Medical Education, 1976, 10, 309-312
General practice teaching -within the hospital M. DRURY Department of Medicine, Queen Elizaheth Hospital, University of Birmingham
ing the need for integration of medical care, the introduction of general practice teaching would be A programme of integrated teaching by consultants worthwhile. If it were to develop in isolation of other and general practitioners is described. The teaching clinical disciplines an opportunity would be lost. If took place in the hospitals used for the purpose by this part of the teaching could be done without erodthe Medical Faculty of the University of Birmingham. ing other curricular time then at least one problem would be solved. A true understanding of the role of medical care Key words : *HOSPITALS, TEACHING; *EDUCATION, in the community may come when students are MEDICAL, UNDERGRADUATE ; GENERAL PRACTICE/ *educ; TEACHING/man; REFERRAL AND CONSULTAtaught within the community but this does not necessarily demonstrate the identity of purpose of TION ; HOSPITALIZATION; ENGLAND the hospital doctor and the general practitioner and the continuity of care required across the artificial Introduction hospital-community frontier. A problem met by those of us who are asked to In an effort to meet both these problems an attempt introduce teaching in general practice into a wellhas been made to provide integrated teaching by established medical school is that of curricular time. consultants and general practitioners within the No department regards itself as having a sufficiency hospitals used by the Medical Faculty of the Univerof either teaching or staff and the introduction of yet sity of Birmingham. This paper describes the initial another area into an already over-stuffed curriculum development and logistics of such a scheme and might seem a last straw. gives a subjective evaluation from the viewpoint of One readily identifiable area of defect in the currithe consultant, the general practitioner and the culum is that of integration between the disciplines student. The use of an experienced teacher in general practhat are taught. Boundaries have been drawn and are maintained. This is nowhere more true than the tice within the ward and concerned with bed-side boundary between hospital medicine and medicine teaching has been described by Anderson et al. (1972). in the community. By its very nature hospital mediIn that study a single teacher contributed to the basic cine tends to be compartmentalized. The National objective of a specialist department. This was afterHealth Service structure ossified a trend which wards extended to incorporate new objectives of a already existed. Generations of students grew up wider context relating to medicine in the community. without ever seeing a general practitioner within the Again, students were exposed to an experienced hospital. Brainwashed into believing that the general teacher using the hospital patients of other general practitioner was, as A. A. Milne would have said, ‘a practitioners as teaching material. bear with very little brain’, the attitudes persisted The programme described here attempts to use through the resident phases of their career. Today the patient’s own general practitioner as the main strenuous efforts are being made to change this. teaching resource within the hospital. It concentrates upon the presentation of the patient and his problems If it were to achieve nothing else than demonstratbefore admission to hospital and after discharge and Correspondence: Dr Michael Drury, Department o f Medithus seeks to demonstrate that hospital admission is cine, University o f Birmingham, Edgbaston, Birmingham often only an episode in a patient’s illness and is B15 2TH.
Summary
309
310
M . Drury
always only an episode in a patient’s life. Several different approaches have been made and their administrative and educational problems looked at. There are advantages and disadvantages inherent in each style but gradually a consensus of views on the correct method has evolved. Initially the teaching periods were carried out in one hospital by one physician. His system was to take a particular case, invite the general practitioner, and present and discuss the case in a 1 hour session. Students were in their first clinical year and the case discussions occurred two or three times during their period of medical clerking. A determined effort was made to expand this form of teaching first to other physicians within the same hospital-eventually five were involved-then to the other major teaching hospital in the group where a further six physicians from two ‘firms’ took part. Subsequently they were expanded to a third hospital and more recently developed within the paediatric department of the Children’s Hospital. Further development is still continuing. Modifications will take place but it seems useful to report upon the present state and the problems that have occurred. For evaluation purposes it was decided to run the groups in the first two teaching hospitals in different ways. In one the students were in their first clinical year and the teaching sessions were directed by the consultant. The group of six or seven students who had been on the firm when the patient was in hospital were present together, often with the registrar and house physician. The general practitioner of the patient took a leading part and the senior clinical tutor in general practice attended as part of the evaluation exercise. Sometimes the patients attended, either because they were still in the ward or, if not, they were invited to come up as outpatients and at this time the opportunity to talk to them and to organize any desirable tests. On other occasions the ward sister, the physiotherapist, the social worker, or health visitor also contributed. At the other major teaching hospital the sessions were organized by the consultant who was in charge of undergraduate teaching but conducted by the senior clinical tutor in general practice with the patient’s own general practitioner. Here the students were in their final clinical year. This programme ran into an early difficulty. Although the students were clinically more mature there were problems about their regular attendance. They were all student house physicians and their ward duties kept many of them
