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 Table of Contents  
BRIEF COMMUNICATION
Year : 2015  |  Volume : 28  |  Issue : 3  |  Page : 205-208

Teaching internal medicine in the community


1 Department of Family Medicine; Clalit Health Services, Northern Region; Faculty of Medicine in Galilee, Bar Ilan University, Bar Ilan University, Ramat Gan, Israel
2 Faculty of Medicine in Galilee, Bar Ilan University, Ramat Gan, Israel
3 Faculty of Medicine in Galilee, Bar Ilan University; Department of Gynecology and Obstetrics, Padeh Medical Center, Poriya, Israel
4 Clalit Health Services, Northern Region, Bar Ilan University1, Ramat Gan, Israel
5 Department of Family Medicine; Faculty of Medicine in Galilee, Bar Ilan University, Ramat Gan, Israel

Date of Web Publication11-Mar-2016

Correspondence Address:
Sophia Eilat-Tsanani
Department of Family Medicine, Emek Medical Center, Amakim Region Office, Afula
Israel
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1357-6283.178606

  Abstract 

Background: Teaching Internal Medicine is mainly hospital-based. Chronic diseases are treated mostly in community-based ambulatory care. This study describes our experience during the first year of teaching Internal Medicine in the community, with a focus on chronic disease management. Methods: This was an observational study describing the content of clinical exposure and the feedback from students after a two-week clerkship in community health centers. Results: Over a period of three months, 54 students spent two weeks in health centers singly or in pairs. The disciplines covered were: Endocrinology, Gastroenterology, Pulmonology, Rheumatology and Geriatrics. In their feedback, the students most frequently noted knowledge acquired in the management of diabetes, infectious diseases and cardiology. The teaching content was determined by the case-mix of patients. The spectrum of conditions was wide. Students who were used to more structured hospital-based study found it difficult to cope with this mode of learning by discovery. Discussion: Future research should concentrate on the transition between the different modes of learning as students move from the hospital to the community setting.

Keywords: Community, internal medicine, undergraduate teaching


How to cite this article:
Eilat-Tsanani S, Weingarten M, Ben-Ami M, Dayan M, Tabenkin H. Teaching internal medicine in the community. Educ Health 2015;28:205-8

How to cite this URL:
Eilat-Tsanani S, Weingarten M, Ben-Ami M, Dayan M, Tabenkin H. Teaching internal medicine in the community. Educ Health [serial online] 2015 [cited 2020 Aug 14];28:205-8. Available from: http://www.educationforhealth.net/text.asp?2015/28/3/205/178606


  Background Top


Undergraduate teaching is traditionally hospital-based, despite the fact that the greater part of patient care is provided on an ambulatory basis, mostly in the community. The development of teaching in the community follows the trend towards the provision of health services outside the hospital.[1]

Several studies report on the experience of teaching students in the community. The models can differ between countries and health systems.[2] National and local conditions influence the models of teaching in the community.[3] One model that has attracted widespread interest is the “longitudinal clerkship” developed at Harvard, where students are attached to ambulatory clinics for a whole year and derive their learning from a cohort of up to 150 personal patients whom they follow across all the different specialists they consult.[4] This model has been adopted in tertiary hospitals, community hospitals, in general practice, and in rural settings, but not, to our knowledge, in urban consultant sub-specialty clinics.

The Faculty of Medicine in the Galilee was established in 2012, with the aim of accommodating medical education both to the present and to the predicted future pattern of health services. Within this context, a decision was made to integrate teaching in the community into clinical clerkships. In this paper, we present our experience with the first year of teaching Internal Medicine (IM) in the community.

According to National Health Law, all Israeli citizens have health insurance. Public health services are provided by four “Sick Funds”. Clalit Health Services (CHS) is the largest of them, providing care to 60% of Israeli citizens and 70% in the north of Israel where this study took place. In the North District of CHS, care is provided in urban Health Centers (HC) and in rural solo practices. In HC, both primary and consultant care are offered, and a wide range of sub-specialist consultants provide support for the care of IM problems. Patients are referred by the primary care general practitioners to these community-based consultant clinics for all problems that do not require hospital services. Patients with chronic diseases are also followed up by internists in these community clinics.

