Abstract
Background: The General Practice Department of Fudan University recognised that a traditional didactic educational approach will not achieve expected learning outcomes. Therefore, the Department adopts an integrated learning and teacher-centred approach.
Aim: To evaluate the effect of introducing integrated learning and a teacher-centred approach to undergraduate medical education in China.
Methods: The concept of integrated learning and the use of a teacher-centred approach was introduced to the General Practice Department of Fudan University's ‘Doctor–Patient Communication Skills’ undergraduate course. A self-designed questionnaire and a questionnaire used by Fudan University to evaluate the students’ satisfaction with their tutors were used to survey 58 medical students.
Results: The self-designed questionnaire gave good reliability and validity results. Based on the survey, 88% of the students both enjoyed the course and rated it highly. The students also showed a high degree of satisfaction with their tutors.
Conclusion: Although the student numbers were low, their comments have indicated that the newly introduced, but optional course has achieved a highly desirable effect amongst the students. We believe that this effect has been created through a change from a didactic approach to teaching to a more student-centred approach and by giving meaning and purpose to the students learning; in effect making teaching and learning an enjoyable and satisfying experience for all.
Introduction
For many years, guided by a traditional teaching approach of teacher-centredness, teaching in China has created a ‘one-way, spoon-feeding’ ethic in its teaching, a very didactic approach from teacher to students, with undergraduate medical education often at the forefront of this style of teaching (Kwan Citation2002; Chang et al. Citation2004; Candela et al. Citation2006; Ridley Citation2007).
With a style that focuses more on ‘teaching’ by teachers than on ‘learning’ by students and lacking any interaction between the students and the teachers, passivity becomes a feature of Chinese students. They are seldom encouraged to express their own opinions through their own initiative, and lacking any opportunity to express their creativity or original thought, show little improvement in their own ability and comprehensive quality.
In recent years the more appropriate integrated learning style and teacher-centred approach has attracted the attention of more and more teachers (Benbassat & Baumal Citation2001; Li et al. Citation2010).
This teaching methodology gives both teacher and student an important role in learning. Both are engaged in a cooperative and collaborative effort to achieve defined learning outcomes, which focus on the needs of the student in terms of future practice, the skills and attitudes to support the student's new knowledge and personal interest. It focuses on the interaction between teaching and learning, and advocates support of the teachers’ and students’ enthusiasm and initiative (Candela Citation2006).
The learning environment itself is one of mutual respect, collaboration, cooperation and support. The teacher recognises that each learner is a unique individual and provides a variety of learning experiences essential to the development of each student, linking content and assessment to practice, while supporting the student's autonomy in identifying and resolving problems and giving the student confidence. So far, very little research on how to use this integrated learning and the teacher-centred approach has been carried in China, with even less pertaining to medical education (Ren et al. Citation2008; Yan et al. Citation2010).
The specialty of General Practice was introduced to China in the late 1980s, with the General Practice Department of Fudan University taking the lead position in China for General Practice (GP) education (Zhang Citation2009). The Department of General Practice came to realise that medical students per-se need help in learning how to interview patients, and to develop their communication skills, and created their new course ‘Doctor–Patient Communication Skills’ in 2009 to fulfil this need.
This is one of the few courses in China to deal with the subject at undergraduate level and to recognise that a traditional didactic educational approach will not achieve the expected learning outcomes. Therefore, the Department decided that it should adopt an integrated learning and teacher-centred approach for student learning, hopefully in order to achieve the desired outcomes.
Method
Fifty-eight medical students selected the ‘Doctor–Patient Communication Skills’ course, as one of their optional learning opportunities, during the Spring Semester of 2009. Because of the options approach and the present structuring of the curriculum, students were accepted from varying courses including: clinical medicine (5-year programme and 8-year programme students, grades 1–6), basic medicine (grades 2 and 4) and forensic medicine (grades 1, 3 and 5) . This variation in the student body reflects the somewhat complicated system of medical education in China, in which students study various pathways towards different levels of achievement and towards different specialties. The educational paths in Chinese Medical schools are different from Westerns models and are well described by Schwarz et al. (Citation2004) and Ren et al. (Citation2008; ).
Table 1. Educational pathways for medical education in China
The ‘Doctor–Patient Communication Skills’ course lasts for 18 weeks, providing two credit hours each week, and providing 10 weeks of lectures and 8 weeks for practice.
The course is taught by two Professors, three Associate Professors and nine GP teachers from the General Practice Department of Fudan University.
The content of the course covers the history of medicine, the humanistic spirit of medicine, medical ethics in China and comparison to International models, the ethics of being a clinician/practitioner, interpersonal relationship skills, medico-legal aspects of the consultation and the doctor–patient relationship including effective and varying communication, plus the effects of behaviour upon communication.
The course places emphasis upon the tutor-student interaction, especially during the eight weeks of practice courses. This takes the form of group discussion, role-play, video analysis of students’ communication with patients and self-reflection exercises, together with practiced communication on standardised patients.
