Current provision of community-based teaching in UK medical schools

We were able to obtain information from the medical school websites about the provision of community-based teaching in all 32 undergraduate medical schools, and this is outlined in table 2 and summarised in table 3. All undergraduate medical schools provided some form of community-based teaching or placement. There was, however, variation in the structure, duration and time in the course when community teaching was delivered (see tables 2 and 3). CBE mainly took the form of clinical placements, patient studies and optional modules. The duration of community-based teaching or placements varied from half day visits to various community settings (as undertaken in schools such as Hull York, Newcastle, Nottingham and St George's) to a year-long module on primary care and population medicine (as undertaken in Brighton & Sussex). Analysis of the varying formats of CBE (with the exclusion of Norwich, due to the lack of year-by-year curriculum details) revealed that most medical schools (a total of 31) provide early exposure to general practice or community teaching. Twenty-eight medical schools (90.3%) provide community teaching from the first year of undergraduate medical education. By the end of the second year of preclinical education, students of 29 medical schools (93.5%) would have received some form of community-based teaching.

The most popular form of community-based teaching within medical schools was general practice placements with 83.9% (26 schools from a total of 31) providing general practice placements within the first 2 years of study. Patient studies were the least common form of placements. These were defined as projects where students visited patients within the community or at home. Only 38.7% (12 schools) provided this format of community education at some point in their courses.

Fourteen (45.2%) medical schools provided regular exposure to community teaching in every year or phase of the course.

With regards to optional modules offered to students, only three of the medical schools offered them—9.7%. This implies that, if students are particularly interested in community care, they may find it difficult to achieve extra studies in this area.

Literature review of studies evaluating community-based teaching

A summary of the studies evaluated in the systematic literature review are outlined in table 4. The main methods of evaluation employed in the studies were questionnaires, interviews and focus groups of the key stakeholders in CBE—students, patients, tutors and other staff in the community setting.

Needs assessment of CBE

Studies of student expectations of CBE highlighted that students valued experiential patient-centred learning and tutor supervision in the community setting.14 ,30 In a Sheffield study,14 students also recognised that CBE was a powerful vehicle for changing their approach to medicine and illness, where the patient as a person is given emphasis over the disease.

Implementation assessment of CBE

All forms of community-based teaching were generally well-received by medical students, patients and participating healthcare professionals, supporting the continuation of existing community-based teaching programmes in the future. This included community-based teaching which was incorporated into specialty modules such as Obstetrics and Gynaecology,31 Psychiatry22 and Surgery.27 The unique approach of incorporating primary healthcare in an intercalated Bachelor of Science medical research year also received positive feedback.23

Three studies found that students preferred the implementation of practice-based teaching over hospital-based teaching. Hastings et al11 found that students in Leicester preferred practice-based teaching on the grounds of both teaching method and content. O'Sullivan et al12 had similar findings among students from University College London, where practice-based teaching bore qualities of better teaching attitudes, teaching methods and course organisation. Interestingly, these findings were consistent with Powell and Easton's27 investigation on Imperial College students undertaking their surgery module. These students preferred surgical teaching within general practices due to the learner-centred approach in teaching, more protected teaching time and regular access to suitable patients for acquiring clinical skills.

The success of community teaching in Leicester was analysed by Hastings et al.11 It was found that the improved quality of teaching by GP tutors was attributed to a higher proportion of GP tutors attending teacher-training courses. General practices were also found to have greater resource availability and NHS funding specifically allocated to support the teaching of medical undergraduates. All these factors placed hospital doctors at a disadvantage in preparing good-quality clinical teaching sessions in comparison to GPs.

Impact assessment of CBE

Studies of CBE impact on students bore the following themes: (1) Learning outcomes, (2) Behavioural changes to primary care and (3) Traits of future doctors. These are summarised in figure 2.

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Figure 2

Key points: impact of community-based education on students.

CBE also had an impact on participating doctors, staff, patients and medical schools. A summary of this is shown in figure 3.

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Figure 3

Key points: impact of community-based education (CBE) on other participants in CBE.

Impact on students: learning outcomes

Implementation of CBE in medical schools had a significant positive impact on medical students’ learning outcomes. The following results provide evidence of the strong educational value among students: 11 studies showed that medical students gained insight into patient-centred medicine and continuity of care, which were learning outcomes that students viewed as important in their education.10 ,13 ,17 ,19–21 ,23 ,25 ,26 ,28 ,32 This was measured quantitatively through questionnaires that were administered to students, supplemented by quantitative feedback gathered from focus groups and interviews.

