnany instances, these fears evolve from the fact that cotnmunity physicians, unlike their academic counterparts, are independent professionals. Most of their economic and personal rewards come from their interartion with patients within the context of a privately controlled, single or small group practice. Likewise, physicians practising in countries where medical care is run by the government may not welcome students, feeling that they interfere with eficiency and intrude upon the doctor-patient relationship. While community physicians may enjoy teaching, it plays and will continue to play a secondary role in their professional lives. The implementation of an educational programme may be viewed as potentially dangerous meddling by the medical school with the professional lives of these clinicians. Reassurance must be given that the 48
Here, the medical school serves as a contractor and negotiates a subcontract with a community to provide educational services to medical students. Thus, while the medical school may retain responsibility for establishing objectives and evaluating final outcomes, control of the educational process is essentially delegated to the community. Implicit in the model are assumptions that the community is highly motivated and possesses the necessary range of teaching and clinical expertise. Although many communities may display such capabilities, these assumptions should be thoroughly tested before implementing this type of relationship. Other problems may also evolve from the contractual relationship. For instance, without supplementary instruction from the medical school faculty, the curriculum will probably be limited by the unique clinical environment (by the number and type of cases, referral patterns, and so on) existing within the community, and students may feel a sense of isolation from the medical school. The Academic Model In this situation, the medical school retains complete control of the educational process. The community is involved only in providing access to a patient population and clinical facilities. Most of the direct teaching is assumed by medical school staff, and the contributions 01‘ private physicians in both student teaching and evaluation are extremely limited. Although some communities may initially feel comfortable with this relationship, most ultimately will assume this excessive control implies that the medical school views their practice habits as substandard. If this occurs, the educational programme almost certainly is doomed to failure. Medical Teacher Vol 6 No 2 1984
In both models, one partner in the medical schoolcommunity relationship assumes dominance over the other in the educational programme. Since one partner is in a subservient position, the potential for conflict is high, and resolution is often difficult.
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
Implementing a Shared System Falling between the contractual and academic models, the shared system implies an active partnership between the medical school and the community. Specific responsibilities are carefully negotiated to achieve the most effective mix of community and medical school resources to meet the objectives of the programme. Generally, community physicians are encouraged to participate in all phases of the programme and to assume primary responsibility in some. They may be involved in the final construction of instructional objectives, participate in didactic teaching sessions, be continuously involved in evaluating clinical skills. and assist in developing final examinations either by writing items or providing feedback about specific quesrions. Although the ‘shared system’ offers the greatest opportunity for cooperation, it is generally the most difficult to establish, Cooperation is largely dependent on effective communications, and communication is often compromised by distance or interinstitutional suspicion. Recognizing this, all administrative arrangements, policymaking processes, public relations strategies, and faculty development activities should be structured at the outset to facilitate communication. Importance o j a Coordinator
Of primary importance is the selection of an individual who will be responsible for managing the educational experience at the local level. Since this individual will serve as the primary implementor and conduit of information flowing between the medical school department and the community, the coordinator needs to be knowledgeable, respected and influential in the community and display potential as a medical school faculty member. Generally, it is preferable to choose a coordinator who is not a new practitioner in the area nor near retirement age. In addition to managing the day-to-day tasks of the programme, the coordinator must be an effective spokesperson for both the community and the medical school. Assuming the coordinator is respected in both institutions, these tasks can be accomplished with minimal difficulty. Obviously, this is not a position to force on someone. Prior to selection, it is helpful for a group of medical school faculty and practising physicians to construct a job description, which may be used in evaluating prospective candidates. The coordinator should be paid by and receive technical and clerical support from the medical school. He or she should also be awarded a faculty appointment. In accomplishing the latter, some of the expectations for this appointment, such as research and publications, may have to be ‘compromised’ in view of the need to find locally respected practitioners. The Medical Teacher Vol 6 No 2 1984
individual selected, however, should be an excellent role model as a physician and display significant interest, and competency in teaching. The Need f o r Education Committees Although the coordinator will serve as the primary link between the medical school department and the community, additional mechanisms must be established to facilitate communication and decision-making. Education committees should be formed at a local level to give advice on the operation of the programme. The membership of the committee should include influential members of the local medical community, the community faculty, and the medical school. Likewise, it is important that the medical school is represented by individuals who are in positions of authority within the institution. Such representation signals the importance of the community programme in the overall structure of the medical school and ensures the community that their concerns are being heard. The committee should assist the coordinator in establishing policies and procedures in operating the clerkship. It should review evaluations and make recommendations regarding the effectiveness of the programme and of the clinical teachers. Recommendations for major programme change may evolve from these bodies and should be forwarded to campus-based committees for consideration. T o encourage further interinstitutional communication, the medical school should consider including community representatives on central committees which deal with curriculum, admissions and student performance. Rapport with Patients Consideration must be given to the establishment of rapport with the patient population that will serve as the focus of student learning. Patients need to understand why students are involved in their care. The responsibility for informing patients must not be left to the community physicians alone. The medical school should provide assistance by meeting with community groups and offering its media resources. Furthermore, it is the responsibility of the medical school to familiarize students with the rights of patients. Avoiding Interinstitutional Upsets A community with enough patients to support an educational programme usually has more than one hospital. If that is true, the medical school inadvertently may involve itself in interinstitutional politics within the community by negotiating with one and not all hospitals or with each hospital separately. Individual agreements may lead to distrust, jealousy and antagonism. For this reason alone, it is advisable to encourage the establishment of an Area Health Education Centre (AHEC) to coordinate all clinical education activities with the community. The AHEC need not include only the university and the general hospitals in the community: members may 49
include orthopaedic or psychiatric hospitals, schools of nursing, physician assistant programmes and community colleges. The AHEC’s charge will vary but, at the very least, it will probably include health education at the undergraduate, graduate, and postgraduate level. This is an expensive venture since there needs to be an additional administrative staff. At Michigan State University, the Director of the AHEC serves as the Assistant Dean for that community.
