Vol. 9, No. 3 Printed in Great BritBin
Family Practice © Oxford University Press 1992
Medical Students' Perceptions of an Undergraduate General Practice Preceptorship Cooper CW. Medical students' perceptions of an undergraduate general practice preceptorship. Family Practice 1992; 9: 323-329. A survey was undertaken to evaluate an undergraduate general practice preceptorship by means of an open-ended six-item questionnaire given to students at the end of their general practice attachment. The aim of the survey was to evaluate the preceptorship as a learning experience and to examine ways in which the preceptorship might be improved. Questionnaires from two medical student years (1985 and 1990) were examined retrospectively. Of 398 potential responders, 386 (97%) had completed questionnaires. Students expressed a very high level of satisfaction with the attachment and this was expressed most often in terms of the personal interest shown by the general practitioner, the variety of clinical problems encountered, and the experience gained in managing common clinical problems. Areas of the attachment which students felt could be improved were: involvement in the consultation, the time constraints on teaching and the teaching of practical skills. The paper discusses possible improvements which could be made to preceptorship programmes on the basis of these findings.
The general practice preceptorship has been studied from a variety of perspectives. It has been found to be very popular among students,' to be a rewarding and stimulating experience for general practitioners,2 and to be well accepted by patients.3 One way of evaluating the preceptorship as a learning experience is from the perspective of students taking part in the preceptorship programme. This evaluation is not without difficulty. A major challenge has been the variable nature of general practice and of the preceptorship experience. This has led to two differing approaches to the evaluation of preceptorship teaching. The first of these places emphasis on the need to state preceptorship objectives and to base evaluation on the extent to which these objectives are seen to have been fulfilled.' The second approach sees the preceptorship as an inherently variable and personal learning experience undertaken by students who are able to discriminate, form opinions and draw from the attachment as one of many undergraduate learning experiences. This approach emphasizes assessment based on an open-ended questionnaire or a narrative of a type described by Friedman et a/.4 Although difficult to quantify, data derived from open-ended questionnaires are interesting, and in the context of planning and improving preceptorships are of great value, because they represent the views of students uninfluenced by preconceptions. One dif-
INTRODUCTION General practice is a community based discipline, so it is appropriate that undergraduate training in general practice should take place away from hospitals and out in the community. General practices are a natural and accessible setting for undergraduate teaching, and over the last two decades have become increasingly involved in teaching undergraduates about general practice. This teaching usually takes place via a preceptorship programme through which individual students are attached to a general practice for part of an undergraduate rotation. Although attachment arrangements vary from school to school the broad aim remains the same: to teach undergraduates something of medicine as it is practiced away from hospitals. The preceptorship is a unique experience for medical students. It takes them out into the community and it teaches them about personalized medical care as it is practiced by the general practitioner. The teaching experience is also unusual as it is the first, and often only, period in the undergraduate curriculum when students receive one to one teaching. The attachment is made all the more unique as it stands in the undergraduate curriculum among less personal hospitalbased clinical rotations. Department of Community Medicine, University of Sydney, 11 Croydon Avenue, Croydon, NSW 2132, Australia.
323
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CHRISTOPHER W COOPER
324
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
METHOD Background The 4-week undergraduate course in general practice at Sydney University has an established preceptorship programme through which students are attached for 2 weeks to one of 240 general practitioners throughout New South Wales. The broad emphasis is to encourage the students to develop their own personal objectives and priorities for the attachment. Guidelines for the attachment are outlined in a handbook given to students and preceptors, and these are intended to encourage students to participate in the consultation and to gain communication, management and practical clinical skills. As part of an on-going assessment of the programme, students are asked to rate their attachment by responding to a six-item open-ended questionnaire (Tables 1-6) which is included in the handbook and collected on the day of the students' return to the university. The open-ended approach was chosen to enable students to express their own feelings about the attachment. In the questionnaire students are asked to explore positive as well as negative aspects of the attachment, and to consider how the attachment might be improved.
