GEP Medicine in Society Guide 2022/23

1. GEP Medicine in Society 2022/23

Medicine in Society is a community-based course for students in years 1 of the GEP MBBS curriculum. The global aims of the course are to introduce students to patients and their experience of health and ill-health over the course of their lives and for students to start to develop and explore their professional identity. 

Students, in groups of 8, will spend 14 days in primary care during the year. Each day is themed and has clear learning objectives. The themes relate to systems that the students have studied recently, e.g. day 13 focusing on pregnancy and childbirth is during, or after, the human development system teaching. The students will also spend time in secondary care. These days are also themed and have a focus on clinical examination skills. 

Students will be engaged in many different activities over the course of the module, including small group tutorials, shadowing and interviewing clinicians and other healthcare professionals, having contact with patients (including home visits), self-directed learning, etc. 

Contacts

Unit Convenors

Primary care

Secondary Care

Dr Elizabeth Gaunt

2. Introduction and Key Information

The curriculum at Queen Mary University of London has been developed in accordance with the GMC’s Outcomes for Graduates (2018). This included recommendations that in all medical school curricula should:

• place a greater emphasis on teaching outside the lecture theatre, hospital and laboratory, in community settings
• enable a broader understanding of public health
• include a greater degree of “vertical” integration of clinical and non-clinical subjects throughout the medical curriculum
• ensure the principles of professional practice form the basis of medical education

Aims

The overall aims of the GEP Medicine in Society Year 1 unit are:

• to introduce students to patients and the patients' experiences of health and ill health over the course of their lives
• for students to start to develop and explore their professional identity. 

Learning Outcomes 

By the end of the course students should be able to:

• explain how patients are affected by their condition/s
• recognise how cultural diversity and health inequalities affect patients' and communities’ experiences of health and healthcare services
• list the public health influences that affect the development of ill-health and the restoration of health
• describe the roles of different members of the primary health care team
• develop, good communication skills with patients, healthcare professionals and between peers
• identify the consultation skills of healthcare professionals
• reflect on their own learning in terms of personal and professional development

3. Primary Care Timetable for GEP Medicine in Society 2022/23

4. Placement checklists

To ensure that you are ready to start the placement and access all the resources that you may need please ensure you have reviewed the relevant checklist. 

4.1. Student checklist

Before placement starts:

If you have any queries, or difficulty in accessing any specific resources, please ask your peers, GP tutor or module administrator/convenors as appropriate. 

5. Example timetable & learning activities

Generic structure: this is only meant as a suggested template for a day and tutors are of course free to design and run their teaching sessions however they wish to. 

Examples of activities that could be delivered virtually or face-to-face:

Tutorials

Student presentations

Online research

Debates

Group discussions

Quizzes/Polls

Role-plays – either in small groups or as whole group with fish bowel set-up (consider specific observation tasks for feedback and discussion)

Case-based discussions

Patient encounters –expert patients with group/small groups, students interview patients in pairs/small groups, home visits

Observing GPs and other healthcare professionals

Interviewing members of primary care team

Joining practice team, or wider MDT, meetings

Reviewing recent journal articles and media publications, especially to discuss current 'hot topics'

Community based activities –initial walkabout to create community profile and subsequent exploration of local area and its services to build on this e.g.  visiting/researching local facilities, attending local groups

Please note this list is not exhaustive.  Ideally each day would include mix of activities, prioritising any patient encounters. There may be times when not all students from the group are completing the same activity, for example if 4 students are able to see a patient on a home visit whilst the other group meet an expert patient at the surgery, and afterwards the whole group reconvenes to discuss their experiences and learning.

There are more detailed suggestions for activities that are specific to each themed day and these are listed under each day, along with the suggested preparatory work for each day.

6. Themed Days - Primary Care

There are 14 placement days in primary care in year 1.

6.1. Introduction to the placement

Preparatory work

In preparation for their first placement day, students should have:

• Prepared questions to ask a team member, focusing on finding out about their training, role and responsibilities within the Primary Health Care Team, and reasons for working in Primary Health Care.  

Aims

• To welcome the students to the practice and introduce them to their GP tutor, their tutor and the practice team. 
• To clarify learning outcomes for the course.

Learning Outcomes

By the end of the day, students should be able to:

• Know how to contact their tutor and/or members of their tutor group
• Describe the overall aims of the course
• Interview a member of staff about their role and responsibilities within the primary care team and report on findings from the interviews 

Example timetable

Suggested Activities

• Introductory activities - meeting tutors and peer group; ice-breaker activity; impact of COVID-19 on placement; overview of course including aims, assessments and student expectations; ground rules discussion outlining group etiquette and professional behaviour expected of students i.e. time keeping, attire, contacting tutor/practice if unable to attend; collecting contact details for each student; other miscellaneous e.g. set up WhatsApp group.
• We have to talk about COVID – see below

• We have to talk about COVID: Some ways to start ·       Q: How do I see this pandemic? ·       Q: How has the world changed? ·       Q: How has my world changed? ·       Q: How have we/I changed? (even the smallest things) ·       Q: What strengths have got/what challenges/where have I drawn solace or anchorage or renewal? Students and tutors could write their answers down and choose whether they wish to share anything with the group. ·       Activity: bring object, picture or music that represents your experience of the pandemic. ·       Self-care and self-compassion; introduce these terms and discuss the importance of developing self-care and how this is key to providing care to others. Look at facilities and services open to NHS staff to support their wellbeing during the COVID-19 pandemic. ·       Signposting; QMUL student support services.

• Who’s who? Identify different members of the practice team. Interview with member of the Primary Care Team about their role.

