702
Journal of the Royal Society of Medicine Volume 83 November 1990
Continuing medical education at a universityevaluation of an MSc programme in general practice L Ridsdale FRCPC MRCGP Department of General Practice, Guy's Campus, London SEI 9RT M Walker MA Cert Ed Department of Education and Design, Brunel University, Egham, Surrey TW2O OJZ Keywords: Continuing medical education; general practice; MSc course
Summary
In 1986 London University launched a new MSc programme for GPs. This paper- describes the problems met with, and the progress made by course members and tutors during the first part-time, 2-year course. We also describe some early measures of the outcome of this form of CME.
Introduction In a recent editorial for the Journal of the Royal College of General Practitioners Pereira Gray (Chairman of the Council of the RCGP) stated': 'Continuing medical education for established general practitioners is emerging as one of the central educational challenges for general practice .
.
A single response to this challenge would be inappropriate. Wood2 reviewed developments in continuing medical education during the 1980s and outlined a range of strategies, but she did not refer to the literature on MSc courses3-5. There could be a number of reasons for this: few MSc degrees are available, work in higher education may not be seen as part of continuing professional development, or MSc courses may be regarded as remote, academic and irrelevant to the daily needs of GPs. Our experience of an MSc course, as course organizer (LR) and as external evaluator (MW) suggests that continuing learning programmes can be created in a university context. In this paper we describe and analyse the first MSc course in General Practice at London University, focusing on the relationship between academic and experiential knowledge, and the contribution of a university course to continuing medical education (CME). Course members and the course In 1986, 12 GPs registered for the -first course which was taught on Wednesdays at the United Medical Schools of Guy's and St Thomas' Hospitals over a 2-year period. The group were socially and professionally heterogeneous. There were nine men and three women, aged from 31 to 57 years. Nine had qualified in Britain. Their motives for taking the course were mixed but everyone came with ideas which they wished to pursue, and each had in mind a practice based project. They never lost sight of these aims returning to them throughout the course. The aims and content of the course have been described6. In the first four terms course members were required to study seven subjects; Research Methods, Epidemiology and Statistics, Clinical Reasoning, Social Science, Medical Ethics and the Learning Process. In the final two terms course members completed a practice-based research project.
At the beginning ofthe course, tutors teaching Social Science, Statistics and Epidemiology placed the concerns and issues of their discipline first, and saw their role as initiating course members into their own disciplinary perspective. On the other hand tutors teaching Medical Ethics, Process of Learning and Research Methods maintained a much weaker boundary between experiential and subject-based knowledge7. They generally centred learning on course members' concerns and subsequently introduced ideas and evidence from the literature to explore the issues raised. Clinical Reasoning differed from the other modules in that its literature was less extensive. In many ways however, this course exemplarized the type of learning the course could provide. It took as its focus the consultation and clinical decision-making. The available literature and course members' experience were subjected to rigorous analysis. Here it seemed that course members were involved in creating the discipline itself. The proces of learning Evaluation of medical education has generally'been undertaken using quantitative techniques. This may,' lead to an input-output or 'before and after' approach. These methods tend to omit the shifts and movements which occur -in the process of any-course which ,wre recorded for this programme by ethiographic techniques8. Over the'six terms important shifts occurred in the style of teaching and learning. Phase I As the course began, some tutors, particularly those whose emphasis was on their own subject were abrupt in reminding course members of their priorities. Tutor: I don't want to talk about diagnosis, I want to talk about problem solving. Alan: I don't -think we work like that. Thtor' 'Well, forget about you, lets just think about this abstract model. (Fieldnotes)
The course member resisted what he saw as inappropriate. On this occasion he was overruled. A less extreme example is given below. The tutor conducts a tutorial wth Jane. He is trying to show how, from within his social science digm, qtionnair are ment to work. Jane's answers to his questions are pIosnlodby a deailed knowledge of the issues of her practice, what she wants to find out about tho is6kw, and the w she has already done in d ing a queionnai He questions her from one perspective, she answers from another. This is not the answer he needed to take further his exposition on the rules of quetionnaire design. He tries again. But this is. not the question Jane needed-to help her confront the issues of her project. It's an uneasy negotiation. (Fieldnotes)
0141-0768/90/
110702-02402.00/0 i 1990
The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 November 1990
In this example, both tutor and course member try to enlighten the other, from their own perspective. It is a negotiation about preconceptions, meanings and relevancies, and it is not an easy one. Occasionally where negotiation was disallowed, frustration and even anger ensued.
