2. The Teaching of Community Medicine in the Undergraduate Curriculum RICHARD L O G A N Medical Student, University of Edinburgh; Joint Winner of BMA Medical Students Prize Essay Competition, 1968

Over the last 50 years hospital medicine has become those diseases which are managed in ‘the world of increasingly complex and specialized, and this has the well’ flickers 1967). This is where the under- produced a corresponding conceptual bias in graduate will see measles, influenza (that precipi- favour of hospital care. It is only recently that the tator of so many spells of hospitalization), simple medical profession has begun to attain a more fractures and ‘tummy aches in sick kids’.’ balanced view and think more in terms of com- In my view, community medicine encompasses munity care. far more than just the management of chronic

Before this century it was frequently both pos- disease in the community, large as t h i s burden is. sible and desirable to treat the patient in the cornuni ty medicine, for the individual, involves comfort of his own home. Where the treatment not Only the management of the Pathology he is was actually carried out was largely irrelevant to liable to Suffer, but also the softening of the non- the outcome of a disease process. Hospitals were Pathological crises of birth, growth, ado1escence, then little more than infirmaries for the old and senescence, and even death - not always to be poverty stricken. As medical knowledge has grad- regarded from the Pathological viewpoint- I use ually expanded in its own peculiar way, a body of the term management to include a recognition of practice has evolved which is only feasible in a high risk PredisPosition, Prevention, Pre-sYmPto- hospital environment. Expensively equipped has- matic detection, diagnosis, treatment, and rehabili- pitals are vital for complex surgical intervention tation- In fact, management embraces medical in disease processes, and for the treatment of the Practice the whole gamut of a disease crises of degenerative disease, such as myocardial Process-

acidosis in diabetes. tion of disturbance of the various social systems which have been placed under stress by disease in

constant availability of these costly hospital re- a member* this the

at home with occasional domiciliary nursing; particularly, aiding the relative - usually mother or

to the to work. I am taking the definition of community medicine as outlined by Vickers (1967) for the following reasons:

Furthermore, there are good medical reasons, (I) Vickers uses the word community in a manner besides economic arguments, for promoting readily understandable to undergraduates in contrast

with other definitions, such as that used in the Todd

itself a considerable trauma and represents a a single finite entity rather than a conglomeration of various aspects of epidemiology, preventive medicine, and the organization of medical care. This, at least, will

further degree of invalidism flickers, 1967). Thus, today, there is a spectrum of disease produce less hostility in medical students than any

treated in hospital and a wider which is previous terminology. (2) The word community usually denotes a degree of geographical proximity, as well as

OccasionallY Prevented, but more Often diagnosed common cultural and economic characteristics. Other and treated outside hospital. It is the management definitions of community medicine do not recognize this

teaching of community medicine as the entity I have to ascribe to the field of community mediche - described.

infarction in ischaemic heart disease and keto- cOI”lUnity medicine ak.0 involves the hlkl-

similarly, many conditions do not warrant the

sources. The bronchitic can be maintained to adjust to an increased burden, and,

diabetic and digitalized patients can be restored daughter - who nurse the Patient. In ’Ome and may often

domiciliary care, since dl”lksion to hospital is in repon. In educational terms, Vickers’s definition covers

of this second category of diseases which 1 wish proximity- (3) I believe there is a good case for the

185

I 86 Richard Logan

cases, this aspect of community practice will require the practitioner to act as co-ordinator of a domiciliary care team composed of the nursing relative, district nurse, psychiatric social worker, almoner, and maybe a disablement resettlement officer. This is what any individual, consciously or subconsciously, expects from his doctor.

With the present structure of the health service, community medicine is largely practised by the general practitioners, local health authorities, and the out-patient clinics of hospitals. These doctors are aided and supplemented by the teams outlined above. Since this essay is concerned with the education of doctors who will be practising in the I ~ ~ O S , it is worth noting that the Todd report envisages the continuing need for and existence of a primary physician in the community setting.

The role of the hospital in this medicine is as a retreat during the acute phases of a disease, allowing transient withdrawal for intensive therapy or dissolution. Naturally, much general surgery is precluded from community medicine by its acute ‘cure or kill’ character. Thus, the distinc- tion between in-patient and community medicine must be seen as a functional distinction and not an administrative artefact.