Questions for students to consider

• Who did you meet from the practice team today? Did anything you found out about that person’s role surprise you?  Were you aware that there was such a role?  Were you aware that so many different people were part of the primary health care team?

6.2. Professionalism

6.3. Social issues in primary care

Preparatory work

In preparation, students should have:

• Looked at the World Health Organisation’s (WHO) information about social determinants of health and their definition and examples of health inequities.
• Read the article 'A perfect Storm' written by Dr Jonathon Tomlinson, a GP in Hackney, where he describes the impact poverty and deprivation have on his practice population as part of his blog 'A Better NHS'.
• Looked at some of the public health profiles e.g. the Marmot indicators of the local practice area.
• Read NHS England's introductory information on social prescribing.
• Reviewed communication skills teaching on person-centred interviewing and thought about how they might start a conversation with a patient and what questions they would ask.

Aims

• To introduce students to the social issues that can impact on patients’ health and their response to ill-health, and the role of the health service and other agencies in supporting these patients.
• For students to meet their first patient as a medical student, either as an observer or a participant in a patient encounter. 

Learning outcomes

By the end of the day students should be able to:

• List some of the social issues that can impact on patient’s health and their experience of healthcare.
• Demonstrate an awareness of the importance of considering social factors when treating patients.
• Discuss the role of the GP and other members of the primary healthcare team in the support and treatment of patients whose social circumstances impact on their health.
• Introduce themselves appropriately to patients they will interview, explaining the purpose of the interview, their role as medical students, how the information will be handled, patient options e.g. free to terminate interview.

Example timetable

Suggested Activities

• Tutorial/group discussion based on preparatory reading and student’s knowledge and awareness of social issues that might impact on patient’s health and their experiences of the healthcare system.
• Interview with a social prescriber, or other healthcare professional, on their role and experience of social issues that are of particular significance in the practice area.
• Join a practice or MDT meeting where complex patients, who often have significant social issues, are discussed.
• Prepare to meet their ‘first’ patient - prepare questions, how to begin and end an interview with a patient, discuss dos and don’ts. Interview a real or simulated patient (using role-play) having first gained consent. NB – these patients won’t necessarily have significant social issues.
• Observations of different staff-patient interactions; students to look out for consultation skills healthcare professionals use to build rapport and facilitate open communication with patients. Students can also make observations of any social issues that are identified, their possible impact and how these are discussed.
• Case studies focussing on the effect of various social issues.
• Research organisations providing support for local people with social issues e.g. homeless shelter, cultural centre, refugee support organisation etc. Working in pairs/small groups, students could choose a particular social issue to focus on and conduct their online research then present their findings back to group.

Questions for students to consider

• Were you surprised at the impact social factors had on the patient you met or discussed? Are these problems the doctor should address?
• Is the health service doing enough to make services accessible to people of all social groups e.g. those of different ethnicities, sexualities, homeless people etc?  What do you think could/should be done differently?
• If you met a patient today, how did you feel you did when you were interviewing them?  Did you feel the patient felt comfortable talking to you?

6.4. Back pain and other chronic pain

Preparatory work

In preparation students should have:

• Reviewed some of the resources on healthtalk.org about chronic pain and used this to find a definition of chronic pain as well as listening to some of the descriptions of the effects of chronic pain on individuals.
• Watched “Understanding Pain: Brainman chooses”, it’s also interesting to read the public comments (with caution). 
• Read the NHS inform’s resource for patients on chronic pain 
• Considered questions to ask a healthcare professional or a patient about dealing with chronic pain.

Aims

To introduce students to this common multifactorial condition, its effects on individuals, families and societies, and to the management approaches for this condition.

Learning outcomes

By the end of the day, the student should be able to:

• Describe the factors that are important in development of chronic, disabling back pain or other pain.
• Summarise the socio-economic impact of these conditions on individuals, society and the health service.
• Identify pharmacological and non-pharmacological treatment options for chronic pain.
• Discuss the effect of chronic pain on the doctor patient relationship.
• Practise interview skills.

Example timetable

Suggested activities

• Tutorial on chronic pain– could include definition of chronic pain, discuss possible causes, outline various treatment options, challenges faced by patients and health services, local pain services, current ‘hot topics’ e.g. opiate prescribing and medical cannabinoids, NICE guidance on chronic pain & the media response to it.
• Student-led research – in 2 groups, search clinical guidelines for chronic pain then each group researches either pharmacological or non-pharmacological treatment options for management chronic pain, consider pros/cons of each and local access to these options. Prepare brief presentation.
• In small groups/pairs, plan interview with a GP or a patient about chronic pain (if possible, please arrange for some students to interview a GP and some a patient so they can compare findings when they meet again as a group).  

Questions for students to consider

• How did dealing with patients with chronic pain affect the health care professional you interviewed?  How did they feel about patients with chronic pain?  How do you think you would deal with this situation?
• How did you feel meeting a patient with chronic pain?  How did you think they were coping with their situation?  What sources of support were they drawing on?

6.5. Stroke

Preparatory work

In preparation students should have:

• Revised what they already know about the pathophysiology of stroke. 
• Reviewed the NICE Clinical Knowledge Summary for Stroke and Transient Ischaemic Attack.
• Watched videos on healthtalk.org of people who have had a stroke or TIA discussing their experiences.
• Looked at the Public Health England (PHE) Act-FAST campaign and considered what makes the poster effective

Aims

To introduce students to the effects of stroke, particularly in relation to mobility and the part played by environmental factors, healthcare and other agencies in supporting the impaired person.