Their questions stemmed from issues and problems within each course member's practice. From the course they acquired knowledge ofthe literature and the research tehniques necesary for a rigorous investigation. In this way doing the projects linked practice and research in a continuous cycle of learning.
Phase II Course tutors were sensitive to anything which detracted from the success oftheir group sessions and keen to try ways of improving their approach to teaching. In general this meant a shift away from a subject-based approach and towards the course members and their existing understanding. As the course progressed tutors increasingly saw course members' knowledge as a resource and their teaching began to incorporate case notes, recorded consultations, hot problems and project research. Rather than discounting examples from everyday work, tutors used this as an avenue towards discussing the existing literature and identifying investigations which might be undertaken in the future. During the second and third terms course members began to comment on this approach. The course is already beginning to widen my views and affect
Conclusions We began by asking: is a university course remote, academic and irrelevant for the needs of general practitioners? We conclude this need not be the case. There were two reasons for this. First, the course members were tenacious in maintaining their original concerns alongside those developed on the course. Second, the sensitivity of the tutors required them to mould the learning process around their students existing expertise. During the first year the course took on a genuinely applied nature. This process was disrupted by the exisn offormal amintions, but was re-established by the completion of a project during the final two terms. We believe that MSc graduates acquired from the course: (1) Knowledge: they are more informed about the publised
my practice. It's making me more self critical ... and the deeper we go into things the more I see the integrative process between the literature and the substantive issues. (Course member's interview)
Phase III By the end of the first year confidence and morale were high. However, in the second year anticipation of examinations began to affect the teaching and learning process. Traditional written examinations counted for 50% of the overall mark, with the remaining 50% of marks being given for the research project. The prospect of examinations affected both tutors and course members. Tutors tended to revert to a literature-centred approach which fostered a split between academic and experiential knowledge. Course members returned to the cue-seeking which had characterized their early days on the course. Then the focus had been what tutors looked for in an essay. Now, focusing on the examinations, course members became strategic again. Mark: it goes back to the essays and personal statements. Would we be expected to use personal statements in exam answers? Tutor: The skill is to be able to relate your interests to the discipline. The key is to have a point which will tie in with the discipline. (Fieldnotes)
Course members formed informal study groups in order to prepare for what they regarded as a threatening experience. Phase IV With the examinations over the course members concentrated upon the research project, which consisted of a practice-based project. This was designed during the Research Methods module and was completed during the final tw~o terms. Topics chosen reflected the concerns which course members had brought to the course with them. They asked questions like: Do the government and patients differ in the criteria with which they evaluate GP services?@ Is systematic screening more effective than case finding?l° Can health screeniing damage your health?11
literature and research evidence on matters which are of local and national significance for GPs. (2) The ability to promote and conduct practice-based research. Six months after completing the programme, five GPs had written up their results for publication. (3) The ability to organize and facilitate learning for others. Before coming on the course, participants were already involved in promoting continuing learning in the profesion. Six months after completing the course, group members had between them taken on 13 additional sessions which involve organizing and facilitating the learning of other GPs.
A new group of GPs has been recruited each year since 1986. Changes have been made to reduce the problems identified. It will be possible to make a fuller assessment of outcome in the future. References 1 Pereira Gray DJ. Continuing education for general practitioners. J R CoUl Gen Pract 1988;38:195-6 2 Wood J. Continuing education in general practice in the UK: a review. Fam Pract 1988;2:62-8 3 Brennan M, McWhinney ER, Stewart M, Weston W. A graduate programme for academic family physicians. Fam Pract 1988;2:165-71 4 Barber H. Higher degrees in general practice. In: Pereira Gray DJ, ed. The medical annual, ayear book ofgeneral practice, Bristol: Wright, 1985 5 Wright HJ. The Med Sc: a contribution to continuing medical education. Practitioner 1985;229:383-5 6 Ridsdale L. A new general practice MSc programme. Pactitioner 1987;231:443-4 7 Bernstein B, ed. On the claification and framing of educational knowledge. In: Clas, codes and control, vol 3. London: Routledge & Kegan Paul, 1977:47-69 8 Walke M. Analysing qualitative data ethaphy and the evaluation of medical education. Med Educ 1989; 23:498-503 9 Smith CH, Armstrong D. A comparison of government and patient criteria in the evaluation of general practitioner services. BMJ 19899:"494-6 10 Pierce M, Lundy 5, Palanisamy A, Winning S, King J. A prspcive randomized controiled trial of methods Of call and recall for cervical cytology. BMJ 1989228S: 160-2 11 Stoate HG. Can screening damag your health? JR Coil
Gen Pract 1989;39:193-5
(Accepted 25 April1990O)
703
Journal of the Royal Society of Medicine Volume 83 November 1990
Continuing medical education at a universityevaluation of an MSc programme in general practice L Ridsdale FRCPC MRCGP Department of General Practice, Guy's Campus, London SEI 9RT M Walker MA Cert Ed Department of Education and Design, Brunel University, Egham, Surrey TW2O OJZ Keywords: Continuing medical education; general practice; MSc course
Summary
In 1986 London University launched a new MSc programme for GPs. This paper- describes the problems met with, and the progress made by course members and tutors during the first part-time, 2-year course. We also describe some early measures of the outcome of this form of CME.
