This week students at Dalhousie Medical School will vote in a referendum on whether a community based primary care clinical experience should included as part of the curriculum in the first 2 years of medical education. I believe it should be and I am posting to express some of the reasons why I support this initiative. I was motivated to make this post because I feel it is important that students have a public forum to exchange views and opinions on this issue and that students take some time to carefully consider their position prior to casting their votes. I hope that not only supporters but also those who feel there is not a need for this addition to our curriculum will contribute their views.
There are many reasons to support the addition of a community medicine practicum in our curriculum but, in the interest of time and attention spans, I am going to focus on two (and trust additional arguments to be voiced by others); first, it is most appropriate to learn the skills and knowledge used to provide general primary care early in one’s medical education, and second, that exposing all medical students to community practice environments early in their educations will increase interest in practicing in communities removed from the major centers and better meet the health care needs of Maritime communities.
GPs are the primary entry point into our medical system and the skills and knowledge applied in general primary care are foundational to the practice of medicine. It seems logical that medical students should learn and practice these skills early in their educations. Although much of the knowledge and skills used in general medicine are introduced in the first two years, there is little opportunity to practice them or to “put them all together” as you must when providing care to a patient who walks into their family doctor’s office. Beyond the benefit of practical training and experience in primary care, students planning to go into non primary care specialties will benefit from a greater understanding of how patients enter the system and receive referral.
Although it is sometimes hard to believe while paying tuition, our medical educations are heavily subsidized by public money. It seems reasonable for some public funds to be allocated to train future physicians, after all when we graduate we will work providing health care to the taxpayers who contributed to our training. But I wonder if citizens who struggle to access the care of a family doctor know that most students at Dal won’t be exposed to a community based general practice role until sometime in their clerkship and that it is quite possible to graduate never having trained outside of a regional centre. All students should see the broad scope of practice enjoyed by physicians practicing in smaller centers and be allowed the opportunity to consider how such a practice would suit their own futures.
Implementing such a substantial program component will not be easy or quick. It will require additional funding and administrative resources. A strong positive response from the student body will give the students and faculty advocating for this change the mandate to continue pursing it with the administration and will communicate to the administration that this initiative needs to be a priority. The challenges of implementation, while very real, should not be reason for withholding support for this initiative.
Thank for you for taking the time to read and consider these points. I hope you will take the time to contribute your own views on this matter.
4 Comments on “Primary care clinical experience”
For the reasons you mention, I agree that this is an area of medical education that is important. Students gaining early exposure to primary care clinical experiences in rural and urban settings may positively influence students and potentially encourage more students to chose primary care as a career.
While I do not oppose the idea of instituting a community based primary care clinical experience, I have few concerns about incorporating more content into our current curriculum in general.
First, I believe that there are a few areas of medicine that are underrepresented in our current curriculum. Two examples quickly come to mind, but only scratch the surface.
1) Anaesthesiology: Aside from pharmacology and a few examples where pain management enters into our tutorial discussions, there is not a lot of opportunity to learn more about anaesthesiology as a profession. The only way is to have a clerkship rotation in this area is by choosing one as your elective in fourth year.
2) Medical Informatics: No matter what career we decide on, medical informatics is becoming an increasingly essential component. Whether it’s conducting efficient and accurate searches for papers and information on the web (does wiki count?), making use of electronic health records and the information that amasses overtime, or collaborating and communicating with other health professionals; understanding and taking advantage of medical informatics will play a huge role in our successful careers.
Aside from a session on MESH pubmed queries, and a few research projects from CECT, this is a largely neglected area, and one that plays an essential role in primary care clinical experience as well.
So my question is, how do we decide which is the most important missing component of our curriculum? Primary Care? Medical Informatics? Or the plethora of other areas that haven’t been mentioned?
Secondly, our current schedule is packed. We have a lot of lectures, tutorials and content in our main 5 units, plus the additional units that take place throughout the year. Many of the things that keep us busy are delivered quite exceptionally, while some aspects are only given small windows to deliver complex content.
Adding more content into our curriculum seems like a great idea, but where will it fit in? Let’s cut ethics down to 3 hours in the year, rather than the already short 7 hours?