TABLE 1 How would you describe the quality of teaching provided? (n = 187) n 1. The GP was always willing to answer questions
86 (45.9)
2. The GP set aside time for discussion
59(31.6)
3. The GP was an enthusiastic, interested teacher
35 (18.7)
4. The GP involved me in performing procedures
33 (17.6)
5. The GP encouraged me to ask questions
17 (9.0)
6. The GP involved me in the consultation
17 (9.0)
7. The GP impressed me by being informed and knowledgeable
15 (8.0)
8. The GP enhanced teaching with humour
3 (1.6)
TABLE 2
How would you describe the ability of the general practitioner to relate to you? (n = 117) n
(%)
1. The GP was friendly and welcoming
61
(52.1)
2. The GP was relaxed and easy going
25
(21.4)
3. The GP understood my needs as a student
25
(21.4)
4. The GP was easy to get on with
23
(19.7)
5. The GP was approachable
16
(19.7)
6. The GP was kind and compassionate
10
(8.5)
7. The GP related to me as a colleague rather than as a student
10
(8.5)
2
(1.7)
8. The GP was willing to listen
The study method In a retrospective review, all questionnaires completed by students from two medical school years (1985 and 1990) were retrieved for analysis. This sample was chosen to include students from medical school years in which the general practice attachment occurred in the fourth undergraduate year of a 5-year medical course (1985) as well as in the fifth undergraduate year of a 6-year medical course (1990). There was no significant difference between student responses from the two years in any of the item-response categories 1-6 and so students from these years were considered as a single group. Of 398 potential responders from the two study years, 386 (97%) had completed questionnaires. Answers to the questionnaires were reviewed and individual comments were noted and assembled into a draft list of answers to each question. Care was taken
(%)
TABLE 3
Were your aims met during the attachment? If not why not? (r\ = 70)
1. I was not involved in the consultation
37 (52.8)
2. I learnt very few practical procedures
28 (40.0)
3. The practice was too specialized
8 (11.4)
4. There was no time for discussion
7 (10.0)
5. There was an insufficient number of patients attending the practice
3
(4.2)
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ficulty with the narrative form encountered by Friedman et al.* was the relative reluctance of students to make critical comments about the attachment. The purpose of this present study was to evaluate a general practice preceptorship scheme by means of a questionnaire which is open-ended but which is directed to the extent of asking students to explore positive and negative aspects of the preceptorship. These data were used as a basis from which the strengths and weaknesses of general practice preceptorship teaching and possible solutions to the problems that have been encountered could be discussed. These considerations are important because they serve as a means by which future general practice preceptorships might be planned, evaluated and improved.
325
AN UNDERGRADUATE GP PRECEPTORSHIP TABLE 4
What were the best things about your attachment? (n = 367)
TABLE 6
What could be done to improve the attachment? (a = 171)
(%)
1. The variety of clinical problems
144
(39.2)
1. The attachment should be longer
76
(44.4)
2. The experience I gained in managing common clinical problems
123
(33.5)
2. There should be greater involvement of the student
33
(19.3)
91
(24.8)
3. There should be more teaching of practical skills
27
(15.8)
24
(14.0)
10
(5.8)
7
(4.1)
4
(2.3)
4
(2.3)
4
(2.3)
2
(1.2)
3. The experience I gained in performing practical procedures 4. The insight I gained into the life of the family doctor
67
(18.3)
4. Students should be given an opportunity to take a patient's history before the consultation
5. The sense of involvement and responsibility
59
(16.1)
5. The GP attachment should be later in the medical course
6. The friendly welcoming attitude of the GP and practice staff
41
(11.2)
7. The experience of relating to patients as people
35
(9.5)
8. Witnessing the different approaches of doctors in a group practice
3.