Introducing teaching into the community clinics requires consideration of several factors, including the tutor, the patient and the student. Time spent on teaching may compete with time devoted to patient care.[1]

In describing our initial experience with the teaching of IM in community consultant clinics, we specifically addressed three questions:





  1. What are the content areas of IM that can be learned in the community clinic, given that the content of practice is defined by the spectrum of problems that the patients present?
  2. What are the difficulties and barriers facing teaching of IM in community clinics?
  3. How do students perceive the role of the internist in the community?


Insights into these issues could generate ideas for future research and practice – such as alternative models of learning medicine in urban community clinics, methods for overcoming existing structural barriers, and the influence of community-based teaching on student perceptions of career choice.


  Methods Top


A total of 54 students in their first year of clinical studies was the focus of this study. Students participate in three years of pre-clinical studies (in universities outside Israel) and three years of clinical studies in Galilee public hospitals and community clinics. Prior to the two-week community clerkship in IM there is a three-month classroom course on introduction to clinical studies, and a 12-week clinical clerkship in IM hospital wards.

Teaching was conducted in three HCs in the northern region of CHS. Six doctors, representing various sub-specialties of IM employed in the HCs' consultant clinics, served as tutors. Disciplines covered were: Endocrinology, Gastroenterology, Pulmonology, Rheumatology and Geriatrics. The tutors had previous experience in teaching in the hospital. Each tutor had a personal training meeting with a senior general practitioner experienced in teaching in community clinics. The tutors were not paid directly for teaching, but were compensated for loss of income.

The learning experience consisted of student observation of the tutor during patient visits, students directly interviewing and examining patients, and discussions on topics related to the patients who were examined each day. One or two students were attached to each tutor at any time. The students rotated among the various sub-specialties every day or half-day depending on tutors' availability. At the end of the day, the students met with one of the tutors to discuss topics that were raised during patients' visits.

The clerkship was evaluated at three levels including the content of teaching and views of students and tutors regarding the clerkship. The tutors kept track of the problems of their visiting patients during the clerkship and the topics discussed in the group session. At the end of the clerkship, a structured feedback session was led by the director of the HC who was responsible for teaching, but not actively involved in the student tutoring process.


  Results Top


Over a three month period, all 54 students spent two weeks in the HCs. The spectrum of conditions covered is presented in [Table 1].
Table 1: List of possible topics to be covered by students in a 2-week community internal medicine clerkship*

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All students took part in the summary discussion and provided oral feedback.

This feedback related to both, the learning content and the learning atmosphere or environment. [Table 2] summarizes issues that were raised repeatedly by the students, including both the major positive aspects and those seen as in need of improvement.
Table 2: Students' comments in oral feedback at the end of the community clerkship*

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The students were surprised at the wide variety of clinical material they encountered in community practice. They noted that learning in the community added to their previous knowledge and helped to complement their knowledge with aspects of treatment and control of chronic diseases and dealing with issues of patient cooperation. The closer relationship with patients exposed the students to new components of the disease and new aspects of the illness experience. The intimate situation of one-to-one (or two-to-one) tutoring was mentioned as very positive. The relaxed atmosphere was also mentioned as an important positive factor in learning.

The students' feedback revealed a high level of satisfaction and high interest in the course material. Subjects in which students felt they acquired most knowledge were endocrinology (especially diabetes), infectious diseases and cardiology. Difficulties mentioned were meeting the patient for a relatively short time during a single visit, without follow-up, and not having adequate time to read and to prepare for the tutor's questions. The students also found it difficult to cope with patients with several co-existing problems; a situation frequently encountered by the internist in the community clinic. These difficulties caused some discomfort in shifting from learning in the hospital to the community clinic.


  Discussion Top


The ambulatory care sector of health services is growing. The nature and scope of medical practice in community clinics is significantly different from hospital practice. Thus, medical school graduates need to be familiar with health services both in hospital and in community settings and acquire medical experience and knowledge in both.

While family medicine is an integral part of undergraduate medical education, teaching specific disciplines in community clinics has been reported from relatively few medical schools.[2] Our initial experience in teaching IM in community clinics has been described here. The clinical material covered various disciplines within IM.

Subjects that were taught both in hospital and the community clinics gave the students the opportunity to learn diseases from different perspectives. Observing the internist at work in the community clinic also gave the students a deeper understanding of the profession. Students reflected on the characteristics of the internist's role in the community clinic, including caring for patients over long periods of time and for various problems with high level of commitment, in the context of relatively short meetings with patients. On the other hand, the students expressed a feeling of discomfort when meeting patients presenting with a wide spectrum of diseases for just a short time, while not being able to prepare by reading beforehand.