Learning outcomes 

By the end of the day, students should be able to:

• Discuss the impact of stroke on an individual and their family and the role of voluntary agencies in providing support
• Demonstrate an understanding of the effect of poor mobility on the individual and the changes needed within the community to be more inclusive of them
• Identify important members of the MDT in assessment and care of patients with impaired mobility
• Describe a health promotion intervention that can reduce the risk of stroke in an individual at risk
• Practise pulse checks, blood pressure measurement, examination of central and peripheral pulses and communication skills

Example timetable

Suggested Activities

• Tutorial on stroke – could cover stroke and TIA, risk factors, possible short and long term sequelae, stroke MDT members and roles, and health promotion interventions that can reduce a patient’s risk; students could work on these areas in breakout groups then present back to whole group.
• Meet with member of MDT to discuss role of team members for stroke / disability care; or join an MDT meeting.
• Research into or visit to a local voluntary agency providing support to stroke patients, and/or interview person working for such an organisation.
• Prepare questions to interview a patient who has problems with mobility.  Include a brief review of their home and work circumstances etc with respect to how well different environments are adapted to help overcome the patient’s disability. 
• Session teaching clinical skills e.g. pulse checks, blood pressure measurement, examination of central and peripheral pulses and practise these; consider how these parameters are being carried out remotely using telemedicine. Students could observe new patient checks.

 Questions for students to consider

• How did you feel meeting a person that had suffered a stroke/had a mobility problem?  What aspects of the meeting were most difficult?  Did the patient seem comfortable with you?  Were you surprised at the impact it has had on their life?
• Did anything about the MDT surprise you? Were you aware that so many different professionals were involved in the care of patients with mobility problems?  What role did the GP play?  Was this what you had expected the GPs role to be?
• Consider the health promotion interventions you have heard about or observed today; what effect do you think that being told you are at high risk of stroke or heart disease has on an individual? 

6.6. Mental health and addiction

Preparatory work

In preparation students should have:

• Researched the national statistics on the incidence and prevalence of mental health problems; The Mental Health Foundation website is one source of statistics on mental health. 
• Reviewed the Mind website as a good starting point for learning about mental illness and how it impacts on people's lives; it has an A-Z of mental health conditions and blogs/video diaries telling people’s stories.
• Looked at the NHS website pages on addiction, which has information on different addictions, treatment options and patient stories.
• Considered how healthcare professionals, including medical students, need to be aware of their own mental health and wellbeing; there are a number of wellbeing resources signposted on the BMJ and the RCGP websites.

Aims

To introduce students to health promotion strategies to improve mental health; to the impact of chronic and acute mental illness on the health of the population and the multi-agency support needed in the promotion of mental health and management of mental illness.  To explore the links between mental illness and addiction.

Learning outcomes

By the end of the day students should be able to:

• Identify local and national strategies to improve mental health
• Discuss the national and practice prevalence of mental illness
• Identify the addictions commonly encountered in the practice population
• Describe the local support services for people with addictions and/or mental illness
• Discuss the different needs of patients with acute and chronic mental health problems
• Know how to access student support services and healthcare practitioner wellbeing resources

Example timetable 

Suggested Activities

• Tutorial on mental health – could cover mental health promotion, acute and chronic mental illness and addiction; group brainstorms and discusses mental health symptoms, different diagnoses, what addictions there are; hot topics e.g. impact of COVID-19 pandemic on people’s mental health and addiction.
• Looking after ourselves as well as our patients; discuss the importance of practitioner self-compassion and how the COVID-19 pandemic has highlighted this; look at resources for healthcare practitioner and medical student mental health and wellbeing; individual task to list things/activities that students find promote their own wellbeing and good mental health and things that don’t (this does not need to then be shared within the group).
• Interview with a patient with chronic mental illness and/or addiction problem.
• Role-play scenarios.
• Research into an agency providing support for people with mental illness or addiction.
• Consider health promotion in regards to mental health and addiction; breakout task in small groups to prepare a piece of health promotion material regarding mental health or addiction.

Questions for students to consider

• How do you feel about mental illness - is it something that can be treated and cured like ‘other’ illnesses that doctors treat?  Are you comfortable speaking to patients with mental health problems?  If not, why not?
• How does society regard people that are addicted to drugs or alcohol?  As sick, mentally ill, deviant, bad, dangerous?  What is the role of the doctor in supporting such patients?
• What practical steps can you take to promote your own wellbeing and good mental health? What signs might you notice if you were struggling with your mental health and how could you access support?

6.7. Coronary heart disease

Preparatory work

In preparation students should have:

• Looked at the NHS conditions website to get a quick overview of what CHD is, how it is diagnosed and treated and the impact it can have on patients' lives.  
• Reviewed this NHS Inform article on the different aspects of prevention of CHD and considered the role that the primary care team play in this.
• Explored the British Heart Foundation website, a useful resource for patient information and support. 
• Watched this (speedy) TED talk by Dr Dean Orrish, an American physician working in the field of preventative medicine, which is about the ‘killer’ American diet causing an obesity epidemic and increasing rates of illness, including CHD.

Aims

To introduce students to the pathophysiology of CHD, its impact on population morbidity and mortality, and the health promotion interventions used to try and reduce CHD.