(8.7)
9. Being in the country
19
(5.2)
13
(3.5)
10. The home visits
TABLE 5
6. The GP attachment should rotate between
7. Attachment should be with group practice
What was the worst thing about your attachment? (n = 104)
1. There was inadequate time for discussion
28
(27.1)
2. There was no opportunity to perform practical procedures
20
(19.4)
27
(26.4)
13
(12.6)
5. The weather
4
(3.8)
6. The lack of variety
6
(5.8)
9
(8.7)
1
(1.0)
5 1
(4.8) (1.0)
3. There was not enough involvement in the consultation 4. The long working hours
7. Not being able to 'sit-in' on certain consultations 8. The loneliness 9. The travelling 10. Not being able to discuss things with other students
country and city practices
8. There should be time allocated for discussion 9. Country attachment should be compulsory after each consultation 10. Students should also be attached to community services
to use the precise words of individual students' answers to each question. Answer-comments which were not precisely the same as those in the list, were added to the list and retained in data. Questionnaires were then again reviewed and the frequency with which each specific comment-answer occurred was noted. To minimize interpretive bias only answers which included precisely the same comments or key words were included in each answer category. Answers which were not precisely the same as those listed, were again added to the list and retained in data. Comment-answers to each question were then assembled in rank order of frequency. RESULTS Tables 1 -6 show the most frequent student answers to the six parts of the questionnaire in rank order of frequency. Although closed-ended scales were not used, a large number of students answered the first two questions in a way that permitted quantification. These specific comments are presented in Figures 1 and 2 on a five point scale of excellent to poor. Figure 3 graphically presents students' answers to the first part of question 3. Students were not obliged to answer all parts of the questionnaire, and it is interesting to note that questions exploring positive aspects of the attachment
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n
326
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
Percentage of students
FIGURE 1
Good
Fair Poor V/A % of students
Quality of teaching provided (total n = 298}
Percentage of students
Excellent Very good Good Fair Poor Student response V/A % of students FIGURE 2 Ability of OP to relate to you (total n = 256)
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Excellent Very good Student response
AN UNDERGRADUATE GP PRECEPTORSHIP 100
327
Percentage of students
NO l^//1 % of students
FIGURE 3 Were your aims met? (total n = 362)
(Questions 4 and 6) were answered much more frequently than those exploring negative aspects of the practice (Questions 3 and 5). The numbers (and °7o) of students answering each question is given at the top of each table. Teaching quality was rated very highly (Figure 1) and this was expressed most commonly (Table 1) in terms of the enthusiasm and willingness of the teacher to answer questions, to set aside time for discussion and to involve the student in performing practical procedures. The ability of the general practitioner to relate to students was rated highly (Figure 2), and expressed most often (Table 2) in terms of the general practitioner as being welcoming, friendly and understanding student needs. A large majority of students (89%) felt their aims were met during the attachment (Figure 3). Where student aims were not met the reasons most often cited (Table 3) were that students learnt very few practical procedures and did not feel involved in the consultation. Tables 4 and 5 describe students' views on what was respectively, the best and worst thing about the attachment. Interestingly and most strikingly students placed emphasis on the experience gained in performing practical procedures. Students' views on what could be done to improve the attachment are given in Table 6. Students felt the attachment should be longer and that there should be greater student involvement in the consultation and in perform-
ing practical procedures. The implications of these Findings are discussed below. DISCUSSION The study revealed a very high level of student satisfaction with the attachment scheme; students enjoyed themselves during the attachment and this is reflected in the large number of positive and enthusiastic comments. Some interesting features emerge when students' comments are examined in detail. Positive aspects of the preceptorship (Tables 2 and 4) were expressed most often in terms of the personal interest shown by the general practitioner and practice staff. Students emphasized the friendly welcoming attitude of the general practitioner, the friendliness of practice staff and the way in which they were involved in the practice. Teaching quality was expressed in the same sorts of terms, relating to the extent to which the general practitioner was willing to devote time to discussion, answer questions and involve the student in the consultation (Table 1). Overall the teaching quality was rated very highly (Figure 1). Parkerson et al.! have quantitively described the variety of clinical problems encountered by students during the attachment and in the present study a number of students mentioned the variety of clinical problems as being one of the best things about the
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YES Student Response
328
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
seem to be a very useful practical as well as educational approach. Students placed surprising emphasis on the importance to them of gaining experience in performing practical procedures during their attachment (Tables 1 and 4). Phillips et al.9 in a review of the clinical content of a general practice preceptorship, reported that students were able to perform very few practical procedures, and the present study demonstrates this as an important area of the attachment about which students expressed dissatisfaction (Tables 3 and 5), and which they felt could be improved (Table 6). This may reflect in part a reluctance on the part of the general practitioner to involve students in performing practical procedures for the reasons discussed above. Spike and Veich10 have noted the extent to which the medical undergraduate curriculum fails to teach students practical skills and on the basis of this, an argument could be made for devoting time during the departmental segment of the general practice rotation to the teaching of practical skills relevant to general practice. The most common student complaint (Table 6) was that the attachment should be longer, and as such this was rather more a measure of the attachment's success. Certainly 2 weeks seems an inadequate period in which to introduce students to general practice. A number of students felt the attachment should be 4 weeks long; some felt it should be 8 weeks in length and that this time could be divided into two 4-week attachments in two different practices. Another idea (Table 6) was that the attachment could rotate through one urban and one rural practice and if the attachment was 4 weeks or more in length this would seem to be a particularly interesting and worthwhile idea. ACKNOWLEDGEMENTS My sincere thanks go to our fifth year medical students who were the inspiration for this paper.
