Doctors-to-be at the doorstep – Comparing service-learning programs in an Asian medical school

Figures & data

Table 1.  Comparison of the PHS and NHS service-learning programs at the Yong Loo Lin School of Medicine, Singapore

Characteristic of program	PHS	NHS
Operational characteristics
Sites of operation	Setting up a mobile clinic in areas of high human traffic (e.g., shopping centers, bus interchanges) in public housing estates	Mobile (door-to-door) in public housing estates
Annual operating budget	USD 6000	USD 4000
Students involved	Medical, nursing, and dentistry students	Medical and nursing students; high school students also assist in providing social support
Target population	Low-income groups in the population living in public housing, without regular access to healthcare	Low-income groups in the population living in public housing, without regular access to healthcare
Services provided	• Free health screening for hypertension (blood pressure), obesity (BMI), and colorectal cancer (FOBT) • Random blood glucose and blood cholesterol • Standard patient education; referral to further health programs; health form completion • Smoking cessation programs • Physical examinations, oral health examinations	• Free health screening for hypertension (blood pressure), diabetes mellitus (fasting blood glucose), dyslipidemia (fasting blood lipid), colorectal cancer (FOBT), and cervical cancer (Pap smear). Screening was provided in the home (FOBT, blood pressure) or at the community centre a 2-min walk from the resident's home (for the fasting blood tests as well as Pap smear) • Random blood glucose • Standard patient education; referral to further health programs; health form completion; social services consult/referral • Smoking cessation programs • Physical examinations, eye examinations
Patient characteristics
Number of patients seen yearly	3000 patients	457 patients
Percentage of patients who are walk-ins	100% (3000/3000)	0% (0/457) (Home-based program)
Percentage of patients seen with family	16.7% (500/3000)	32.8% (150/457)
Student participation
Size of student team	4–5 students	4–5 students
Training provided	Student handbook, online notes and material, and 1-day lecture	Student handbook, online notes and material, and 1-day lecture
Composition of student team	Preclinical students led by at least one student with clinical experience; mixed medical and nursing teams wherever possible; under the supervision of faculty physicians	Preclinical students led by at least one student with clinical experience; mixed medical and nursing teams wherever possible; under the supervision of faculty physicians
Number of patients seen per student, over the course of the program	16 patients	Eight patients

Table

Practice points

Service-learning is a powerful, but underutilized, educational tool in Asian medical schools. Service-learning programs, in the Asian context, have potential educational value for medical students in a wide range of domains. The home-based approach of providing medical care to low-income populations is superior at teaching certain aspects of community care as compared to the centre-based approach.

Table 2.  The pedagogical value of the PHS (clinic-based) and the NHS (home-based) for medical students who participated in either the PHS or the NHS program in 2010

