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Community-bespoke doctoring
THE LANCET Number 8898
EDITORIAL
Community-bespoke doctoring From time to time medical educators are befriended by curious souls, who, in an attempt to make polite conversation, inquire as to whether changes are occurring in medical education. The usual response is to offer such persons a detailed description of how medical education is is the midst of great reform. Yet to be honest, the "reforms" are seldom bold enough to depart from tradition and redefine the mission of medical education directly to address the needs of society today. Instead educational changes are incremental ones, driven more by a need to keep up to date and to persuade funders (public and private) that something is changing. Why has medical education been so unwilling to change? Obvious factors are professional opposition, institutional obstacles, and government barriers. Unfortunately, just at a time when medical education should be more exciting than ever-ripe with opportunities for students to pursue special areas of interest, filled with new high-tech teaching tools and new low-tech adult learning theories-we continue to treat students as passive receptacles and effectively prevent them from tailoring their education to individual requirements. We ask them to sit in lecture halls and memorise details that are of dubious value to clinical practice while we ignore environmental, social, and psychological influences on health. They are regularly taught by specialists and ultraspecialists; contact with generalists is usually limited to informal "experiential" activities, often at extramural sites with no formal curriculum and little attempt at evaluation. So, why are we continually surprised that each year we turn out groups of students who are good at passing standardised tests designed to measure retention of scientific facts but who are untested in their ability to communicate, to solve problems, to integrate, and to understand the community that they will soon serve? Medical schools have largely lost touch with the needs of society,’ focusing instead on hospital care and high technology rather than the March 12, 1994
in which treatment must occur, and the health needs of the community.2 In short, academic medicine has not lived up to its social contract with the local, national, or global
patient, the social
context
3
community.
The Association for the Study of Medical Education (ASME) recently published a report4 on the ways in which medical educators are addressing some of these concerns. Specifically, the study examines the current and proposed use of community teaching among medical schools in the UK. ASME’s goal is admirable: to disseminate innovative educational approaches and thus allow cooperation among the many schools that are considering curricular revision. The well-organised monograph contains an executive summary and several appendices, each brimming with details of individual medical schools’ plans for increasing
community-based learning. Unfortunately, however, the monograph uses an overly broad definition of community medicine. Rather than focusing on learning about a community-its health status, its organisational units, prevalent medical conditions, self-defined health needs, barriers to meeting those needs, and use of health resources in the community-the report defines community medicine as "any teaching in the undergraduate course that is not hospital based". Thus, the mere transportation of hospital-based teaching to a clinic or general practitioner’s office constitutes community medicine. This latter type of experience is better described as ambulatory medicine, wherein the reader understands that all that is different in the education is the geographical location. Whilst ambulatory teaching may solve logistical problems (space shortages, declining number of
patients, shrinking hospital budgets), to move teaching away from the inpatient setting is not necessarily a big step forward. Likewise, although use of community-based instructors may help to address shortages in university-based faculty, such a 613
change connotes neither innovation nor improved quality. Experience with implementation of the Doctoring Curriculum at the University of California, Los Angeles, has shown just how difficult it is to ensure quality control of preceptors in community-based learning sites.5 Community experts (physicians and others) are eager to teach and only too willing to take on groups of medical students but they are often unwilling to commit time to faculty development and quality improvement. Thus simply taking care of patients does not ensure that providers are carrying out the task well not does it ensure they can teach the skills to
others. The
ASME
report
outlines
four
types
of
community learning experiences: (a) agency-based teaching; (b) general-practice-based teaching; (c) community-based teaching by specialists; and (d) community-oriented teaching. This last area comes closest to real community-based medicine-the application of concepts from quantitative disciplines such as epidemiology, economics, health services, and statistics and from social sciences such as cultural anthropology, sociology, communication theory, and psychology.’i The risk of simply stationing students at community agencies without other educational innovations is that the student will fail to grasp the bigger picture of illness. One possibility is to use a case-based, problem-based, approach to drive the students’ learning. By this students become actively involved in means understanding how community medicine impacts on the patient, the community, and the health care system. This method has been adopted successfully at UCLA, where students seek to understand how to deal with complex health topics such as the needs of an ageing population, of a society composed of ever more diverse cultures and ethnic origins, and of consumers who are increasingly dissatisfied with medicine.6 Students also have to cope with inequities in access to care, substance abuse, and lack of preventive services, and face up to domestic violence.