1
2
3
4
3
6
REFERENCES Smith SR, MacLeod NM. An innovative family medicine clerkship. J Fam Pract 1981; 13: 687. Forbes JA. Southampton: The first years. V. Primary medical care in Southampton. Br Med J 1976; 2: 161. Report of the West London Faculty of the Royal College of General Practitioners. Patients' attitudes to the presence of undergraduate students in general practice. Practitioner 1972; 825. Friedman CP, Baker RM, Ilderton EP. Functions of a family medicine preceptorship. J Med Educ 1979; 54: 567. Parkerson GR Jr, Muhbaier LH, Falcone JC. A comparison of students' clinical experience in family medicine and traditional clerkships. J Med Educ 1984; 59: 124. Berenbaum I, Young R, Lazerson AM, Shaw P, McCahan J, Taylor DF. Teaching and funding of primary care education in third year clerkships. J Med Educ 1984; 59: 730.
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attachment (Table 4). Students also placed emphasis on the importance to them of gaining experience in managing common clinical problems not seen in hospitals. Other aspects of the attachments the students particularly enjoyed were the home visits, and students attached to rural practices enjoyed the experience of being away from the city and in the country. Students also enjoyed the experience of relating to patients as people, although very little direct comment was made about the importance of the psychological and social dimensions of illness. This finding is at variance with the findings of a study using a closedended questionnaire reported by Berenbaum et al.6 One important aim of the study was to identify areas of the attachment which might be improved. Probably the most important issue which emerged from the study was the importance to students of a sense of involvement in the consultation. Involvement in the consultation was cited by students as being one of the best things about the attachment (Tables 1 and 4), but a lack of involvement was also seen by many students as an area of dissatisfaction (Tables 3 and 5) and was often mentioned as one aspect of the attachment which could be improved (Table 6). One constraint to greater student involvement is likely to be the close doctor-patient relationship which so characterizes general practice. A number of students reported feeling embarrassed in the presence of the doctor and the patient, and one frequent comment was that students felt uncomfortable at not being able to sit-in on certain consultations (Table 5). Related to this may be a reluctance on the part of general practitioners to involve students in the management of patients in private practice. In this context patients are often perceived by general practitioners as being less likely to accept the presence of a student.7 The findings of a study which explored patients' attitudes to this question, however, indicate that this anxiety is unfounded and that patients readily accept student involvement in the consultation.3 Students greatly appreciate an approach (Table 2) in which they are treated as a colleague who can contribute to the running of the practice, and one important educational advantage of this is that the teaching emphasis moves away from the passive transfer of information towards learning through involvement which is enjoyable, highly motivating and effective. Another area of difficulty is the time constraint imposed on teaching in the 'real' world of general practice away from university teaching units. One suggestion made by students (Table 6) was that time could be allocated before or after a consultation for discussion, although this approach may not often be possible in practice. A related issue is the extent to which time devoted to teaching represents a financial burden to the general practitioner. Lindenmuth et al.* found that in a number of busy practices student involvement in the consultation increased the number of patients seen without decreasing patient satisfaction, and this would
AN UNDERGRADUATE GP PRECEPTORSHIP 7
8
Moorehead R. The experiences of students and their teachers in a general practice preceptorship scheme. Aust Fam Phys 1976; 5: 213. Lindenmuth NW, Stone AW, Donaldson M. The effect of third year clinical clerks on physician productivity in primary care practice. J Med Educ 1978; 53: 357.
329
' Phillips WR, Rosenblatt RA, Gordon MJ, Fletcher RM. Clinical content of the WAMI community clerkship in family medicine. JMed Educ 1982; 57: 615. 10 Spike N, Veich C. Competency of medical students in general practice procedural skills. Aust Fam Phys 1991; 20: 586.