Clerkships in the community clinics enable the students to behave as adult learners, which is important for their future as doctors. Teaching in the community was not conducted by the book, but was driven by the variety of clinical situations brought by the patients, encouraging students to search for knowledge driven by their experience in practice. Previous studies have described the model of experience-based learning (EBL) in the primary care setting.[5] This first clerkship was not planned specifically as EBL, but we learned that activating the students, by interviewing and examining the patients, generated the motivation for deeper learning around the case material.

Meeting with the patients during one visit without follow-up was a new experience for students. This suggests the possibility of combining learning IM in the community clinic and in hospital as a way of seeing the disease in the context of its natural history,[3] as well as providing an appreciation of the various roles that doctors from different specialties play in patient care. The experience of interviewing patients in the community was an opportunity to get to know the patients from a closer perspective and enabled the students to experience the impact of patient-centeredness.

The students' feeling of acquiring knowledge in the community corresponded well with their tutors' impression of their progress. The students' feedback, reflecting surprise at the range of content of community practice, echoed the tutors' own feelings of community practice having been viewed as inferior. The clerkship helped to correct this impression.

The problem of teaching time versus time for clinical work was raised and is a recognized problem in ambulatory care teaching.[2],[6] In contrast, there were no problems with obtaining consent for interviewing and examining patients by students. The issue of payment for the tutors was raised and has been reported before in other ambulatory teaching contexts.[7] It is difficult to calculate the value of teaching for a few days for each tutor, but some kind of compensation is planned for the future (e.g., support for attending conferences).

In their feedback, the students reflected to us the characteristics of medical care in the community - the wide range of diseases and of clinical situations, expanding the picture of the natural history of a disease. This in itself indicates the added value of teaching IM in the community clinics.

Although we did not systematically study the responses of the tutors to their new role as teachers, we were told that teaching in the one-to-one situation enabled the tutors to identify gaps in the students' knowledge and allowed direct monitoring of clinical skills. Since the tutors are remunerated on the basis of the volume of clinical service they provide, teaching is not generally worthwhile for them, being time consuming. Nonetheless, the tutors welcomed the opportunity to teach students. Teaching introduced a change in their routine and they noted that it helped them to improve their clinical practice.

Overall, our study is descriptive without a control group; the students came from one medical school and spent a limited number of days with each tutor.

Nevertheless, we can conclude that introducing learning in the community clinics through the IM clerkship was feasible and helped to enrich the content of learning. In the future, we need to address the difficulties identified in teaching clinical medicine in the community.

Acknowledgement

The authors would like to thank the Internists in the Health Centers for their cooperation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Yonke AM, Foley RP. Overview of recent literature on undergraduate ambulatory care education and a framework for future planning. Acad Med 1991;66:750-5.  Back to cited text no. 1
    
2.
Williams CK, Hui Y, Borschel D, Carnahan H. A scoping review of undergraduate ambulatory care education. Med Teach 2013;35:444-53.  Back to cited text no. 2
    
3.
Benor DE, Hogfoll SE, Prywes M. Important issues in community-oriented medical education. In: Schmidt HG, Lipkin, editors. New Directions for Medical Education. 1st Ed. Springer-Verlag; 1989. p. 51-65.  Back to cited text no. 3
    
4.
Hirsh D, Walters L, Poncelet AN. Better learning, better doctors, better delivery system: Possibilities from a case study of longitudinal integrated clerkships. Med Teach 2012;34:548-54.  Back to cited text no. 4
    
5.
Hay A, Smithson S, Mann K, Dornan T. Medical students' reactions to an experience-based learning model of clinical education. Perspect Med Educ 2013;58-71  Back to cited text no. 5
    
6.
Mathers J, Parry J, Lewis S, Greenfield S. What impact will an increased number of teaching general practices have on patients, doctors and medical students? Med Educ 2004;38:1219-28.  Back to cited text no. 6
    
7.
Ryan MS, Vanderbilt AA, Lewis TW, Madden MA. Benefits and barriers among volunteer teaching faculty: Comparison between those who precept and those who do not in the core pediatrics clerkship. Med Educ Online 2013;18:1-7.  Back to cited text no. 7
    



 
 
    Tables

  [Table 1], [Table 2]



 

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