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
Faculty Development
Among the resources available to an off-campus teaching programme, the most important are the local physicians who volunteer both their time and their patients. Indeed, the success or failure of the programme will depend largely on the level and quality of volunteer faculty cooperation. It is essential that a comprehensive programme of faculty development is established, which includes both the training and the incentives necessary to achieve effective participation. Role of Workshops
The training component of the faculty development programme should begin with a series of activities directed at oricntating local faculty. Prior to the arrival of the students, introductory planning workshops focussed on familiarizing the community faculty members with the objectives and structure of the programme should be implemented. The workshops should outline the general expectations for a community faculty member in the programme and give community practitioners an opportunity to react to their assigned responsibilities. Although most community faculty members will be satisfied with the role of preceptor, some may wish to extend their teaching beyond the clinical setting. Wherever possible, opportunities for more extensive instructional involvement should be made available. Evaluation
of Clinical
Teachers
Subsequent faculty training programmes should be responsive to specific needs as identified by the faculty members themselves or through a carefully structured system that has evaluated faculty effectiveness. Faculty members should be informed at the outset that both the medical school and the community are committed to offering a high quality educational programme and, therefore, will jointly monitor its effectiveness through continuous reviews of student and faculty performance. In developing a system of faculty evaluation, techniques should be used that are efficient, unobtrusive, and successful in identifying specific instructional problems. Direct observation, for example, though effective, is extremely timc-consuming and often threatening to community physicians. Most programmes depend on student feedback as an indicator of faculty performance. Faculty rating forms, completed by students, generally provide a reasonable indication of instructional performance. The results of .5u
student ratings should be anonymously returned to the faculty member along with specific suggestions for improvement, if weaknesses are identified. Generally, students approach the task of rating their teachers in a positive manner and provide constructive teedback on the faculty member’s instructional performance. Occasionally, however, the ratings and/or comments can be destructive. In these cases, rather than forwarding the comments directly to the faculty member, it is perhaps best to clarify concerns in individual meetings with the students before providing verbal feedback to the taculty member. Another method used to assess faculty performance is through monitoring student performance on content or clinical skills examinations. If repeated groups of students do not possess adequate knowledge or appropriate skills in a given area, it may be an indication of less than adequate instruction. Regardless of the methods used, results of faculty performance evaluations should be reviewed by the community educational programme committee. In extreme cases where performance is consistently poor, consideration should be given to removing or reassigning the individual. OnEoing Faculty Development In most cases, however, instructional problems can be constructively resolved through ongoing faculty development activities. Perhaps the best form of faculty development is ‘one-on-one’ interaction between the faculty member and the coordinator or another respected teacher. In these sessions, problems can be discussed frankly, and suggestions for improvement can be provided in a less threatening setting. To address more generalized problems or to seek overall improvement in a given area, the faculty development workshop should be considered. Although they are often requested and promote good public relations, workshops are variably attended by volunteer community faculty. Busy practitioners generally find it difficult to spend a half or full day attending a programme that deals entirely with teaching techniques. Despite these drawbacks, faculty development programmes can be extremely useful in promoting an awareness of effective instructional methods and identifying instructional resources available both within the community and within the medical school. The programmes should be carefully planned, however, in an effort to reflect the needs of the faculty in a given setting. Rewards and Incentives In addition to providing training opportunities, a comprehensive faculty development programme must include a system of rewards and incentives to stimulate a continuing commitment. Unlike their university-based colleagues, volunteer community faculty members receive few, if any, economic rewards for their participation. Some, in fact, may suffer a loss of income as a result of teaching medical students. Thus, the traditional academic reward system is not usually applicable to the Medical Teacher Vol 6 No 2 1984
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
