Learning in underserved UK areas: a novel approach (original) (raw)
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Medical education in (and for) areas of socio-economic deprivation in the UK
Education for Primary Care
Our system of medical education is still designed to produce community clinicians only as a by-product, an afterthought following a core curriculum designed by and for specialists. Its central aim remains the production of specialist excellence, unsullied by prior contact with the society it serves. It is training the wrong people, at the wrong time, in the wrong skills, and in the wrong place. The core curriculum for all doctors should be primary care: this should be taught where it is actually carried out, within communities; and the primary generalists produced in this way require not a year or two of rehabilitation in specialised vocational training, but a lifetime of in-service postgraduate study [1]. Much has changed in the 33 years since Julian Tudor Hart wrote this about medical education in the United Kingdom (UK) but are we still training the 'wrong people, at the wrong time, in the wrong skills, and in the wrong place'? In 2010, the Independent Commission on the Education of Health Professionals for the twenty-first century concluded that, globally, 'the content, organisation, and delivery of health professionals' education have failed to serve the needs and interests of patients and populations' [2]. In a linked Lancet editorial, Richard Horton described critical failures in health professional education systems worldwide including a 'chronic lack of primary care workers, rural-urban disparities, too little attention to disease prevention, isolation from the social sector, and insufficient concern with the social determinants of health and citizens' engagement in health' [3]. This sounds all too familiar and is the wider global and multi-professional context within which general practitioner (GP) teaching and training in the UK fits. This article will focus on the particular challenges of GP teaching (undergraduate) and training (postgraduate) in (and for) areas of severe socioeconomic deprivation (sometimes referred to as 'Deep End' general practice [4]). It is now widely accepted that most medical schools do not provide students with adequate general practice teaching time [5]. This is one of several drivers of the current workforce 'crisis' in UK general practice [6,7]. The Department of Health in England's target is for half of all medical students to become GPs [8]. Surveys suggest that general practice is the first career choice for less than a quarter of UK medical graduates [9,10].
2018
Across all medical schools, there is a drive to improve the quantity and quality of undergraduate (UG) teaching in general practice. There are particular challenges related to UG general practice teaching in areas of socioeconomic deprivation (the Deep End). The inverse care law is the fundamental barrier to improving the volume and quality of medical education in areas of deprivation. Simply put, practices in more deprived areas struggle to meet the needs of the higher proportion of patients with complex health and social problems, resulting in limited capacity to take on teaching roles. The higher proportion of smaller, often singlehanded, practices in deprived areas makes it more difficult to accommodate teaching and training requirements. There are relatively more GPs in Deep End practices approaching retirement, meaning recruitment to these areas is all the more pressing, with knock-on effects for medical education. The particular nature of clinical work in deprived areas, characterised by high volumes of alcohol and drugs problems, multimorbidity, psychological distress, polypharmacy, vulnerable families and other social problems, results in particular learning needs, which are inadequately addressed by current UG medical curricula.
MedEdPublish, 2019
This article was migrated. The article was marked as recommended. Many medical programmes around the world seek to provide experiences for their students in rural and remote health, community and primary care, with a view to encouraging future doctors to practice in under resourced and under-doctored areas of the world. New schools (and satellites of existing schools) have been established in rural and remote areas with a view to recruiting students from those areas who will go on to practice there. In these new schools, and in more traditional programmes, the primary curriculum models in use are either short placements in selected areas (including overseas electives) or immersive longitudinal clerkships, typically in a primary/community setting. A wealth of evidence exists of the success of these approaches, however, for many schools, the curriculum is more fixed and there are limited opportunities for introducing what can be seen as more radical change. In this paper, we describe ...
Rural and Remote Health, 2016
, is the placement of medical students for 25% of their clinical placement time in general practices. The largest component is a 15-week 'student attachment' in primary care during the final year, which required the development of a new network of teaching practices in a rural district of England about 90 km (60 mi) from the main campus in North Staffordshire. The new accommodation and education hub was established in 2011-2012 to enable students to become immersed in those communities and learn about medical practice within a rural and remote context. Objectives were to evaluate the rural teaching from the perspectives of four groups: patients, general practice tutors, community hospital staff and students. Learning outcomes (as measured by objective structured clinical examinations) of students learning in rural practices in the final year were compared with those in other practices. Methods: Data were gathered from a variety of sources. Students' scores in cohort-wide clinical assessment were compared with those in other locations. Semi-structured interviews were conducted with general practice tutors and community hospital staff. Serial focus groups explored the perceptions of the students, and questionnaires were used to gather the views of patients. Results: Patients reported positive experiences of students in their consultations, with 97% expressing willingness to see students. The majority of patients considered that teaching in general practice was a good thing. They also expressed altruistic ideas about facilitating learning. The tutors were enthusiastic and perceived that teaching had positive impacts on their practices despite negative effects on their workload. The community hospital staff welcomed students and expressed altruistic ideas about helping them learn.
