1. Medicine in Society 2021/22

Medicine in Society is a community-based course for students in years one and two of the MBBS curriculum. The global aims of the course are to introduce students to patients and the patients' experiences of health and ill-health over the course of their lives.

In year one students, in groups of 10-12, will attend a general practice placement for 12 alternate Thursdays throughout the academic year. Each day is themed and has clear learning objectives. The theme relates to the system the students are covering at the time, e.g. day 11 focusing on pregnancy and childbirth is during the human development system teaching.

For the 2020/21 academic year, due to the COVID-19 pandemic, the course will initially be delivered virtually, with a view to students attending the practice in person in small groups from 2021 depending on the progress of the pandemic. 

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. 

2. Introduction

The curriculum at Barts and the 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 aim of the Medicine in Society Year 1 unit is to introduce students to patients and the patients' experiences of health and ill health over the course of their lives.

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. Timetable for Medicine in Society 2021/22

4. Example timetable & learning activities

5. Preparing for placement - Student and Tutor guidance

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. 

5.1. Student checklist

5.2. Tutor checklist

6. Themed Days

There are 12 placement days in year 1.

6.1. Day 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 and virtual learning; 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. Day 2: The Doctor Patient Relationship

Preparatory work

In preparation, students should have:

• Read the General Medical Council’s (GMC) good medical practice and the British Medical Association’s (BMA) ethics toolkit for medical students; this contains lots of useful and accessible information for students.  The GMC have also produced specific guidance on Doctor's use of social media). 
• Read this student perspective on the doctor-patient relationship.
• Looked at their practice's website and reviewed the practice summary on Public Health England's (PHE) National General Practice Profiles website to get an idea of the practice's locality and patient population.
• Established which Clinical Commissioning Group (CCG) and/or health authority their placement is in and read from the relevant Local Authority Health Profile to get a feel for what some of the major causes of morbidity and mortality are in the area. Whether or not their first placement is in Tower Hamlets students might like to read this Profile of Tower Hamlets to get a feel for the area local to the Medical School, this may be similar or very different to the area where their GP practice is located.  
• Found a definition and the main principles of health promotion.

Aims

• To introduce students to the professional and ethical framework of the health professional-patient relationship in clinical consultation.
• To consider how COVID-19, specifically the increased use of remote consultation, has impacted on the doctor patient relationship.
• To orientate students to the practice area.
• To introduce health promotion and illness prevention activities in primary care.

Learning Outcomes

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

• Explain the ethical and practical guidelines for interviewing patients, including how to obtain consent from a patient for history-taking
• Describe some reasons why patients present in general practice
• Identify some of the skills healthcare professionals use in their relationships with patients
• Start to build a community profile of the local area and reflect upon what their observations tell them about the area and the community
• Describe some health promotion interventions that occur in primary care, such as a new patient check
• Be aware of some of the main areas of impact of COVID-19 in primary care

Example timetable

Suggested Activities

• Tutorial - What is professionalism? Could include ethics, consent, social media/confidentiality, professional relationships; how students are expected to conduct themselves – attendance, group conduct, dress code. Consider specifics for virtual platforms; ethics and COVID-19; so many ‘hot topics’ e.g. PPE, remote consultations, practitioner wellbeing. Lots COVID-19 specific guidance and FAQs on BMA site
• to include ethical issues and obtaining consent for interviewing and physical examination.
• Breakout task - ethical cases given to students to discuss in small groups e.g.  consent, confidentiality, unprofessional colleague, inappropriate use social media. Regroup and debrief after small group discussions.
• Remote consultation RCGP resources
• Community area profile – group discussion of pre-reading, PHE’s profiles for the borough and the practice. What did students notice for London/specific borough/practice compared to national data? e.g. see age profile graph showing younger age of London/Newham’s population - how might this affect health and socioeconomic issues in area?
• Virtual walkabout – students are assigned a patch/road in practice catchment area. Could use Google maps, other local area maps e.g. Newham LocalView Maps, where you can enter practice address and then search for nearby facilities, and local services websites e.g.  Active Newham map and information. Signpost where else students could find local information to help them build a community profile, such as local press and social media or searching for other online resources e.g. YouTube video (watch from 6.30-9.30) walking through the Stratford centre. Each group notes down their key observations to present to the group. After this, students should attempt to generate hypotheses about possible health and social problems (and opportunities) for the practice population; there is further guidance for students in appendix 7.3.
• Health promotion; note generally what health promotion information the practice displays on its website and within the waiting and clinical areas e.g. posters/screen displays.
• Impact of COVID-19 on primary care e.g.  increased use of remote consultation and telemedicine, possible group discussion of benefits and disadvantages of this.
• Observe a member of the primary care team carry out a health promotion intervention e.g. new patient check, dietary advice, routine health check.