away. After 1 year it was decided to go back to the first clinical year students. In the last 12 months of the programme eighty sessions have been held. At seventy-five of them the invited general practitioner was able to attend. Five sessions proceeded without the general practitioner because, at the last moment, he was unable to attend. In these the senior clinical tutor ‘acted’ as the attending general practitioner. In seventeen further sessions the general practitioner declined the invitation to attend and the class was cancelled. Therefore in over three-quarters of the teaching classes the patient’s own doctor was present. Reasons for declining were usually lack of time, but afterwards several general practitioners remarked that lack of confidence within the hospital setting was a major factor. Two doctors attended three sessions during the year and three doctors attended two, so that sixty-eight follow-up evaluation questionnaires were sent out, fifty-six were returned. The sessions were held either from 11 to 12 noon, from 12 to 1 p.m. or from 1 to 2 p.m. as these seemed to be the times doctors could most conveniently leave their practices. An attendance of 1 hour at a teaching session very often means 2 hours off the practice and is clearly a substantial commitment. No fees were available for general practitioners taking part. An early decision that had to be taken was whether to select cases by doctors, or doctors by cases. It was recognized that the former policy would result in the development of a small cadre of well-briefed teachers but it was thought that this would defeat the secondary objectives which were to facilitate the meeting of hospital doctors and general practitioners and might also exclude doctors who had genuine contributions to make. Certain objectives were defined at the beginning of the programme : 1. To demonstrate the reasons for hospital referral. 2. To show how social and psychological factors are important elements in planning care. 3. To demonstrate the resources available in the community for continuing care, and the communication needs for continuity of care.
These were not exclusive in that if the discussion that followed each presentation began to explore other topics and these were clearly of interest, this was encouraged. Table 1 shows how these objectives were achieved as judged by the attending students. Gradually it became apparent that more careful
General practitioner hospitaI teaching
311
TABLE 1 Scale point Obiective
1
2
3
4
5
Mean
N
1 . To demonstrate the reasons for hospital referral 2. To show how social and psychological factors are important elements in planning care 3. To demonstrate the resources available for continuing care and the communication needs of continuity of care
8 2
24 3
31 20
39 64
25 38
3.3 4.0
127
2
8
41
39
37
3.8
127
months after the end of the session. Lastly, hospital consultants were written to and their replies and comments noted. One hundred and twenty-seven students were asked at the end of the session to grade on a 1-5 scale an answer to two questions. The results are shown in Table 2. The fifty-six replies to questionnaires sent out to general practitioners represents an 82% response rate. All fifty-six respondents believed the stated objectives to be relevant to the method of teaching. Fifty-two believed that the objectives had been met, one that they were partially met and three that they had not been met at all. None felt that other objectives would have been more appropriate. All fifty-six respondents stated that they had enjoyed the session, an important criterion of success in my view. Fifty-two general practitioners felt they had benefited from the session, four did not. Fifty-four of the respondents found the time and place of the teaching session reasonably convenient. What sort of frequency would the general practitioner be prepared to accept for these sessions? Nine would be prepared to attend once a year, twentyfour twice a year and twenty-three more than twice a year. Each general practitioner was asked if he had any further comments. Twenty replied at length to this suggestion, five making suggestions about alterations to the organization of the sessions and the remainder commenting on the content, asking for more
structuring was required, particularly of the frequency of sessions and the nature of the cases to be discussed. Students spend 5 months in their junior clerking with a medical firm. All participants have agreed that there is a danger of the programme becoming too repetitious if the sessions are held too frequently. It appears that one session a month suits students and doctors and these have now been designed to show one patient with an acute medical problem, two patients with chronic medical problems, one whose problems are of a mainly social context and one patient with a poor prognosis. Respective examples of these include acute myocardial infarction, chronic bronchitis and rheumatoid arthritis, the elderly sick and the patient with malignant disease. The student who has clerked the case begins with a brief (10 minute) case presentation. This is followed by the contribution of the general practitioner who brings the medical record envelope with him and the subsequent discussion is conducted by the hospital consultant or GP teacher. Evaluation Evaluation of the programme has been carried out in three ways. One hundred and twenty-seven students were presented with a questionnaire at the beginning of each session and these were returned at the end. General practitioners who had attended were circulated with a brief questionnaire about 2
TABLE 2. Students were also asked to rate on a 1-5 scale, for each of the three stated objectives, their views as to whether they had been fulfilled or not fulfilled ~~
~
~~
~
~
~
~
~
~
Scale point 1
2
3
4
(useless) D o you think this is a useful addition to hospital teaching? 2. Did you obtain the sort of information that you needed? 1.