What the Undergraduate Needs to Know Historically, medical education has evolved around the large hospitals where the student could witness a wide spectrum of disease. Today, with so many conditions treated and managed in the community, the spectrum of disease treated in hospitals has become much narrower (Wearn, 1961). T o many undergraduates, medicine amounts to little more than a series of acutely ill, bedridden patients suffering from rare diseases, with the therapeutic emphasis on the treatment of organ failure. In fact, the spectrum has been so reduced that many medical schools now recognize this deficiency in their teaching of hospital training, and have at- tempted to remedy the situation by the teaching of general practice.

However, the rationale for the teaching of general practice has been that, although it is not very relevant to hospital medicine, half the students would become general practitioners anyway. At present this approach is rather limited because the teaching is regarded as a substitute for postgraduate specialist training in general practice and, therefore, excludes the wider con- cepts of community medicine.

A More Ambitious Course If our medical schools still believe in a basic medical degree, given at the end of the undergraduate course as recognition of the completion of a broad but non-specialist training, then a more ambitious course in community medicine is necessary to demonstrate to the undergraduate a much wider spectrum of disease. This would not be the semi- vocational exercise (General Medical Council, 1967), that general practice courses are regarded as at present, but would be relevant to all. Without proper teaching in community medicine, the under- graduate will continue to see disease processes and their management only as snapshots rather than as a continuing film.

The aim of a course of this kind would be to develop an approach to disease, where the student recognized that a disease state was the meeting point of both biophysical and psychosocial factors, and that it produced psychosocial reverberations as well as biophysical ones. This would not be an attempt comprehensively to cram the student with information, but to give him the power to utilize knowledge gained throughout his years of practice (Ellis, 1960).

The social sciences must be shown to be as relevant to the doctor’s aim ‘to cure sometimes, to relieve often, and to comfort always’, as the bio- physical sciences are now recognized to be. This teaching would strive to fulfil the sentiment of the Goodenough Committee expressed two decades ago that ‘the ideas of social medicine must per- meate the whole of medical education’ (Ministry of Health, 194).

Four Major Areas With this general approach in mind, it is worth- while considering what particular aspects of com- munity medicine might be taught to undergrad- uates. These could be split into four major areas: (I) the physical aspects of community medicine; (2) the social aspects of disease in the community; (3) the management of this disease; and (4) epide- miology as the relevant research method in the community.

Physical Prospects The pathologist’s continual cri de caeur is that the student must appreciate diseases as more than a fixed histological section or the preserved jar in the museum. Yet no real attempt has been made to show disease as an ongoing process. Similarly,

‘87 2. The Teaching of Community Medicine in the Undergraduate Curriculum

clinicians now vainly attempt to remind us that, for every case of Addison’s disease seen on their wards, there will be a score of diabetics and hundreds of iron-deficiency anaemias unrecognized and untreated outside the hospital.

A proper course in community medicine would correct both these weaknesses in present teaching. The student would see disease in its presympto- matic state and, with sensible teaching, the patho- logy could be traced through the stages producing symptoms, diagnoses, occasional crises, treatment, management, rehabilitation, and possibly the final demise. Furthermore, secondary prevention in- volving detection of the presymptomatic state, and tertiary prevention involving rehabilitation and avoidance of chronic handicap, could be demon- strated in a setting where it must be increasingly practised (Logan, 1963). Also, the concept of the prevalence of a condition will spring to life in a practitioner’s surgery, where a procession of bron- chitics may constitute an evening’s surgery (Lancet, 1962).

Social Aspects The teaching of the social aspects of community medicine would aim to demonstrate the psycho- social factors in the aetiology of a disease. The concept of social pathologies, such as criminal behaviour and drug addiction, could usefully be developed as conditions creating a predisposition to physical disease. These may themselves not be strictly medical problems, but as they are pre- sented to the practitioner, he must ameliorate them in order to treat the medical conditlon satisfactorily. Alcoholism and self-poisoning represent two conditions in which social factors are already appreciated by most undergraduates.

Probably more important than the understand- ing of the psychosocial factors in the aetiology of a condition is an appreciation of the effect of disease on the related social systems. The absolution of the sick from various responsibilities may severely disturb a family, particularly the member who must take up their burden; t h i s may even produce further physical sickness such as peptic ulceration.

Therapeutics in the Community The third facet of teaching is that of therapeutics in the community. For the undergraduate in his teaching hospital, this mainly means prescribing drugs and advising complete procedures, such as surgery and radiotherapy, all of which he himself

does not administer. The situation in the com- munity is very different as is testified by the medical student who noted ‘the sobering effect of the know- ledge that your medicine was going to be taken! (c.f. one’s efforts in the pharmacology class where the product disappeared down the sink)’ (Brother- ston, Martin, and Scott, 1959). Students taught community therapeutics would learn how to pre- scribe simply and accurately so that their instruc- tions were understood. The useless prescribing, which general practitioners sometimes perpetrate, might be radically reduced by this teaching.