Learning outcomes

By the end of the day, should be able to:

• Explain the process of development of CHD
• Outline the impact of CHD on individuals and on population morbidity and mortality
• Describe key health promotion interventions to reduce morbidity and mortality due to CHD
• Discuss the impact of CHD on an individual patent
• Identify key policy documents relating to CHD

Example timetable

Suggested Activities

• Tutorial on CHD – could include the pathophysiology of CHD; students present on different cardiac conditions; group makes list of risk factors for CHD (modifiable/non-modifiable) and consider health promotion interventions to tackle modifiable risk factors; discuss the impact CHD has on the workload of the practice; review any hot topics e.g. COVID-19 and cardiovascular disorders.
• Review of the practice strategy for monitoring and managing patients with known CHD and at risk of CHD (NSF targets etc.)
• Observation of health promotion interventions aimed at preventing or reducing the risk of CHD.
• Interview a patient with, or at risk of, CHD.
• Case studies – e.g. new patient checks, look for risk factors – which are modifiable and what are the next steps in advising and supporting this patient?
• In small groups visit/research local services/facilities that provide support for people with or at risk of CHD and/or meet someone involved with delivering these services e.g. interview a community cardiac nurse.
• In pairs, students choose a health promotion topic related to CHD and prepare some guidance to give patients.

• Individual meeting with GP tutor for formative feedback on progress to date with learning activities, first written assessment and on professional attitude and conduct.     

  
  

Questions for students to consider

• If you met a patient with CHD– how did they describe their life, what did they find most difficult, had they made any lifestyle changes following their diagnosis?
• What local services and facilities did you find out about today? How did they try to meet the needs of the local community? What else do you think would be beneficial to support better health promotion in the area?
• You may have a meeting today with your tutor.  How do you feel you are progressing? Have you set yourself any learning outcomes as a result of your experiences so far? Were you surprised at your tutor’s analysis of your progress?

6.8. Respiratory disease

Preparatory work

In preparation students should have reviewed the following resources;

• The British Thoracic Society has lots of useful resources e.g. clinical guidelines for respiratory conditions.
• The British Lung Foundation website has details of different respiratory conditions, UK statistics for lung disease and an excellent section where you can get a patient’s perspective on COPD by reading and watching the stories of people who live with and have experienced COPD.
• The Asthma UK website also has useful resources e.g. asthma action plans.
• The BMJ Best Practice on Coronavirus disease 2019 (COVID-19) is a comprehensive and free online resource that covers various aspects of COVID-19, including epidemiology, diagnosis, management and follow up.
  

Aims

To introduce students to respiratory illness, its impact on patients, society and the practice workload; and to introduce students to health promotion measures designed to improve respiratory health. To consider the changes and challenges in assessing and managing respiratory conditions during the COVID-19 pandemic.

Learning outcomes

By the end of the day students should be able to:

• List common respiratory illnesses in children and adults that are seen in primary care
• Describe the basic assessment of a child with an upper respiratory tract illness (URTI)
• Describe and reflect on the impact of chronic respiratory disease from a patient’s perspective, focusing on the issues of loss of function, autonomy, and well-being and its impact on daily life
• Outline the health promotion interventions, including smoking cessation interventions, provided by the practice team to prevent or manage respiratory illness
• Demonstrate a basic examination of the respiratory system
• Demonstrate the measurement and interpretation of peak expiratory flow

Example timetable

Suggested Activities

• Tutorial on respiratory illnesses – could include brainstorm of common respiratory symptoms presenting in primary care, long term respiratory diseases and their impact on patients and the practice team’s workload, students presenting pre-agreed topics based around preparatory work, ‘hot topics’ e.g. COVID-19.
• Sit in on a routine clinic with a member of the primary care team and observe particularly respiratory presentations, including acute and chronic symptoms, long term condition management e.g. asthma checks, health promotion activities e.g. flu jabs.
• Interview a patient with a respiratory condition.
• Teaching session with practice nurse to demonstrate spirometry and/or peak flow measurement (NB-there are lots of videos of this if no one can deliver the teaching session) and/or case studies interpreting peak flow and spirometry results.
• Introduction to examination of the respiratory system, adults and/or children, and to what extent this has changed due to COVID-19 e.g. remote assessment. This video from eGPlearning considers the respiratory exam by video consultation 

Questions for students to consider

• If you met a patient with COPD or asthma– how did they describe their life, what did they find most difficult, did they see themselves as ill?
• Did you see or discuss acute respiratory illnesses?  How did this impact on the GP’s workload?  Should patients do more to self-manage minor illness?  How can healthcare professionals support them to do this?
• How has COVID-19 changed how acute respiratory symptoms are assessed and managed?
• How has COVID-19 affected people with chronic lung disease?

6.9. Diabetes

6.10. Nutrition and gastrointestinal disorders

Preparatory work

In preparation students should have:

• Looked at some of the resources available on the NHS Live Well website focussing on healthy eating, exercise and weight management. 
• Reviewed guidance information from The Mental Health Foundation  on wellbeing and nutrition. 
• Researched some chronic gastrointestinal conditions; the NHS inflammatory bowel disease information is a good place to start and the Crohn’s and Colitis UK website also has lots of information, including this video.
• Listened to Michael Serres talk about his bowel transplant to gain a patient’s perspective and specifically to hear his views about how healthcare practitioners should communicate with and involve their patients in the decision making processes.
• Considered the sensitivities of investigating patients’ beliefs and attitudes towards weight, diet and exercise.

Aims

To increase students’ awareness of the relationship between food, health and ill health and to introduce students to patient presentations with GI disorders.