community setting. Instead, the reward system must reinforce participation through recognition of the faculty mber as both a teacher and a clinician. Rccognition may be provided in a variety of ways. The receipt of a clinical faculty appointment is considered a reward by many community physicians. Many schools presrnt the volunteer faculty members with certificates of appoiiitment, which may be framed and displayed in the physician's office or clinic. The appointment should include preferential treatment in the use of university facilities and in the sale of tickets to athletic or cultural events. The performance of a clinical faculty member also may be recognized through promotion. Community educational programme committees should recommend promotion, according to established guidelines, for those faculty members displaying outstanding performance. Awards from the medical school or the students are particularly gratifying and promote a strengthened commitment to the programme. A more substantive though subtle form of recognition may be achieved by providing opportunities for volunteer faculty members to become more significantly involved in medical school operations. At a minimum, their views should be assessed and carefully considered by medical school committees as they review curricular and other acadtmic policies. A better approach is to include representativvs of the volunteer faculty members on departmental and school committees. In addition to providing an important perspective and stimulating communication betwwn the campus and community, such involvement enhanct-s the perceived importance of the volunteer faculty to thr medical school. Thc medical school can also reward community faculty members by offering opportunities for continued learning and career development. It may, for example, provide an indivicltral faculty member with funds to attend a specialized twining programme or may assist in writing grant proposals, designing research studies, and/or preparing papers tor publication.
Final Thoughts The establishment of a productive relationship between a community and a medical school is not easy. Some have described this relationship as analogous to a marriage in which success is dependent on mutual needs, honesty, patience and understanding. '*'As with all marriages, there will be stormy times but also opportunities for each partner to grow and enhance individual strengths. Continuing education in the community, for example, will be strengthened as a result of the interactions between community physicians, the medical school faculty and students. At the same time, there will be opportunities for the medical school to develop a better understanding of the realities and problems of community health care and to translate this new awareness into cooperative programmes of research and service which are fully responsive to community needs. The central beneficiary of this relationship, however, continues to be the student who will, through a well-planned alliance, receive a highquality medical education.
Medical Teacher Vol 6 No 2 1984
References
'Hunt AD. A time lor change and reform. In: Hunt AD, Weeks LE (eds). Medical education since 1960: marching to a diJerent drummer. East Lansing: Michigan State University Foundation, 1979. *Richards RW. Innovations in health projessions tducalion. Geneva: World Health Or,qanization, 1978. 'Beljan JR. Living with community hospitals: strategies t o make the marriage work. In: Hunt AD, Weeks LE (eds). Medical education sincr 1960: marching to a ifzJermt drummer. East Lansing: Michigan State University Foundation, 1979. 'Dcrzon RA. Marriage of mrdical schools and teaching hospitals.JMed Ed, 1978; 53: 19-25.
Education for the Professions The theme for the next Annual Conference of the Society for Research into Higher Education is Education for the Professions. A volume of introductory papers illustrating major themes in education for the professions of Engineering, Medicine and Management is in preparation. The conference will be held at the Imperial College of Science and Technology on 17 to 19 December 1984. Further information from Dr Sinclair Goodlad, Room 501EE, Imperial College of Science and Technology, London SW7 2AZ.
Project a Lively Image There is now a simple way of adding animation to the established merits of the overhead projector as an audiovisual aid. Movimate is a DIY kit produced by Technical Animations Ltd. It is based on the use of polarized film and is a simple and effective way of indicating movement in printed graphics, particularly schematic diagrams and flow charts. Movimate allows anyone with basic graphics skills to prepare their own animated transparencirs for use on an overhead projector, simply by applying sections of animated film to the areas where movement is to be shown. An aluminium stand supporting a rotating disc of clear polarized film immediately below the lens of the projector is the other essential element of the kit. The 'black-out' effect created by the spinning disc moving in opposition to the polarised film on the transparency produces the effect of movement on the projected image. A variety of polarized film, each of which produces a different motion effect on screen, is included in the pack. This is useful for anyone used to preparing slides for overhead projection for training seminars, lectures and conferences. The Movimate kit retails for f249 and is available, with additional supplies of animated film, from Technical Animations Ltd, 3 Osiers Road, Wandsworth, London, SW18. Tel. 01-874 4152.
