HOSPITAL TRAINING AS PREPARATION FOR GENERAL PRACTICE

HOSPITAL TRAINING AS PREPARATION FOR GENERAL PRACTICE

372 TABLE VIII-CORRELATIONS OF PROFESSOR MCBEATH’S ESTIMATES WITH DIFFERENT PARTS OF THE EXAMINATION interviewed the students for me, and Professor M...

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372 TABLE VIII-CORRELATIONS OF PROFESSOR MCBEATH’S ESTIMATES WITH DIFFERENT PARTS OF THE EXAMINATION

interviewed the students for me, and Professor McMichael, my external examiner. I am most grateful to all the other examiners and to the students who willingly subjected themselves to the interview experiment. REFERENCES

Cast, D. M. D. (1940) Brit. J. educ. Psychol. 10, 49. Cowles, J. T., Hubbard, J. P. (1952) J. med. Educ. 27, 14. Finlayson, D. S. (1951) Brit. J. educ. Psychol. 21, 126. Gulliksen, H. (1950) Theory of Mental Tests. New York. Hartog, P. (1941) The Marking of English Essays. London. Rhodes, E. C. (1935) An Examination of Examinations. -

London.

logic of this university. I told Professor McBeath that I suspected that some factor or factors that make up personality might be influencing the results, and asked the students without reference to our own of them. Unfortunately, the time available for interview was only about ten minutes per student. Professor McBeath chose to allot marks for intelligence, for confidence, for the power ofexpression, and for an over-all impression. These various assessments were then correlated with the marks of different parts of the examination, and the results are shown in table vm. Most of the correlations were low and statistically insignificant, but there is some consistency of pattern which suggests that, had we studied a larger group of students, significant results would have been found for more of the correlations. Professor McBeath’s most efficient estimate of the marks of the different parts of the examination is his estimate of " expression." In the case of the total mark in medicine, the correlation with " expression" was -f-0.45, and significant at the 0.05 probability level, which suggests that the ability to express oneself may be important in passing the final examination. him to

-

-

The Marks of Examiners.

(1936)

Sinclair, D. C.

(1955) Medical Students

London. and Medical Sciences.

London.

Vernon, P. E. (1940) The Measurement of Abilities. London.

assess

knowledge

DISCUSSION

Few firm conclusions can be drawn from this section of the investigation. Us main importance lies in its having demonstrated the need for further work. There is some evidence to suggest that factual knowledge may not be very important in the clinical examinations, but that some factor or factors in personality may play a part. It is important that we should establish what skills or personal attributes influence the examiner, so that we may assess them more efficiently and know what we are assessing. Probably it is as important that a doctor should have a suitable personality as it is for him to be in possession of factual knowledge. I believe that until we have further information on these matters, we should not alter the present system of interview examinations.

HOSPITAL TRAINING AS PREPARATION FOR GENERAL PRACTICE KEITH HODGKIN M.A., B.M. Oxfd, M.R.C.P. GENERAL

PRACTITIONER, REDCAR,

CLINICAL training begins in hospital, and this early experience profoundly influences the efficiency and outlook of the family doctor. I assess here from records collected at the time : (a) the differences between clinical work in hospital and that subsequently encountered in general practice ; and (b) the ways in which early hospital experience influences the development of a family doctor. The suggestions made are intended, not as criticisms of the present curriculum, but to indicate ways in which my own training and development into a general practitioner could have been helped and improved. It is thirteen years (excluding Naval service) since I first entered hospital as a clinical student. Of this time, half has been spent in hospital and half in general practice. Throughout these years I have kept records of nearly every patient whoni I have had under my care. For the period of undergraduate training these records also include most of the cases that I saw at clinical demonstrations and ward rounds.

