Early practical experience and the social responsiveness of clinical e
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《英国医生杂志》
1 Hope Hospital (University of Manchester School of Medicine), Manchester M6 8HD, 2 University of Queensland School of Medicine, PO Box 4143, Rockhampton, Queensland 4700, Australia, 3 University of Maastricht, PO Box 616, 6200 MD, Maastricht, Netherlands, 4 University of Newcastle, Newcastle upon Tyne NE2 4HH, UK
Correspondence to: T Dornan tim.dornan@manchester.ac.uk
Objectives To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence.
Design A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001.
Data sources Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration.
Selection of studies All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication.
Results Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations.
Conclusion Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.
General Medical Council. Tomorrow's doctors. 2nd ed. London: GMC, 2002.
Harden RM. Integrated teaching—what do we mean? A proposed taxonomy. Med Educ 1998;32: 216-7.
Dahle LO, Brynhildsen J, Berbohm Fallsberg M, Rundquist I, Hammar M. Pros and cons of vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum: examples and experiences from Linkoping, Sweden. Med Teach 2002;24: 280-5.
Dornan T, Bundy C. What can experience add to early medical education? Consensus survey. BMJ 2004;329: 834-7.
Dornan T L, Margolis SA, Ypinazar V, Scherpbier A, Spencer J. How can experience in clinical and community settings contribute to early medical education? www.bemecollaboration.org/topics.htm (accessed 19 Jul 2005).
Albanese M, Norcini J. Systematic reviews: what are they and why should we care? Adv Health Sci Educ Theory Pract 2002;7: 147-51.
Kirkpatrick DL. Evaluation of training. In: Craig R, Bittel L, eds. Training and development handbook. New York: McGraw-Hill, 1967: 87-112.
Lynch DC, Teplin SE, Willis SE, Pathman DE, Larsen LC, Steiner BD, et al. Interim evaluation of the rural health scholars program. Teach Learn Med 2001;13: 36-42.
Grayson MS, Klein MP, Franke KB. Impact of a first-year primary care experience on residency choice. J Gen Intern Med 2001;16: 860-3.
Levy BT, Hartz A, Merchant ML, Schroeder BT. Quality of a family medicine preceptorship is significantly associated with matching into family practice. Fam Med 2001;33: 683-90.
Mengel MB, Davis AB. Required first-year generalist clinical experience courses and their relationship to career choice: the critical effect of family medicine involvement. Fam Med 1995;27: 652-7.
Dobie SA, Carline JD, Laskowski MB. An early preceptorship and medical students' beliefs, values, and career choices. Adv Health Sci Educ Theory Pract 1996;2: 35-47.
Quinby PM, Papp KK. Adopt-a-student, early mentoring in family medicine. Med Teach 1995;17: 47-53.
Vaz R, Gona O. Undergraduate education in rural primary health care: evaluation of a first-year field attachment. Med Educ 1992;26: 27-34.
Barley G, O'Brien-Gonzales A, Hughes E. What did we learn about the impact on students' clinical education? Acad Med 2001;76(4 suppl): s68-71.
Riley K, Myers W, Gordon MJ, Laskowski M, Kriebel S, Dobie S. A collaborative approach to a primary care preclinical preceptorship for underserved settings. Acad Med 1991;66: 776.
Mann MP. A light at the end of the tunnel: the impact of early clinical experiences on medical students. Presented at the annual meeting of the American Educational Research Association, New Orleans, LA, 4-8 April, 1994.
Kent GC. Medical student's reactions to a nursing attachment scheme. Med Educ 1991;25: 23-32.
Hampshire A. Providing early clinical experience in primary care. Med Educ 1998;32: 495-501.
Rooks L, Watson RT, Harris JO. A primary care preceptorship for first-year medical students coordinated by an area health education center program: a six-year review. Acad Med 2001;76: 489-92.
Steele D, Susman J, McCurdy F, O'Dell D, Paulman P, Stott J. The Interdisciplinary Generalist Project at the University of Nebraska Medical Center. Acad Med 2001;76(4 suppl): s121-6.
Novack DH, Dube C, Goldstein MG. Teaching medical interviewing. A basic course on interviewing and the physician-patient relationship. Arch Intern Med 1992;152: 1814-20.