5
Mean
N
(very useful)
0
0
17
48
62
4.4
127
0
11
33
57
26
3.8
127
312
M . Drury
emphasis to be placed on further contact with the group of students and suggesting that they might take them to see the patient in the home. This is a measure of their enthusiasm but is not a part of the defined objectives of this section of the curriculum. Finally what of the consultants who took part in the sessions? Each one stated that he enjoyed the sessions. The greatest single benefit, stressed by each consultant, was the advantage of meeting the patients’ own general practitioners and seeing problems from both sides of the fence. There was a danger in running them too frequently and there were considerable benefits seen in bringing in to the discussion other paramedical staff involved in patient care outside the hospital.
Discussion This programme is not an easy one to organize. It requires about 2 weeks advance notice of the name of the patient and the time of the session being given to the general practitioner. Even then it has, in the first case, required a direct telephone call to the general practitioner by the GP tutor explaining the system and the method in order to overcome initial anxiety. It is possible that with increasing familiarity this problem may disappear and certainly second attenders have found it much easier. The programme, as it expanded to involve more firms, eventually involved about two sessions a week. It seems desirable that one general practitioner, who has contacts with the hospital, should be delegated as the local organizer. His role is to obtain patient details from the consultant who has selected the case, contact the practitioner and attend the session until he is dealing with doctors who have been round the circuit two or three times before. Not every general practitioner is a good teacher. Not every method of medical practice is acceptable to the hospital doctor, and occasionally the methods described have been, to say the least, unorthodox. However, a case could be made out for showing students the reality of medical life, encouraging them to develop their own critical faculties and educating hospital consultants and general practitioners in this non-threatening way. Indeed it is not uncommon that the unorthodox proves correct. However, students are occasionally exposed to poor practice methods and it is not always easy to point this out to the students without causing embarrassment or being unethical.
Additional points that have been brought out in the discussions that take place during the session include : (i) The demonstration of the different roles and the different methods adopted in primary and secon dary medical care. (ii) The great need for proper communication be tween the general practitioner and the consultant. (iii) The importance of the family in the manage ment of ill people. (iv) The development of the doctor/patient re lationship. What has been particularly apparent is the widen ing of the perspectives of all who are taking part, an the personal value to participants of viewing teach ing as an integrative function, Further development that are being explored are the encouragement of subsequent visit by the student to the patients home with the attending general practitioner, an the gradual expansion of the programme to involv other disciplines. It is not envisaged that this pro gramme could or should replace experiences that student will gain by working in the community Indeed at Birmingham such a programme is bein developed. Rather that it will form a useful adjunc to hospital based teaching and to the breakdown o artificial boundaries between medicine in the hospita and medicine in the community. The only place to teach family medicine is in th community for that is the environment wherein it ethos lies. What is apparent is that by bringing th general practitioner into the hospital and perhap bringing the consultant out into general practice, on can demonstrate the inter-relationship and inter dependence of different disciplines in whole patien care. Our experience leads us to believe that thi programme should be extended and developed s that it may include other specialities in this metho of teaching.
Acknowledgments Many people have helped with this programme. I particular I should like to thank Professor R Hoffenberg, the consultants from the Centra Birmingham Health District and the many genera practitioners who have taken part. Reference
ANDERSON, J., DAY,J.L. & FREELING, P. (1972) The gener practitioner as a teacher of undergraduate students hospital. Journal of the Royal College of General Pract tioners, 22, 6 16.