Students’ appreciation and understanding of the role of primary care was found in four studies.20 ,21 ,28 ,32 This was revealed through questionnaires, where students rated the extent of their understanding of primary care and its relationship with other levels of care. Two studies reported the benefit of community placements in broadening the student's awareness of teamwork in multidisciplinary teams.19 ,30 Another study reported the positive finding of successfully exposing students to a broad and varied range of clinical problems in a community setting.33

In comparison to hospital-based teaching, improved confidence in clinical skills and competencies was found to be a favourable outcome of CBE in four studies.10 ,12 ,19 ,20 This finding was derived from questionnaires and focus group interviews from students who had experienced CBE.

Two studies found no difference in academic performance between students under CBE and ‘traditional’ hospital-based teaching.17 ,20 One study of students who undertook a specialty placement in Obstetrics and Gynaecology also found that there was no difference in clinical performance as rated by their tutors, and no statistically significant difference in student final clerkship grades.34

Although most evaluations produced consistent evidence on the benefits of community teaching, two studies highlighted the lack of in-depth knowledge of specialist teaching when conducted by GP tutors: the significance of this finding was measured qualitatively through student interviews,27 and quantitatively through academic scores for the respective specialty modules.34

Impact on students: behavioural changes to primary care

Two studies found that the implementation of CBE resulted in a reversal of negative attitudes towards primary care, and an increase of interest in general practice as a career option among students.23 ,32

Impact on students: traits of future doctors

Studies also showed that medical graduates from curricula with increased emphasis on community-based teaching were at no disadvantage to graduates from the traditional hospital-based teaching.17 ,33 Academically, graduates from a community-based curriculum performed as well as their counterparts on their final formative assessments. Moreover, graduates from curricula where community-based teaching had been offered had the advantage of increased confidence in communication skills and clinical skill competencies. This outcome of CBE was evaluated in three studies.17 ,20 ,28 Two of these three studies additionally reported that graduates felt less confident in their medical knowledge on disease processes.20 ,28 However, there was no evident difference found in comparison to graduates of ‘traditional’ programmes of old medical curricula which had no CBE component when measured by academic results and feedback from educational supervisors.20 ,28

Impact on others involved in CBE orogrammes

In three studies, it was found that GP tutors and participating staff had both role satisfaction and development of professional and personal ethics.7 ,13 ,24 Grant and Robling24 also found strengthened team ethics between members of the primary healthcare team.

Doctors and staff, however, were found to have organisational issues in juggling community teaching with practice commitments. The expense of one over the other was described in CBE implemented by the University of Birmingham.7 The unfavourable outcome of blurred boundaries in the doctor–patient relationship was also reported as a concern in two studies.18 ,22

Five studies evaluated the positive patient outcomes of CBE: Four of these studies reported the beneficial sense of empowerment that patients gained from participating in community teaching.9 ,21 ,22 ,24 The remaining study reported that patients developed feelings of altruism from helping medical students in their education.18

Apart from gaining a sense of empowerment, Walters et al22 also reported the development of a more balanced doctor–patient relationship, and a therapeutic benefit for the patients as a result of talking to students about their medical condition.

Among these five studies on patient outcomes, two studies included further evaluations on the negative impact that resulted from patient participation. The negative outcomes comprised, reinforced feelings of ill-health which may be distressing or anxiety-provoking and concerns of breaching patient confidentiality.18 ,22

Powel et al's 27 evaluation also shed light on the benefits that medical schools gained from tapping into teaching within the community. By doing so, medical schools were able to increase the availability of learning opportunities to medical students.

Two studies raised the possibility of the negative impact that CBE would have on hospital tutors.7 ,13 The concern raised in these studies was with regards to a shift of focus away from teaching conducted by hospital-based tutors, and towards an emphasis on teaching in the community.

Cost assessment of CBE

Only one study evaluated the costs of running a community-based course. An evaluation of CBE in Cambridge revealed that the programme was cost-feasible as the total expenditure on one student-year of community-based teaching was within the cost estimates of Service Increment for Teaching (SIFT) funding.17 The study also noted that the balance between placement costs and facilities costs stood at a ratio of approximately 2:1, which is a reverse of the traditionally allocated 1:4 ratio in SIFT funds. This finding implied that the traditional allocations for SIFT funds would be inappropriate when applied to community-based teaching.