Orbell S, Abraham C. Behavioural sciences and the real world: Report of a community interview scheme for medical students. Med Educ 1993;27: 218-29.
Fernald DH, Staudenmaier AC, Tressler CJ, Main DS, O'Brien-Gonzales A, Barley GE. Student perspectives on primary care preceptorships: Enhancing the medical student preceptorship learning environment. Teach Learn Med 2001;13: 13-20.
Alford C, Miles T, Palmer A, Espino D. An introduction to geriatrics for first-year medical students. J Am Geriatrics Soc 2001;49: 782-7.
Johnson AK, Scott CS. Relationship between early clinical exposure and first-year students' attitudes toward medical education. Acad Med 1998;73: 430-2.
Friedberg M, Glick S. Graduates' perspective of early clinical exposure. Educ Health 1997;10: 205-11.
Frank D. An integrated curriculum for teaching preparatory clinical skills at a traditional medical school. Teach Learn Med 1996;8: 4-9.
Chisholm MA, McCall CY, Francisco GEJ, Poirier S. Student Exposure to Actual Patients in the Classroom. Am J Pharm Educ 1997;61: 364-70.
Cooper HC, Gibbs TJ, Brown L. Community-orientated medical education: extending the boundaries. Med Teach 2001;23: 295-9.
Waddell RF, Davidson RA. The role of the community in educating medical students: Initial impressions from a new program. Educ Health 2000;13: 69-76.
Bucci KK, Maddox RW, Holmes TJ, Broadhead WE, Tse C-KJ. Implementation and evaluation of a shadow program for PharmD students. Am J Pharm Educ 1993;57: 44-9.
Nieman LZ, Foxhall LE, Groff J, Cheng L. Applying practical preventive skills in a preclinical preceptorship. Acad Med 2001;76: 478-83.
Madray H, Pfeiffer CA, Ardolino A. Teaching patient wellness to first-year medical students: the impact on future ability to perform the history of present illness. Med Educ 2000;34: 404-8.
Allen SS, Bland CJ, Harris IB, Anderson D, Poland G, Satran L, et al. Structured clinical teaching strategy. Med Teach 1991;13: 177-84.
Rogers JC, Dains JE. Can first year students master clinical skills. Acad Med 2001;76: 1065-6.
Linder BM, Saha A, Heseltine GF. Teaching clinical skills to new medical students: the Oman experience. Med Educ 1992;26: 282-4.
Niemi PM. Medical students' professional identity: self-reflection during the preclinical years. Med Educ 1997;31: 408-15.
Elnicki DM, Halbritter KA, Antonelli MA, Linger B. Educational and career outcomes of a medicine preceptorship for first-year students. J Gen Intern Med 1999;14: 341-6.
Rogers JC, Swee DE, Ullian JA. Teaching medical decision making and students' clinical problem solving skills. Med Teach 1991;13: 157-64.
Pamies RJ, Herold AH, Roetzheim RG, Woodard LJ, Micceri T. Does early clinical exposure enhance performance during third-year clerkship? J Nat Med Assoc 1994;86: 594-6.
Carney P, Baron ME, Grayson MS, Klein M, Cochran N, Eliassen MS, et al. The impact of early clinical training in medical education: A multi institutional assessment. Acad Med 1999;74(1 suppl): s59-s67.
Satran L, Harris IB, Allen S, Anderson DC, Poland GA, Miller WL. Hospital-based versus community-based clinical education: Comparing performances and course evaluations by students in their second-year pediatrics rotation. Acad Med 1993;68: 380-2.
Freeman J, Cash C, Yonke A, Roe B, Foley R. A longitudinal primary care program in an urban public medical school: Three years of experience. Acad Med 1995;70(11 suppl): S64-S68.
Thomas EJ, Hafler JP, Woo B. The patient's experience of being interviewed by first-year medical students. Med Teach 1999;21: 311-4.
Murray E. Challenges in educational research. Med Educ 2002;36: 110-2.
Dornan T. Osler, Flexner, apprenticeship, and "the new medical education." J R Soc Med 2005;98: 91-5
Irvine D. The performance of doctors: new professionalism. Lancet 1999;353: 1174-7.