General practice teaching -within the hospital M. DRURY Department of Medicine, Queen Elizaheth Hospital, University of Birmingham
ing the need for integration of medical care, the introduction of general practice teaching would be A programme of integrated teaching by consultants worthwhile. If it were to develop in isolation of other and general practitioners is described. The teaching clinical disciplines an opportunity would be lost. If took place in the hospitals used for the purpose by this part of the teaching could be done without erodthe Medical Faculty of the University of Birmingham. ing other curricular time then at least one problem would be solved. A true understanding of the role of medical care Key words : *HOSPITALS, TEACHING; *EDUCATION, in the community may come when students are MEDICAL, UNDERGRADUATE ; GENERAL PRACTICE/ *educ; TEACHING/man; REFERRAL AND CONSULTAtaught within the community but this does not necessarily demonstrate the identity of purpose of TION ; HOSPITALIZATION; ENGLAND the hospital doctor and the general practitioner and the continuity of care required across the artificial Introduction hospital-community frontier. A problem met by those of us who are asked to In an effort to meet both these problems an attempt introduce teaching in general practice into a wellhas been made to provide integrated teaching by established medical school is that of curricular time. consultants and general practitioners within the No department regards itself as having a sufficiency hospitals used by the Medical Faculty of the Univerof either teaching or staff and the introduction of yet sity of Birmingham. This paper describes the initial another area into an already over-stuffed curriculum development and logistics of such a scheme and might seem a last straw. gives a subjective evaluation from the viewpoint of One readily identifiable area of defect in the currithe consultant, the general practitioner and the culum is that of integration between the disciplines student. The use of an experienced teacher in general practhat are taught. Boundaries have been drawn and are maintained. This is nowhere more true than the tice within the ward and concerned with bed-side boundary between hospital medicine and medicine teaching has been described by Anderson et al. (1972). in the community. By its very nature hospital mediIn that study a single teacher contributed to the basic cine tends to be compartmentalized. The National objective of a specialist department. This was afterHealth Service structure ossified a trend which wards extended to incorporate new objectives of a already existed. Generations of students grew up wider context relating to medicine in the community. without ever seeing a general practitioner within the Again, students were exposed to an experienced hospital. Brainwashed into believing that the general teacher using the hospital patients of other general practitioner was, as A. A. Milne would have said, ‘a practitioners as teaching material. bear with very little brain’, the attitudes persisted The programme described here attempts to use through the resident phases of their career. Today the patient’s own general practitioner as the main strenuous efforts are being made to change this. teaching resource within the hospital. It concentrates upon the presentation of the patient and his problems If it were to achieve nothing else than demonstratbefore admission to hospital and after discharge and Correspondence: Dr Michael Drury, Department o f Medithus seeks to demonstrate that hospital admission is cine, University o f Birmingham, Edgbaston, Birmingham often only an episode in a patient’s illness and is B15 2TH.
Summary
309
310
M . Drury
always only an episode in a patient’s life. Several different approaches have been made and their administrative and educational problems looked at. There are advantages and disadvantages inherent in each style but gradually a consensus of views on the correct method has evolved. Initially the teaching periods were carried out in one hospital by one physician. His system was to take a particular case, invite the general practitioner, and present and discuss the case in a 1 hour session. Students were in their first clinical year and the case discussions occurred two or three times during their period of medical clerking. A determined effort was made to expand this form of teaching first to other physicians within the same hospital-eventually five were involved-then to the other major teaching hospital in the group where a further six physicians from two ‘firms’ took part. Subsequently they were expanded to a third hospital and more recently developed within the paediatric department of the Children’s Hospital. Further development is still continuing. Modifications will take place but it seems useful to report upon the present state and the problems that have occurred. For evaluation purposes it was decided to run the groups in the first two teaching hospitals in different ways. In one the students were in their first clinical year and the teaching sessions were directed by the consultant. The group of six or seven students who had been on the firm when the patient was in hospital were present together, often with the registrar and house physician. The general practitioner of the patient took a leading part and the senior clinical tutor in general practice attended as part of the evaluation exercise. Sometimes the patients attended, either because they were still in the ward or, if not, they were invited to come up as outpatients and at this time the opportunity to talk to them and to organize any desirable tests. On other occasions the ward sister, the physiotherapist, the social worker, or health visitor also contributed. At the other major teaching hospital the sessions were organized by the consultant who was in charge of undergraduate teaching but conducted by the senior clinical tutor in general practice with the patient’s own general practitioner. Here the students were in their final clinical year. This programme ran into an early difficulty. Although the students were clinically more mature there were problems about their regular attendance. They were all student house physicians and their ward duties kept many of them
