Using community diagnosis on primary care placements for medical students

ABSTRACT

Background: Over 35 years ago Julian Tudor Hart highlighted how medical undergraduate education needed to adapt to produce clinicians who were better situated in communities. However, we still struggle to engage medical students in understanding the social and environmental determinants of health, the value population level data and public health interventions. Our approach: Third year medical students carried out a community diagnosis project where they evaluated quantitative, qualitative and observational data for the community in which they were living. They examined Public Health England fingertips data to choose a topic, gathered and evaluated further information, considered potential solutions, and created a 5-min presentation for their small group tutorial. The students were supported by GP tutors from East London, allowing a novel role for GP tutors to teach on this topic. Evaluation: GP tutors and students gave positive feedback on both the design and delivery of the module. Students frequently made the link between their previous theoretical teaching in public health and the application of it in the GPCD module, appreciated the value of investigating their local area and commented upon the opportunity to consider the wider determinants of health. The GP tutors felt the project gave the students an insight into the lived realities of others. Conclusions: This module was an effective cross-collaborative approach between primary care and public health. It gave a practical application to build on previous theoretical public health learning, and evidence of transformational learning for the students, helping them to understand the impact of health inequalities.

KEYWORDS:

• Community based medical education
• health inequalities
• social and environmental determinants of health
• public health

Background

Over 35 years ago Julian Tudor Hart highlighted how medical undergraduate education needed to adapt to produce clinicians who were better situated in communities [1]. Community-orientated medical education is an approach taken by medical schools, using a range of techniques and tools, to support student learning about community related issues.

However, there remains challenge in engaging medical students in understanding some key underpinnings of community-based medical education – for example, the social and environmental determinants of health, the value of population level data and public health interventions. Critical failures still persist in medical education to adequately train sufficient primary care workers to address the social determinants of health and give enough attention to disease prevention [2]. The Lancet commission on medical education for the twenty-first century was highly critical of medical schools for not responding to community and societal needs in their curricula, stating that ‘fragmented, outdated, and static curricula are producing ill-equipped graduates’ [3]. Furthermore, the World Health Organisation (WHO) has called for ‘socially accountable’ medical schools, defining them as ‘the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region and/or nation that they have a mandate to serve’ [4].

It is recognised that medical school public health teaching can provide content and methods to assist this shift, and help produce graduates capable of responding to today’s healthcare challenges [5,6]. However, despite being increasingly emphasised by a variety of stakeholders [7–9], public health remains an area that is poorly engaged with by medical students and largely an under-represented discipline in medical curricula [10]. Students can often hold the perception of public health as being outside a doctor’s scope of practice [11]. There is also evidence of a lack of ‘inspirational teaching’ in public health with excessive focus on epidemiology and biostatistics rather than social justice issues [7].

At many medical schools, public health teaching is carried out by epidemiologists, researchers and academics, making it potentially harder for students to see the direct relevance of this teaching to their role as doctors in improving the health of their patients. Community-based experiences require students to consider the health needs of the populations with whom they work, as well as of individual patients within that community [12]; as such, GPs are ideally placed to teach about the health of their communities, which can allow students, whose focus is often on managing the individual health of patients, to see the importance of also addressing population health needs.

Methods

Third-year medical students undertook a week-long General Practice ‘community diagnosis’ module (‘GPCD’) as part of their undergraduate primary care teaching. The WHO has defined community diagnosis as ‘a quantitative and qualitative description of the health of citizens and the factors which influence their health’. It identifies problems, proposes areas for improvement and stimulates action [13,14]. The medical school uses a spiral curriculum design where there is an iterative revisiting of topics, subjects or themes throughout the course, this deepens knowledge with each successive encounter building on the previous one [15]. The GPCD module built upon both previous Primary Care placements and Public Health teaching in years 1 and 2, and aimed to provide a practical application of the Year 3 public health theoretical teaching that was delivered immediately prior to the GPCD module.

For preparation, the students were given background reading about undertaking a community diagnosis project and e-modules to explore health inequalities and Tudor Hart’s inverse care law. An initial small group tutorial allowed the students to discuss their findings from examining public health data, choose a focus their project on and brainstorm how to collect further data on this topic. As it was acknowledged the module ran over a short time-frame, students were signposted to example community topics to focus upon, such as obesity, fuel poverty, green space analysis and homelessness. Students evaluated quantitative, qualitative and observational data for the community in which they were living. They examined Public Health England (PHE) ‘fingertips’ data, and then gathered and evaluated further information via internet research and interviews with members of the local population.

A ‘drop-in’ session was organised later in the week for students to ask medical school academics any questions about their topic. Finally, in a second tutorial, the students presented their GPCD projects in a 5 min presentation, with the opportunity for other students and their GP tutor to ask questions and share experiences. GP tutors nominated the best presentations for a medical school prize. Students worked individually on their projects but were supported to carry out their projects by GP tutors from the educational community, allowing a novel role for GP tutors that taught on this module.

Evaluation forms were sent to students and GP tutors at the end of the placement for their feedback on this module, and students and GP tutors were invited to separate focus group interviews to discuss their experiences. A thematic analysis was undertaken of the student and tutor evaluations.