Data collection from the students was carried out by using a self-designed questionnaire (). It covers general demographic data of students (age, gender, grade and clinical major) as well as a student's personal evaluation of the tutors and the teaching. The questionnaire contains 28 questions about the students’ opinions of teacher's attitude, teaching methodology, classroom management and teaching content, the effect of the teaching and the interaction between the teacher and the students.
Figure 1. Self-designed evaluation questionnaire.
The evaluation of the course uses a five point grading scale, ranging from very satisfied (5), satisfied, ordinary, deficient in areas to bad (1). The reliability of the evaluation questionnaire was tested with Cronbach's alpha coefficient and showed a high degree of reliability. The validity of the evaluation questionnaire was tested with Spearman Rank Correlation Coefficient and it also showed good correlation among various aspects of the questionnaire. Each evaluation questionnaire is followed by five free-text questions covering any general comments on the course, existing problems and future suggestions.
The questionnaire from Fudan University, related to the student's satisfaction with their tutors consisted of 11 items pertaining to overall satisfaction.
Students were surveyed at the end of the course and the two questionnaires were collected before the students left classroom. A total of 116 questionnaires (two for each student) were collected, giving a total response rate of 100%. However, as seen from the various tables not all questions were answered by the students.
Statistical analysis
All the data from the questionnaire were inputted into Excel and analysed with SPSS 11.0.
Results
General demographic information of the students
The students consisted of 25 males and 33 females, with ages from 19 to 28. Among them, the majority (50) majored in clinical medicine, five of them majored in basic medicine and three in forensic medicine. For the clinical medicine group, there were 40 students from the 5 year Bachelors programme (two from Grade 5, eight from Grade 4, nine from Grade 3 and 21 from Grade 2). From the 8 year Masters/Doctoral programme there were 10 students (one from Grade 6, eight from Grade 3 and one from Grade 2)
Of all the students, 16 are in Grade 4 and above (senior), 42 are below Grade 4 (junior) (Table 2).
Reliability and validity of the evaluation questionnaire
Reliability
Reliability refers to the reproducibility of measuring tools, and indicates the proximity of the results from repeated measurement. It reflects to what extent the measuring tools can identify differences between the subjects tested. The higher the reliability coefficient, the more reliable the test result. Analysis with Cronbach's alpha coefficient indicates that the self-designed assessment questionnaire is well internally-consistent at different aspects. The Cronbach's alpha coefficient of each aspect of the evaluation is over 0.7, the coefficient in total is 0.951, which shows a high degree of reliability of the results ().
Table 2. Basic information of students
Table 3. Reliability of self-designed evaluation questionnaire
Validity
The validity of evaluation questionnaire mainly refers to consistency between measured results by the evaluating tool and the real situation. It basically evaluates the authenticity and accuracy of the results of the evaluation tool. The higher the validity, the more capable the tool is to show the authentic character of the subject of study. The Spearman Rank Correlation Coefficient was used to analyse the correlation between the dimension of each aspect of the questionnaire and it indicates a good correlation between the various aspects ().
Table 4. The validity of the self-designed evaluation questionnaire
Result of general evaluation
Based on the evaluation, we found that the students rate the course highly in respect to teacher's attitude, teaching means and method, classroom management and teaching content, teaching effect and interaction between teacher and students. For various evaluation aspects, each average score stands at over 90 points and the median is over 95 points. The median is a parameter for central tendency measurement or average level. It is the middle measurement in a set of measurements that are arranged in order. Actually it is the fiftieth percentile when percentiles are used. In this study, as the set of measured variables of scoring are not normally distributed, it is more significant to use median than average score to designate the central tendency ().
Table 5. Evaluation scoring at different evaluation aspect in percentages
The students, regardless of which grade they are in and regardless of sex or type of major, appear to have the same opinion of the course and the differences of evaluation scoring are shown to have no statistical significance.
Evaluation of students’ degree of satisfaction with teachers
The evaluation results show that students have a high degree of satisfaction with their tutors/teachers. For the 11 items surveyed, nine items showed a satisfaction rate (including very satisfied and satisfied) over 95%, other items, i.e. offering efficient and convenient means of communication with students, show satisfaction rates of 90.87%, and another item, linking content to the latest ideas, concepts and achievements, shows satisfaction rates of 91.31% ().
Table 6. Assessment of student's degree of satisfaction with teachers
Areas of improvement and suggestions about the course
The evaluation shows that 87.92% of the students liked the new course. The students liked the practice course better than lectures.
During the evaluation, the students pointed out that the teachers of this course are knowledgeable, enthusiastic and humorous. They are full of charm and experience, conscientious in their work and they use different teaching methodologies appropriately and they are flexible in teaching. Their lecturing is novel, lively and visually attractive. The teaching contents are rich, practical, deeply meaningful, persuasive and enlightening. The teachers guide the students in discussing their own ideas and initiatives. The teacher–student interaction is satisfactory and the teacher's positive remarks on students give them confidence.
They think the atmosphere of the class is lively and students’ own initiative, and personal interest of learning, are heightened. Also, the humanistic spirit and the communication skills acquired in the course attracted the students greatly. Some students gave comments that the ‘Doctor–Patient Communication Skills’ course is the most lively course in the medical school and they look forward to each session.