Hospital

and General Practice :

There is as

a

considerable element of

questions, but this error the questions are shortened.

long

essay

It is recommended that

more use

should be made of the eliminates

multiple-choice technique of examining, which marking error. There is reasonably good agreement between

examiners in the clinical and oral parts of the examination, but there are doubts as to what they agree on. It appears likely that factors unconnected with medical knowledge may play an important part in determining success in this part of the examination. Until further information is available on such factors, these interview examinations should not be changed. I am most grateful to all who cooperated with me in this investigation. In particular, I would thank Dr. E. Cheeseman and Mr. S. J. Kilpatrick, of the department of social and preventive medicine, who have given invaluable help with the For the purpose of this study, Dr. statistical approach. Cheeseman developed an interesting theoretical account of the relation of the correlation coefficient to the analysis of variance. I would also mention, in particular, Professor McBeath, who

Comparison

clinical material in in family practice, but I have often wondered whether most medical schools realise how great is the difference. The accompanying figures, which are based on my own experience, show the extent and quality of this difference.

generally admitted that the hospitals differs greatly from that

MATERIAL AND

error in the marking of diminishes progressively

a

It is

Summary The final medicine examination at the Queen’s University of Belfast has been investigated. The most important findings are as follows :

YORKSHIRE

The material

analysed

METHOD

consists of :

318 " incidents of sickness " seen on ward rounds and at demonstrations during three years in hospital as a student. (2) 986 " incidents of sickness " under my care as a resident houseman in three jobs (as house-surgeon, house-physician, and children’s house-physician). These cases also include 75 post-mortem examinations during a year as pathology

(1)

registrar. (3) 2500 practice on

"

a

incidents of sickness " during a year in housing estate in an industrial area.

general

In each group records were kept of history and examination with possible and probable diagnoses. From these data I have compiled figs. 1-11, which show the difference between the three groups. These figures have been built up as follows : In each group the " morbidity-rate " per 1000 incidents of disease has been calculated. The total diseases seen were then split up into " system groups " according to the International Classification. In each figure all cases seen in general practice are on the right side of the vertical axis, while all cases seen in hospital are on the left. The position of a disease in any of the figures depends on whether it is predominantly a disease

373 of general practice or of hospital and the extent to which it predominates. Thus diseases seen mostly in general practice occupy the top right-hand part, and diseases met with chiefly in hospital occupy the bottom left-hand portion.

RESULTS

represent the major portion of a family Figs. doctor’s clinical work, covering all mental illness, all diseases of respiratory, gastro-intestinal, genito-urinary, and skeletal systems, and bacterial and virus All these figures show diseases. how clearly widely hospital experience differs from that in general practice. As regards mental disease (fig. 1), it is characteristic that the G.P.’s 1-6

biggest problem-"simple anxiety " -was not clearly defined in my student and hospital notes and does not even have a proper category in the International Classification of DisThis term " simple anxiety is used to cover all patients with normal (adequate) personalities who are afraid or who have symptoms associated with fear (palpitation, the jumpiness, air-hunger, &c.) ; precipitating fear in most cases is usually openly admitted (e.g., of ease.

"

blood-pressure, tuberculosis, pregnancy) and requires no refined

cancer, or

psychological technique for its discovery. History, examination, and reassurance of these patients is a most important part of the family doctor’s job. My student records fail to show any evidence of this problem or how to tackle it. At first in general practice I was irritated by the amount of " socalled neurosis " and it took several years to overcome this irritation and develop ways of helping patients with complaints coloured by anxiety. I believe that this difficulty was a direct result of a training which had failed to prepare me for this

problem. Figs. 7-10

Fip. 1-5-Comparison of experience in hospital and in general practice. Light stippling = student experience.

cover all malignant, and discardiovascular neurological, ease, plus a miscellaneous group of metabolic, endocrine, and blood disorders. A different pattern emerges, because these diseases hre more uniformly serious and therefore cases tend to be collected in hospital ; and if anything, hospital training tends to over-emphasise the importance of these diseases. In fact a third (96) of the cases demonstrated to me on student ward rounds consisted of almost untreatable malignant or neurological disease. This perhaps explains why, like many other doctors, I am needlessly excited by finding a case of, for example, cancer or motor-neurone disease. Only in the miscellaneous group (fig. 11) is there an apparent similarity between hospital and general practice. The similarity, which is " apparent only, is the result of including many different disabilities under general headings. Thus if " fractures and sprains " is split up into its two parts, very few of the sprains will be found in hospital while the family doctor sees only a few fractures.