Most of the "new" approaches to community medicine outlined in the ASME report (and common to medical schools elsewhere) consist of small block rotations (2-4 weeks) usually in the preclinical years. Students learn quickly that genuine doctors (and medical educators) do not regard this as the material of "real" medicine, and the knowledge, skills, and attitudes acquired soon become extinguished. Beginning during the first year of medical school students should be taught interviewing skills, the role of the family, epidemiology, and the impact of chronic illness on a person; and the clear message should be that this is
614
only the introduction, not the entire learning opportunity. There are few among us who could not benefit from further learning about doctor-patient communication, family dynamics, epidemiology, clinical decision-making, and the like. The risk of block rotations is that they package community another little box with an accompanying set of facts to be memorised. Few schools have attempted to use the community through all years of’medical school as a tool to help students understand the various aspects that clinicians need to master to become proficient in problem solving for a patient. A fundamental defect of medical education reform is the lack of attention to a basic concept of medical educationintegration. Until educators integrate it both vertically and horizontally with other parts of the medical school curriculum, community-based medicine is destined to be forever an orphan topic. medicine
into
Most medical schools have identified other areas that are crying out for change-eg, a need to strengthen clinical teaching and evaluation (of faculty and students) and to focus on active learning; new strategies for teaching clinical decision-making in an effort to provide more appropriate care; and new teaching methods that emphasise cost-effective management based on an understanding of ethics, epidemiology, economics, psychology, and other social sciences. Since there are numerous medical schools, each with similar goals, and often selecting students from the same applicant pool, there is a unique opportunity here for carefully controlled studies to evaluate curricula. There are also several newly refined evaluation tools that might help to assess outcome. Until we pool our interests, our skills, our resources, and our imaginations and seriously address curriculum research we can only hope that by chance some students will end up with the attributes that society is seeking for its next generation of physicians and
beyond.
The Lancet 1 2 3
Connelly JE. The medical school’s mission and the population’s health. Ann Intern Med 1991; 115: 969-72. Showstack J, Fein O, Ford D, et al. Health of the public: the academic response. JAMA 1992; 267: 2497-502. Colloton JW. Academic medicine’s changing covenant with society.
White KL,
Acad Med 1989; 64: 55-60. 4
McCrorie P, Lefford F, Perrin F. Medical undergraduate community based teaching: a survey for ASME on current and proposed teaching in the community and in general practice in UK universities. ASME occasional publication no 3. London: ASME, 1993.
5
Wilkes MS, Slavin S, Usatine R. Doctoring: curriculum. Acad Med 1994; 69: 191-93.
6
Blendon RJ. Three systems:
Quart 1989; 11: 2-14.
a
comparative
a
longitudinal generalist
survey. Health
Management
EDITORIAL
Community-bespoke doctoring From time to time medical educators are befriended by curious souls, who, in an attempt to make polite conversation, inquire as to whether changes are occurring in medical education. The usual response is to offer such persons a detailed description of how medical education is is the midst of great reform. Yet to be honest, the "reforms" are seldom bold enough to depart from tradition and redefine the mission of medical education directly to address the needs of society today. Instead educational changes are incremental ones, driven more by a need to keep up to date and to persuade funders (public and private) that something is changing. Why has medical education been so unwilling to change? Obvious factors are professional opposition, institutional obstacles, and government barriers. Unfortunately, just at a time when medical education should be more exciting than ever-ripe with opportunities for students to pursue special areas of interest, filled with new high-tech teaching tools and new low-tech adult learning theories-we continue to treat students as passive receptacles and effectively prevent them from tailoring their education to individual requirements. We ask them to sit in lecture halls and memorise details that are of dubious value to clinical practice while we ignore environmental, social, and psychological influences on health. They are regularly taught by specialists and ultraspecialists; contact with generalists is usually limited to informal "experiential" activities, often at extramural sites with no formal curriculum and little attempt at evaluation. So, why are we continually surprised that each year we turn out groups of students who are good at passing standardised tests designed to measure retention of scientific facts but who are untested in their ability to communicate, to solve problems, to integrate, and to understand the community that they will soon serve? Medical schools have largely lost touch with the needs of society,’ focusing instead on hospital care and high technology rather than the March 12, 1994
in which treatment must occur, and the health needs of the community.2 In short, academic medicine has not lived up to its social contract with the local, national, or global
patient, the social
context
3
community.