51
Plan an Off-Campus Clinical Teaching Programme
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
GERALD B. HOLZMAN and WILLIAM S. ABBETT Gerald B. Holzman, MD, is Professor and Vice Chairman, Department of Obstetrics and Gynecology, Medical College of Georgia and William S. Abbett, PH.D,is Assistant Dean, College of Human Medicine, and Assistant Professor, Ojfice of Medical Education Research and Development, Michigan Slate University, East Lansing, Michigan, USA.
Teaching i n non-university hospitals not only supplements university-based educational resources but also provides students with greater opportunities to be involved with cases frequently encountered in actual practice. It also strengthens continuing education of doctors in the community, and can lead to a better understanding of the realities and problems of community health care. Success is partially dependent upon initial planning, which should include setting objectives, adapting them to the educational environment, and choosing a n environment in which they are likely to succeed. Acceptance within the community is dependent upon prior knowledge of the political structure and the involvement of those people who command the respect of the community at large. Teaching should be shared between the university and the community, not just delegated either to the community or assumed totally by the university. Faculty development is crucial initially and on a continuing basis. This article is based on the American system, but is relevant to other situations.
Advantages of Experience i n Non-university Hospitals Although the initial motivation to seek off-campus teaching facilities may have been economic (for example, inability to construct or expand a university hospital), most schools involved in community-based education have found the experience intrinsically rewarding. For example, proponents suggest that training students in community settings provides a more realistic introduction to clinical medicine.* Rather than focusing on the ‘rare clinical case’ normally found in the tertiary care university facility, students in community hospitals have more opportunities to be involved with cases frequently encountered in actual practice. Students also have a chance to observe the importance of other community agencies in the promotion and maintenance of health. The use of community hospitals has served to reinforce the importance of primary care in response to mandates for increased manpower in that area.’ Some Problems
Over the past 20 years, there has been a dramatic increase in the use of community hospitals, that is non-university hospitals, as sites for undergraduate clinical education. Sonic of these hospitals have a long tradition of training house oflicers; others have had no experience whatsoever in the education of medical students or recent graduates. In the United States, many of the schools established since 1960 have turned to the community hospital as the primary setting for their clinical education programmes.’ Other more established colleges of medicine, in response to increasing demands, have also turned to these facilities to supplement university-based educational resources. 46
However, even the proponents of community-based education agree that there are problems inherent in ofl-silt, clinical teaching. Student education may be severely handicapped in sites with limited patient populations, outmoded facilities, and/or inadequate teaching staffs. There is also the problem of ensuring consistency of learning across multiple sites. Indeed, a clerkship offered in one community hospital may be quite different in structure from one given in another facility. Such differences may produce serious discrepancies in what is learned. Finally, there may be problems of commitment and control. In most cases, community hospitals receive only minimal remuneration for hosting a clerkship, and community physicians generally serve as faculty on a Medical Teacher Vol 6 No 2 1984
volunteer basis. Since it may be perceived as peripheral to the central functions of the hospital and medical staff, student education may be given a relatively low priority by hospital administrators and community practitioners. As such, the day-to-day administrative operation of a clerkship (for example, student, faculty, patient, and facility scheduling) can often be problematic.
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
The Experience at Michigan State University Many schools have been successful in dealing with these problems and have developed exceptionally good educational experiences for students in community settings. The College of Human Medicine at Michigan State University, for example, has been involved in community-based education since 1970 and currently conducts undergraduate clinical education in hospitals located in seven Michigan communities. The College has experienced both the benefits and problems associated with a multi-site clinical endeavour. Although this experience has not resulted in the definition of a ‘fool-proof prescription, it has strongly suggested the importance of thoughtful planning as the critical prerequisite for success in community-based education. In the remaining sections of this paper, we outline essential steps in the planning process and offer some practical suggestions to those developing off-site teaching programmes. Setting Objectives The first and most important step in any planning process is determining the objectives or desired outcomes of the programme to be developed. Once established, these will serve to guide subsequent stages of the planning process and will later function as reference points against which success will be measured. The planning objectives should clearly and realistically describe expectations for student learning. They should define the fundamental concepts and skills that students are expected to acquire as a result of a clerkship experience. This alone, however, is not enough to facilitate later planning and evaluation. The planning objective should specify what should be learned, what experiences may be used to enhance learning, and how one will know whether or not the objectives has been met. The objectives should be categorized in some fashion to reflect their relative importance in the education of a medical student. Rather than using a complicated ranking scheme, it is enough simply to classify the objectives into three groups: 0 Absolutely essential. 0 Desirable, though not essential. 0 ‘Extra added attractions’.