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Family Practice © Oxford University Press 1992
Medical Students' Perceptions of an Undergraduate General Practice Preceptorship Cooper CW. Medical students' perceptions of an undergraduate general practice preceptorship. Family Practice 1992; 9: 323-329. A survey was undertaken to evaluate an undergraduate general practice preceptorship by means of an open-ended six-item questionnaire given to students at the end of their general practice attachment. The aim of the survey was to evaluate the preceptorship as a learning experience and to examine ways in which the preceptorship might be improved. Questionnaires from two medical student years (1985 and 1990) were examined retrospectively. Of 398 potential responders, 386 (97%) had completed questionnaires. Students expressed a very high level of satisfaction with the attachment and this was expressed most often in terms of the personal interest shown by the general practitioner, the variety of clinical problems encountered, and the experience gained in managing common clinical problems. Areas of the attachment which students felt could be improved were: involvement in the consultation, the time constraints on teaching and the teaching of practical skills. The paper discusses possible improvements which could be made to preceptorship programmes on the basis of these findings.
The general practice preceptorship has been studied from a variety of perspectives. It has been found to be very popular among students,' to be a rewarding and stimulating experience for general practitioners,2 and to be well accepted by patients.3 One way of evaluating the preceptorship as a learning experience is from the perspective of students taking part in the preceptorship programme. This evaluation is not without difficulty. A major challenge has been the variable nature of general practice and of the preceptorship experience. This has led to two differing approaches to the evaluation of preceptorship teaching. The first of these places emphasis on the need to state preceptorship objectives and to base evaluation on the extent to which these objectives are seen to have been fulfilled.' The second approach sees the preceptorship as an inherently variable and personal learning experience undertaken by students who are able to discriminate, form opinions and draw from the attachment as one of many undergraduate learning experiences. This approach emphasizes assessment based on an open-ended questionnaire or a narrative of a type described by Friedman et a/.4 Although difficult to quantify, data derived from open-ended questionnaires are interesting, and in the context of planning and improving preceptorships are of great value, because they represent the views of students uninfluenced by preconceptions. One dif-
INTRODUCTION General practice is a community based discipline, so it is appropriate that undergraduate training in general practice should take place away from hospitals and out in the community. General practices are a natural and accessible setting for undergraduate teaching, and over the last two decades have become increasingly involved in teaching undergraduates about general practice. This teaching usually takes place via a preceptorship programme through which individual students are attached to a general practice for part of an undergraduate rotation. Although attachment arrangements vary from school to school the broad aim remains the same: to teach undergraduates something of medicine as it is practiced away from hospitals. The preceptorship is a unique experience for medical students. It takes them out into the community and it teaches them about personalized medical care as it is practiced by the general practitioner. The teaching experience is also unusual as it is the first, and often only, period in the undergraduate curriculum when students receive one to one teaching. The attachment is made all the more unique as it stands in the undergraduate curriculum among less personal hospitalbased clinical rotations. Department of Community Medicine, University of Sydney, 11 Croydon Avenue, Croydon, NSW 2132, Australia.
323
Downloaded from http://fampra.oxfordjournals.org/ at University of California, Santa Barbara on July 25, 2015
CHRISTOPHER W COOPER
324
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
METHOD Background The 4-week undergraduate course in general practice at Sydney University has an established preceptorship programme through which students are attached for 2 weeks to one of 240 general practitioners throughout New South Wales. The broad emphasis is to encourage the students to develop their own personal objectives and priorities for the attachment. Guidelines for the attachment are outlined in a handbook given to students and preceptors, and these are intended to encourage students to participate in the consultation and to gain communication, management and practical clinical skills. As part of an on-going assessment of the programme, students are asked to rate their attachment by responding to a six-item open-ended questionnaire (Tables 1-6) which is included in the handbook and collected on the day of the students' return to the university. The open-ended approach was chosen to enable students to express their own feelings about the attachment. In the questionnaire students are asked to explore positive as well as negative aspects of the attachment, and to consider how the attachment might be improved.