The Association for the Study of Medical Education (ASME) recently published a report4 on the ways in which medical educators are addressing some of these concerns. Specifically, the study examines the current and proposed use of community teaching among medical schools in the UK. ASME’s goal is admirable: to disseminate innovative educational approaches and thus allow cooperation among the many schools that are considering curricular revision. The well-organised monograph contains an executive summary and several appendices, each brimming with details of individual medical schools’ plans for increasing
community-based learning. Unfortunately, however, the monograph uses an overly broad definition of community medicine. Rather than focusing on learning about a community-its health status, its organisational units, prevalent medical conditions, self-defined health needs, barriers to meeting those needs, and use of health resources in the community-the report defines community medicine as "any teaching in the undergraduate course that is not hospital based". Thus, the mere transportation of hospital-based teaching to a clinic or general practitioner’s office constitutes community medicine. This latter type of experience is better described as ambulatory medicine, wherein the reader understands that all that is different in the education is the geographical location. Whilst ambulatory teaching may solve logistical problems (space shortages, declining number of
patients, shrinking hospital budgets), to move teaching away from the inpatient setting is not necessarily a big step forward. Likewise, although use of community-based instructors may help to address shortages in university-based faculty, such a 613
change connotes neither innovation nor improved quality. Experience with implementation of the Doctoring Curriculum at the University of California, Los Angeles, has shown just how difficult it is to ensure quality control of preceptors in community-based learning sites.5 Community experts (physicians and others) are eager to teach and only too willing to take on groups of medical students but they are often unwilling to commit time to faculty development and quality improvement. Thus simply taking care of patients does not ensure that providers are carrying out the task well not does it ensure they can teach the skills to
others. The
ASME
report
outlines
four
types
of
community learning experiences: (a) agency-based teaching; (b) general-practice-based teaching; (c) community-based teaching by specialists; and (d) community-oriented teaching. This last area comes closest to real community-based medicine-the application of concepts from quantitative disciplines such as epidemiology, economics, health services, and statistics and from social sciences such as cultural anthropology, sociology, communication theory, and psychology.’i The risk of simply stationing students at community agencies without other educational innovations is that the student will fail to grasp the bigger picture of illness. One possibility is to use a case-based, problem-based, approach to drive the students’ learning. By this students become actively involved in means understanding how community medicine impacts on the patient, the community, and the health care system. This method has been adopted successfully at UCLA, where students seek to understand how to deal with complex health topics such as the needs of an ageing population, of a society composed of ever more diverse cultures and ethnic origins, and of consumers who are increasingly dissatisfied with medicine.6 Students also have to cope with inequities in access to care, substance abuse, and lack of preventive services, and face up to domestic violence.
Most of the "new" approaches to community medicine outlined in the ASME report (and common to medical schools elsewhere) consist of small block rotations (2-4 weeks) usually in the preclinical years. Students learn quickly that genuine doctors (and medical educators) do not regard this as the material of "real" medicine, and the knowledge, skills, and attitudes acquired soon become extinguished. Beginning during the first year of medical school students should be taught interviewing skills, the role of the family, epidemiology, and the impact of chronic illness on a person; and the clear message should be that this is
614
only the introduction, not the entire learning opportunity. There are few among us who could not benefit from further learning about doctor-patient communication, family dynamics, epidemiology, clinical decision-making, and the like. The risk of block rotations is that they package community another little box with an accompanying set of facts to be memorised. Few schools have attempted to use the community through all years of’medical school as a tool to help students understand the various aspects that clinicians need to master to become proficient in problem solving for a patient. A fundamental defect of medical education reform is the lack of attention to a basic concept of medical educationintegration. Until educators integrate it both vertically and horizontally with other parts of the medical school curriculum, community-based medicine is destined to be forever an orphan topic. medicine
into
Most medical schools have identified other areas that are crying out for change-eg, a need to strengthen clinical teaching and evaluation (of faculty and students) and to focus on active learning; new strategies for teaching clinical decision-making in an effort to provide more appropriate care; and new teaching methods that emphasise cost-effective management based on an understanding of ethics, epidemiology, economics, psychology, and other social sciences. Since there are numerous medical schools, each with similar goals, and often selecting students from the same applicant pool, there is a unique opportunity here for carefully controlled studies to evaluate curricula. There are also several newly refined evaluation tools that might help to assess outcome. Until we pool our interests, our skills, our resources, and our imaginations and seriously address curriculum research we can only hope that by chance some students will end up with the attributes that society is seeking for its next generation of physicians and
beyond.
The Lancet 1 2 3
Connelly JE. The medical school’s mission and the population’s health. Ann Intern Med 1991; 115: 969-72. Showstack J, Fein O, Ford D, et al. Health of the public: the academic response. JAMA 1992; 267: 2497-502. Colloton JW. Academic medicine’s changing covenant with society.
White KL,
Acad Med 1989; 64: 55-60. 4
McCrorie P, Lefford F, Perrin F. Medical undergraduate community based teaching: a survey for ASME on current and proposed teaching in the community and in general practice in UK universities. ASME occasional publication no 3. London: ASME, 1993.
5
Wilkes MS, Slavin S, Usatine R. Doctoring: curriculum. Acad Med 1994; 69: 191-93.
6
Blendon RJ. Three systems:
Quart 1989; 11: 2-14.
a
comparative
a
longitudinal generalist
survey. Health
Management