Learning outcomes

By the end of the day, students should be able to:

• Describe the components of a ‘healthy diet’
• List the current recommendations for daily exercise
• Describe some of the broad spectrum of symptoms that relate to the GI tract
• Describe the impact of a chronic bowel disorder on a patient’s life
• Discuss how embarrassing symptoms might influence people’s decision to visit their doctor
• Discuss the role of the primary care team in encouraging people to lead healthier lives

Example timetable

Suggested Activities

• Tutorial on GI disorders – could include students presenting about different GI disorders, discussing common GI symptoms presenting in primary care, considering the role of the primary healthcare team in assessing and advising on diet and exercise.
• Introduction to abdominal examination and link this with GI symptoms.
• Interview a patient with a chronic GI condition.
• Role-play scenarios with a focus on how the doctor can help put a patient at ease and facilitate the discussion of potentially embarrassing symptoms and/or how to empathetically open discussions about diet and exercise with an overweight patient.
• Visit or conduct online research into a local organisation relevant to diet and/or exercise e.g. local group providing advice on diet, nutrition and/or cooking to young mothers. Interview a local provider of these services e.g. meeting with fitness instructor providing ‘exercise on prescription’ or an adviser from local ‘Weight Watchers’ group.
• Look at this open access collection of articles from the BMJ on nutrition and health, entitled “Food for thought” and choose an article to read and discuss as a group or in breakout groups. 
• Have an individual formative feedback discussion with GP tutor on progress on the course so far, including first written assessment, plan for poster assignment and professional attitude and conduct.

Questions for students to consider

• If you met a patient with a bowel disorder – how comfortable did they feel about discussing the problem?  How comfortable did you feel?  What helped or hindered your discussion?  What can you do to help put patents at ease in talking about potentially embarrassing topics?
• What did you learn about weight management and nutritional advice in primary care?  Did the healthcare team see this as an important part of their role?   Do you think this should be the responsibility of the healthcare team?  What alternative sources of help/support might patients use?

6.11. Cancer in primary care

6.12. The older person

Preparatory work

In preparation students should have:

• Reviewed NHS England’s key priorities for improving care for older people.
• Watched this video from The GMC- Older Adults about top tips on communicating with the older patient
• Looked at these blogs; ‘Elderspeak’ and ‘A quest for clearer thinking on ageing’.
• Looked at some of the resources available on the British Geriatric Society’s website about coronavirus and older people and considered how the COVID-19 pandemic has impacted this population.
  

Aims

To introduce students to the biomedical and social implications of ageing, the demographic changes in the population and the implications of this for health and social services.

Learning Outcomes

 By the end of the day, students should be able to:

• Recognise ageing as a natural, developmental process
• Describe different ways that older people are regarded within different groups and communities
• Describe the range of services, people and agencies that are involved in the support of the older patient in the local community
• Demonstrate appropriate communication skills with an older patient (with suitable empathy, respect and interest)
• Explain some of the implications for health and social services of an ageing population

Suggested Activities

• Tutorial on ageing and health-could discuss students own experiences of ageing in their family/community, review practice population statistics, key health promotion areas for older people or review of recent ‘hot topic’ e.g.  COVID-19 and care homes.
• Patient interviews – either observing healthcare professional or student-led.
• Visit to local care home or other residential or daycare facility for older people.
• Group discussion about ageism in society and healthcare; read article from Age & Ageing “Ageism and COVID-19: what does our society’s response say about us?” . Scope for student debate e.g. Is the healthcare system ageist?
• Visit or research local agencies and/or meet with a professional providing services for older people.

Questions for students to consider

• Did the patient you met describe any benefits of being older?  Did anything surprise you?
• Do you think ageism is an issue on our society and/or healthcare system? Have you seen any example of ageism personally or professionally?

6.13. Pregnancy and childbirth

Preparatory work

 In preparation students should have:

• Found out about the range of local maternity services available to women; and some local and national data relating to childbirth.
• Prepared some questions in order to talk to a pregnant woman about her choices for antenatal care and the birth of her child.
• Looked at the NHS website, it’s heath A-Z  has a wealth of information for patients covering everything from fertility and conception to childbirth, and specifically reviewed the section covering antenatal care.
• Reviewed some of the information about pregnancy on the healthtalk.org website.
• Thought about the choices women face when they are pregnant, where they might seek information and what role healthcare professionals have in empowering women to make informed choices; the NIHR ‘Care and decision-making in pregnancy’ overview is  a good staring point for some of these questions.
• Looked at the MBRRACE-UK website, focussing on the inequalities in maternal mortality (this infographic highlights the key messages from the 2019 report).
  

Aims 

To understand the course of an uncomplicated pregnancy; to be aware of the choices women have about their pregnancy and childbirth and to gain an understanding of the importance in facilitating and respecting these choices.

Learning Outcomes

By the end of the day, students should be able to:

• describe an uncomplicated pregnancy and childbirth;
• list some the possible choices that women can make in relation to ante-natal care and place of birth;
• discuss the different factors that influence women’s choices about their pregnancy and childbirth;
• describe a health promotion intervention for pregnant women provided by the practice;
• critically consider the health promotion information available within the practice;
• practise blood pressure measurement and urinalysis.

Example timetable

Suggested Activities

• Tutorial on pregnancy and childbirth – could include discussion or debate of the question/s ‘is pregnancy a medical condition?’ and/or ‘what is the role of the medical profession?’; consider that the GP is often the first point of contact for a pregnant woman and what is covered in this initial appointment e.g. early discussion of choice about whether to proceed with the pregnancy, calculating gestation, discussing local antenatal care options; antenatal care schedule and check-ups including why do we check BP, urine, fundal height and fetal movements?
• Pregnancy timeline activity – students work in pairs/small groups to put key pregnancy milestones at the correct gestation.
• Health promotion during pregnancy– could include group discussion of areas/activities this covers e.g.  advice around smoking, diet, exercise, alcohol and immunisations; consider what information is available within the practice and what services the practice offers?
• Interview a pregnant, or recently pregnant, woman with a view to discussing her choices, and how she (and her partner/family) arrived at them; if possible, look at handheld antenatal notes.
• Interview with a healthcare professional, or other person, involved in providing services for pregnant women.
• Discuss informed consent and choices in the context of pregnancy and childbirth, the importance of communication skills, and the role of the GP, and other healthcare professionals, in in facilitating and respecting women’s choices; could use include role-play scenarios, case discussions, patient stories.
• Practise blood pressure measurement and urinalysis.