374 There are two important omissions from this material : 1. No obstetric cases have been included because the cases seen in hospital and general practice were sufficiently similar for the former to provide a reasonable preparation for the latter. Thus approximately 110 normal deliveries were seen during the hospital period, while 50 normal deliveries were done in one year of general practice. The abnormal deliveries seen in general practice, like the serious pathological diseases, were of course even more adequately covered by the It is, however, hospital experience. important to realise that these hospital figures include work done in a resident obstetric house job. 2. No cases of ear, nose, and throat, eye, or skin disease are shown during the hospital period. Apparently I did not, as a student, consider them sufficiently important. It is of interest to find this remarkable gap in just those subjects which might have been very useful in general practice. The reason was, I think, that these subjects had been tacked on to the main course and were always regarded as extras of less Unfortunately I never importance. obtained any experience in these specialties as a houseman and the result has been a gap in my knowledge which I

always regret. Discussion

The strates

analysed clearly two

material demonmain points :

1. That the average gives the newly

ence

hospital experiqualified G.P. a

understanding of the serious disease he is likely to see in practice. If anything, the emphasis it places on these diseases is so great that the young a.p. may be perturbed by the necessity of dealing with less, serious disease. 2. That a very large proportion of the disorders (75% in my case) dealt with by a family doctor is never seen in hospital at all. good

The chief effects of these two factors on the potential family doctor can be summarised as follows : 1. Lack of confidence arising from uncertainty.-The newly qualified G.P. is probably acutely aware that he has never

cared for

a

child with measles

before, and is unable when talking with the parents to speak with the authority that gives confidence. If this is his first contact with such parents it may be a long time before he can give them confidence again. 2. 1B([ istakes due to ignorance of the clinical picture of common diseases.Many of the causes of neck stiffness or enlarged spleen may be known to the young G.P. fresh from hospital, but unless he is aware that acute tonsillitis may be associated with both these signs he will make unnecessary mistakes. 3. Lack of standards (or method) for dealing with the most covrznzon problems of family practice.-A good example of this is simple anxiety. In hospital the young doctor has learnt that the object of history-taking and examination is diagnostic, and the principle of interrogating and examining patients for purely therapeutic reasons is foreign to h-im. Yet a family doctor’s ability

375

gain the confidence of his patients may depend more upon this simple measure than on any other. 4. The feeling that general practice is inferior to hospital practice.-As in other spheres such a feeling arises from initial lack of confidence.

to

The problems brought to a family doctor cover a much wider field than is suggested by this analysis in terms of incidents of sickness." The work of the family doctor falls into four main groups. The first two of these (groups A and B below) cover work concerned with diagnosis and formal therapeutics ; this work has already been considered. The last two groups (C and D) cover wider aspects.

Group A.-The early recognition of major disease which requires either immediate diagnosis and treatment (e.g., appendicitis or pneumonia) or further elucidation in hospital (e.g., a suspected neoplasm or unexplained loss of weight). Group B.-The recognition and management of the so-called minor ailments.

Group C.-Advisory, supervisory, and preventive measures (e.g., much paediatric and antenatal care). Group D.-Assisting patients to make mental and physical adjustments to problems such as old age, chronic ill health, anxiety, and convalescence. It is true that the object of a student’s training is not give a balanced clinical experience, but to develop in him the knowledge and insight that will enable him to help his patients most. But can teachers who are wholly concerned with hospital work be sufficiently aware of the problems and methods of G.P.s to correct the bias of hospital training1 As this analysis has shown, only 25% of the-G.P.’s work overlaps with work in hospital. For the remaining 75% all that the hospital teacher can do is to stress basic principles common to all medical problems, such as the importance of a full examination and thinking in terms of past experience. Such points are important, but unless they are related continually to the actual problems of general practice their significance in family practice will often be forgotten by the student. A lecturer in obstetrics might consider that experience in a hospital antenatal clinic prepares the potential family doctor for a similar job in general practice. In fact such clinics only taught me the indications for admitting antenatal patients to hospital-i.e., the point at which the family doctor’s job ends. I learnt nothing of the positive side of the family doctor’s job, such as the gradual building up of the pregnant mother’s trust and confidence in her midwife and doctor, which is such a big factor in the obstetrics of general practice. The basic need is to widen the scope of the student’s training to include something of the principles and methods of family practice, without confusing him. to