These rankings will prove useful later when the objectives are being used as criteria for planning decisions. The clerkship planning objectives initially should be formulated by and reflect the considered judgment of the medical school faculty. Although they will serve to guide decisions made in the planning process, they should not be viewed as inviolate, but must be reviewed continuously Medical Teacher Vol 6 No 2 1984
in the light of the realities of a given community setting. Assessing the Educational Environment The second major step in planning an off-site clerkship involves a careful assessment of potential educational resources available in the community. Information on the nature and adequacy of clinical facilities and existing patient populations should be gathered and assessed in relationship to the defined clerkship objectives. Of critical importance is the availability of private physicians to serve as a volunteer faculty in the proposed clerkship. This should include consideration of the physicians’ existing patient loads as well as their interest in involving students in their practices, primarily in the hospital but also in their private offices if outpatient clinical opportunities are not available within the hospital. Other resources should be considered in determining the appropriateness of the site. For example, if the site is beyond commuting distance from the main campus, it is essential to consider the availability of temporary housing facilities for medical students. If students are required to stay at the site to complete several clerkships, the potential for other facilities and student services should be determined. Among these are the availability of low-cost housing for single and married students, employment opportunities for spouses, medical and psychological services, and recreational facilities. Assessing the Political Structure and Climate Assuming the community resource base is adequate to meet clerkship objectives, the next step in the planning process is to assess the feasibility of implementing the clerkship in the light of the political structure and climate in the medical community. It would be naive to assume that an externally sponsored educational programme could be implemented in a community without becoming involved in .the political affairs of that community. Indeed, the likelihood of successfully implementing and/or maintaining an educational programme in an unsupportive or openly hostile political environment is minimal. Those who try generally find themselves confronted with insurmountable ‘roadblocks’, or are embroiled in timeconsuming political battles which compromise and frustrate the educational process. To avoid this outcome, it is essential to assess carefully the political environment before the community is selected as a teaching site. This assessment should be focussed on obtaining a clear understanding of both the political structure of the medical community and the underlying issues that may tend to motivate local political activity for or against the proposed educational programme. Taking account of 'Hidden ’ Power Structures In attempting to understand the political structure of a given community, it is important to recognize that political power, or the ability to influence community opinion and action, generally does not reside in a single individual. 47
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
It is, of course, easy to identify those individuals who derive their power from the positions they hold in various community health care organizations. Hospital administrators, chiefs of staff, and local medical society officers, h y virtue of the authority of their positions, can significantly influence the medical community. Yet, these individuals alone may not represent fully the complete power structure. Lying beneath the organizational charts, there are often ‘hidden’ power structures, which may be far more influential in controlling community action. Local physicians, for example, who control large numbers of referrals, or the community philanthropist, who selectively donates large sums ‘to promote health care’, may be significant components of this hidden system. There are also individuals who, by virtue of their professional or community standing, can influence both opinions and action. It is essential that the views of all who hold power be ronsidcred in relationship to the educational progratntne. T h e likelihood for success is further increased if rc-presentatives of both the formal and hidden power structures are involved in both the final planning and ongoing operation of‘ the clerkship.
medical school neither wants to control them nor tell them how to practise, and that their patients will be respected. The greatest fear of community physicians is that, with the potential influx of full-time medical school faculty, practice income will decrease. This fear probably is unjustified in distant communities unless the school plans to locate a number of the full-time faculty at the site. In nearby communities, however, the fear may well be justified and will need to be addressed. In cases where conflict is not easily resolved, it is important for the community and medical school leadership to agree on mechanisms (for example, committees, policies) that may effectively respond to specific problems as they arise.
Structuring the Relationship
Ensuring that Motives are Congrucnt
Once a clear understanding of the climate is achieved, consideration must be given to establishing a relationship that clarifies the responsibilities of both the medical school and the community in operating the educational programme. There are at least three models to consider: the ‘contractual model’, the ‘academic model’ and the ‘shared system’.
