Community Based Learning

1. Community Based Learning C21: Modernising Medical Education in CardiffAnnual Curriculum Away DayFriday 16th September 2011, All Nations’ Centre

2. ‘To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all’. Sir William Osler

3. C21 strap line: To produce excellent clinicians who understand their patients and the world in which we all live and work

4. GMC requirements • Prof Jim McKillop, Chair of Undergraduate Board, Education and Training Committee, GMC (AMEE conference, Glasgow 2010): • Early clinical contact • Professionalism stream throughout the course • Clinical and practical skills from early stage • Integration of scientific and clinical material • Room for innovation and individuality – both for students and the course

5. Rationale for Clinical Learning in the early years Integrate clinical, basic, behavioural and social sciences Explore patients’ experiences of illness Gain competence in history taking Become proficient in conducting physical examinations Develop a patient-centred approach to clinical practice Develop professional attitudes Learn clinical reasoning and decision making skills Experience a wide range of specialties

6. Experience of a more personal relationship with patients in their own settings Experience patient contact and continuity of care over a length of time and in appropriate settings – especially for long term conditions More opportunities to sample and contribute to community projects and get involved Contextualises learning - effect of social environment on health and healthcare, effects of diversity and disadvantage of different types Patients are willing to participate Students may be more likely to come back to work in these settings Students will learn transferable skills and informed professional attitudes Rationale for Community Based Learning in early years

7. Issues in ‘traditional’ training: NHS greater emphasis on primary care and community services Shorter inpatient stays reducing learning opportunities Pressure to meet waiting list targets Changes in junior Dr hours Fragmentation of firms within hospitals Competition with postgraduate training Increased numbers of students Increasing specialisation reduces the numbers of patients suitable for undergraduate training Rationale for Community Based Learning in early years

8. So - what’s the evidence? • Systematic review 2006: • How can experience in clinical and community settings contribute to early medical education? • 6 electronic databases + 6 journals hand searched (1992 – 2001) • 73 studies – 25% comparative, 75% descriptive • 277 educational outcomes:

9. Systematic Review findings: • Fosters self-awareness and empathetic attitudes towards sick people • Boosts students’ confidence, motivates and satisfies • Helps develop professional identity, roles and responsibilities • Better understanding of underserved communities and their needs • Learn the context of medicine delivery better: communication, multi-disciplinary working, health care systems, population health needs • Gives relevance to medical biosciences and makes them easier to learn • Motivates teachers and patients • Increased recruitment to areas and specialties under-doctored, if clinical experience in those areas. • Entering FY1 less stressful – better interpersonal skills

10. ‘…we start our clinical placements early. We tend to get to grips with communication skills, patient rapport quite quickly. I think this is a really good part of the curriculum because we have really early patient contact – which is why many of us want to be doctors in the first place! It certainly reinforces learning outcomes and revision, as we see in reality what we see in books’. ‘teaches us things that cannot be learned from books’ ‘value being able to explore social and psychological determinants of health and illness through contact with real patients’ Students’ comments from published literature:

11. How do we apply this to the Cardiff curriculum? • Develop learning outcomes for community based learning • Primary Care • Aspects of • Public Health • Social sciences medicine • Psychology • Develop structures for community based learning • Phase 1 • Phase 2 • Phase 3 • Identify placement capacity issues and funding capacity issues • Engage and involve stakeholders, incorporate ideas • Develop new learning sessions and link to curriculum and assessment programme via learning outcomes

12. C21: Phase 1 The Mature Family Old Age 1 Introduction to Medicine in Cardiff The Young Family Conception Foetal Life 2 Old Age 2 Research Block 2 Infancy Childhood 2 Adolescence Young Adult 2 Maturity 2 • Clinical Case Led Chronological Life Cycle – 20 weeks in year 1 and 26 weeks in year 2 • Small Group Facilitated Sessions • Community based clinical placements – up to 20 half days Year 1 and 26 half days Year 2 • Programme of lectures, seminars, practicals and clinical skills • Year 1: • Basic Science applied to medicine and basic clinical consulting • Normal Structure and Function • Year 2: • Consolidate knowledge and skills with application to more complex clinical presentations • Abnormal Structure and Function