Questions for students to consider

• How did you view pregnancy and childbirth before today?  Have your views changed at all as a result of today’s meetings and discussions?
• How important do you think it is that women should have choices, and adequate information and support to make these choices, in pregnancy and childbirth?  Do you think this could pose difficulties for the healthcare professionals caring for pregnant women?  How might you deal with patients making choices that you did not agree with?

6.14. The young child

Preparatory work

In preparation students should have:

• Read or reviewed the recommended resources, including taking a look at the Birth to Five book; this book was until recently give to all new parents in the UK and it is still available as a PDF from the Northern Ireland Public Health Agency.  In England and Wales, it has been superseded by the NHS conditions website pages, particularly the information under the ‘newborn’ and ‘babies and toddlers’ tabs. Both resources provide information for parents on all aspects of caring for a new baby and both include the voices of new parents.
• Looked at some of the information on the Mumsnet website. It hosts many discussion threads and enables you to see some of the concerns both new parents, and more experienced ones, have about caring for their children.
• Reviewed the current UK routine child immunisation schedule.
Researched the recent fall in uptake of these routine immunisations and considered why this might be. 
• Prepared some questions for their meeting with a mother and her baby.

Aims

To give students an opportunity to meet with and talk to a mother and her baby. To gain an understanding of the health monitoring and health promotion provided for babies and young children by the primary health care team.

Learning Outcomes

By the end of the day, students should be able to:

• Describe the daily routine for one mother and baby or young child that they have met
• List some of the health promotion services provided by the practice for mothers and their babies
• Describe in detail one health promotion intervention provided for babies or young children
• Describe some of their experiences communicating and engaging with the children
• Discuss the most significant changes parents have to deal with after the birth of a child
• Practise interview skills, and communication through play

Example timetable

Suggested Activities

• Tutorial on mother and baby – could include health promotion services for mothers and babies; discuss 6-8 week postnatal and baby check-up (look at red book); role of other healthcare professionals e.g. health visitors; hot topics e.g. effect of COVID-19 on vaccination uptake.
• Role play scenarios tackling parental concerns about immunisations and misinformation e.g. about MMR.
• Debate e.g. Is breastfeeding the best way of feeding an infant? Are mandates, legislation or sanctions a good way to increase uptake of routine childhood immunisations?
• Prepare for meeting a mother and her baby; plan questions for parent/s e.g. daily routine, changes parents deal with after the birth of a child, what questions/concerns they have for GP or other healthcare professionals e.g. feeding. Interview a mother/family and their baby.
• Sit in with a GP for the 6-8 week mother and baby check and/or with the practice nurse for infant/child immunisations.
• Meet with practice nurse/health visitor to discuss their role in caring for mothers and their babies and young children.
• Research into and/or visit to a local voluntary agency providing support to parents and their babies/children e.g. local NCT group, feeding café, children’s centre; meet with a person who delivers this support.
• Final feedback meeting with GP tutor.

  Questions for students to consider

• Did anything surprise you about your meeting with a mother or parent/s and their baby/young child?  What sort of support do you think new parents might need from health care professionals?
• There have been some well–documented controversies around vaccination of children.  What do you think the role of the GP/Health visitor is in this area?  How would you deal with patients whose views conflicted with the advice you were giving to them?

7. Assessment

Attendance

Student attendance is recorded at each placement.  Students should consider a placement day to be a work day and attendance is expected every day.  If you are unable to attend you must inform your tutor in advance and report your absence to the school via the MedSoc QM+ area. 

Tutors must inform us at the time of any non-attendance and whether the student informed them of this or if it was unexplained.  

Please click here for link to the self certificate form.

7.1. Reflective pieces

7.2. Professionalism assessment

As part of the final assessment tutors must complete a Professionalism Assessment on each student.  Tutors are asked to give students formative feedback on their professionalism when they review progress during the year so students have opportunities to modify their behaviour before they are formally assessed at the end of the year. 

7.3. Final Assessment

8. Appendices

These are the appendices. 

8.1. COVID-19 and Virtual teaching

Due to the ongoing challenges in healthcare as a result of the COVID-19 pandemic, primary care teaching will be delivered virtually by GP tutors in Term 1 (Sep-Dec 2021).  In January 2022, if is feasible, small groups of students can visit the practice each week while their peers join remotely. 

There is detailed guidance to support the delivery of virtual learning experiences on the CBME virtual teaching website. This website contains information and resources to support the setup and delivery of teaching using group video calls through Microsoft Teams. There is also information about the consent process for virtual teaching involving patients. 

8.2. Student Safety Policy

ONLINE SAFETY

Please refer to the CBME virtual teaching website, which includes information about confidentiality and consent relating to virtual teaching involving patients; there are links to both GMC and BMA guidance as well. 

ESCORTED VISITS

These refer to visits to patients in their own homes by members of the primary care team accompanied by the medical student. The patient's permission for the medical student to be present during the home visit should be obtained.

UNESCORTED VISITS

Where students are expected to visit patients in their own homes without an accompanying healthcare worker the supervising clinician will have previously selected and consented an appropriate patient for such an activity. Patients will have been given details about the purpose of the visit, the timing and the names of the students.