Results

By way of illustrating the range of projects undertaken, students presented on a variety of different topics ranging from childhood obesity to air pollution to isolation in the elderly. One project interviewed people who were homeless in Camden and suggested providing mobile phones could improve their access to healthcare. Another student investigated childhood obesity in Tower Hamlets by using a Facebook survey of local residents and observing the eating habits after school. They suggested a mobile van selling healthy eating options outside of schools could help address childhood obesity.

Medical student feedback

Students gave positive feedback about the prepared resources (such as the e-learning and the handbook), with many also specifically commenting upon the value of the independent data sources.

The Fingertips tool was really good.

I found the council ward profiles very useful and local government reports.

Students frequently made the link between their previous theoretical teaching in public health and the application of it in the GPCD module (the main aim of the module).

It felt related to real-life, gave a practical way to understand the theory from public health.

We discussed inequalities a lot in Public Health [teaching week], but when you see it this week in your area it gets really highlighted.

The module gave me the opportunity to get out into the community, identify issues and come up with ideas to solve them. Very interesting experience, highly valuable.

Students also talked about the value of undertaking the module in a context local to them.

When you are made to look at your own area, you take more in, seeing other peoples’ presentations – makes you think about where am I going to be working in, in the future … for my next [hospital] placement, I want to look at what the area is like there.

Interesting to learn about my local area, it has given me a greater insight into how health determinants shape health.

Doing my own research into my local area gave me an appreciation of how different life is for a student here compared to the average resident.

Students commented upon the opportunity to consider the wider determinants of health during the module.

It’s important to consider the why behind people’s health choices and behaviours.

Really agree, helpful to take a closer look, not just wider determination of health, but how everything interacts … thinking about how all of the info is available and how links to create problems …

The main criticisms of the module stemmed from the tight timeframes for the tutorials (only 75 min each) and the length of the module as a whole. Many students would have appreciated a longer time allocated to the module, especially to collect more qualitative data.

GP tutor feedback

GP tutors were also satisfied with both the design and delivery of the module by virtual format, recognising the value of this module for students when face-to-face placements were not possible. Many cited the preparatory e-learning modules as particularly strong resources. When GP tutors reflected upon the topics that the students had presented, they acknowledged the strength in the ‘richness in the variety … different topics in different areas’.

The GP tutors felt the project gave the students an insight into the lived realities of others.

Some really had their minds opened about the different realities that patients inhabit.

Actually doing a project in the area they were living in put into reality the theory they had been covering.

Lots chose to interview people they would not have had conversations with normally.

What was really powerful was students looking at an area they knew well. It was really powerful when the students realised something about their borough that they previously hadn’t considered, and it brought many things into plain sight and made them curious.

Finally, many GPs commented on their own enjoyment teaching it:

I loved doing the module and was so impressed by the students.

Loved the module - it is the best thing I have done in so many years.

I really enjoyed facilitating the sessions this week.

I was incredibly inspired by the student presentations and the work they were doing.

Discussion

The module was well received by both students and tutors in terms of content and format. Given that medical schools are currently continuing to teach during a pandemic, there was also strength in the overall module design in that it could be delivered both virtually and in person in terms of flexibility for future delivery. Although the module ran virtually, the students were still fully immersed in the communities which they were investigating and appreciated this. It is also gratifying to hear how much the GP tutors, most working clinically in the midst of a pandemic, genuinely enjoyed teaching this new module and recognised its value for both students and themselves.

Feedback particularly highlighted the strength of the resources provided as well as the opportunity for students to explore large datasets such as PHE Fingertips and local authority data.

Students made the link between previous theoretical public health teaching and this practical application of what had previous been learnt, acknowledging the ‘spiral curriculum’ design, which ensures that public health teaching is embedded through several stages of the medical school [15].

The thematic analysis of the evaluation also identified that the module had given students the opportunity to experience ‘transformational learning’, that is ‘leading the learner to re-evaluate underlying assumptions and worldviews to provide new perspectives’ [16]. This is supported by some of the GP tutor quotes which highlighted that in examining the areas in which the students themselves were living meant that the students gained new insights and understandings of these communities, and summarised in the following quote by a student:

A lot of peeps going to medical school are not from lower class background, so to look at areas of deprivation can be more eye opening; a medical student from well off family may have blinkers on and not be aware of what is going on in areas of deprivation.

Not just seeing but actually living the new perspective is a critical pillar of transformative learning.

The high level of student engagement in the module may partially stem from its timely introduction: health inequalities were being highlighted due to the Covid-19 pandemic, the Black Lives Matter movement, and medical students were calling for improvements in the ways that higher education institutions were preparing them to tackle health inequalities, racial discrimination and social injustices [17].

Although this module was delivered by the GP academic department at the medical school, it relied heavily upon previous public health teaching that had been delivered by different departments at different curriculum stages. Recognition at the curriculum design stage that teaching on applied Public Health topics can benefit from a collaborative cross-departmental approach as demonstrated here can potentially lead to a more authentic and effective learning experience for the students.

Disclosure statement

No potential conflict of interest was reported by thewere authors.