Professional Documents
Culture Documents
1, 2002
TWELVE TIPS
AMANDA HOWE
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK
SUMMARY Teaching and learning in primary care and experience: and the last three address factors pertaining to
community settings is now a very common aspect of most the tutor and their peer setting.
medical trainings, and there is a growing expertise and evidence
Med Teach Downloaded from informahealthcare.com by Library of Health Sci-Univ of Il on 10/28/14
ISSN 0142–159X (print)/ISSN 1466–187X online/02/010009–04 © 2002 Taylor & Francis Ltd 9
DOI: 10.1080/00034980120103423
Amanda Howe
Tip 3 learner(s) will require some protected time with the lead
tutor, and this will require preparation by both parties,
Community-based learning is a culture shock: induct students
especially if the course objectives are complex or require
into it
technical equipment. Students will also need protected
Whether students enter community settings early in their time with appropriate and consent-given patients, and the
course or after a number of years in training, they may tutoring staff will themselves need protected time to
find the combination of undifferentiated clinical problems, develop their skills, plan teaching sessions, and evaluate
the less hierarchical environment and the emotional nature their impact. With a small team in a community setting,
of the patient’s world-view a considerable personal chal- there will be little likelihood that staff can teach at short
lenge. This is particularly the case if they have been notice, so forward planning and resource input are both
located away from their peer group or usual lifestyle: for essential for genuine availability of protected time.
example, if an individual is attached to a primary care Community staff therefore need to be proactive in their
team on a residential rural placement. Prior sensitization approach to the learning programme, in order to assure its
training afforded to many professional workers entering quality.
new cultural settings is often neglected by central curric-
ulum planners, so the need to brief (and debrief) students
Tip 6
early in the attachment may make a considerable differ-
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ence to their attitudinal adaptation, and to their Support and guidance—make the most of the exceptional poten-
understanding of the factors influencing community staff tial of community-based learning for pastoral care and personal
behaviour. The first contact with a community can be a mentoring
marvellous learning experience if well handled, and espe-
The clinical method of primary care-based staff lends itself
cially if the peer group can compare and contrast their
to the use of relationships to extend learners’ potential.
experiences within the learning setting, thus ‘bringing
They often see students in smaller cohorts, making the
unsystematised personal experience under critical control
learners’ needs and abilities more visible. Students value
by developing greater awareness of how it is used, and re-
personal feedback on their performance greatly, often
examining taken for granted assumptions’ (Eraut, 1994).
having unwarranted concerns about their own abilities.
This does not imply a need to convert the students to your
Community staff should make the most of their consider-
own values, but to be open and reflective about their
able interpersonal skills to develop student insight into
For personal use only.
developing understanding.
their performance (both strengths and weaknesses), and
can also be valuable to central staff in picking up students
Tip 4 with problems.
Many community staff have responded to their new role
The curriculum—know why the learners are there
with a touching concern for the personal well-being of the
Many medical staff in primary care have not adjusted to students (Howe et al., 2001). A tendency to advocate on
the changes in community-based teaching since they were behalf of students may need to be moderated in discussion
sent to a GP for a two-week ‘sit in and see what we do’ with central faculty, who will have a broader view of both
course of the opportunistic (and often counterproductive) the statutory regulations and the need to be equitable
kind. Although learners differ, there is a clear educational across the peer group. Nevertheless, taking up issues on
imperative to understand the nature of the curriculum, behalf of individuals and the group may be immensely
and to arrange the learning opportunities accordingly. It is valuable, and can bring about important quality
essential that staff and students establish a common view improvements.
of their learning needs; that tutors appreciate any core
objectives for the community placements; that they know
Tip 7
something of where the placement fits within the broader
curriculum; and that the basic facts are also conveyed to Assessment—take it seriously
other staff who play a role in the learners’ experience.
There are many developments in medical education
While structured teaching may be challenging to
designed to make assessment both an adequate reflection
the vagaries of the clinical setting, it is known that
of the eventual professional role, and reliable across
community-based teaching can both be valued for this
different settings and assessors. It is, of all the key elements
(Howe, 2000) and criticized if the placement opportunities
of a medical curriculum, the one that is particularly scruti-
appears to depart from the placement’s goals (Roberts
nized by external bodies such as the General Medical
et al., 2000).