TABLE 1 How would you describe the quality of teaching provided? (n = 187) n 1. The GP was always willing to answer questions
86 (45.9)
2. The GP set aside time for discussion
59(31.6)
3. The GP was an enthusiastic, interested teacher
35 (18.7)
4. The GP involved me in performing procedures
33 (17.6)
5. The GP encouraged me to ask questions
17 (9.0)
6. The GP involved me in the consultation
17 (9.0)
7. The GP impressed me by being informed and knowledgeable
15 (8.0)
8. The GP enhanced teaching with humour
3 (1.6)
TABLE 2
How would you describe the ability of the general practitioner to relate to you? (n = 117) n
(%)
1. The GP was friendly and welcoming
61
(52.1)
2. The GP was relaxed and easy going
25
(21.4)
3. The GP understood my needs as a student
25
(21.4)
4. The GP was easy to get on with
23
(19.7)
5. The GP was approachable
16
(19.7)
6. The GP was kind and compassionate
10
(8.5)
7. The GP related to me as a colleague rather than as a student
10
(8.5)
2
(1.7)
8. The GP was willing to listen
The study method In a retrospective review, all questionnaires completed by students from two medical school years (1985 and 1990) were retrieved for analysis. This sample was chosen to include students from medical school years in which the general practice attachment occurred in the fourth undergraduate year of a 5-year medical course (1985) as well as in the fifth undergraduate year of a 6-year medical course (1990). There was no significant difference between student responses from the two years in any of the item-response categories 1-6 and so students from these years were considered as a single group. Of 398 potential responders from the two study years, 386 (97%) had completed questionnaires. Answers to the questionnaires were reviewed and individual comments were noted and assembled into a draft list of answers to each question. Care was taken
(%)
TABLE 3
Were your aims met during the attachment? If not why not? (r\ = 70)
1. I was not involved in the consultation
37 (52.8)
2. I learnt very few practical procedures
28 (40.0)
3. The practice was too specialized
8 (11.4)
4. There was no time for discussion
7 (10.0)
5. There was an insufficient number of patients attending the practice
3
(4.2)
Downloaded from http://fampra.oxfordjournals.org/ at University of California, Santa Barbara on July 25, 2015
ficulty with the narrative form encountered by Friedman et al.* was the relative reluctance of students to make critical comments about the attachment. The purpose of this present study was to evaluate a general practice preceptorship scheme by means of a questionnaire which is open-ended but which is directed to the extent of asking students to explore positive and negative aspects of the preceptorship. These data were used as a basis from which the strengths and weaknesses of general practice preceptorship teaching and possible solutions to the problems that have been encountered could be discussed. These considerations are important because they serve as a means by which future general practice preceptorships might be planned, evaluated and improved.
325
AN UNDERGRADUATE GP PRECEPTORSHIP TABLE 4
What were the best things about your attachment? (n = 367)
TABLE 6
What could be done to improve the attachment? (a = 171)
(%)
1. The variety of clinical problems
144
(39.2)
1. The attachment should be longer
76
(44.4)
2. The experience I gained in managing common clinical problems
123
(33.5)
2. There should be greater involvement of the student
33
(19.3)
91
(24.8)
3. There should be more teaching of practical skills
27
(15.8)
24
(14.0)
10
(5.8)
7
(4.1)
4
(2.3)
4
(2.3)
4
(2.3)
2
(1.2)
3. The experience I gained in performing practical procedures 4. The insight I gained into the life of the family doctor
67
(18.3)
4. Students should be given an opportunity to take a patient's history before the consultation
5. The sense of involvement and responsibility
59
(16.1)
5. The GP attachment should be later in the medical course
6. The friendly welcoming attitude of the GP and practice staff
41
(11.2)
7. The experience of relating to patients as people
35
(9.5)
8. Witnessing the different approaches of doctors in a group practice
3.
