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Medical students in general practice: students' learning experiences and perspectives from supervisors and patients

Haffling, Ann-Christin LU (2011) In Lund University, Faculty of Medicine Doctoral Dissertation Series 2011:7.
Abstract
During the last decades considerably more of medical students’ clinical training has shifted into general practice. The aim of this thesis was to study medical students’ learning experiences in general practice, work-based assessment, and the perspectives of GP supervisors and patients.
Results
Senior students’ learning in a portfolio pilot was mainly on patient-centred communication, clinical reasoning and professional development. Junior students appreciated contact with good role models.
Long-term use of a work-based assessment tool for senior students significantly increased the proportion of specific goals and feedback to students, supervisors’ stringency of the assessment, and their satisfaction with the tool. The work-based... (More)
During the last decades considerably more of medical students’ clinical training has shifted into general practice. The aim of this thesis was to study medical students’ learning experiences in general practice, work-based assessment, and the perspectives of GP supervisors and patients.
Results
Senior students’ learning in a portfolio pilot was mainly on patient-centred communication, clinical reasoning and professional development. Junior students appreciated contact with good role models.
Long-term use of a work-based assessment tool for senior students significantly increased the proportion of specific goals and feedback to students, supervisors’ stringency of the assessment, and their satisfaction with the tool. The work-based assessment and the portfolio assessment had acceptable reliability, validity and educational impact.
GPs were highly motivated teachers and took pride in their discipline. In their teaching of junior students, their main reward was improved quality of own work. Their predominant problem was lack of time for teaching, but relationship to patients and provision of feedback were other concerns. Teacher training was required.
The vast majority of patients were satisfied with both senior and junior student encounters, even though caution was recommended when patients attend for sensitive matters. Patients perceived their teaching role mainly as facilitators of students’ development of professional skills. (Less)
Popular Abstract (Swedish)
Vårdcentralspraktik är viktig för blivande läkare
När du som patient besöker din vårdcentral, kan det hända att du erbjuds att få prata med och att få bli undersökt av en läkarkandidat, innan du träffar din läkare. Naturligtvis kan du tacka nej, men nästan alla patienter tycker att det är en positiv upplevelse. De flesta distriktsläkare är entusiastiska och duktiga handledare och läkarkandidaterna får en god utbildning under sin vårdcentralspraktik.
Den del av läkarutbildningen, då kandidaterna träffar patienter, har förr nästan enbart varit förlagd till universitetssjukhus. Nu kommer alltfler läkarkandidater ut till vårdcentralerna för olika praktikperioder. Vi vet väldigt lite om vad de läkarstuderande lär sig och får för erfarenheter... (More)
Vårdcentralspraktik är viktig för blivande läkare
När du som patient besöker din vårdcentral, kan det hända att du erbjuds att få prata med och att få bli undersökt av en läkarkandidat, innan du träffar din läkare. Naturligtvis kan du tacka nej, men nästan alla patienter tycker att det är en positiv upplevelse. De flesta distriktsläkare är entusiastiska och duktiga handledare och läkarkandidaterna får en god utbildning under sin vårdcentralspraktik.
Den del av läkarutbildningen, då kandidaterna träffar patienter, har förr nästan enbart varit förlagd till universitetssjukhus. Nu kommer alltfler läkarkandidater ut till vårdcentralerna för olika praktikperioder. Vi vet väldigt lite om vad de läkarstuderande lär sig och får för erfarenheter av denna praktik, och vi vet inte heller så mycket om hur praktiken uppfattas av distriktsläkarna och deras patienter. I denna avhandling undersöker jag dessa frågor i fyra olika studier.
Vad tycker patienterna?