The therapeutic problems of chronic disease requiring careful management and rehabilitation just do not exist for the undergraduate isolated in a teaching hospital. Arranging physiotherapy, chiropody, or medical social work are things undergraduates hear about almost as peripheral problems. So the student must be taught to ap- preciate these problems as they arise in such conditions as myocardial infarction. To most undergraduates the care of this type of patient ceases when he is discharged from the ward for convalescence, yet for the general practitioner the problems of rehabilitation and of restoring him to work are just beginning.

The student should also appreciate that the community is the best place for treating chronic degenerative disease if severe handicap and invalidism are to be avoided. These problems of management, which the student must understand, frequently cast the practitioner in the role of head of a multilateral domiciliary care team, whose organization is quite informal. It is the practitioner who must weld t h i s team into a functioning unit

The net result of this teaching in community therapeutics would be to re-emphasize that order of priorities already quoted - comfort always, relieve commonly, and cure sometimes.

‘g63)’

Epidemiology and Research The fourth facet of community medicine, of which I think the undergraduate should be aware, is that of epidemiology. In all branches of medicine, as in community medicine, practice and research go hand in hand. The student should understand that epidemiology is the research method particularly relevant to community medicine, and he should appreciate its relationship to the other methods of medical research - clinical observation and labora- tory experiment (Morris, 1967).

I88 Richard Logan

Epidemiology has suddenly become fashionable since it is one of the main ways of investigating disease and its relation to our modern way of life. As diseases of affluence assume greater and greater importance, it is especially important that the student appreciate the uses of epidemiology (Morris, 1959) and be conversant with the research techniques of epidemiologists.

The undergraduate should understand how epidemiology can tell us more about the cause of disease and what form a disease process takes. The delineation of high risk predisposition in the development of such conditions as diabetes and ischaemic heart disease, and the recognition of pre-malignant changes in cancer, must be stressed as the results of epidemiological investigations. The identification of clinical syndromes and pre- symptomatic states should be understood as a product of epidemiological research, in the same way as our knowledge of the relationship between smoking and lung cancer.

In this way, the teaching of epidemiology will help undergraduates to see the overall pattern of disease in the comunity. The student would recognize the existence of various groups, as analysed by epidemiologists, each of which have predilections for various diseases and conditions ; then, when in practice, he would be conscious of the social forces, physical risks, and environmental conditions that might influence the health - social or medical - of his patients.

It has been suggested that the undergraduate should be taught something about the work of the welfare services and how to use them. No doubt the student will absorb some facts about how the welfare state works, but teaching expressly on this subject is not necessary at this level. Furthermore, this sort of knowledge is best obtained while in practice where it can be seen to be more relevant.

Teachers of community medicine should not make the mistake, made in almost all other subjects, of trying to teach too much. It will be enough if the undergraduate understands a patient in terms of the psychosocial implications of his condition rather than merely as an isolated incident of patho- logy.

From Programme into Practice It has already been remarked that the difference between in-patient and community medicine is one of function - that is, they represent different approaches to the same problem. Thus, the teach-

ing aim must be to inculcate an approach, and this is best done by intermittent teaching throughout the years of clinical training. The amount of teaching need not be very great, since, at under- graduate level, there is no large body of systematic learning to be mastered. New curricula, the oc- cupational disease of Deans, are not necessary to this teaching; rather more important is the judic- ious punctuation of existing curricula with the relevant aspects of community medicine. Further- more, the teaching must incorporate such well- recognized prerequisites of the learning process as clarity of purpose, study incentives, and a suitable form of examination (Ellis, 1960). With these principles in mind, a course can be constructed which develops as a logical sequence, along with hospital teaching and the acquisition of clinical methods.

The Todd report envisages the pre-chical student as having several courses in the behavioural sciences (Royal Commission on Medical Educa- tion, 1968). Obviously, to understand the psycho- social aspects of the abnormal, the student must have some appreciation of normal behaviour. So, in the future, at the beginning of his clinical train- ing the student can be expected to have some knowledge of the behavioural sciences, particul- arly those related to the problems of the sick in society.