away. After 1 year it was decided to go back to the first clinical year students. In the last 12 months of the programme eighty sessions have been held. At seventy-five of them the invited general practitioner was able to attend. Five sessions proceeded without the general practitioner because, at the last moment, he was unable to attend. In these the senior clinical tutor ‘acted’ as the attending general practitioner. In seventeen further sessions the general practitioner declined the invitation to attend and the class was cancelled. Therefore in over three-quarters of the teaching classes the patient’s own doctor was present. Reasons for declining were usually lack of time, but afterwards several general practitioners remarked that lack of confidence within the hospital setting was a major factor. Two doctors attended three sessions during the year and three doctors attended two, so that sixty-eight follow-up evaluation questionnaires were sent out, fifty-six were returned. The sessions were held either from 11 to 12 noon, from 12 to 1 p.m. or from 1 to 2 p.m. as these seemed to be the times doctors could most conveniently leave their practices. An attendance of 1 hour at a teaching session very often means 2 hours off the practice and is clearly a substantial commitment. No fees were available for general practitioners taking part. An early decision that had to be taken was whether to select cases by doctors, or doctors by cases. It was recognized that the former policy would result in the development of a small cadre of well-briefed teachers but it was thought that this would defeat the secondary objectives which were to facilitate the meeting of hospital doctors and general practitioners and might also exclude doctors who had genuine contributions to make. Certain objectives were defined at the beginning of the programme : 1. To demonstrate the reasons for hospital referral. 2. To show how social and psychological factors are important elements in planning care. 3. To demonstrate the resources available in the community for continuing care, and the communication needs for continuity of care.
These were not exclusive in that if the discussion that followed each presentation began to explore other topics and these were clearly of interest, this was encouraged. Table 1 shows how these objectives were achieved as judged by the attending students. Gradually it became apparent that more careful
General practitioner hospitaI teaching
311
TABLE 1 Scale point Obiective
1
2
3
4
5
Mean
N
1 . To demonstrate the reasons for hospital referral 2. To show how social and psychological factors are important elements in planning care 3. To demonstrate the resources available for continuing care and the communication needs of continuity of care
8 2
24 3
31 20
39 64
25 38
3.3 4.0
127
2
8
41
39
37
3.8
127
months after the end of the session. Lastly, hospital consultants were written to and their replies and comments noted. One hundred and twenty-seven students were asked at the end of the session to grade on a 1-5 scale an answer to two questions. The results are shown in Table 2. The fifty-six replies to questionnaires sent out to general practitioners represents an 82% response rate. All fifty-six respondents believed the stated objectives to be relevant to the method of teaching. Fifty-two believed that the objectives had been met, one that they were partially met and three that they had not been met at all. None felt that other objectives would have been more appropriate. All fifty-six respondents stated that they had enjoyed the session, an important criterion of success in my view. Fifty-two general practitioners felt they had benefited from the session, four did not. Fifty-four of the respondents found the time and place of the teaching session reasonably convenient. What sort of frequency would the general practitioner be prepared to accept for these sessions? Nine would be prepared to attend once a year, twentyfour twice a year and twenty-three more than twice a year. Each general practitioner was asked if he had any further comments. Twenty replied at length to this suggestion, five making suggestions about alterations to the organization of the sessions and the remainder commenting on the content, asking for more
structuring was required, particularly of the frequency of sessions and the nature of the cases to be discussed. Students spend 5 months in their junior clerking with a medical firm. All participants have agreed that there is a danger of the programme becoming too repetitious if the sessions are held too frequently. It appears that one session a month suits students and doctors and these have now been designed to show one patient with an acute medical problem, two patients with chronic medical problems, one whose problems are of a mainly social context and one patient with a poor prognosis. Respective examples of these include acute myocardial infarction, chronic bronchitis and rheumatoid arthritis, the elderly sick and the patient with malignant disease. The student who has clerked the case begins with a brief (10 minute) case presentation. This is followed by the contribution of the general practitioner who brings the medical record envelope with him and the subsequent discussion is conducted by the hospital consultant or GP teacher. Evaluation Evaluation of the programme has been carried out in three ways. One hundred and twenty-seven students were presented with a questionnaire at the beginning of each session and these were returned at the end. General practitioners who had attended were circulated with a brief questionnaire about 2
TABLE 2. Students were also asked to rate on a 1-5 scale, for each of the three stated objectives, their views as to whether they had been fulfilled or not fulfilled ~~
~
~~
~
~
~
~
~
~
Scale point 1
2
3
4
(useless) D o you think this is a useful addition to hospital teaching? 2. Did you obtain the sort of information that you needed? 1.