13. Put yourself in their shoes... The Mature Family Old Age 1 Introduction to Medicine in Cardiff Adolescence, young adulthood and the young family Conception Foetal Life 2 Old Age 2 Research Block 2 Infancy Childhood 2 Adolescence Young Adult 2 Maturity 2 Oncology Hospital Front Door Chronic Disease Women, Children and Family Neuroscience and Mental Health Complex Needs and Rehabilitation Science in Practice Elective Senior Student Assistantship Junior Student Assistantship Primary Care Attachment

14. 40 year old IT salesman from Newport • Attending an international conference in Paris • Several episodes of palpitations each lasting a few minutes • Lifestyle Information and Family History • Although he and his wife are worried, he hasn’t been to see a doctor yet Mr Pritchard a salesman with palpitations

15. C21: Phase 1 Typical Week Taught Hours: Lectures - 3 hours Practicals – 6 hours Clinical Skills (incl demo) – 4 hours Small Group Learning – 4.5 hours Community based Learning – 3.5 hours Self Directed Learning – 10.5 hours Total – 31.5hours

16. Clinical Skills Lab: • Measuring and assessing the pulse • Communication skills • Developing active listening skills • Meaning of patient centred consulting and background to the concept • How professional understanding of ‘palpitations’ might differ from lay perspectives • Focussed history taking for patients presenting like Mr Pritchard • Community Based Learning: • Visit facilitated by GP Tutor • Home visit in pairs to patient with history of palpitations • Experiential Learning: how patients present and psychosocial and lifestyle factors affecting that presentation • How patients would be assessed in a general practice setting, incorporating principles learnt from Clinical Skills Lab Clinical Learning

17. Funding • Capacity • Organisation • ‘Students don’t get the same experience – eg if based in Biosciences Cathays Park versus Merthyr Health Park’ • Rotate groups every few blocks • Aim for equivalence in content • Some of the block community learning will be about the community site • Merthyr – mining tradition/ closure of mines -effect on community/ unemployment and health/ how we bring about change and work with communities • Cardiff – comparisons between Butetown/ Grangetown and Vale of Glamorgan/ Barry. Effect of a port city/ minority groups/ why people settle here Threats

18. Working with partners in the NHS: CwmTaf LHB and Merthyr Health Park Bridgend Hospital teaching and learning facilities Barry Community Hospital Gwent hospitals Opportunities for active patient involvement Involving the Patients Association in planning Expert patients as teachers Involvement in curriculum development, lay representation – the patient perspective on chronic illness management, diversity and equality, ethical dilemmas or dr/Patient communication Training in patient centredness, shared decision making Developing a sense of ‘service’ to communities and social accountability Opportunities for the School, the University and local communities

19. C21 Phase 2 + Phase 3 (still fluid…) Phase 2: Patient pathways - Following patients out to their homes and communities Longitudinal case studies in each block – similar in style to the current Oncology project ? Assessed by case based discussion with a panel of tutors Reflective diaries, eportfolio logs Phase 3: Primary Care attachment – 8 weeks, 6.5 attached to GP. Development of learning curriculumto deliver agreed Primary Care and other community learning outcomes Oncology Hospital Front Door Chronic Disease Women, Children and Family Neuroscience and Mental Health Complex Needs and Rehabilitation Science in Practice Elective Senior Student Assistantship Junior Student Assistantship Primary Care Attachment

20. Finalise Learning Outcomes from the submitted discipline groups Develop a series of cases which reflect basic science learning linking to Community Based and other clinical learning outcomes Establish community based placements – capacity and funding Recruit and train small group facilitators Draft handbooks for students and facilitators Pilot case based learning and some community placements Design the assessment and feedback programme Develop academic and administrative structures to support and maintain teaching and learning Ensure continuity of learning into Phases 2 and 3, keeping the core curriculum focussed Community Based Learning: Next Steps