Understanding rural clinical learning spaces: Being and becoming a doctor
Medical teacher, 2014
Context: Calls for health professions education that can foster transformative educational experiences have been voiced. Studies suggest that extended clinical training at rural sites potentially provides transformative learning spaces. This article explores 'being and becoming' as a construct for understanding the student experience at a rural clinical school (RCS). Methods: Sixty-two in-depth interviews were conducted over a three-year period with RCS students, graduates (as interns) and intern supervisors. Thematically analysed data were mapped according to the adapted Kirkpatrick model for appraising educational interventions. Drawing on realist perspectives, findings were further analysed to discern the mechanisms influencing the being and becoming of junior doctors. Results: Responses provided evidence of changed attitudes and behaviour, and the adoption of professional practice that was seen to influence patient outcomes. Analysis highlighted sharing of values through...
Health Sociology Review, 2019
Globally there is an urban/rural divide in relation to health and healthcare access. A key strategy for addressing general practitioner shortages in rural areas is GP vocational training in rural places, as this may aid in developing practitioners’ scope, values and community orientation, and increase propensity for rural practice. This creates a need for deeper understanding of the nature and quality of this training. Rural GPs are well-positioned to reflect on vocational learning in ‘place’. We aimed to explore rural GPs’ perceptions and experiences of GP vocational learning in relation to rural places. Semi-structured interviews were conducted with 25 GPs based in smaller rural communities in Tasmania. Inductive and theoretical thematic analysis was undertaken. Rural places provide learning opportunities for GP registrars, which shape the relationships between GPs and registrars and their communities. Rural GPs are committed to developing the next generation and improving access to primary care for their communities. Rural places provide unique learning environments for general practice, including rich learning, relationships and community commitment.
BMC medical education, 2005
Earlier studies have successfully demonstrated that medical students can achieve success in core clinical rotations with long term attachments in small groups to rural general / family practices. In this study, three students from a class of 226 volunteered for this 1-year pilot program, conducted by the University of Queensland in 2004, for medical students in the 3rd year of a 4-year graduate entry medical course. Each student was based with a private solo general practitioner in a different rural town between 170 and 270 km from the nearest teaching hospital. Each was in a relatively isolated rural setting, rated 5 or 6 on the RRMA scale (Rural, Remote, Metropolitan Classification: capital city = 1, other metropolitan = 2, large regional city = 3, most remote community = 7). The rural towns had populations respectively of 500, 2000 and 10,000. One practice also had a General Practice registrar. Only one of the locations had doctors in the same town but outside the teaching practi...
A systematic literature review of undergraduate clinical placements in underserved areas
Medical Education, 2013
Context-The delivery of undergraduate clinical education in under-served areas is increasing in various contexts across the world in response to local workforce needs. A collective understanding of the impact of these placements is lacking. Previous reviews often take a positivist approach by looking only at outcome measures. This review addresses the question: What are the strengths and weaknesses for medical students and supervisors of community placements in under-served areas? Methods-A systematic literature review was carried out by database searching, citation searching, pearl growing, reference list checking, and use of own literature. The databases included MEDLINE, EMBASE, PsycINFO, Web of Science, and ERIC. Search terms used were combinations and variations of four key concepts exploring GP primary care, medical students, placements, and location characteristics. The papers were analysed using a textual narrative synthesis. Findings-The initial search identified 4923 results. After removal of duplicates and screening of titles and abstracts, 185 met the inclusion criteria. These full articles were obtained and were assessed for their relevance to the research question, fifty-four were then included in the final review. Four main categories were identified: student performance, student perceptions, career pathways, and supervisor experiences. Conclusions-This review reflects the emergent qualitative data, as well as quantitative data used to assess initiatives. Under-served area placements have produced many beneficial implications for students, supervisors, and the community. There is a growing amount of evidence regarding rural, under-served areas but little in relation to inner-city, deprived areas, and none in the UK.
… Education, 2000
Introduction In an attempt to address the rural medical workforce maldistribution and the concurrent inappropriate caseload at the urban tertiary teaching hospitals, Flinders University and the Riverland Division of General Practice decided to pilot, in 1997, an entire year of undergraduate clinical curriculum in Australian rural general practice. This program is called the Parallel Rural Community Curriculum (PRCC). This paper is a discussion of the aims of the programme; student selection; practice recruitment; curriculum structure, and academic content, together with lessons learnt from the evaluation of the ®rst cohort of students' experience of the course. Methods Independent external evaluators undertook a thematic analysis of a series of structured interviews of students and faculty involved in both the PRCC and the traditional curriculum. The mean examination results were determined and a rank order comparison of student academic performance was undertaken. Results The eight selected volunteer students reported greater access to patients and clinical learning opportunities than their mainstream counterparts and learned clinical decision making in the context of the whole patient, their family, and the available community resources. They identi®ed patients with`core' clinical conditions and had a longitudinal exposure to common diseases, whereas hospital-based peers had a cross-sectional exposure to highly ®ltered illness. The PRCC students' academic performance improved in comparison with that of their tertiary hospital peers' and in comparison to their own results in previous years. Conclusion The PRCC curriculum has cut across the traditional clinical discipline boundaries by teaching in an integrated way in rural general practice. It has af®rmed the potential role of true generalist physicians in undergraduate medical education.