Jag använde mig av enkäter för att ta reda på patienternas uppfattning om hur det kändes att prata med och/eller att bli undersökt av en läkarkandidat. När det gällde kandidater tidigt i utbildningen, var nästan alla patienter neutrala eller positiva till att ha en kandidat närvarande. De flesta skulle utan vidare göra om det, och de patienter, som hade tillfrågats innan de träffade kandidaten, var extra positiva (Studie I). Jag undersökte också vad patienterna tyckte om att samtala med och bli undersökta av en kandidat som gick sista året på sin utbildning, innan de fick träffa sin läkare. Det visade sig att nästan alla var nöjda, dels för att de hade blivit noggrant undersökta, men också för att det kändes bra att ha fått göra nytta för läkarutbildningen. Några tyckte att kandidaten verkade osäker eller att besöket tog för lång tid. Flera patienter menade att det var viktigt att också få prata med sin läkare ensam. De flesta patienterna skulle utan vidare delta igen, men om de behövde söka för personliga problem eller genomgå intima undersökningar, var en del mer tveksamma. Jag frågade också om patienterna tyckte de kunde lära kandidaterna något. Den uppgift de tyckte var extra viktig var att bidra med råd i kandidaternas utveckling av attityder och kommunikationsfärdigheter, men en del patienter uppfattade sig även som experter på eller som exempel på sin sjukdom, eller som en ”del i en verklighet” (Studie IV).
Vilka erfarenheter får läkarkandidaterna?
I den första studien ingick även en undersökning av läkarkandidaternas skrivna synpunkter på tre dagars praktik på vårdcentral. Den viktigaste erfarenheten var möten med goda ”rollmodeller” för läkaryrket, men kandidaterna upplevde också en ökad motivation för sina fortsatta studier, när de kunde koppla ihop sina teoretiska kunskaper med patienternas sjukdomssymtom. Flera hade också god nytta av de många möjligheter de fick på vårdcentralen för samtal med och kroppsundersökning av patienter (Studie I).
De läkarstuderande, som går sista året av sin utbildning, praktiserar sammanlagt sexton dagar på vårdcentral. De har en personlig handledare, som ofta är med dem i patientarbetet. Jag utvecklade ett strukturerat bedömningsformulär, som kunde användas för både kandidaternas självvärdering och för handledarnas synpunkter på kandidaternas styrkor och svagheter i patientarbetet. Det används efter halva praktiken, då man kommer överens om mål för fortsättningen, samt vid praktikens avslutning. Jag ville undersöka hur detta fungerade under en längre tidsperiod, och samlade in samliga formulär under sex terminer. Det visade sig att nästan alla kandidater fick specifika mål vid första bedömningstillfället, men att bara drygt hälften fick specifika synpunkter vid praktikens avslutning. Handledarna och kandidaterna enades ofta om mål, som rörde patientsamtalets struktur och ”patientcentrering”, trots att man var eniga om att de största svagheterna oftast var att ställa diagnos och föreslå behandling. Med ökad erfarenhet av formuläret blev handledarna lite strängare i sina bedömningar och alltmer nöjda med formuläret. Med tiden ökade andelen specifika mål och specifika synpunkter, delvis genom en förbättrad ”feedbackkultur” på vårdcentralen. Läkarkandidaterna själva var till övervägande del nöjda med de mål och de synpunkter de fick (Studie II).
Praktiken under utbildningens sista år ska inte bara ge kandidaterna möjlighet att utveckla sina kunskaper och färdigheter, utan även bidra till deras professionella utveckling med ökad självkännedom och förmåga till eftertanke. Detta kan inte bedömas genom vanliga skrivningsfrågor, utan en tilläggstentamen krävs. Vi gjorde därför ett försök med 35 frivilliga läkarkandidater, som samlade dokument från praktiken i en ”kursportfölj” och kompletterade med skrivna funderingar över vad de lärt sig under praktikperioden. Portföljen blev sedan utgångspunkten för en tentamen, där kandidaten fick diskutera och fördjupa sina tankar tillsammans med en lärare. Innehållet i de skrivna ”uppsatserna” undersöktes och visade sig vara av hög kvalitet. Det berörde flera olika delar av kandidaternas professionella utveckling med tankar kring kommunikation, attityder, empati och etik i möten med patienter. Fyra olika lärare läste och betygsatte senare alla uppsatser, och beräkningar visade att tentamensformen kunde betraktas som rättvis. Kandidaterna var nöjda och rekommenderade att kursportföljen infördes som en tilläggstentamen för samtliga kandidater, vilket också skedde (Studie III).