5
Mean
N
(very useful)
0
0
17
48
62
4.4
127
0
11
33
57
26
3.8
127
312
M . Drury
emphasis to be placed on further contact with the group of students and suggesting that they might take them to see the patient in the home. This is a measure of their enthusiasm but is not a part of the defined objectives of this section of the curriculum. Finally what of the consultants who took part in the sessions? Each one stated that he enjoyed the sessions. The greatest single benefit, stressed by each consultant, was the advantage of meeting the patients’ own general practitioners and seeing problems from both sides of the fence. There was a danger in running them too frequently and there were considerable benefits seen in bringing in to the discussion other paramedical staff involved in patient care outside the hospital.
Discussion This programme is not an easy one to organize. It requires about 2 weeks advance notice of the name of the patient and the time of the session being given to the general practitioner. Even then it has, in the first case, required a direct telephone call to the general practitioner by the GP tutor explaining the system and the method in order to overcome initial anxiety. It is possible that with increasing familiarity this problem may disappear and certainly second attenders have found it much easier. The programme, as it expanded to involve more firms, eventually involved about two sessions a week. It seems desirable that one general practitioner, who has contacts with the hospital, should be delegated as the local organizer. His role is to obtain patient details from the consultant who has selected the case, contact the practitioner and attend the session until he is dealing with doctors who have been round the circuit two or three times before. Not every general practitioner is a good teacher. Not every method of medical practice is acceptable to the hospital doctor, and occasionally the methods described have been, to say the least, unorthodox. However, a case could be made out for showing students the reality of medical life, encouraging them to develop their own critical faculties and educating hospital consultants and general practitioners in this non-threatening way. Indeed it is not uncommon that the unorthodox proves correct. However, students are occasionally exposed to poor practice methods and it is not always easy to point this out to the students without causing embarrassment or being unethical.
Additional points that have been brought out in the discussions that take place during the session include : (i) The demonstration of the different roles and the different methods adopted in primary and secon dary medical care. (ii) The great need for proper communication be tween the general practitioner and the consultant. (iii) The importance of the family in the manage ment of ill people. (iv) The development of the doctor/patient re lationship. What has been particularly apparent is the widen ing of the perspectives of all who are taking part, an the personal value to participants of viewing teach ing as an integrative function, Further development that are being explored are the encouragement of subsequent visit by the student to the patients home with the attending general practitioner, an the gradual expansion of the programme to involv other disciplines. It is not envisaged that this pro gramme could or should replace experiences that student will gain by working in the community Indeed at Birmingham such a programme is bein developed. Rather that it will form a useful adjunc to hospital based teaching and to the breakdown o artificial boundaries between medicine in the hospita and medicine in the community. The only place to teach family medicine is in th community for that is the environment wherein it ethos lies. What is apparent is that by bringing th general practitioner into the hospital and perhap bringing the consultant out into general practice, on can demonstrate the inter-relationship and inter dependence of different disciplines in whole patien care. Our experience leads us to believe that thi programme should be extended and developed s that it may include other specialities in this metho of teaching.
Acknowledgments Many people have helped with this programme. I particular I should like to thank Professor R Hoffenberg, the consultants from the Centra Birmingham Health District and the many genera practitioners who have taken part. Reference
ANDERSON, J., DAY,J.L. & FREELING, P. (1972) The gener practitioner as a teacher of undergraduate students hospital. Journal of the Royal College of General Pract tioners, 22, 6 16.
