GP trainers: Innovations in medical undergraduate teaching

New techniques are being used in undergraduate medical teaching.

Students felt ethics training was better learnt in work groups
Students felt ethics training was better learnt in work groups

Dr Linda Miller discusses the benefits and how they may shape future GPs.

As increasing numbers of medical graduates are accepted into UK medical schools each year, the undergraduate curriculum is changing.

Innovations in learning aim to engage large numbers of students in new and exciting ways. The learning techniques discussed below are not restricted to medical students and will equally benefit GP registrars.

Computer-assisted learning
Internet-based learning is increasingly used in the undergraduate curriculum. Work can now be done, assessed and feedback offered online. Students can work at their own pace and repeat modules until they are satisfied with their understanding and self-assessments.

With increasing numbers of medical students, this is an efficient way of delivering factual knowledge. Some students appreciate the opportunity to ask questions online rather than in a full lecture theatre.

Online forums can be developed to stimulate debate. In addition, lecturers can monitor who is online, for how long and how many times modules are repeated.

A team of psychiatrists at Edinburgh University recognised that e-learning could be useful and have developed interactive modules, including a module on alcohol, which takes the form of a 'virtual soap opera'.1

Elsewhere, modules have been developed to enhance clinical skills, such as learning how to weigh and measure a baby.

Although there are few studies with clear predefined outcome criteria, in a review of the evidence for computer-assisted learning (CAL) outcomes were generally positive.2

Effectiveness and cost-effectiveness are yet to be proven although the benefits of remotely accessible material for students on community placements are clear. In the future online learning modules may be shared between universities and students may select a variety of face-to-face and online modules from different sources.

Students recognise that some topics are more appropriate for other styles of learning. A questionnaire showed that many students felt ethics was better learnt in groups work rather than just lectures.3

Problem-based learning
Problem-based learning (PBL) is now part of the curriculum in at least one-third of British medical schools.

PBL is defined as a method involving problem-first learning via work in small groups and independent study. The group examines a scenario, utilises prior knowledge and identifies learning objectives.

The group develops its research, critical appraisal, presentation and interpersonal skills, taking it in turns to chair and scribe the meeting.

Learning objectives are identified and distributed and after research is presented to the group. Reflection on the learning outcomes and peer feed-back on individual performance completes the cycle.

However, some feel that PBL has been too widely accepted despite a lack of rigorous assessment.4 One systematic review found inadequate literature to perform a meta-analysis but found positive outcomes from the papers that were studied.5

For those who had PBL undergraduate training, self-assessments were high regarding competency in team work, continuity of care, appreciation of social and emotional aspects of healthcare, legal and ethical aspects, attitudes to personal health and well-being, use of IT, evidence-based medicine and coping with uncertainty.

Reviews of medical student opinion and clinical competence of F1 doctors support PBL, but critics argue that only long-term assessment of competence, such as incidence of complaints, will give true feedback.

Consultation skills
Emphasis on communication skills in the medical curriculum has increased in recent years.

Many schools use consultations with actor patients, audiovisual recording assessment and feedback in small groups to develop communication skills.

Students learn the importance of body language, how to detect verbal cues and how to use silence and empathic statements sincerely and appropriately. Ethical dilemmas, giving bad news and dealing with embarrassing problems can all be incorporated into scenarios used in these sessions.

Final year students can develop their skills in differential diagnosis and management. The sessions also teach students how to give and receive peer feedback.

Cross-specialty integration
Most medical schools are endeavouring to increase vertical integration; integrating basic sciences with clinical practice.

In the future, there may well be better cross-specialty integration, for example combining hospital psychiatry with primary care sessions in psychiatry.

A study in Birmingham found that benefits included: a greater breadth of experience; a better understanding of the patient experience; learning about mental illness from the GP perspective and the normalisation of mental illness and increased empathy.6

Portfolios
Many medical schools use a logbook approach so undergraduates can document their new skills. Incorporating techniques, such as significant event audit (SEA), can encourage reflection to identify learning needs.

Students on a three-week GP placement who used a portfolio said they thought more about the patients that were the subject of their SEAs and valued the support from their GP teachers, but found the approach time consuming.

It is recognised that learning triggered by emotion (eg. a reaction to a significant event) is longer lasting than purely 'intellectual' learning.

Further assessment of longer-term portfolio use and its effects would be interesting.7

Students are strategic learners; they will inevitably commit most time to learning that specifically relates to exam performance. New interactive learning methods are a variation from lectures and rote learning.

Whatever mode of teaching is used, to ensure attendance or involvement there must be some form of assessment following the teaching.

  • Dr Miller is a GP and medical student tutor in west London
Learning points

1. Computer-assisted learning lets students work at their own pace.

2. Problem-based learning is a technique using group learning.

3. Learning to give and receive feedback is an essential skill for a medical career.

4. Techniques such as significant event audit encourage reflection to identify learning needs.

References

1. Hare E, Evans P, McIntosh CE, Thomson LDG. Case-based online learning for medical undergraduates. Psychiatr Bull R Coll Psychiatr 2007; 31: 73-5

2. Greenhaigh T. Computer assisted learning in undergraduate medicine. BMJ 2001; 322: 40-4.

3. Johnston C, Haughton P. Medical students' perceptions of their ethics teaching. Med Ethics 2007; 33: 418-22.

4. Norman G. Problem-based learning makes a difference, but why?. CMAJ 2008; 178 (1): 61-2.

5. Koh G, Khoo HE, Wong MK, Koh D. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ 2008;178 (1): 34-41.

6. Oakley C and Oyebode F. Medical students' views about an undergraduate curriculum in psychiatry before and after clinical placements. BMC Medical Educ 2008; 8: 25.

7. Grant A et al. Exploring students' perceptions on the use of significant event analysis, as part of a portfolio assessment process in general practice, as a tool for learning how to use reflection in learning. BMC Medical Educ 2007; 7:5.

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