"The Second Stage The undergraduate medical student should be introduced to general practice at the very heart of his hospital training-i.e., at the ward round. My reason for believing this is that in my own written accounts of student ward rounds there were endless points of interest to a G.P. which had been left unemphasised. These points could have been used to illustrate every facet of the family doctor’s work and would have given me as a student a picture of medicine as a whole that otherwise was unobtainable. Attaching undergraduate students for short periods to a family doctor (or G.P. unit) may enable them to learn a little about the methods of general practice, but is likely to muddle them ; and they will certainly regard this as an extra that has little bearing on finals. Students whom I have taken on my rounds in general practice seem confused by its range and worried by the uncertainty of much of its diagnosis. It would not be difficult to get one or two general practitioners who were interested in teaching to take an active part in every student ward round or demonstration. They could indicate the family doctor’s part as need arose. If this were painstakingly done, the training of students could be greatly enriched. It is certainly as valuable to hear a family doctor discussing the antecedent circumstances of a case as to hear a pathologist discussing its outcome. "

"

The Third Stage This would consist in a six-month apprenticeship to a family doctor at the intern stage. Unfortunately, as things stand at present, it would be extremely hard to find G.P.s prepared to provide facilities for this. The presence of students will always be a strain on the average family doctor, because the relationship with his patients is so personal. Nevertheless, I believe that the development of this form of postgraduate training should be one aim of all family doctors. In such ways students would be made increasingly aware of the vital part which the family doctor plays in bringing patients nearer to health. They could see, long before they experienced it, that general practice is one of the most important and fascinating branches of medicine. I thank Prof. Donald Court for his of this paper.

help

and criticism

THE TUTORIAL SYSTEM IN MEDICAL SCHOOLS JOHN R. ELLIS M.B.E., M.A., M.D. Camb., F.R.C.P. ASSISTANT PHYSICIAN TO

THE

LONDON

HOSPITAL ; SUB-DEAN

OF THE LONDON HOSPITAL MEDICAL COLLEGE

SUGGESTIONS

experience leads me to believe that the scope of a student’s training could be thus widened without either confusing him or adding greatly to the undergraduate curriculum. General practice is the background to all hospital medical practice, and this background could be shown to the student continually and gradually in three main stages. The First Stage Greater emphasis should be placed throughout a student’s training on the basic aims of every doctor. I believe that insufficient stress is layed, either in hospital or out of it, on developing the fundamental attitude that every contact with a patient should be used to bring the patient nearer to health in body and mind, and that there is no other justification whatever for seeing any patient. If this basic principle of medicine were stressed throughout a student’s training he would enter general practice prepared to deal with the problems which he finds there, instead of being disappointed to discover that it differs so greatly from his hospital experience. My

own

.

IN the field of medical education the individual needs of the student have received little emphasis; consequently attention to these needs has come to be regarded with slight distrust if not with real opposition. In the past it has frequently been said that the good student will always adequately look after himself, and that for the others nothing can be done save somehow to force into them as many as possible of the essential facts. This, in view of the power of modern medicine, is not very kind to future patients ; especially as there is now no agreement as to what facts are essential, nor certainty that qualification ensures possession of them all. It would seem fair to abandon this attitude until we know whether, when students have had the advantages of individual help, their capabilities still justify this

unflattering

assessment.

The Need for

a

Tutorial

System

If the student is to be given a basis for lasting efficiency and safety in practice he must be well grounded in clinical observation, acquire method of rational and