The Clinical Years The first year of clinical training is concerned with developing the undergraduate’s ability to elicit symptoms and signs, and the knowledge to fit these facts into a pattern and diagnostic grouping. During the first weeks of this year, the teaching in community medicine should aim to give the stud- ent a frame of reference for this in-patient teaching.

First, this would involve some visits to a general practitioner’s surgery to get an idea of the fre- quency and mode of presentation of diseases. Then a couple of visits to out-patient departments would follow - the next stage in those conditions requiring hospitalization. Later in the year, visits to geriatric wards, an old folks’ home or nursing home, an industrial rehabilitation unit, Remploy factory, and occupational centre for the handi- capped would all demonstrate the sequelae of that previously isolated incident in the ward (Logan, 1960). Further visits to the general practitioner throughout this period would be utilized to demon- strate domiciliary care and rehabilitation in the

2. The Teaching of Community Medicine in the Undergraduate Curriculum

less crippling and more transitory disorders. After each visit, tutorials and group discussions

could be used to discuss the problems of the patient and the aims of the general practitioner’s therapy. In this way, the student could witness both the situation preceding admission to the ward and the continuing care of the patient after his discharge from hospital.

To facilitate this teaching, it will be necessary to have a department of general practice or com- munity medicine, with about 30 general praai- tioners attached to it and paid as part-time tutors for a year of 200 undergraduates. The department would ensure that each tutor knew what was the aim of his teaching, and that his teaching was co- ordinated with that of other departments.

The allocation to each student of two or three families, possibly with members already sick or in various high-risk groups, might be used as a teaching method which would ensure contact over several years of clinical teaching (Lancet, 1962). In this way, the student might get an idea of the long-term problems of community medical care.

At the same time, the social aspects of in-patient cases must be demonstrated to the undergraduate along with the clinical aspects. The student could be made responsible for contacting the general practitioner and relatives - something which housemen rarely have time to do. Decisions as to the destination of the patient ready for discharge, and an outline of the ongoing nature of disease with its management and possible outcome should be discussed with the student. Medical social workers and occupational therapists could be used to give small group tutorials on the wards to explain their place in the care of a patient. Medical students must be made to realize that social history is more than ‘fags and booze’, and this will mean educating many junior hospital staff who have never practised outside their ivory towers.

The systematic instruction in medicine and surgery should consist of more seminars, case pre- sentations, and team teaching intercalated in the formal lecture course. This is already often done with the conditions of alcoholism and self-poison- ing, using a neurologist, a gastrointestinal special- ist, and a psychiatrist. There are many more con- ditions, such as chronic bronchitis and diabetes, where other combinations of specialties could be used to good effect.

Epidemiology

The teaching of epidemiology at undergraduate level must involve a certain amount of descriptive epidemiology of common conditions, and also an appreciation of epidemiological methods. This first part should be taught along with the systematic teaching of medicine and surgery. Thus, there would be lectures on the epidemiology of ischaemic heart disease, and cardiovascular disease, respira- tory disease, and on peptic ulcer and gastro- intestinal disease. These lectures would delineate the variable incidence of a condition in different groups and explain possible factors of aetiological significance. One or two general lectures on epide- miology, at the beginning of clinical teaching, might help to introduce the subject and to avoid the hostility with which it is met at present. Since the subject is at the moment so unpopular, there is need for some careful consideration as to the form and contact of these lectures.

The teaching of epidemiological method should be undertaken in the second year of clinical teach- ing, or, at least, when the undergraduate has some facility in clinical method. If a population such as Holland had access to is available, then it might be possible to teach by precept, giving undergraduates experience in screening techniques and collection of data by house to house survey (Holland, 1968). The value of this teaching is far from proven and many medical schools may not have the resources to undertake it.

More generally applicable is the seminar tech- nique advocated by Terris (1966). This technique uses tutorials and prepared epidemiological exer- cises which require the student to answer questions about the various procedures undertaken, as part of the investigation of the epidemiology of a disease. The exercises are prepared before the tutorial, which is spent discussing the various points raised. This technique has the advantage of being cheap and also provides material for a discussion between teachers and students, thus avoiding the ‘mini- lecture tutorial’; the chief drawback is the lack of practical work involved.

Undoubtedly, any technique used to teach epidemiological or any scientific method must require a high degree of student involvement to have any effect at all. Certainly, the present situa- tion, where epidemiology is regarded as nothing more than an unpleasant excrescence of social medicine, must be avoided.

