Letters to the editor

Attitudes to undergraduate medical training

Dear Sir

Training for medical undergraduates in the United Kingdom has undergone considerable reform in recent years with a greater emphasis on problem based, self-directed learning and a drive away from traditional structured teaching. The GMC recommends that ‘factual information be kept to the essential minimum’. There is no evidence that these changes produce doctors better equipped for clinical practice.

A qualitative study involving two videotaped 45-minute discussions was conducted, involving groups of medical teachers and final-year medical students from Guy's, King's and St Thomas’ Hospital Medical Schools, London, at a district general hospital in South East England. Recurrent themes in these discussions were identified and explored in the context of recent changes in the delivery of medical education in England.

Themes from the teachers’ interviews included:

• the need for a strong knowledge base: recognition that ‘complete’ doctors cannot be produced in five years; the teachers favoured an apprenticeship style of teaching;

• teaching should encourage problem-solving and clinical decision-making but trends away from traditional curricula are having the opposite effect.

  What you can give with your good manner and good behaviour should not be a substitute for your ability to deal with the patient.

• teachers should be facilitators in self-directed learning: without appropriate guidance students are not likely to filter and discriminate information.

  What is very conspicuous is that a lot of what a student sees, he does not connect; and he does not understand the difference between learning and connecting information.

The following themes emerged from the student interview:

• structured small-group bedside teaching and tutorials are favoured: students agreed that clinicians with an interest in teaching should have time set aside to teach topics they feel are relevant on the wards;

• the need for strong knowledge base prior to clinical exposure: a basic knowledge of clinical medicine and pathology is required in preparation for clinical attachments;

• the quality of clinical teaching on student attachments varies widely;

• problem-based learning is unpopular: all students felt self-directed learning worked well only after formal teaching on the subject.

Conclusion

Reforms in the medical undergraduate curriculum have met with moderate success. While everyone agrees on the need for doctors to be empathic, analytical and good communicators, a sound grasp of clinical principles, basic knowledge and reliable clinical skills are essential.

Georgina Malakounides¹, Emyr Prys Moelwyn Humphreys² & Seema Biswas¹

¹Department of General Surgery Kent and Canterbury Hospital Canterbury, Kent, UK

²Department of Rheumatology University Hospital of Wales Cardiff, UK Email: [email protected]

Connecting passions: medical students and teachers in paediatrics

Dear Sir

In redesigning our medical student curriculum, we unearthed a valuable learning opportunity. First, we noticed that an increase in problem-based/small-group learning was in fact going to exclude a number of experts who had valued making a contribution to the medical students’ learning via lectures. Simultaneously, we realized an untapped resource: the large number of clinical and research experts throughout this major teaching hospital who had previously not taught the medical students. We recognized that, with an appropriate mechanism, we could provide a rich and vast field of ‘learning by networking’ for the students (Bligh, 1985), and that more individual choices of study areas in project-type work could foster self-directed learning (Murdoch-Eaton & Jolly, 2000).

This recognition builds on the identification by Harden et al. (1984) of five reasons to support the inclusion of electives in the curriculum: coping with the overcrowded curriculum; providing students with increased responsibility to further their own learning; facilitating career choice by students; meeting students’ individual aspirations; bringing about attitude change. Our process has identified additional reasons.

We now have a successful elective programme within the nine-week Child and Adolescent Health course. We approached a number of subject experts throughout the hospital—and eventually more approached us—and, if interested in hosting an elective, they were assisted in writing objectives and resources/learning opportunities to guide a student's learning over 4–10 hours of study. The emerging electronic bank of over 50 electives accommodates the interests of approximately 300 students in four terms per year. Many supervisors take more than one student in their elective.

The supervisor monitors the student's work and assesses the achievement of the objectives in either a two-page report or a presentation to their department meeting. We also select 10 students to present to the whole student body in what has become a central and respected event in the final week of the programme each term. Many of these presentations are very clever and creative; one student presented a poem, which was subsequently published in a medical journal (Richards, 2004).

Occasionally, supervisors and other teachers have been critical of a lack of ‘self-directedness’ amongst the students but more commonly the supervisors enjoy having a student who has a particular interest in their field. In routine exit surveys, students’ experiences are monitored and they too mostly report satisfaction with the programme. We have had success in matching passions and recommend the process to others.

Jenny K. Gough, Zoe McCallum & Michael Marks

Royal Children's Hospital, Melbourne/

Department of Paediatrics,

University of Melbourne, Australia

Email: [email protected]

Student attitudes towards the doctor–patient relationship in a medical college in western Nepal

Dear Sir

Patient-centred care taking into account patients’ preferences, concerns and emotions may achieve more favourable patient outcomes (Stewart, 1984). Many medical schools teach communication skills and humanistic attitudes to their students. The Manipal College of Medical Sciences, situated in Pokhara, western Nepal is affiliated to the Kathmandu University for undergraduate teaching. The preclinical curriculum (first four semesters) is integrated, organ system-based and partly problem-based. The student attitude towards the doctor–patient relationship was assessed among the first, second (preclinical) and sixth (clinical) semester students in the month of August 2003. Demographic information was collected; student attitudes were measured using the previously validated Patient-Practitioner Orientation Scale (Krupat et al., 1999). The total, caring and sharing scores were calculated and the association of the scores with the demographic variables was noted.

In total, 71 first-, 94 second- and 86 sixth-semester students participated in the study (91.3% of the 275 eligible students). The mean ± SD total, caring and sharing scores were 3.66 ± 0.5, 3.46 ± 0.57 and 3.86 ± 0.64 respectively. Extroverted respondents had higher caring scores. The sixth-semester students had lower scores compared with those in the first and second semester. Among the sixth-semester students, the self-financing students had a higher total score. No significant association of other variables with the scores was seen.

Our scores were lower than those reported in a previous study and no influence of gender on the scores was seen (Haidet et al., 2002). Social norms in South Asia favour a more doctor-centred relationship. With increasing education, the nature of the relationship is changing. Many students have been educated in English-medium schools and have difficulty in communicating in the languages spoken by the patients. Further studies are required; the results obtained from the present and future studies will be helpful in designing doctor–patient relationship courses for Nepal.

P.R. Shankar, A.K. Dubey, P. Subish & V.Y. Deshpande

Department of Pharmacology

Manipal College of Medical Sciences

PO Box 155, Deep Heights

Pokhara, Nepal

Email: [email protected]