Commentary
Open Access

The developing role of Community-Based Medical Education

John Dent[1]

Institution: 1. AMEE
Corresponding Author: Dr John Dent ([email protected])
Categories: Educational Strategies, Medical Education (General), Curriculum Evaluation/Quality Assurance/Accreditation
Published Date: 07/07/2016

Abstract

Not requied for this editorial.

Keywords: community-based education; rural medical education; medical education; curriculum reform

Introduction

The mantra that undergraduate medical education is best provided in a tertiary referral teaching hospital still enjoys international currency.  Many medical schools across the world continue to retain a traditional curriculum which can be defined as being teacher-centred, information gathering, discipline-based and hospital-based, having a standard programme and being apprenticeship-based. 

One route to revising a curriculum, popularised more than 30 years ago now, is the SPICES approach (Harden, Sowden & Dunn,1984).  In this model a move towards the opposite end of the spectrum was described for each of these traditional elements.  They proposed a curriculum with the acronym SPICES which could be Student-centred, Problem-based, Integrated and Community-based, having Electives and being Systematic in approach. This SPICES model has become a method by which a curriculum can be evaluated and on which a new curriculum or course can be designed (Dent 2014).  While each of these elements is interesting in its own place we are concerned in this themed issue of MedEdPublish with exploring ideas and examples of just one, Community-Based Medical Education (CBME).

What is CBME?

Community based teaching has been described as “medical education that is based outside a tertiary or large secondary level hospital (and which) is focussed on the care provided to patients both before the decision to refer to a tertiary hospital and after the decision to discharge the patient from such care” (Worley & Couper 2013).  In 2014 Simon Stevens, the Chief  Executive of the NHS in England, emphasised the role which community hospitals have to play by saying that more patients should be treated in their own communities rather than in centralised specialist hospitals.  As always, student teaching should go to where there are patients to see, so venues available for teaching in the community may now include a community health care clinic; a regional diagnostic and treatment centre or cottage hospital; a general / family practice centre; as well as patient’s homes, schools or work places. 

Why teach in the community?

Increasing student numbers in teaching hospitals are not matched by an increase in the number of in-patients suitable for student teaching.  This overcrowded environment does little to foster either student teaching or patient care and may contribute to additional risks by increasing student stress and teacher burn-out.  In contrast, CBME allows students to experience a more personal relationship with patients, to recognise the importance of treating people instead of ‘a disease’ and in addition can show how the social environment has a significant impact on health and healthcare (Howe 2001).  The benefits of a community-orientated programme have been described by Habbick & Leeder (1996) as:

  • Offering a broader range of learning opportunities for students to acquire knowledge, skills and attitudes
  • Promoting a more patient–orientated perspective
  • Deepening the range of health and illness issues and the working of the health and social services
  • Deepening an awareness of the contribution of social and environmental factors to the causation and prevention of illness and an enhanced view of multidisciplinary working and possibly of increased recruitment into primary care

In addition Worley and Couper (2013) suggests that students can learn about:

  • general and family medicine
  • a particular specialty
  • multiple disciplines concurrently as their whole curriculum may be based in an extended rural programme

Senior students in prolonged rural placements found that they had increased patient contact, increased time in clinical settings, increased time spent being supervised and were better prepared for their forthcoming FY1 year as a junior doctor (Dent et al 2007).  It was also shown that undergraduate medical education can safely be delivered in ambulatory and community settings without compromising academic standards (Worley  et al 2000).

Examples

Examples of successful curricula based on or including significant elements of CBME have been described ranging from an increased use of ambulatory care teaching venues (Dent 2005, Latta et al 2013), through extended placements in General Practice (Oswald et al 2001), to emersion programmes in rural clinical practice (Worley et al 2000, Rourke & Frank 2005).  Recent papers in MedEdPublish from UK, Australia and the USA report a variety of examples of CBME.  Bourke & Wright (2015) from Melbourne, Australia, affirmed that a rural background is a predictor of future rural practice and went on to report a change in student-attitude towards a rural career in those who took a rural health module.  From Glasgow, UK, Mullen & Smith (2016) report a Student Selected Component (SSC) which assessed student attitudes to addiction by placing them in a community-based initiative which provided experience in managing these patients.  A further paper from Baltimore, USA, (Rios et al 2015)  reported on the role of community service in contributing to personal and professional growth.