I 90 Richard Logan

General Practice Attachments Many medical schools have introduced, or are introducing, a final phase, when the undergraduate is given some real responsibility for patients - that is, as a semi house officer. Compulsory general practice attachments, as in Kansas, would provide the undergraduate with further insight into com- munity practice, particularly the therapeutic aspect.

During this attachment, the student would see that 90% of conditions which a general practitioner treats regularly without recourse to any hospital facilities. He would also see further domiciliary care, immunization of infants, antenatal and post- natal check-ups, the neonate in the home, and geriatric care. The student need not be a passive observer of these practices and could undertake many routine procedures with the practitioner standing in loco cunsultundi (Logan, 1960). The student would also be able to obtain a working knowledge of the welfare services and the local health authorities. The problems and practice of secondary and tertiary preventive measures, in- volving pre-symptomatic screening and the pre- clusion of disability, would become meaningful during this period.

The length of this attachment need only be about four weeks and definitely no longer than eight weeks. The general practitioners would, ideally, be paid for their part, since this would encourage a professional attitude towards their role. If this teaching took place in the setting of a health centre with case discussions, the student would benefit even further from this period.

Assessment Medical schools are now generally aware of the inadequacy of the present written examinations as ‘stiflers of thought with largely descriptive questions that dull rather than stimulate the in- tellect’ (Pickering, 1958). The assessment of the undergraduate training in community medicine is probably best undertaken by a combination of assessment on the ward, written examination in epidemiology, and written reports from both general practitioner and student of the attachment period.

The assessment on ward work by the medical staff would have all the advantages of the oral examination - and all its disadvantages. The written examination in epidemiology might incorporate a multi-choice paper as well as a preprepared essay.

The reports from general practice would provide further flexible assessment and would give the student the opportunity to express what he thought had been achieved.

Present Teaching None of these proposals for teaching community medicine is completely original. In fact, all have been experimented with in various medical schools, and yet no British medical school teaches com- munity medicine as such; none has attempted to give the student a systematic approach.

At present, all teaching in the subject is unco- ordinated and fragmented by teaching from de- partments of medicine, social medicine, general practice, and even industrial health and psychiatry. To the student, the teaching lacks any unifying concept and is totally unintegrated with the rest of his clinical teaching.

Several reports have emphasized how under- graduates appreciate some teaching in general practice (Maclean, 1961; Logan, 1963; Richard- son, 1965). Most would like longer attachments and 75y0 thought they were essential. Most medical schools do teach general practice, often using some sort of attachment to a general practice.

Recently, Pearson, Eimerl, and Byrne (1968) conducted a survey of all student attachments beyond university owned practices. Their findings were disconcerting, but not very surprising. Most attachments were found to be ‘amateur, haphazard, and lacking in academic supervision’. Further, ‘general practitioners, for their part, receive rela- tively few students but with little support manage to achieve a better demonstration than might be anticipated but less than is needed‘. The medical schools were found to adopt a rather casual ap- proach, and in only three of 25 medical schools was the attachment compulsory.

To ease these problems and to counteract the bias towards in-patient medicine, they suggest the creation of a faculty of community medicine ‘to make it easier for the student to understand the problems and challenge of practice in the com- munity’.

In fact, examples of more effective general practice attachments can be seen in the preceptor- ship of the University of Kansas, and in Great Britain, in the studentships at Charing Cross Medical School (Heller and Heller, 1968). The five-week preceptorship in Kansas is similar to our present attachments, but the ever-efficient Ameri-

2. The Teaching of Community Medicine in the Undergraduate Cum*culum 191

cans have put this period on a highly organized and effective basis, with the preceptor being paid for his trouble. The student lives with his pre- ceptor for the whole time and attends all his preceptor's medical activities.

At Charing Cross, the studentships are three months long - probably longer than is necessary at undergraduate level. Only half the period is spent in general practice, while the other six weeks are spent in other fields of community medicine, such as local health authorities, industrial medicine services, and a hospice for the care of terminal illness. Maybe a condensed version of this attach- ment is what we must work towards in Britain. In th is country, we are fortunate in having com-

prehensive welfare services. It is ironic that under- graduates are taught so little of this medicine. This is a situation that should not continue, since the present trend is for more disease to be managed in the community and for domiciliary care to play an ever-increasing role. For the future, it is to be hoped that undergraduates will be trained in a manner more appropriate to the kind of medicine that they, as doctors, will increasingly practise. Requests for reprints should be senr to R.F.A.L., 102 Thirlestone Road, Edinburgh 9-

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