I n dealing with the community leadership, it is necessary
The Contractual Model
to identify and address in a forthright manner all issues
that tnay affect the successful implementation and operation of the proposed clerkship. As a first step, medical school planners should clearly understand the motives of the community for wanting the educational programme. At the same time, the community should understand the motives of the medical school. In many instances, the motives (for example, a mutual desire to train students in realistic settings or the need to bolster continuing medical education efforts) will be congruent. In other cases, however, the motives may be in conflict. The medical school, for example, may see the establishment of a residency programme as one of its long-term goals, while the community may want no part of such a programme. Overcoming the Fears o j Community Prac&i&ioners Thc concerns and fears of community practitioners, whether justified or not, may also form the basis for conflict. In tnany instances, these fears evolve from the fact that cotnmunity physicians, unlike their academic counterparts, are independent professionals. Most of their economic and personal rewards come from their interartion with patients within the context of a privately controlled, single or small group practice. Likewise, physicians practising in countries where medical care is run by the government may not welcome students, feeling that they interfere with eficiency and intrude upon the doctor-patient relationship. While community physicians may enjoy teaching, it plays and will continue to play a secondary role in their professional lives. The implementation of an educational programme may be viewed as potentially dangerous meddling by the medical school with the professional lives of these clinicians. Reassurance must be given that the 48
Here, the medical school serves as a contractor and negotiates a subcontract with a community to provide educational services to medical students. Thus, while the medical school may retain responsibility for establishing objectives and evaluating final outcomes, control of the educational process is essentially delegated to the community. Implicit in the model are assumptions that the community is highly motivated and possesses the necessary range of teaching and clinical expertise. Although many communities may display such capabilities, these assumptions should be thoroughly tested before implementing this type of relationship. Other problems may also evolve from the contractual relationship. For instance, without supplementary instruction from the medical school faculty, the curriculum will probably be limited by the unique clinical environment (by the number and type of cases, referral patterns, and so on) existing within the community, and students may feel a sense of isolation from the medical school. The Academic Model In this situation, the medical school retains complete control of the educational process. The community is involved only in providing access to a patient population and clinical facilities. Most of the direct teaching is assumed by medical school staff, and the contributions 01‘ private physicians in both student teaching and evaluation are extremely limited. Although some communities may initially feel comfortable with this relationship, most ultimately will assume this excessive control implies that the medical school views their practice habits as substandard. If this occurs, the educational programme almost certainly is doomed to failure. Medical Teacher Vol 6 No 2 1984
In both models, one partner in the medical schoolcommunity relationship assumes dominance over the other in the educational programme. Since one partner is in a subservient position, the potential for conflict is high, and resolution is often difficult.
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
Implementing a Shared System Falling between the contractual and academic models, the shared system implies an active partnership between the medical school and the community. Specific responsibilities are carefully negotiated to achieve the most effective mix of community and medical school resources to meet the objectives of the programme. Generally, community physicians are encouraged to participate in all phases of the programme and to assume primary responsibility in some. They may be involved in the final construction of instructional objectives, participate in didactic teaching sessions, be continuously involved in evaluating clinical skills. and assist in developing final examinations either by writing items or providing feedback about specific quesrions. Although the ‘shared system’ offers the greatest opportunity for cooperation, it is generally the most difficult to establish, Cooperation is largely dependent on effective communications, and communication is often compromised by distance or interinstitutional suspicion. Recognizing this, all administrative arrangements, policymaking processes, public relations strategies, and faculty development activities should be structured at the outset to facilitate communication. Importance o j a Coordinator
Of primary importance is the selection of an individual who will be responsible for managing the educational experience at the local level. Since this individual will serve as the primary implementor and conduit of information flowing between the medical school department and the community, the coordinator needs to be knowledgeable, respected and influential in the community and display potential as a medical school faculty member. Generally, it is preferable to choose a coordinator who is not a new practitioner in the area nor near retirement age. In addition to managing the day-to-day tasks of the programme, the coordinator must be an effective spokesperson for both the community and the medical school. Assuming the coordinator is respected in both institutions, these tasks can be accomplished with minimal difficulty. Obviously, this is not a position to force on someone. Prior to selection, it is helpful for a group of medical school faculty and practising physicians to construct a job description, which may be used in evaluating prospective candidates. The coordinator should be paid by and receive technical and clerical support from the medical school. He or she should also be awarded a faculty appointment. In accomplishing the latter, some of the expectations for this appointment, such as research and publications, may have to be ‘compromised’ in view of the need to find locally respected practitioners. The Medical Teacher Vol 6 No 2 1984
individual selected, however, should be an excellent role model as a physician and display significant interest, and competency in teaching. The Need f o r Education Committees Although the coordinator will serve as the primary link between the medical school department and the community, additional mechanisms must be established to facilitate communication and decision-making. Education committees should be formed at a local level to give advice on the operation of the programme. The membership of the committee should include influential members of the local medical community, the community faculty, and the medical school. Likewise, it is important that the medical school is represented by individuals who are in positions of authority within the institution. Such representation signals the importance of the community programme in the overall structure of the medical school and ensures the community that their concerns are being heard. The committee should assist the coordinator in establishing policies and procedures in operating the clerkship. It should review evaluations and make recommendations regarding the effectiveness of the programme and of the clinical teachers. Recommendations for major programme change may evolve from these bodies and should be forwarded to campus-based committees for consideration. T o encourage further interinstitutional communication, the medical school should consider including community representatives on central committees which deal with curriculum, admissions and student performance. Rapport with Patients Consideration must be given to the establishment of rapport with the patient population that will serve as the focus of student learning. Patients need to understand why students are involved in their care. The responsibility for informing patients must not be left to the community physicians alone. The medical school should provide assistance by meeting with community groups and offering its media resources. Furthermore, it is the responsibility of the medical school to familiarize students with the rights of patients. Avoiding Interinstitutional Upsets A community with enough patients to support an educational programme usually has more than one hospital. If that is true, the medical school inadvertently may involve itself in interinstitutional politics within the community by negotiating with one and not all hospitals or with each hospital separately. Individual agreements may lead to distrust, jealousy and antagonism. For this reason alone, it is advisable to encourage the establishment of an Area Health Education Centre (AHEC) to coordinate all clinical education activities with the community. The AHEC need not include only the university and the general hospitals in the community: members may 49
include orthopaedic or psychiatric hospitals, schools of nursing, physician assistant programmes and community colleges. The AHEC’s charge will vary but, at the very least, it will probably include health education at the undergraduate, graduate, and postgraduate level. This is an expensive venture since there needs to be an additional administrative staff. At Michigan State University, the Director of the AHEC serves as the Assistant Dean for that community.