Students in Year 1 and 2 should always visit in pairs or as a group of 3.

If the following are adhered to all should be well:

1. Know where you are going and plan your journey
2. Ask for help and instructions from your tutor if unsure 
3. Ensure your practice knows where you are going and when you are expected back
4. Be clear about the purpose of your visit and how to conduct yourself
5. Always carry your identification card, adequate finances to get you home, your mobile phone and have access to a map
6. Terminate and excuse yourself from the visit if for any reason you feel unsafe 

Students are asked to discuss with their tutors any planned visits they feel uncomfortable with, in which case the tutor will accompany you. 

You can access details of your practice if you have lost the information, provided you know the rough location and name from: https://www.nhs.uk/service-search/find-a-gp. In London you can plan a route using the Transport for London or Citymapper websites or apps. 

8.3. Community Area Profile

INTRODUCTION

On Day One of your placement you may be invited to walk around the local area, making observations about the place, the facilities, and the local community. The aim of this activity is for you to gather knowledge of the neighbourhood by applying and developing your skills of observation. You should make observations and note them down. Although only one session is allocated for this task, you may discover additional information about the neighbourhood and its communities on subsequent days and you should use this to supplement your initial observations. After your walkabout you should get together with your group and try to develop some hypotheses about the local area, and what they might mean in terms of problems and opportunities for your practice.

The checklist of categories listed below are applicable to a wide variety of neighbourhoods, but not all will necessarily relate to the area you will be in. However, as you consider each section, please note that it is not only the presence of certain elements that are significant, but also their absence. You may not have time to comment on every category, but make brief notes on what you discover, as you will be able to discuss these issues further with your tutor.

GUIDELINES

Within your local area, record your observations on the following:

Housing:

• Type e.g. houses, terraces, flats
• Ownership e.g. owner-occupied, private rented, council-owned
• State of repair
• Empty, multi-occupied
• Access for residents e.g. is there a lift? Does it work?

Industrial and commercial property:

• Type e.g. factories, workshops, offices
• Is there evidence to suggest whether the business employs people living locally or from outside the area?

Shops:

• What do they sell? / What services do they offer?
• Do the products cater for a particular religious or ethnic group?
• Do they serve the immediate neighbourhood or a wider area?
• Are they chain stores or small businesses?
• Who owns the shops? Do the names of the shops indicate the presence of particular nationalities?

Places to eat and drink:

• Type e.g. pubs, cafes, restaurants, takeaways
• Which ethnic groups provide the food and who are their customers?

Local offices serving the area:

• Which offices serve the local area? e.g. housing, social services, social security, jobcentre, post office, police station, advice centre

Educational facilities:

• Which schools (nursery, primary and secondary) and colleges serve the local area?

Leisure and recreation facilities:

• Are there any sports facilities, places of entertainment or libraries?
• What are their opening hours? How much do they cost?
• Are there any open spaces, parks or playgrounds?
• Are these safe, supervised and well maintained?

Health services:

• e.g. health centres/clinics/General Practitioners
• Where are the nearest dentists, chiropodists, chemists and hospitals?
• Are there any centres for alternative medicine/therapies?
• Places of worship and cultural centres:
• e.g. churches, mosques, synagogues

Community facilities:

• e.g. community centres, tenant halls, meeting places, social clubs
• What kinds of groups meet at these places? e.g. playgroups, tenants 
  associations, youth clubs

Transport:

• What major roads, railway lines, canals exist in the area?
• Do they service the local community or are they for commuters?
• Do they appear to be boundaries or barriers?
• What is the volume and nature of road traffic?
• Are there pedestrian crossings, subways and bridges?
• What type of public or private transport is there?
• Are there bus stops, tube and BR stations, mini-cab offices?
• What routes do they take and how frequent are they?
• Is the transport accessible for the elderly and parents with buggies?

Derelict land:

• What is the condition of such sites?

Historic features:

• e.g. places of worship, cemeteries, monuments, plaques
• Is there evidence of communities with a long presence and/or communities with 
  little or no current link with the area?

Additional environmental facilities: 

• Street lighting – does this seem adequate to provide a well-lit safe area?
• Condition of paving – could this cause problems for people with walking difficulties?
• Accumulation of rubbish – e.g. domestic, furniture, commercial
• Availability of public telephones
• Evidence of who appears to be investing resources in the area (e.g. new developments) – who will they benefit?

IN ADDITION, YOU MAY WANT TO USE THE FOLLOWING QUESTIONS TO GUIDE YOU AS YOU WALK AROUND THE AREA:

• What do you consider are the most significant characteristics of the area?
• What do you think are the positive and negative features of living in the area?
• Can you identify any major issues facing the local community?
• Are the local services appropriate and accessible? If they are not present in the area, how far away are they and how might local residents get to them?
• How could health and other statutory services in the area be improved to cater for the needs of a particular group in the area? (e.g. the elderly, lone parents,people with disabilities, the Bengali community)
• Is there anything you consider unusual, that you have never seen before or would expect to see but have not?
• Have you observed evidence of collective action taken by local people to address a community issue? (e.g. a poster advertising a public meeting or a local campaign group meeting at the community centre)
• Have you seen any food you have not eaten before? Find out what it is.

8.4. Reflective Writing Resources

‘Medical education has traditionally focussed on the assimilation of vast amounts of knowledge and on clinical apprenticeship as the ‘hallmark’ of good training, and has undervalued reflection in learning.  Today, however, medical and dental education needs to prepare students for lifelong learning.  It must foster professionals who take a deep approach to learning and equip students to determine their own learning needs, set their own learning goals and monitor the occurrence of continuing progress.  To achieve this, a more reflective approach is called for’ (Pee et al, 2000).