(8.7)
9. Being in the country
19
(5.2)
13
(3.5)
10. The home visits
TABLE 5
6. The GP attachment should rotate between
7. Attachment should be with group practice
What was the worst thing about your attachment? (n = 104)
1. There was inadequate time for discussion
28
(27.1)
2. There was no opportunity to perform practical procedures
20
(19.4)
27
(26.4)
13
(12.6)
5. The weather
4
(3.8)
6. The lack of variety
6
(5.8)
9
(8.7)
1
(1.0)
5 1
(4.8) (1.0)
3. There was not enough involvement in the consultation 4. The long working hours
7. Not being able to 'sit-in' on certain consultations 8. The loneliness 9. The travelling 10. Not being able to discuss things with other students
country and city practices
8. There should be time allocated for discussion 9. Country attachment should be compulsory after each consultation 10. Students should also be attached to community services
to use the precise words of individual students' answers to each question. Answer-comments which were not precisely the same as those in the list, were added to the list and retained in data. Questionnaires were then again reviewed and the frequency with which each specific comment-answer occurred was noted. To minimize interpretive bias only answers which included precisely the same comments or key words were included in each answer category. Answers which were not precisely the same as those listed, were again added to the list and retained in data. Comment-answers to each question were then assembled in rank order of frequency. RESULTS Tables 1 -6 show the most frequent student answers to the six parts of the questionnaire in rank order of frequency. Although closed-ended scales were not used, a large number of students answered the first two questions in a way that permitted quantification. These specific comments are presented in Figures 1 and 2 on a five point scale of excellent to poor. Figure 3 graphically presents students' answers to the first part of question 3. Students were not obliged to answer all parts of the questionnaire, and it is interesting to note that questions exploring positive aspects of the attachment
Downloaded from http://fampra.oxfordjournals.org/ at University of California, Santa Barbara on July 25, 2015
n
326
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
Percentage of students
FIGURE 1
Good
Fair Poor V/A % of students
Quality of teaching provided (total n = 298}
Percentage of students
Excellent Very good Good Fair Poor Student response V/A % of students FIGURE 2 Ability of OP to relate to you (total n = 256)
Downloaded from http://fampra.oxfordjournals.org/ at University of California, Santa Barbara on July 25, 2015
Excellent Very good Student response
AN UNDERGRADUATE GP PRECEPTORSHIP 100
327
Percentage of students
NO l^//1 % of students
FIGURE 3 Were your aims met? (total n = 362)
(Questions 4 and 6) were answered much more frequently than those exploring negative aspects of the practice (Questions 3 and 5). The numbers (and °7o) of students answering each question is given at the top of each table. Teaching quality was rated very highly (Figure 1) and this was expressed most commonly (Table 1) in terms of the enthusiasm and willingness of the teacher to answer questions, to set aside time for discussion and to involve the student in performing practical procedures. The ability of the general practitioner to relate to students was rated highly (Figure 2), and expressed most often (Table 2) in terms of the general practitioner as being welcoming, friendly and understanding student needs. A large majority of students (89%) felt their aims were met during the attachment (Figure 3). Where student aims were not met the reasons most often cited (Table 3) were that students learnt very few practical procedures and did not feel involved in the consultation. Tables 4 and 5 describe students' views on what was respectively, the best and worst thing about the attachment. Interestingly and most strikingly students placed emphasis on the experience gained in performing practical procedures. Students' views on what could be done to improve the attachment are given in Table 6. Students felt the attachment should be longer and that there should be greater student involvement in the consultation and in perform-
ing practical procedures. The implications of these Findings are discussed below. DISCUSSION The study revealed a very high level of student satisfaction with the attachment scheme; students enjoyed themselves during the attachment and this is reflected in the large number of positive and enthusiastic comments. Some interesting features emerge when students' comments are examined in detail. Positive aspects of the preceptorship (Tables 2 and 4) were expressed most often in terms of the personal interest shown by the general practitioner and practice staff. Students emphasized the friendly welcoming attitude of the general practitioner, the friendliness of practice staff and the way in which they were involved in the practice. Teaching quality was expressed in the same sorts of terms, relating to the extent to which the general practitioner was willing to devote time to discussion, answer questions and involve the student in the consultation (Table 1). Overall the teaching quality was rated very highly (Figure 1). Parkerson et al.! have quantitively described the variety of clinical problems encountered by students during the attachment and in the present study a number of students mentioned the variety of clinical problems as being one of the best things about the
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YES Student Response
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seem to be a very useful practical as well as educational approach. Students placed surprising emphasis on the importance to them of gaining experience in performing practical procedures during their attachment (Tables 1 and 4). Phillips et al.9 in a review of the clinical content of a general practice preceptorship, reported that students were able to perform very few practical procedures, and the present study demonstrates this as an important area of the attachment about which students expressed dissatisfaction (Tables 3 and 5), and which they felt could be improved (Table 6). This may reflect in part a reluctance on the part of the general practitioner to involve students in performing practical procedures for the reasons discussed above. Spike and Veich10 have noted the extent to which the medical undergraduate curriculum fails to teach students practical skills and on the basis of this, an argument could be made for devoting time during the departmental segment of the general practice rotation to the teaching of practical skills relevant to general practice. The most common student complaint (Table 6) was that the attachment should be longer, and as such this was rather more a measure of the attachment's success. Certainly 2 weeks seems an inadequate period in which to introduce students to general practice. A number of students felt the attachment should be 4 weeks long; some felt it should be 8 weeks in length and that this time could be divided into two 4-week attachments in two different practices. Another idea (Table 6) was that the attachment could rotate through one urban and one rural practice and if the attachment was 4 weeks or more in length this would seem to be a particularly interesting and worthwhile idea. ACKNOWLEDGEMENTS My sincere thanks go to our fifth year medical students who were the inspiration for this paper.