Medical Professionalism Project. Medical professionalism in the new millennium: a physicians' charter. Lancet 2002;359: 520.(Sonia Littlewood, medical student1, Valm)
Correspondence to: T Dornan tim.dornan@manchester.ac.uk
Objectives To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence.
Design A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001.
Data sources Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration.
Selection of studies All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication.
Results Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations.
Conclusion Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.
General Medical Council. Tomorrow's doctors. 2nd ed. London: GMC, 2002.
Harden RM. Integrated teaching—what do we mean? A proposed taxonomy. Med Educ 1998;32: 216-7.
Dahle LO, Brynhildsen J, Berbohm Fallsberg M, Rundquist I, Hammar M. Pros and cons of vertical integration between clinical medicine and basic science within a problem-based undergraduate medical curriculum: examples and experiences from Linkoping, Sweden. Med Teach 2002;24: 280-5.
Dornan T, Bundy C. What can experience add to early medical education? Consensus survey. BMJ 2004;329: 834-7.
Dornan T L, Margolis SA, Ypinazar V, Scherpbier A, Spencer J. How can experience in clinical and community settings contribute to early medical education? www.bemecollaboration.org/topics.htm (accessed 19 Jul 2005).
Albanese M, Norcini J. Systematic reviews: what are they and why should we care? Adv Health Sci Educ Theory Pract 2002;7: 147-51.
Kirkpatrick DL. Evaluation of training. In: Craig R, Bittel L, eds. Training and development handbook. New York: McGraw-Hill, 1967: 87-112.
Lynch DC, Teplin SE, Willis SE, Pathman DE, Larsen LC, Steiner BD, et al. Interim evaluation of the rural health scholars program. Teach Learn Med 2001;13: 36-42.
Grayson MS, Klein MP, Franke KB. Impact of a first-year primary care experience on residency choice. J Gen Intern Med 2001;16: 860-3.
Levy BT, Hartz A, Merchant ML, Schroeder BT. Quality of a family medicine preceptorship is significantly associated with matching into family practice. Fam Med 2001;33: 683-90.
Mengel MB, Davis AB. Required first-year generalist clinical experience courses and their relationship to career choice: the critical effect of family medicine involvement. Fam Med 1995;27: 652-7.
Dobie SA, Carline JD, Laskowski MB. An early preceptorship and medical students' beliefs, values, and career choices. Adv Health Sci Educ Theory Pract 1996;2: 35-47.
Quinby PM, Papp KK. Adopt-a-student, early mentoring in family medicine. Med Teach 1995;17: 47-53.
Vaz R, Gona O. Undergraduate education in rural primary health care: evaluation of a first-year field attachment. Med Educ 1992;26: 27-34.
Barley G, O'Brien-Gonzales A, Hughes E. What did we learn about the impact on students' clinical education? Acad Med 2001;76(4 suppl): s68-71.
Riley K, Myers W, Gordon MJ, Laskowski M, Kriebel S, Dobie S. A collaborative approach to a primary care preclinical preceptorship for underserved settings. Acad Med 1991;66: 776.
Mann MP. A light at the end of the tunnel: the impact of early clinical experiences on medical students. Presented at the annual meeting of the American Educational Research Association, New Orleans, LA, 4-8 April, 1994.
Kent GC. Medical student's reactions to a nursing attachment scheme. Med Educ 1991;25: 23-32.
Hampshire A. Providing early clinical experience in primary care. Med Educ 1998;32: 495-501.
Rooks L, Watson RT, Harris JO. A primary care preceptorship for first-year medical students coordinated by an area health education center program: a six-year review. Acad Med 2001;76: 489-92.
Steele D, Susman J, McCurdy F, O'Dell D, Paulman P, Stott J. The Interdisciplinary Generalist Project at the University of Nebraska Medical Center. Acad Med 2001;76(4 suppl): s121-6.
Novack DH, Dube C, Goldstein MG. Teaching medical interviewing. A basic course on interviewing and the physician-patient relationship. Arch Intern Med 1992;152: 1814-20.
Orbell S, Abraham C. Behavioural sciences and the real world: Report of a community interview scheme for medical students. Med Educ 1993;27: 218-29.