However, some students point out that the course, being new, lacked an associated textbook, restricting their understanding and command of knowledge. Due to the fact that no restriction is imposed on the grade of students to select the course, there are some lower-grade or junior students, with a degree of lack in medical knowledge, who have some difficulties in understanding some of the cases. Also, some students think that as 58 students have selected the class, it is too large and not everyone has the chance to interact in the class, and the teacher–student interaction is restricted to a small number of more vocal students.
Discussion
During the course of teaching, the teachers paid much attention to some key areas of the integrated learning and teacher-centred approach:
making effective preparation of a teaching plan and creating purpose for the learning;
teachers tried their best to collect practical, authentic and realistic cases for their teaching and select proper means according to different teaching contents (He et al. Citation2007);
encouraged the students to use their own initiative. In integrated learning and a teacher-centred approach, the teacher is not just the designer and organiser of a teaching plan, but is also the guide and promoter of the teaching activities. The teacher's duty is to involve the students and encourage them to speak out whatever they want to say and avoid spending too much time in unnecessary issues. The teacher should excite the students’ interest in the topics so as to create an enthusiastic academic atmosphere. Also, the conduct of the class and the effect of education shall be ensured (He et al. Citation2007; Ridley Citation2007; Curry Citation2008; Dalley et al. Citation2008);
the teaching process stresses personal enlightenment and guidance. The teacher must guide students in actively participating in all teaching activities, letting students show their views, cherish and encourage students’ creativity of thinking and encourage them to challenge. Teachers should also respect different ideas, tolerate and accept wrong opinions whilst guiding the students to the truth, guide students to listen to others’ ideas, and respect views that differ from their own. The teacher shall help students learn how to compare and analyse through the process of understanding, discussion, memorisation and feedback. The teacher shall also help students to improve the ability to think, communicate and analyse problems;
teachers should try and use different and appropriate methods of teaching and learning (Benbassat & Baumal Citation2001; Curry Citation2008; Pinheiro & Heflin Citation2008; Steven et al. Citation2008; Bratt Citation2009). The General Practice Department encourages and actively uses small group discussion, role-play, video analysis and self-reflection exercises and uses standardised patients to promote reality. The problems must be designed and submitted as in the real world that the students will encounter in their future professional field. For example, the teacher uses important topics such as ‘breaking bad news’, ‘how to communicate with angry relatives of the patient’ etc. and allows the students to act either as the doctor, patient or relative. After they have finished role-play, the teacher encourages the students to discuss the advantages and disadvantages of each of them rather than teaching the students that there is a right and a wrong way to interview patients.
In this specific course, the students are put in the specific situation and acquire essential experience in communication. Their boldness is fostered and confidence heightened. Also, the standardised patient was used to promote reality. The class was divided into three groups. Each group communicated with one standardised patient. The standardised patients were trained specially before the class commenced. The teacher permitted the standardised patient to take control of the interview and talk not only about his / her symptoms, but also about his / her personal and family situation, preferences and concerns. Afterwards, all the students express their personal opinions, and the standardised patients give their own comments on the student's behaviour, creating a useful feedback loop for student learning. Later, it is the tutor's function to give comments and to summarise the student's activity with a view of overall improvement.
As a research activity, this article itself has created a useful learning activity amongst faculty members. Although they were not personally asked to complete an evaluation questionnaire, it was felt that they all gained from this new approach.
The weaknesses of the study are in the low number of students created by the options approach to the course and the inconsistency within the numbers of students answering all aspects of the questionnaire. This maybe due in part to a cultural norm of non-blame amongst students to their respected tutors.
As a new course, the ‘Doctor–Patient Communication Skills’ course still has some deficiencies in its teaching practice and needs further improvement. The priority problems for future improvement is how to balance the numbers appropriately: to restrict the number of attendees to each individual course, so as to increase the opportunity of interaction and understanding, whilst increasing the number of times the course is offered to ensure all students are given an opportunity to develop the core skills defined. It would also be of advantage for students to be given extra opportunity to take their newly developed skills out into the real world of real patients, whether it is in the hospital or the community. Listening to the students, it would also be of help to either create a specific text book for the course or use a standard text from other countries.
Conclusion
The students’ comments have indicated that the new teaching course was an enjoyable learning experience, something not always experienced by students in China. Therefore, we believe that our approach is a valid contribution to the clinical training of medical students. The students’ comments have indicated that the new optional course, ‘Doctor–Patient Communication Skills’, has achieved a good effect, making teaching and learning an enjoyable and satisfying experience for its participants.
Acknowledgements
The authors recognise that this work could not have been carried out without the never ending support of Professor Zhu Shanzhu, Director of General Practice Department of Fudan University. The authors would like to thank Prof. Trevor Gibbs, Dr. Yu Danghui and Dr. Zeng Yong, for their many helpful comments and suggestions on writing this article.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
Funding
Research for this article was supported by the Department of General Practice, Fudan University.
Conflicts of interest
None.
Ethical Approval
This study was approved by Shanghai Medical College Ethics Committee.
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