The material presented here seeks to analyse the strengths and weaknesses of educating medical and healthcare professionals in a community setting.
It explores the role of clinical, institutional, social and personal relationships in developing a framework for describing quality in community-based undergraduate medical education.
This model describes four key relationships, the four Rs, in which the medical student must be immersed to facilitate high quality learning.
- These four Rs are the relationships between
- clinicians and patients;
- health service and university research;
- government and community; and
- personal principles and professional expectations.
The model is proposed as a valid framework for articulating the important principles in CBME, and describes why community-based medical and health care education is such an attractive alternative, and why relationships do matter.
How does it work?
The axes are interdependent. The quality of the whole is more than the sum of the parts when they are integrated with integrity. The relationships are represented by the four intersecting axes of the diagram:
The Clinical Axis
The first R describes the curriculum facilitating the student's entry into the doctor-patient or healthcare professional-patient relationship.
Ward-based and short-term community attachments may not allow students to get to know either the patients or their supervisors in any depth.
An extended apprenticeship-style community based attachment where students gain a respected hands-on role in the health team and are mentored by generalist role models can give students a privileged welcome to 'their' patients and increase their clinical confidence.
Ideally the learning should be from all members of the health care team.
The Institutional Axis
Students’ experiences in clinical settings are heavily influenced by the relationships between medical and health care schools or universities and their health service partners.
These relationships see the University and health service provide a team based approach, giving the student the opportunity to not only learn the curriculum, but put it into effective practice.
The key concept in a university health service relationship is that of ‘authentic supported learning’: the health service provides the context for authentic learning, whilst the University or school provides organisational and teaching support to the student in their learning.
The Social Axis
A symbiotic approach challenges clinical education to become embedded in the real world, to be visible, relevant, supported and accountable to the community and its representatives.
The relationship between the Community with its own needs and desire for active involvement, and the Government, providing policies and financial support, is fundamental to achieving a symbiotic curriculum and meeting the learning needs of students.
The Personal/Professional Axis
Balancing personal and family priorities with the expectations and patients and colleagues has been shown to have adverse effects on the wellbeing of both healthcare professionals and students.
Students need to grow emotionally, especially in the way they approach their own capacity for error. This cannot be learnt from textbooks.
It requires a student to be stimulated to learn ethics, morals and values by being confronted by the frequent conflict between their own ideals and theories and how they see medicine practised in real life.
This learning is facilitated when students are able to participate actively in the ongoing decision-making for 'their' patients within extended community-based attachments. In this situation they often become their patient's advocate.
In a community setting they have the opportunity to develop far less hierarchical relationships with both their supervising clinicians and their patients. They can interact in non-clinical settings such as shopping centres and sporting clubs.