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
Faculty Development
Among the resources available to an off-campus teaching programme, the most important are the local physicians who volunteer both their time and their patients. Indeed, the success or failure of the programme will depend largely on the level and quality of volunteer faculty cooperation. It is essential that a comprehensive programme of faculty development is established, which includes both the training and the incentives necessary to achieve effective participation. Role of Workshops
The training component of the faculty development programme should begin with a series of activities directed at oricntating local faculty. Prior to the arrival of the students, introductory planning workshops focussed on familiarizing the community faculty members with the objectives and structure of the programme should be implemented. The workshops should outline the general expectations for a community faculty member in the programme and give community practitioners an opportunity to react to their assigned responsibilities. Although most community faculty members will be satisfied with the role of preceptor, some may wish to extend their teaching beyond the clinical setting. Wherever possible, opportunities for more extensive instructional involvement should be made available. Evaluation
of Clinical
Teachers
Subsequent faculty training programmes should be responsive to specific needs as identified by the faculty members themselves or through a carefully structured system that has evaluated faculty effectiveness. Faculty members should be informed at the outset that both the medical school and the community are committed to offering a high quality educational programme and, therefore, will jointly monitor its effectiveness through continuous reviews of student and faculty performance. In developing a system of faculty evaluation, techniques should be used that are efficient, unobtrusive, and successful in identifying specific instructional problems. Direct observation, for example, though effective, is extremely timc-consuming and often threatening to community physicians. Most programmes depend on student feedback as an indicator of faculty performance. Faculty rating forms, completed by students, generally provide a reasonable indication of instructional performance. The results of .5u
student ratings should be anonymously returned to the faculty member along with specific suggestions for improvement, if weaknesses are identified. Generally, students approach the task of rating their teachers in a positive manner and provide constructive teedback on the faculty member’s instructional performance. Occasionally, however, the ratings and/or comments can be destructive. In these cases, rather than forwarding the comments directly to the faculty member, it is perhaps best to clarify concerns in individual meetings with the students before providing verbal feedback to the taculty member. Another method used to assess faculty performance is through monitoring student performance on content or clinical skills examinations. If repeated groups of students do not possess adequate knowledge or appropriate skills in a given area, it may be an indication of less than adequate instruction. Regardless of the methods used, results of faculty performance evaluations should be reviewed by the community educational programme committee. In extreme cases where performance is consistently poor, consideration should be given to removing or reassigning the individual. OnEoing Faculty Development In most cases, however, instructional problems can be constructively resolved through ongoing faculty development activities. Perhaps the best form of faculty development is ‘one-on-one’ interaction between the faculty member and the coordinator or another respected teacher. In these sessions, problems can be discussed frankly, and suggestions for improvement can be provided in a less threatening setting. To address more generalized problems or to seek overall improvement in a given area, the faculty development workshop should be considered. Although they are often requested and promote good public relations, workshops are variably attended by volunteer community faculty. Busy practitioners generally find it difficult to spend a half or full day attending a programme that deals entirely with teaching techniques. Despite these drawbacks, faculty development programmes can be extremely useful in promoting an awareness of effective instructional methods and identifying instructional resources available both within the community and within the medical school. The programmes should be carefully planned, however, in an effort to reflect the needs of the faculty in a given setting. Rewards and Incentives In addition to providing training opportunities, a comprehensive faculty development programme must include a system of rewards and incentives to stimulate a continuing commitment. Unlike their university-based colleagues, volunteer community faculty members receive few, if any, economic rewards for their participation. Some, in fact, may suffer a loss of income as a result of teaching medical students. Thus, the traditional academic reward system is not usually applicable to the Medical Teacher Vol 6 No 2 1984
Med Teach Downloaded from informahealthcare.com by Florida International University on 12/26/14 For personal use only.