Fernald DH, Staudenmaier AC, Tressler CJ, Main DS, O'Brien-Gonzales A, Barley GE. Student perspectives on primary care preceptorships: Enhancing the medical student preceptorship learning environment. Teach Learn Med 2001;13: 13-20.
Alford C, Miles T, Palmer A, Espino D. An introduction to geriatrics for first-year medical students. J Am Geriatrics Soc 2001;49: 782-7.
Johnson AK, Scott CS. Relationship between early clinical exposure and first-year students' attitudes toward medical education. Acad Med 1998;73: 430-2.
Friedberg M, Glick S. Graduates' perspective of early clinical exposure. Educ Health 1997;10: 205-11.
Frank D. An integrated curriculum for teaching preparatory clinical skills at a traditional medical school. Teach Learn Med 1996;8: 4-9.
Chisholm MA, McCall CY, Francisco GEJ, Poirier S. Student Exposure to Actual Patients in the Classroom. Am J Pharm Educ 1997;61: 364-70.
Cooper HC, Gibbs TJ, Brown L. Community-orientated medical education: extending the boundaries. Med Teach 2001;23: 295-9.
Waddell RF, Davidson RA. The role of the community in educating medical students: Initial impressions from a new program. Educ Health 2000;13: 69-76.
Bucci KK, Maddox RW, Holmes TJ, Broadhead WE, Tse C-KJ. Implementation and evaluation of a shadow program for PharmD students. Am J Pharm Educ 1993;57: 44-9.
Nieman LZ, Foxhall LE, Groff J, Cheng L. Applying practical preventive skills in a preclinical preceptorship. Acad Med 2001;76: 478-83.
Madray H, Pfeiffer CA, Ardolino A. Teaching patient wellness to first-year medical students: the impact on future ability to perform the history of present illness. Med Educ 2000;34: 404-8.
Allen SS, Bland CJ, Harris IB, Anderson D, Poland G, Satran L, et al. Structured clinical teaching strategy. Med Teach 1991;13: 177-84.
Rogers JC, Dains JE. Can first year students master clinical skills. Acad Med 2001;76: 1065-6.
Linder BM, Saha A, Heseltine GF. Teaching clinical skills to new medical students: the Oman experience. Med Educ 1992;26: 282-4.
Niemi PM. Medical students' professional identity: self-reflection during the preclinical years. Med Educ 1997;31: 408-15.
Elnicki DM, Halbritter KA, Antonelli MA, Linger B. Educational and career outcomes of a medicine preceptorship for first-year students. J Gen Intern Med 1999;14: 341-6.
Rogers JC, Swee DE, Ullian JA. Teaching medical decision making and students' clinical problem solving skills. Med Teach 1991;13: 157-64.
Pamies RJ, Herold AH, Roetzheim RG, Woodard LJ, Micceri T. Does early clinical exposure enhance performance during third-year clerkship? J Nat Med Assoc 1994;86: 594-6.
Carney P, Baron ME, Grayson MS, Klein M, Cochran N, Eliassen MS, et al. The impact of early clinical training in medical education: A multi institutional assessment. Acad Med 1999;74(1 suppl): s59-s67.
Satran L, Harris IB, Allen S, Anderson DC, Poland GA, Miller WL. Hospital-based versus community-based clinical education: Comparing performances and course evaluations by students in their second-year pediatrics rotation. Acad Med 1993;68: 380-2.
Freeman J, Cash C, Yonke A, Roe B, Foley R. A longitudinal primary care program in an urban public medical school: Three years of experience. Acad Med 1995;70(11 suppl): S64-S68.
Thomas EJ, Hafler JP, Woo B. The patient's experience of being interviewed by first-year medical students. Med Teach 1999;21: 311-4.
Murray E. Challenges in educational research. Med Educ 2002;36: 110-2.
Dornan T. Osler, Flexner, apprenticeship, and "the new medical education." J R Soc Med 2005;98: 91-5
Irvine D. The performance of doctors: new professionalism. Lancet 1999;353: 1174-7.
Medical Professionalism Project. Medical professionalism in the new millennium: a physicians' charter. Lancet 2002;359: 520.(Sonia Littlewood, medical student1, Valm)