Introduction In a recent editorial for the Journal of the Royal College of General Practitioners Pereira Gray (Chairman of the Council of the RCGP) stated': 'Continuing medical education for established general practitioners is emerging as one of the central educational challenges for general practice .
.
A single response to this challenge would be inappropriate. Wood2 reviewed developments in continuing medical education during the 1980s and outlined a range of strategies, but she did not refer to the literature on MSc courses3-5. There could be a number of reasons for this: few MSc degrees are available, work in higher education may not be seen as part of continuing professional development, or MSc courses may be regarded as remote, academic and irrelevant to the daily needs of GPs. Our experience of an MSc course, as course organizer (LR) and as external evaluator (MW) suggests that continuing learning programmes can be created in a university context. In this paper we describe and analyse the first MSc course in General Practice at London University, focusing on the relationship between academic and experiential knowledge, and the contribution of a university course to continuing medical education (CME). Course members and the course In 1986, 12 GPs registered for the -first course which was taught on Wednesdays at the United Medical Schools of Guy's and St Thomas' Hospitals over a 2-year period. The group were socially and professionally heterogeneous. There were nine men and three women, aged from 31 to 57 years. Nine had qualified in Britain. Their motives for taking the course were mixed but everyone came with ideas which they wished to pursue, and each had in mind a practice based project. They never lost sight of these aims returning to them throughout the course. The aims and content of the course have been described6. In the first four terms course members were required to study seven subjects; Research Methods, Epidemiology and Statistics, Clinical Reasoning, Social Science, Medical Ethics and the Learning Process. In the final two terms course members completed a practice-based research project.
At the beginning ofthe course, tutors teaching Social Science, Statistics and Epidemiology placed the concerns and issues of their discipline first, and saw their role as initiating course members into their own disciplinary perspective. On the other hand tutors teaching Medical Ethics, Process of Learning and Research Methods maintained a much weaker boundary between experiential and subject-based knowledge7. They generally centred learning on course members' concerns and subsequently introduced ideas and evidence from the literature to explore the issues raised. Clinical Reasoning differed from the other modules in that its literature was less extensive. In many ways however, this course exemplarized the type of learning the course could provide. It took as its focus the consultation and clinical decision-making. The available literature and course members' experience were subjected to rigorous analysis. Here it seemed that course members were involved in creating the discipline itself. The proces of learning Evaluation of medical education has generally'been undertaken using quantitative techniques. This may,' lead to an input-output or 'before and after' approach. These methods tend to omit the shifts and movements which occur -in the process of any-course which ,wre recorded for this programme by ethiographic techniques8. Over the'six terms important shifts occurred in the style of teaching and learning. Phase I As the course began, some tutors, particularly those whose emphasis was on their own subject were abrupt in reminding course members of their priorities. Tutor: I don't want to talk about diagnosis, I want to talk about problem solving. Alan: I don't -think we work like that. Thtor' 'Well, forget about you, lets just think about this abstract model. (Fieldnotes)
The course member resisted what he saw as inappropriate. On this occasion he was overruled. A less extreme example is given below. The tutor conducts a tutorial wth Jane. He is trying to show how, from within his social science digm, qtionnair are ment to work. Jane's answers to his questions are pIosnlodby a deailed knowledge of the issues of her practice, what she wants to find out about tho is6kw, and the w she has already done in d ing a queionnai He questions her from one perspective, she answers from another. This is not the answer he needed to take further his exposition on the rules of quetionnaire design. He tries again. But this is. not the question Jane needed-to help her confront the issues of her project. It's an uneasy negotiation. (Fieldnotes)
0141-0768/90/
110702-02402.00/0 i 1990
The Royal Society of Medicine
Journal of the Royal Society of Medicine Volume 83 November 1990
In this example, both tutor and course member try to enlighten the other, from their own perspective. It is a negotiation about preconceptions, meanings and relevancies, and it is not an easy one. Occasionally where negotiation was disallowed, frustration and even anger ensued.