	Participated in either NHS 2010 (N = 64) or PHS 2010 (N = 594)
Domains which student felt that service-learning program had helped them improve	Participated only in NHS 2010 n (%)	Participated only in PHS 2010 n (%)	Unadjusted OR (95% CI)	p-Value	Adjusted OR (95% CI)^1	p-Value
Leadership skills
Feel responsible for others in the community
No	4 (6.3)	76 (12.8)	2.20 (0.78–6.23)	0.159	2.04 (0.72–2.03)	0.182
Yes	60 (93.8)	518 (87.2)
Improve my leadership skills
No	19 (29.7)	192 (32.4)	1.13 (0.65–1.99)	0.778	1.16 (0.65–2.07)	0.623
Yes	45 (70.3)	401 (67.6)
Communication skills
Participate in community affairs
No	1 (1.6)	99 (16.7)	12.60 (1.73–91.92)	<0.001	11.23 (1.53–82.24)	0.017
Yes	63 (98.4)	495 (83.3)
Develop communication, listening and negotiation skills
No	2 (3.1)	90 (15.2)	5.54 (1.33–23.04)	0.007^a	4.69 (1.12–19.65)	0.034^a
Yes	62 (96.9)	504 (84.8)
Teamwork
Think of others
No	3 (4.7)	119 (20.0)	5.09 (1.57–16.52)	0.001^a	4.10 (1.25–13.44)	0.020^a
Yes	61 (95.3)	475 (80.0)
Appreciate teamwork and co-operation among peers
No	1 (1.6)	100 (16.8)	12.75 (1.75–93.03)	<0.001^a	11.03 (1.50–80.76)	0.018^a
Yes	63 (98.4)	494 (83.2)
Be tolerant of different people
No	2 (3.1)	110 (18.5)	7.05 (1.70–29.24)	0.001	6.09 (1.46–25.42)	0.013
Yes	62 (96.9)	484 (81.5)
Respect different opinions
No	6 (9.4)	116 (19.5)	2.35 (0.99–5.57)	0.061	2.02 (0.84–4.84)	0.115
Yes	58 (90.6)	478 (80.5)
Compromise
No	6 (9.4)	130 (21.9)	2.71 (1.14–6.42)	0.022^a	2.46 (0.99–5.64)	0.054^a
Yes	58 (90.6)	464 (78.1)
Comprehend the moral and ethical issues in healthcare
No	232 (39.1)	9 (14.1)	3.92 (1.90–8.08)	<0.001^a	3.41 (1.64–7.10)	0.001^a
Yes	362 (60.9)	55 (85.9)
Ability to see consequences
Think about the future
No	6 (9.4)	180 (30.3)	4.20 (1.78–9.92)	<0.001	3.67 (1.54–8.74)	0.003
Yes	58 (90.6)	414 (69.7)
Critical thinking skills
Think critically
No	9 (14.1)	163 (27.4)	2.31 (1.12–4.78)	0.024	2.00 (0.96–4.18)	0.066
Yes	55 (85.9)	431 (72.6)
Ability to identify social issues
Identify social issues and concerns
No	3 (4.7)	167 (28.1)	7.95 (2.46–25.69)	<0.001^a	6.63 (2.04–21.56)	0.002^a
Yes	61 (95.3)	427 (71.9)
Action skills
Take action
No	6 (9.4)	108 (18.2)	2.15 (0.90–5.11)	0.083	1.83 (0.76–4.41)	0.175
Yes	58 (90.6)	486 (81.8)
Build confidence and take on new responsibilities
No	0 (0.0)	133 (22.4)	1.14 (1.10–1.18)	<0.001	NC	NC
Yes	64 (100.0)	461 (77.6)
Gaining of knowledge
Appreciate and identify gaps or deficiencies in healthcare system
No	7 (10.9)	200 (33.7)	4.13 (1.85–9.23)	<0.001	3.53 (1.57–7.96)	0.002
Yes	57 (89.1)	394 (66.3)
Appreciate my own health, living condition
No	5 (7.8)	155 (26.1)	4.17 (1.64–10.57)	0.001	3.45 (1.35–8.84)	0.010
Yes	59 (92.2)	439 (73.9)
Improve knowledge on long-term management of chronic diseases
No	12 (18.8)	217 (36.5)	2.50 (1.30–4.78)	0.004^a	2.09 (1.08–4.05)	0.030^a
Yes	52 (81.3)	377 (63.5)
Appreciate challenges to healthcare faced by poorer Singaporeans
No	2 (3.1)	157 (26.4)	11.14 (2.69–46.07)	<0.001^a	9.07 (2.18–37.77)	0.002^a
Yes	62 (96.9)	437 (73.6)
Application of knowledge
Improve my ability to interact with patients
No	2 (3.1)	125 (21.0)	8.26 (1.99–34.25)	<0.001	6.68 (1.60–27.93)	0.009
Yes	62 (96.9)	469 (79.0)
Improve my ability to interact with patient's family/relatives
No	3 (4.7)	61 (95.3)	10.09 (3.13–32.56)	<0.001^a	9.06 (2.79–29.42)	<0.001^a
Yes	61 (95.3)	397 (66.8)
Be more confident in counseling patients to adopt healthy lifestyles
No	5 (7.8)	181 (30.5)	5.17 (2.04–13.10)	<0.001	4.36 (1.71–11.13)	0.002
Yes	59 (92.2)	413 (69.5)
Clearly understand criteria for recommending screening tests
No	7 (10.9)	167 (28.1)	3.19 (1.42–7.12)	0.003^a	2.62 (1.16–5.93)	0.021^a
Yes	57 (89.1)	427 (71.9)
Appreciate need to extend psychosocial help to patients
No	4 (6.3)	213 (35.9)	8.39 (3.01–23.39)	<0.001^a	7.15 (2.55–20.07)	<0.001^a
Yes	60 (93.8)	381 (64.1)
Be more confident in encouraging patient compliance
No	1 (1.6)	174 (29.3)	26.10 (3.59–189.67)	<0.001^a	22.48 (3.08–163.86)	0.002^a
Yes	63 (98.4)	420 (70.7)
Improve my ability to make a clinical diagnosis
No	20 (31.3)	267 (44.9)	1.79 (1.03–3.12)	0.046	1.86 (1.04–3.32)	0.036
Yes	44 (68.8)	327 (55.1)
Improve my ability to carry out clinical procedures
No	2 (3.1)	249 (41.9)	22.37 (5.42–92.33)	<0.001^a	19.87 (4.80–82.34)	<0.001^a
Yes	62 (96.9)	345 (58.1)

Notes: NC: The values cannot be calculated because of a zero value in one cell.