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REFERENCES Smith SR, MacLeod NM. An innovative family medicine clerkship. J Fam Pract 1981; 13: 687. Forbes JA. Southampton: The first years. V. Primary medical care in Southampton. Br Med J 1976; 2: 161. Report of the West London Faculty of the Royal College of General Practitioners. Patients' attitudes to the presence of undergraduate students in general practice. Practitioner 1972; 825. Friedman CP, Baker RM, Ilderton EP. Functions of a family medicine preceptorship. J Med Educ 1979; 54: 567. Parkerson GR Jr, Muhbaier LH, Falcone JC. A comparison of students' clinical experience in family medicine and traditional clerkships. J Med Educ 1984; 59: 124. Berenbaum I, Young R, Lazerson AM, Shaw P, McCahan J, Taylor DF. Teaching and funding of primary care education in third year clerkships. J Med Educ 1984; 59: 730.
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attachment (Table 4). Students also placed emphasis on the importance to them of gaining experience in managing common clinical problems not seen in hospitals. Other aspects of the attachments the students particularly enjoyed were the home visits, and students attached to rural practices enjoyed the experience of being away from the city and in the country. Students also enjoyed the experience of relating to patients as people, although very little direct comment was made about the importance of the psychological and social dimensions of illness. This finding is at variance with the findings of a study using a closedended questionnaire reported by Berenbaum et al.6 One important aim of the study was to identify areas of the attachment which might be improved. Probably the most important issue which emerged from the study was the importance to students of a sense of involvement in the consultation. Involvement in the consultation was cited by students as being one of the best things about the attachment (Tables 1 and 4), but a lack of involvement was also seen by many students as an area of dissatisfaction (Tables 3 and 5) and was often mentioned as one aspect of the attachment which could be improved (Table 6). One constraint to greater student involvement is likely to be the close doctor-patient relationship which so characterizes general practice. A number of students reported feeling embarrassed in the presence of the doctor and the patient, and one frequent comment was that students felt uncomfortable at not being able to sit-in on certain consultations (Table 5). Related to this may be a reluctance on the part of general practitioners to involve students in the management of patients in private practice. In this context patients are often perceived by general practitioners as being less likely to accept the presence of a student.7 The findings of a study which explored patients' attitudes to this question, however, indicate that this anxiety is unfounded and that patients readily accept student involvement in the consultation.3 Students greatly appreciate an approach (Table 2) in which they are treated as a colleague who can contribute to the running of the practice, and one important educational advantage of this is that the teaching emphasis moves away from the passive transfer of information towards learning through involvement which is enjoyable, highly motivating and effective. Another area of difficulty is the time constraint imposed on teaching in the 'real' world of general practice away from university teaching units. One suggestion made by students (Table 6) was that time could be allocated before or after a consultation for discussion, although this approach may not often be possible in practice. A related issue is the extent to which time devoted to teaching represents a financial burden to the general practitioner. Lindenmuth et al.* found that in a number of busy practices student involvement in the consultation increased the number of patients seen without decreasing patient satisfaction, and this would
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Moorehead R. The experiences of students and their teachers in a general practice preceptorship scheme. Aust Fam Phys 1976; 5: 213. Lindenmuth NW, Stone AW, Donaldson M. The effect of third year clinical clerks on physician productivity in primary care practice. J Med Educ 1978; 53: 357.
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' Phillips WR, Rosenblatt RA, Gordon MJ, Fletcher RM. Clinical content of the WAMI community clerkship in family medicine. JMed Educ 1982; 57: 615. 10 Spike N, Veich C. Competency of medical students in general practice procedural skills. Aust Fam Phys 1991; 20: 586.
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