Their questions stemmed from issues and problems within each course member's practice. From the course they acquired knowledge ofthe literature and the research tehniques necesary for a rigorous investigation. In this way doing the projects linked practice and research in a continuous cycle of learning.
Phase II Course tutors were sensitive to anything which detracted from the success oftheir group sessions and keen to try ways of improving their approach to teaching. In general this meant a shift away from a subject-based approach and towards the course members and their existing understanding. As the course progressed tutors increasingly saw course members' knowledge as a resource and their teaching began to incorporate case notes, recorded consultations, hot problems and project research. Rather than discounting examples from everyday work, tutors used this as an avenue towards discussing the existing literature and identifying investigations which might be undertaken in the future. During the second and third terms course members began to comment on this approach. The course is already beginning to widen my views and affect
Conclusions We began by asking: is a university course remote, academic and irrelevant for the needs of general practitioners? We conclude this need not be the case. There were two reasons for this. First, the course members were tenacious in maintaining their original concerns alongside those developed on the course. Second, the sensitivity of the tutors required them to mould the learning process around their students existing expertise. During the first year the course took on a genuinely applied nature. This process was disrupted by the exisn offormal amintions, but was re-established by the completion of a project during the final two terms. We believe that MSc graduates acquired from the course: (1) Knowledge: they are more informed about the publised
my practice. It's making me more self critical ... and the deeper we go into things the more I see the integrative process between the literature and the substantive issues. (Course member's interview)
Phase III By the end of the first year confidence and morale were high. However, in the second year anticipation of examinations began to affect the teaching and learning process. Traditional written examinations counted for 50% of the overall mark, with the remaining 50% of marks being given for the research project. The prospect of examinations affected both tutors and course members. Tutors tended to revert to a literature-centred approach which fostered a split between academic and experiential knowledge. Course members returned to the cue-seeking which had characterized their early days on the course. Then the focus had been what tutors looked for in an essay. Now, focusing on the examinations, course members became strategic again. Mark: it goes back to the essays and personal statements. Would we be expected to use personal statements in exam answers? Tutor: The skill is to be able to relate your interests to the discipline. The key is to have a point which will tie in with the discipline. (Fieldnotes)
Course members formed informal study groups in order to prepare for what they regarded as a threatening experience. Phase IV With the examinations over the course members concentrated upon the research project, which consisted of a practice-based project. This was designed during the Research Methods module and was completed during the final tw~o terms. Topics chosen reflected the concerns which course members had brought to the course with them. They asked questions like: Do the government and patients differ in the criteria with which they evaluate GP services?@ Is systematic screening more effective than case finding?l° Can health screeniing damage your health?11
literature and research evidence on matters which are of local and national significance for GPs. (2) The ability to promote and conduct practice-based research. Six months after completing the programme, five GPs had written up their results for publication. (3) The ability to organize and facilitate learning for others. Before coming on the course, participants were already involved in promoting continuing learning in the profesion. Six months after completing the course, group members had between them taken on 13 additional sessions which involve organizing and facilitating the learning of other GPs.
A new group of GPs has been recruited each year since 1986. Changes have been made to reduce the problems identified. It will be possible to make a fuller assessment of outcome in the future. References 1 Pereira Gray DJ. Continuing education for general practitioners. J R CoUl Gen Pract 1988;38:195-6 2 Wood J. Continuing education in general practice in the UK: a review. Fam Pract 1988;2:62-8 3 Brennan M, McWhinney ER, Stewart M, Weston W. A graduate programme for academic family physicians. Fam Pract 1988;2:165-71 4 Barber H. Higher degrees in general practice. In: Pereira Gray DJ, ed. The medical annual, ayear book ofgeneral practice, Bristol: Wright, 1985 5 Wright HJ. The Med Sc: a contribution to continuing medical education. Practitioner 1985;229:383-5 6 Ridsdale L. A new general practice MSc programme. Pactitioner 1987;231:443-4 7 Bernstein B, ed. On the claification and framing of educational knowledge. In: Clas, codes and control, vol 3. London: Routledge & Kegan Paul, 1977:47-69 8 Walke M. Analysing qualitative data ethaphy and the evaluation of medical education. Med Educ 1989; 23:498-503 9 Smith CH, Armstrong D. A comparison of government and patient criteria in the evaluation of general practitioner services. BMJ 19899:"494-6 10 Pierce M, Lundy 5, Palanisamy A, Winning S, King J. A prspcive randomized controiled trial of methods Of call and recall for cervical cytology. BMJ 1989228S: 160-2 11 Stoate HG. Can screening damag your health? JR Coil
Gen Pract 1989;39:193-5
(Accepted 25 April1990O)
703