community setting. Instead, the reward system must reinforce participation through recognition of the faculty mber as both a teacher and a clinician. Rccognition may be provided in a variety of ways. The receipt of a clinical faculty appointment is considered a reward by many community physicians. Many schools presrnt the volunteer faculty members with certificates of appoiiitment, which may be framed and displayed in the physician's office or clinic. The appointment should include preferential treatment in the use of university facilities and in the sale of tickets to athletic or cultural events. The performance of a clinical faculty member also may be recognized through promotion. Community educational programme committees should recommend promotion, according to established guidelines, for those faculty members displaying outstanding performance. Awards from the medical school or the students are particularly gratifying and promote a strengthened commitment to the programme. A more substantive though subtle form of recognition may be achieved by providing opportunities for volunteer faculty members to become more significantly involved in medical school operations. At a minimum, their views should be assessed and carefully considered by medical school committees as they review curricular and other acadtmic policies. A better approach is to include representativvs of the volunteer faculty members on departmental and school committees. In addition to providing an important perspective and stimulating communication betwwn the campus and community, such involvement enhanct-s the perceived importance of the volunteer faculty to thr medical school. Thc medical school can also reward community faculty members by offering opportunities for continued learning and career development. It may, for example, provide an indivicltral faculty member with funds to attend a specialized twining programme or may assist in writing grant proposals, designing research studies, and/or preparing papers tor publication.
Final Thoughts The establishment of a productive relationship between a community and a medical school is not easy. Some have described this relationship as analogous to a marriage in which success is dependent on mutual needs, honesty, patience and understanding. '*'As with all marriages, there will be stormy times but also opportunities for each partner to grow and enhance individual strengths. Continuing education in the community, for example, will be strengthened as a result of the interactions between community physicians, the medical school faculty and students. At the same time, there will be opportunities for the medical school to develop a better understanding of the realities and problems of community health care and to translate this new awareness into cooperative programmes of research and service which are fully responsive to community needs. The central beneficiary of this relationship, however, continues to be the student who will, through a well-planned alliance, receive a highquality medical education.
Medical Teacher Vol 6 No 2 1984
References
'Hunt AD. A time lor change and reform. In: Hunt AD, Weeks LE (eds). Medical education since 1960: marching to a diJerent drummer. East Lansing: Michigan State University Foundation, 1979. *Richards RW. Innovations in health projessions tducalion. Geneva: World Health Or,qanization, 1978. 'Beljan JR. Living with community hospitals: strategies t o make the marriage work. In: Hunt AD, Weeks LE (eds). Medical education sincr 1960: marching to a ifzJermt drummer. East Lansing: Michigan State University Foundation, 1979. 'Dcrzon RA. Marriage of mrdical schools and teaching hospitals.JMed Ed, 1978; 53: 19-25.
Education for the Professions The theme for the next Annual Conference of the Society for Research into Higher Education is Education for the Professions. A volume of introductory papers illustrating major themes in education for the professions of Engineering, Medicine and Management is in preparation. The conference will be held at the Imperial College of Science and Technology on 17 to 19 December 1984. Further information from Dr Sinclair Goodlad, Room 501EE, Imperial College of Science and Technology, London SW7 2AZ.
Project a Lively Image There is now a simple way of adding animation to the established merits of the overhead projector as an audiovisual aid. Movimate is a DIY kit produced by Technical Animations Ltd. It is based on the use of polarized film and is a simple and effective way of indicating movement in printed graphics, particularly schematic diagrams and flow charts. Movimate allows anyone with basic graphics skills to prepare their own animated transparencirs for use on an overhead projector, simply by applying sections of animated film to the areas where movement is to be shown. An aluminium stand supporting a rotating disc of clear polarized film immediately below the lens of the projector is the other essential element of the kit. The 'black-out' effect created by the spinning disc moving in opposition to the polarised film on the transparency produces the effect of movement on the projected image. A variety of polarized film, each of which produces a different motion effect on screen, is included in the pack. This is useful for anyone used to preparing slides for overhead projection for training seminars, lectures and conferences. The Movimate kit retails for f249 and is available, with additional supplies of animated film, from Technical Animations Ltd, 3 Osiers Road, Wandsworth, London, SW18. Tel. 01-874 4152.
51