It is important that students develop a habit of assessing their own learning needs, developing strategies to meet them and reflecting on their own learning and personal development.  

‘Reflection - the conscious weighing and integrating of views from different perspectives – is a necessary prerequisite for the development of a balanced professional identity … acquiring knowledge and practical skills alone are not enough to become a medical professional.  Reflecting on education and clinical experiences in medical practice, including one’s own behaviour, becomes crucial’ (Boenink et al, 2004). 

Reflective Practice

Introduced as a concept for many professions in the 1980s

Means that we learn by thinking about things that have happened to us and seeing them in a different way.

There are three components

• Experiences – that happen to a person
• Reflective process – that enables a person to learn from their experience
• Action – resulting from the new perspective taken as a result of the reflection

Reflection as a learning activity comes from educational theory, Kolb (1984) describes a cycle of stages that are gone though in learning from experience:

                                                       OBSERVATION                

ACTION                                                                                                                      REFLECTION           

                                     CONCEPT DEVELOPMENT and THEORISING

Levels of Reflection

Goodman (1984) describes three levels of reflection:

• Level 1:  Reflection to reach given objectives – criteria for reflection are limited to technocratic issues of efficiency, effectiveness and accountability i.e. students gives an account of an incident and demonstrates some learning
• Level 2: Reflection on the relationship between principles and practice – there is an assessment of the implications and consequences of actions and beliefs as well as the underlying rationale for practice i.e. students begin to link theory to practice and to extrapolate their experiences to other similar situations
• Level 3: Reflection which besides the above incorporates ethical and political concerns – issues of justice and emancipation enter the deliberations over the value of professional goals and practice and the practitioner makes links between the setting of everyday practice and broader social structure and forces e.g. health economics and resources.

Frameworks for Reflection

There are many frameworks that can be used to encourage and support reflection; the choice of framework depends on the student’s skills and experience and may change as students become more expert in their reflections.  A range of frameworks and tools follow:

Helping students to reflect:

Consider what you did on your placement visit today…did anything that happened during the day surprise you?  Has anything that happened during the day contradicted or challenged your ideas or expectations?  Have your views changed?  For example:

If you met a patient:

How did the patient’s life experiences differ from your own?

Did you feel able to empathise with the patient?

If you were shadowing a healthcare professional:

Did anything about the person’s role surprise you?  Do you think the roles of all members of the MDT are valued?  How do you feel about team working with other professionals? 

Your knowledge:

Have you identified gaps in your knowledge or skills?  How might you go about addressing these?

Or you might like to use one of the following frameworks to reflect on your experience:

A Learning Experience (Pee et al, 2002)

Briefly describe what happened.

• Describe your feelings at the time this happened.
• Why do you consider this experience to be worthy of reflection?
• What strengths in your clinical practice did this experience demonstrate?
• What learning needs did this experience reveal to you?

Gibbs Reflective cycle (1988)

                                                                                                Description

                                                                                            (What happened)

Action Plan                                                                                                                                                                                                                  Feelings

(If it arose again what                                                                                                                                                                                              (what were you

would you do?)                                                                                                                                                                                                      thinking and feeling?)

Conclusion                                                                                                                                                                                                                    Evaluation

(What else could you                                                                                                                                                                                      (What was good and bad about

Have done?)                                                                                                                                                                                                      the experience?)

                                                                                                      Description

                                                                                (What sense can you make of the situation?)

Borton’s Developmental Framework (1970)

This is a simple model that is suitable for novice practitioners, at its simplest it’s three steps can be summarised as:

• What?
• So what?
• Now what?

i.e. the What questions such as:  What happened?, What was I doing? Serve to identify the experience and describe it in detail.

The So what? Questions include questions like: So what do I need to know in order to understand this situation? So what does this tell me about me? About my relationship with the patient? With the other members of the team? I.e. the student breaks down the situation and tries to make sense of it by analysing and evaluating in order to draw conclusions. 

The Now what? Questions e.g. Now what do I need to do to make things better?  Now what might be the consequences of this action?  At this stage the student plans intervention and action according to personal theory devised.

Johns Model of Structured reflection (1994)

Compiled by Maria Hayfron-Benjamin,

Lecturer in Medical Education,

Barts and the London School of Medicine and Dentistry

m.j.hayfron-benjamin@qmul.ac.uk

References

Boenink AD, Oderwald AK, deJonge P, vanTilburg W and Smal JA (2004) Assessing student reflection in Medical Practice.  Medical Education, 38, 368 – 377.

Borton, T. (1970) Reach, Touch and Teach.  London: Hutchinson

Gibbs, G. (1988) Learning by Doing.  Oxford Polytechnic, Oxford

Goodman, J. (1984) Reflection and teacher education: a case study and theoretical analysis.  Interchanges, 15, 9 – 26

Jasper, M.  (2003) Beginning Reflective Practice.  Nelson Thornes, Cheltenham.

Johns, C. (2000) Becoming a Reflective Practitioner. Blackwell Science, Oxford.

Palmer, A., Burns, S.  and Bulman, C. (1994) Reflective Practice in Nursing.  Blackwell, Oxford.

Pee B, Woodman T, Fry H, and Davenport E. (2000) Practice-based learning: views on the development of a reflective learning tool.  Medical Education, 34, 754 – 761.

Pee B, Woodman T, Fry H and Davenport E. (2002) Appraising and assessing reflection in students’ writing on a structured worksheet.  Medical Education, 36, 575 – 585