Vad tycker handledarna?
Jag intervjuade trettio handledande distriktsläkare vid lika många vårdcentraler om deras då helt nya uppgift att undervisa läkarkandidater i patientsamtal och kroppsundersökning under den tidiga delen av utbildningen. De flesta handledarna var positiva, och deras viktigaste drivkraft var att få visa hur viktigt arbetet på vårdcentralen var. För handledarna fanns flera vinster med undervisningen, där den viktigaste var att kvaliteten på deras eget arbete förbättrades. Handledarna tyckte också att arbetet blev trevligare genom kontakten med de motiverade och entusiastiska kandidaterna. Det största problemet var stress och tidsbrist, men flera var också oroliga över sin kontakt med patienterna eller hade svårt att ge utvecklande synpunkter på kandidaternas prestationer. Vi uppmärksammade också ett stort behov av handledarutbildning (Studie I). (Less)
Please use this url to cite or link to this publication:
author
supervisor
oppenent
  • professor Cecilia Björkelund, Enheten för Allmänmedicin, Sahlgrenska Akademin, Göteborgs Universitet
organization
year
type
Dissertation (Composite)
subject
keywords
medical education, general practice, feedback, self-assessment, patients, work-based assessment, portfolio, reflection SoTL, clinical reasoning, undergraduate, communication skills
categories
Higher Education
in
Lund University, Faculty of Medicine Doctoral Dissertation Series
volume
2011:7
pages
164 pages
publisher
Lund University
defense location
Aulan, CRC, entrace 72, SUS Malmö
defense date
2011-01-28 13:15
ISSN
1652-8220
ISBN
978-91-86671-55-6
language
English
LU publication?
yes
id
1748850
references
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date last changed
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@phdthesis{1748850,
  abstract     = {During the last decades considerably more of medical students\textquoteright{} clinical training has shifted into general practice. The aim of this thesis was to study medical students\textquoteright{} learning experiences in general practice, work-based assessment, and the perspectives of GP supervisors and patients.     
Results
Senior students\textquoteright{} learning in a portfolio pilot was mainly on patient-centred communication, clinical reasoning and professional development. Junior students appreciated contact with good role models. 
Long-term use of a work-based assessment tool for senior students significantly increased the proportion of specific goals and feedback to students, supervisors\textquoteright{} stringency of the assessment, and their satisfaction with the tool. The work-based assessment and the portfolio assessment had acceptable reliability, validity and educational impact.  
GPs were highly motivated teachers and took pride in their discipline. In their teaching of junior students, their main reward was improved quality of own work. Their predominant problem was lack of time for teaching, but relationship to patients and provision of feedback were other concerns. Teacher training was required.
The vast majority of patients were satisfied with both senior and junior student encounters, even though caution was recommended when patients attend for sensitive matters. Patients perceived their teaching role mainly as facilitators of students\textquoteright{} development of professional skills.},
  author       = {Haffling, Ann-Christin},
  isbn         = {978-91-86671-55-6},
  issn         = {1652-8220},
  keyword      = {medical education,general practice,feedback,self-assessment,patients,work-based assessment,portfolio,reflection
SoTL,clinical reasoning,undergraduate,communication skills},
  language     = {eng},
  pages        = {164},
  publisher    = {Lund University},
  school       = {Lund University},
  series       = {Lund University, Faculty of Medicine Doctoral Dissertation Series},
  title        = {Medical students in general practice: students' learning experiences and perspectives from supervisors and patients},
  volume       = {2011:7},
  year         = {2011},
}