Conclusions

Whether further appreciation of the role of CBME by medical schools can still occur is debatable.  Does the initiative lie with individual faculty members who see the advantages of this and have the enthusiasm to pursue an “bottom-up” approach to curricular reform?  Or does a change in this direction on the SPICES spectrum require the explicit directives of senior faculty and curriculum committees before it can take effect?  It would be interesting to hear the opinion of readers on this question.  If  you have an example of CBME which you would like to report, or an opinion to contribute for discussion, then please make use of this exciting new facility on MedEdPublish to share this with us.  

Take Home Messages

Notes On Contributors

Dr John Dent is Honorary Reader in Medical Education and Orthopaedic Surgery at University of Dundee, AMEE International Relations Officer, an Associate Editor of Medical Teacher and an International Member of the editorial board of the Korean Journal of Medical Education. His main research areas relate to ambulatory care teaching and the development of community-based education. He is currently a tutor for AMEE on the ESME–Online and the new ESME-Student course. With Professor Ronald Harden he co-edited the internationally acclaimed, multi-author text, “A Practical Guide for Medical Teachers” (4th ed), Elsevier, which was Highly Commended in the annual BMA Book Awards, 2010. 

Acknowledgements

Bibliography/References

Bourke L, Wright J (2015). Perceptions of rural practice among metropolitan medical students undertaking a rural health module. AMEE MedEdPublish.

http://dx.doi.org/10.15694/mep.2015.006.0011  

Dent J (2014). Using the SPICES model to develop innovative teaching opportunities in ambulatory carer venues. KJME 26 (1):3-7   

Dent J, Skene, Nathwani D, Pippard M, Ponnamperuma G, Davis M (2007) .Design, implementation and evaluation of a medical education programme using the ambulatory diagnostic and treatment centre. Med Teach 2007, 29:341-345

http://dx.doi.org/10.1080/01421590701509720   

Dent JA (2005). AMEE Guide number 26: Clinical teaching in ambulatory care settings – making the most of learning opportunities with outpatients. Medical Teacher 27:302-315

http://dx.doi.org/10.1080/01421590500150999

Habbick BF, Leeder SR (1996). Orienting medical education to community need: a review. Med Educ, 30:163-171

http://dx.doi.org/10.1111/j.1365-2923.1996.tb00738.x   

Harden RM, Sowden S, Dunn WR (1984). Educational strategies in curriculum development: the SPICES model. Med Educ 18: 284-297

http://dx.doi.org/10.1111/j.1365-2923.1984.tb01024.x   

Howe A (2001). Patient-centred medicine through student-centred teaching – a student perspective on the key impacts of community-based learning in undergraduate medical education. Med Educ 35: 666-672

http://dx.doi.org/10.1046/j.1365-2923.2001.00925.x   

Latta L, Tordoff D Manning P, Dent J (2013). Enhancing clinical skill development through an ambulatory medicine teaching programme: an evaluation study. Med Teach 35: 648-654

http://dx.doi.org/10.3109/0142159X.2013.801553

Mullen K, Smith I (2016). Medical students' attitude towards the addictions. AMEE MedEdPublish

http://dx.doi.org/10.15694/mep.2016.000011   

Oswald N, Anderson T & Jones S (2001). Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical course. Med Educ 35:782-788

http://dx.doi.org/10.1046/j.1365-2923.2001.00981.x   

Rios NR, Zhang TT, Stewart R (2012). Personal and professional growth through community service; a medical student reflection. AMEE MedEdPublish.   

http://www.mededworld.org/getattachment/MedEdWorld-Papers/Papers-Items/Personal-and-Professional-Growth-through-Community/Growth-through-Community-Service.pdf

Rourke J, Frank JR (2005). Implementing the CanMEDS physician roles in rural specialist education: the multi-specialty community training network. Education for Health 18(3):368–378, Joint issue with Rural and Remote Health 5:406.

Stevens S (2014). NHS chief Simon Stevens: We need cottage hospitals.

http://www.telegraph.co.uk/news/health/news/10864015/NHS-chief-Simon-Stevens-We-need-cottage-hospitals.html

Worley P, Silagy C, Prideaux D, Newble D, Jones A. (2000). The parallel rural community curriculum: an integrated clinical curriculum based on rural general practice. Med Educ 34:207-209

http://dx.doi.org/10.1046/j.1365-2923.2000.00668.x   

Worley PS, Couper ID. (2013). In the community. JA Dent & RM Harden. A Practical Guide for Medical Teachers, Elsevier, Edinburgh

Appendices

Declarations

There are some conflicts of interest:
I am the Guest Editor of AMEE MedEdPublish for the theme of Community-based Medical Education.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Reviews

Please Login or Register an Account before submitting a Review

John Cookson - (18/08/2016) Panel Member Icon
/
I enjoyed this paper.

