Early clinical exposure in primary care – an experience from Slovenia

Marija Petek ŠterIgor Švab

Janko KersnikNena Kopčavar GučekZalika Klemenc Ketiš

Davorina Petek

Department for family medicineUniversity of Ljubljana

SloveniaDepartment for family medicine

University of MariborSlovenia

Content

• Introduction by participants ( 10’)• Short presentation of Slovenian ECE curricula:

background, presenting our experiences about early clinical exposure (ECE) (30’)

• Buzz grope (three participants) – discussing about the situation on their own faculty ( country) (30’)

• Plenary discussion with presenting different experiences and ideas (20’)

ECE- background

• Early clinical exposure (ECE) helps medical students to develop appropriate attitudes towards their learning and future medical practice.

• ECE increase the student’s motivation for theoretical studies

• opportunity for improving communicacion skills• hepful in established a good doctor-patient

relationship and understand the patient as a human beeing

ECE – background

• Traditional medical schools: two or three years elapse befor students come into contact with patients

• Modern medical schools: Early contact with patients

• BMJ 1976: description of Early medical contact in Southampton (Grat Britan): introduce students to a healthy women during pregnancy, labor, the puerperium and during the six weeks after delivery.

• Many medical schools practice ECE in the first two years of the undergraduate course.

ECE in general practice

• Communication is a core element of general practice

• GPs can make important contributions to teaching of interviewing skills, even to students with minimal clinical experiences

• Students find the environment of general practice supportive and appreciate the variety of patients seen and individual tuition.

• GP’s : emotional needs: contact with enthusiastic students and gain in self-esteme

ECE in Slovenia• Changes of curriculum in medicine and dental

medicine at Medical faculty Ljubljana 2009/10• Before 2009: the firs contact with patient in the 3rd

year (propedeutics)• New curriculum at the Medical faculty of Ljubljana

introduced early clinical exposure for the first year medical students through the subject “Communication”.

• Decision for the introduction of this subject is based on the empirical recognition of the fact that previous programme lacked the necessary knowledge and experience for good interpersonal communication

Aim of ECE

• To teaching and learning medical students about the importance of communication in contact with patient, to teach the basic principals of communication with people and patients and help students to understand that good relationship with patients and colleagues are of outmost importance for effective treatment.

Objectives of ECE

• Providing students with the basic knowledge on medical psychology

• teach them how to communicate with healthy people and patients

• present them the rules for communication within a small group

• help to understand that good doctor-patients relationship is crucial for the successful treatment.

Structure of the curriculume• 4 credits• Mandatory for students of medicine and dental medicine• 1st semester ( 300 students)The curriculum consists of:• theoretical part (lectures from medical psychology)• practical part (communication in a small group using prepared

vignettes, interview with nursing home residents and observation of general practitioners' work during their 1-day practice attachment).

Faculty: • Cooperation between Department for psychiatry and Department

for family medicine• External Collaborators: nursing homes staff and tutors in the offices

Teaching methods

• Lectures• Seminars• Small group work• Fieldwork (nursing home)• Individual work (seminar, report from clinical

visit)• Clinical visit• Discussion with feedback

Lectures

• Basic knowledge about medical psychology• Basic knowledge about communication with

people and patients (verbal and non-verbal communication)

Seminars• Characteristics of elderly people (nursing home

residents) and communication with elderly • ( taking into account their health related

problems)• Presentation of the protocol for semi-structured

interview with nursing home resident • Behavior in the office and ethical principle of

physicians work• Presenting the protocols for observing

communication in the office

Small grupe work

• Communication in a small group (12-14 students) using prepared vignettes:

• Presenting the method • Demonstration of role play and effective feedback • Role play in a group of three students using three

different vignettes (alcohol related problems, obesity, lose of the partner) including feedback

• Role play: Presenting the interview with nursing home residents

• Final remarks, questions…

Fieldwork• Interview with nursing home residents:• Six to eight nursing homes in a neighborhood of the

Medical faculty - contraction with Medical faculty• Nursing home staff: rules of behavior, ethical principals • Students in pairs: one of the student performing a

semi-structured interview according to the instructions and the second one is an observer

• One hour time for each interview• After the firs interview with the firs patients, the role

with the second patient was changed ( an observer became an interviewer)

Individual workSeminar about visit in the nursing homeFour part: • Data gathering (reasons for admition in nursing home,

typical day, physical problems, psychical problems, medication, functional status, relations to relatives, staff and other residents)

• Analysis - the main problems of the resident and potential solutions

• Analysis communication of the colleague• The main gain, feelings or fears related to the visit in

nursing homeAnalysis of the communication between patient and general

practitioner in the office based on the protocols

Clinical visit

• One day attachment in general practice• General practices all over Slovenia (choose by

the student, tutors trained in giving feedback)• Student is an observer of general

practitioner’s work and communication• Protocols for observation (20 consultations)

Protocol for observing general practitioners work and communication

Discussion with feedback

• Small group work with presenting the seminars with feedback

• Discussion about the experiences from communication with patients

Assessment

• Students have to pass theoretical and practical part of the exam. Each part contribute 50% of final mark

• Theoretical part: MCQ questions ( 60% of points)

• Practical part: Seminar and analysis of the communication at office visit (written, oral), criteria for evaluation was prepared in advance

Students feedback

• During the curriculum: we appreciated students’ oral feedback

• On the end of the curricula: students written feedback with the evaluation of the overall curricula and parts of the curricula using evaluation form (Likert scale 1 to 5)

• Students feedback is of most importance for future improvement of the curricula

Students’ feedback and assessment of the curricula - overall

• Student’s assessed ECE as of outmost important for their personal and professional development

• They found that good relationship is important part of treatment

• They would like to have more practical work and oportunity for communication

Students’ feedback and assessment of the curricula -Interview with nursing

home residents• Fears that their skills of communication is

inadequate (welcome and respect by the staff and patients)

• Emphatic relationship with the elderly• They found that elderly people are much

more positive and more vital in their mind that they think before

• An opportunity to learn from life experiences of elderly people

Students’ feedback and assesment of the curricula –office visit

• White coat – they found themselves as future physicians

• They found that the physicians work is complex with many dilemmas

• Motivation for future study• Confirmed that decision to became physician

is appropriate

Teachers and tutors experiences

Positive experiences:• feasible to organize: enthusiasm of the staff in

nursing homes and offices• acceptable to patients: most of the patients find

the ECE as important and participate in the curricula,

• educationally effective: students greately valid their extensive contact with patients

Evaluation: subjective in assessing of practical part of the curricula

Dilemmas

• Inadequate knowledge and experiences in communication

• Personal immaturity: problems with acceptance of professional and ethical norms

• Interview with elderly nursing home residents is too demanding (no knowledge about the characteristics of residents, problem with empathy, dealing with emotional reactions, ethical issues)

Plans for the future

• More opportunity for practice communication• Assessment of practical part should be more

objective• Study literature – a textbook for students• Communication as a part of curriculum in

each study year (to prevent erosion of empathy in clinical years)

Conclusions• Student’s assessed ECE as of outmost important for

their personal and professional development • Teachers have positive experiences: feasible to

organize, acceptable to patients, educationally effective

• EPC motivate and satisfied students of the health professions and helped them acclimatize to clinical environments, developed professionally, interact with patients with more confidence, and less stress, developed self reflection and professional identity. They mad them more real and relevant to clinical practice.

Buzz group work

• Three participant from different medical schools (countries)

• In brief present you curricula about ECE and your experiences

• Compare your experiences to the others• Prepare points for discussion