¹Adjusted for gender, degree of clinical exposure (pre-clinical or clinical year), and role in program (committee member or volunteer).

^aAreas in which there were differences in the educational experience reported by both students who had participated in PHS or NHS, and in students who had participated in both PHS and NHS.

Table 3.  The pedagogical value of the PHS (clinic-based) and the NHS (home-based) for medical students who participated in both the PHS and NHS programs in 2010 (N = 166)

	Participated in both NHS 2010 and PHS 2010 (N = 166)
Domains which student felt that service-learning program had helped them improve	Those who agreed for NHS n (%)	Those who agreed for PHS n (%)	p-Value
Leadership skills
Feel responsible for others in the community
No	164 (98.8)	146 (88.0)	0.039
Yes
Improve my leadership skills
No	133 (80.1)	106 (63.9)	<0.001
Yes
Communication skills
Participate in community affairs
No	163 (98.2)	152 (91.6)	1.00
Yes
Develop communication, listening and negotiation skills
No	165 (99.4)	147 (88.6)	0.016^a
Yes
Teamwork
Think of others
No	164 (98.8)	148 (89.2)	0.031^a
Yes
Appreciate teamwork and co-operation among peers
No	166 (100.0)	149 (89.8)	0.031^a
Yes
Be tolerant of different people
No	161 (97.0)	146 (88.0)	0.289
Yes
Respect different opinions
No	164 (98.8)	145 (87.3)	0.008
Yes
Compromise
No	162 (97.6)	141 (84.9)	0.002^a
Yes
Comprehend the moral and ethical issues in healthcare
No	145 (87.3)	123 (74.1)	0.004^a
Yes
Ability to see consequences
Think about the future
No	132 (79.5)	117 (70.5)	0.227
Yes
Critical thinking skills
Think critically
No	156 (94.0)	136 (81.9)	0.012
Yes
Ability to identify social issues
Identify social issues and concerns
No	159 (95.8)	128 (77.1)	<0.001^a
Yes
Action skills
Take action
No	164 (98.8)	149 (89.8)	0.125
Yes
Build confidence and take on new responsibilities
No	156 (94.0)	136 (81.9)	0.022
Yes
Gaining of knowledge
Appreciate and identify gaps or deficiencies in healthcare system
No	156 (94.0)	140 (84.3)	0.227
Yes
Appreciate my own health, living condition
No	150 (90.4)	135 (81.3)	0.250
Yes
Improve knowledge on long-term management of chronic diseases
No	138 (83.1)	114 (68.7)	0.004^a
Yes
Appreciate challenges to healthcare faced by poorer Singaporeans
No	165 (99.4)	121 (72.9)	<0.001^a
Yes
Application of knowledge
Improve my ability to interact with patients
No	152 (91.6)	146 (88.0)	0.289
Yes
Improve my ability to interact with patient's family/relatives
No	148 (89.2)	123 (74.1)	<0.001^a
Yes
Be more confident in counseling patients to adopt healthy lifestyles
No	154 (92.8)	143 (86.1)	1.00
Yes
Clearly understand criteria for recommending screening tests
No	163 (98.2)	142 (85.5)	0.013^a
Yes
Appreciate need to extend psychosocial help to patients
No	157 (94.6)	137 (82.5)	0.021^a
Yes
Be more confident in encouraging patient compliance
No	158 (95.2)	132 (79.5)	<0.001^a
Yes
Improve my ability to make a clinical diagnosis
No	136 (81.9)	118 (71.1)	0.092
Yes
Improve my ability to carry out clinical procedures
No	162 (97.6)	84.9 (92.2)	0.004^a
Yes

Notes: ^aAreas in which there were differences in the educational experience reported by both students who had participated in PHS or NHS, and in students who had participated in both PHS and NHS.