However, perhaps it is time for a ‘speech for the defence,’ in this case for hospitals, say those of significant size, 400+ beds and a range of specialists. I’m a retired UK hospital consultant and undergraduate dean, spending many years trying to increase the proportion of the curriculum spent in the ‘community’.

First some clarity about definitions. Community-based education is described as that ‘outside a tertiary or large secondary level hospital’, but incorporating a community hospital. What that means depends on where you are. In the UK, most of the population lives within a 30-minute ambulance drive from a large hospital. Beds in any community hospital provide ‘step-down’ care. This is quite different where distances are measured in hundreds rather than in tens of miles. A community hospital in the Australian outback or American mid-west will deal with a very wide range of problems including emergency surgery and obstetrics. Student experience will be very different and we should be wary of applying research performed in one to the other.

Secondly, what do we want to achieve? The setting, the learning framework, needs to be congruent with the course outcomes. More medical education in the community may be a ‘good thing’ but only if it enables students to meet those outcomes. Education in the community, or indeed anywhere else, is predicated not on the perceived nature of the experience in isolation but whether that experience matches the outcomes. The outcomes come first.

It may be worth rehearsing some aspects of hospital-based practice in the UK which support important learning outcomes found in most courses.
• Acute care; obvious but needs saying. Most episodes of any severity will end up with a hospital attendance of some sort.
• Following disease progression over minutes, hours or days. Observing the developing pathophysiology of any disease is crucial to understanding its nature.
• In-patients are generally available for comparatively long periods of time. Students can spend a long time with an individual patient and the patient is often still there hours or days later for the tutor to check their findings.
• Students can be more self-directed and ‘can put themselves about’ more readily in a hospital.
• Imaging disease; pathology is important, the community provides experience of family and psycho-pathology but cellular and whole organ pathology is important too. Imaging techniques (the pictures not just the reports) provide insight into disease processes. Important now autopsies are rare.
• Many important conditions are relatively infrequent in the community; a single afternoon in a hospital out-patient clinic (an underused asset) can provide a range of experience that would otherwise take weeks.

Several management issues favour hospitals
• Larger resources mean that student problems with, say, teaching quality or relationships are more easily managed.
• Library and IT facilities are more extensive. Video connections are more realistic.
• Management issues-placement numbers, contracting issues, financial flows, quality assurance-are more efficiently handled
• Student travel costs are minimised.
• Social opportunities for students are more extensive
Mohamed Al-Eraky - (13/07/2016) Panel Member Icon
/
Thank you John for your structured argument to advocate the significance and the urgency of the move towards community-based medical education (CBME). Adding to the Western examples, I am glad that there are good initiatives in Asia and Latin America, as indicated by Ravi in the reviews. Also my colleague Anthony from Ghana is doing his PhD from Maastricht on CBME. I am convinced that individual visionary people can add more SPICES to medical education worldwide.
P Ravi Shankar - (08/07/2016) Panel Member Icon
/
I enjoyed reading this paper. Community-based medical education (CBME) has always been one of my areas of special interest. Having completed a FAIMER fellowship in health professions education I have always been interested in CBME programs around the world. I do agree that the community may be a better learning site for students than the tertiary care teaching hospital. It has also been shown that learning in the community is one among the many interventions favoring a career in primary practice, as mentioned by the author. Canada and Australia have been pioneers in this concept and Brazil also has made remarkable progress in linking medical education and health systems. In South Asia, Sri Lanka is quiet successful in delivering healthcare to its citizens. The Aga Khan University in Pakistan, Christian Medical College, India are good examples. Patan Academy of Health Sciences in Nepal is a school with a strong CBME program.
In the examples section, does the author mean ‘immersion’ or is ‘emersion’ the correct word? I enjoyed reading this brief overview of CBME and the call for papers for this themed issue. In Caribbean medical schools with students predominantly from the United States and Canada, the emphasis on and opportunities for CBME continue to offer opportunities for improvement. Developing closer links with the health systems of countries where the schools are located and the fact that very few graduates from these medical schools are likely to practice in the Caribbean are challenges. Health fairs and community events have been used by these schools to provide a certain amount of community exposure to students during the basic science years.