My last point is that the way to address our ‘lack’ of primary care clinical exposure may in fact already exist. In addition to our required course content, our school has many different societies and interest groups covering a wide range of topics. These interest groups are dedicated to exploring the issues relating to their areas as well as generating awareness and interest. The fact that there is an upcoming referendum speaks to the success of interest groups as an adjuvant to our curriculum. People who strongly believe family medicine is important and needs more attention have met throughout the school year and have worked together to raise awareness and interest in this field.
The solution I propose may not be perfect, but we are all responsible adults capable of taking steps to advance our understanding of areas important to us.
Hi Med 1’s!
I know I’m not one of the 94 monkeys, but Shane told me about his blog on the referendum and I thought I’d check it out. I appreciate Shane’s support, but I think Aaron;s comments raise some important and interesting points as well. I just wanted to make a quick comment about a couple of them.
First, I completely agree that primary care is not the only aspect of our curriculum that is seriously laking. If I had more time on my hands, I’d gladly help with hold a referendum on some of them as well to see what other things students want to see added, and anesthesia in particular would easily get my “yes” vote. This however doesn’t mean that we should hold back on making a change in one area because another one is still a few steps behind.
Second, I believe primary care is a bit unique because unlike any other individual speciality which may have say 5 at most people from each class enter, family medicine (even if its not because you want it) will end up being what at least a third to half of the class does because that’s what the health care system needs in order to function. Those 30-40 monkeys might want to know what they have in store for them. Not to mention, that all specialists will interact with family docs, and their patients will all interact with family docs, so some appreciation of what they do goes a long way.
Third and finally, please remember we specified this as a “COMMUNITY CLINICAL” experience, so since sitting in the tupper for another dry lecture is neither community or clinical, we are saving you in advance for something of that nature.
We want this to be a fun and exciting part of pre-clerkship, a chance to practice some of the clinical skills you have learned, and learn some more. In addition, it will get students out of the tupper, and learn how broad our potential futures can be.
To end, I really encourage others to identify other aspects of the curriculum you think could be improved and act on it. Although student groups are a perfect first start, there sometimes comes a time where the school also must take responsibility and not leave it all to the work of the students, which is what I personally think this referendum is about. The Family Medicine Interet Group does a lot to support family medicine, but I think its time the school steps in and does more too! Vote and show us whether or not you agree!
I used to be on the commitee pushing for the “yes in this referendum. So I feel bad throwing in my 2 cents on the opposite side, but I voted “no”. There are a host of reasons but I’m going to list the ones I think are most pertinent:
1) As Aaron pointed out our curriculum is already too stretched as is. We should only be adding things in if we are taking things out. If we are going to propose to add anything to the curriculum, such a proposition should be coupled with what we are proposing to take out, or a stipulation that we intend to extend the academic year.
2) We cannot fully appreciate time in primary care because we do not yet have all the “pieces” to put together in a primary care setting
3) We do have a required rotation in family in third year, where we will all be exposed to family and be able to put the “pieces” together. This I feel is sufficient exposure to the “whole picture” family scene.
4) As to a disproportionate amount of time being dedicated to various specialities in comparison to family medicine: All the other specialties are part of family medicine. All of our education is what family medicine is.
I apologize to my friends on the referendum commitee for becoming a turncoat.
Tim
Hi Guys,
I just finished reading this series of posts and also feel quite strongly about this referendum. I appreciate both sides of the argument but really see inclusion of rural family exposure (emphasis on rural) as an imperative. Coming from a rural background and with some knowledge of the challenges faced by rural physicians (largely ignored here at school unless spoken about negatively) I think the current emphasis on subspecialization, research and lifestyle is actually unethical.
No one talks about the responsibility we have as medical students to the greater community. And let’s face it…the greater community in this province in still rural. I see a major (and self-serving; if you want to know why ask me) disconnect between what our education should be preparing us for and what it is. Take a look at this years’ matches. Even better take a look at the proportion of Dal graduates that go work in rural NS. Let’s not forget that most of us are only here because we are from the maritimes….I hope you don’t think you owe this area nothing.
I’m not saying that we have to feel guilty about our future career choices, but increased exposure to rural practice would undoubtedly help where help is desperately needed and we have the power to help with this. I do think the administration should feel guilty about not exposing us to rural practice already.
It’s a question of priorities; if we have no room make some. I really think it’s as simple as that.
I hope that you guys will really think about it, not just for the sake of this referendum, but consider what this province has done (and is doing….bigtime) for you, and what your average NS-er (who would probably have less than you think in common with the inhabitants of this peninsula) would think about the way things are.