Council. One of the biggest challenges to face community-
based tutors and their academic colleagues is the role of
Tip 5 such a dispersed group in assessment, given the challenges
that this brings to reliability. Community-based staff,
Ensure some precious protected time—it is essential to teaching
unlike hospital or university staff, rarely get together, and
and learning
are often even more diverse as individuals than those oper-
Each course organizer should specify the extent to which ating in secondary care. The tip here is to ensure that you
learners can work unsupervised (senior student clinic), in understand what your role is in assessment. Faculty should
conjunction with you (shared learning), or need 100% train you for this task as much as for the teaching, as the
commitment (group tutorial). In any placement, the consequences of an inaccurate or unjustifiable summative
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Twelve tips for community-based medical education
Tip 8
Tip 11
Med Teach Downloaded from informahealthcare.com by Library of Health Sci-Univ of Il on 10/28/14
modate large numbers of students but it is rare that the current crisis in professional confidence is harsh for all
building of new additional premises can be justified, espe- disciplines, but undermining the motivation of primary
cially in settings that are owned by the doctors rather than care teams to teach would be an unjustifiable outcome
the health service or university. Successful teaching can given the burgeoning evidence base of good practice by this
occur in other locations (e.g. a community hospital) if they sector. Nevertheless, there continues to be a sense in which
are easy and safe to access, familiar to patients, and simi- community-based courses are marginal to the positivist
larly equipped. bioscience that dominates most medical schools, and the
pendulum of power may swing the other way. This may
sound overly political, but there is an international agenda
Tip 9
for medical schools about their …
Learning from experience—the value of being involved in
education for the tutor’s own professional development
Tip 12
All key community staff who take responsibility for medical
Social accountability—community-based learning is in the front
education should be given appropriate staff training and
line
regular updates, with provision of guidance for other staff
who make an occasional contribution. If this is not avail- The moral imperative to move medical schools from ivory
able, the programme organizers should be reconsidering tower to public reciprocity is one with which the majority
their position! Staff training, new contact with one’s peer of primary care staff will have some sympathy. As patient
group, the constant stimulus of being involved with advocates, and with the daily experience of our patients’
students, and the role of reflection and evaluation in socioeconomic sufferings, family medicine has been key to
developing one’s own skills are all valuable opportunities confronting the dehumanizing aspects of both medical
for continuing professional development, and can be care and medical education. One of the key roles that
accredited towards revalidation. The quality uplift of prac- community-based learning can play is to show students
titioners’ skills by becoming involved in teaching is well real life; for staff, this means supporting students in their
established (Murray et al., 1997), and the policy of using dawning awareness that doctors should be socially
active educational environments as an incentive to recruit- accountable (and ensuring that this leads to a moral chal-
ment of staff is widespread in Europe and Australasia lenge rather than despair!). Staff often cannot articulate
(Worley et al., 2000). The ‘cycle of satisfaction’ experi- why it is that they feel students should have more commu-
enced by community-based tutors (Howe, 2000) is a nity exposure—but it may be that it is only when exposed
potential protection against burnout, because it reduces the to the humour and courage of people in their everyday
professional isolation inherent in community practice, and interactions with health and illness that we can truly see
can also unite teams in a new common task. Which relates the limits and the great opportunities which becoming a
to the need to … doctor affords to us.
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Amanda Howe
H ABBICK, B.F., & L EEDER, S.R. (1996) Orienting medical education MURRAY, E., JOLLY, B. & M ODELL, M. (1997) Can students learn
to community need: a review, Medical Education, 30, pp. 163–171. clinical method in general practice? A randomised crossover trial
H AMPSHIRE, A. (1998) Providing early clinical experience in primary based on objective structured clinical examinations, British
care, Medical Education, 32, pp. 495–501. Medical Journal, 315, pp. 920–923.
H OWE, A. (2001) Patient-centred medicine through student-centred R OBERTS C., H OWE A., W INTERBURN, S. &, F OX, N. (2000) ‘Not so
teaching—a student perspective on the key impacts of community- easy as it sounds’—a study of a shared learning project between
based learning in undergraduate medical education, Medical medical and nursing undergraduate students, Medical Teacher, 22,
Education, 35, pp. 666–672. pp. 386–391.
H OWE, A. & I VES, G. (2001) Does community-based experience W ORLEY, P., S ILAGY, C., PRIDEAUX, D., N EWBLE, D. & JONES. A.
alter career preference? New evidence from a prospective longitu- (2000) The Parallel Rural Community Curriculum: an integrated
dinal cohort study of undergraduate medical students, Medical clinical curriculum based in rural general practice, Medical Educa-
Education, 35, pp. 391–397. tion, 34, pp. 558–565.
For personal use only.
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