Questions for students to consider

• What reasons do patients present in general practice? Do you think patients communicate differently with non-clinical and with clinical staff. 
• Why should you ensure patient’s consent to any examination and treatment has been obtained?
• How has the COVID-19 pandemic changed the day-to-day workings of primary care and the patient’s experience of “seeing” their GP?
• Why is health promotion important in primary care?  What do you think the GPs role is in health promotion?  Which other healthcare professionals have health promotion roles?
• Having completed your community profile, what did you think of the area?  Were you taken aback by anything?  Did you think the facilities in the area would help people to live a healthy lifestyle?  What would you like to change about the area and why?

6.3. Day 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'. And listened to him being interviewed on the ‘Finding Fairhealth’ podcast in which he discusses the effects of coronavirus on people living in deprivation.
• Looked at the Fairhealth wiki for further information about vulnerable groups and steps healthcare workers can take to support those most at risk.
• Looked at some of the public health profiles e.g. the Marmot indicators of the local practice area.
• Completed some reading about social prescribing.
• Thought about how they might start a conversation with a patient and what questions they would ask. Considered these suggestions on how to build rapport with patients.

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.
• Reflect on their first experience of meeting a patient for the first time as a medical student.

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 virtual 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.
• Virtual 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. Day 4: The Older patient

Preparatory work

In preparation students should have:

• Read about ageing and health. 
• Looked at these blogs; ‘Elderspeak’ and ‘A quest for clearer thinking on ageing’.
• Reviewed NHS England’s key priorities for improving care for older people.
• Considered the implications for society, and health and social services, of an ageing population.
• 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

 Example timetable

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 topics’ e.g.  COVID-19 and care homes.
• Patient interviews – either observing healthcare professional or student-led
• Virtual 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?
• Research local agencies or meet with a professional providing services for older people.
• Meeting with GP tutor for formative feedback on progress to date with learning activities and on professional attitude and conduct.     

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?
• You may have a meeting today with your tutor.  How are you finding the placement so far? How do you feel you are progressing?  Have you noticed any changes in yourself?  Do you feel comfortable in the group?  Do you feel comfortable meeting patients? 

6.5. Day 5: 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 this Brainman video; it’s also interesting to read the public comments (with caution). 
• Read about arthritis and different management options for this condition on the versus arthritis website.
• 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 – 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 (FPM statement, Nov 2019), current draft NICE guidance on chronic pain (due Sep 2020) & the media response to it.
• Student-led research – 2 groups, pharmacological and non-pharmacological treatment options for management chronic pain, pros/cons of each, consider local access to these options. Present back to group and discuss.
• 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).  
• Meeting with GP tutor for formative feedback on progress to date with learning activities and on professional attitude and conduct.     

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?
• You may have a meeting today with your tutor.  How are you finding the placement so far? How do you feel you are progressing?  Have you noticed any changes in yourself?  Do you feel comfortable in the group?  Do you feel comfortable meeting patients? 

6.6. Day 6: Respiratory Medicine

Preparatory work

In preparation students should have reviewed the following resources;

• 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. This resource is updated regularly.
• Public health England’s Inhale data, which is an online tool showing information about respiratory diseases, including COPD and asthma, for each clinical commissioning group (CCG) area.
• Another useful source for local information about respiratory disease, including clinical priorities and services, is the interactive map on the Respiratory Futures website.
• The British Thoracic Society has lots of useful resources e.g. clinical guidelines for respiratory condition and COVID-19 information for people with lung disease.
• 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.

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 to 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.
• Virtually sitting in on 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?

6.7. Day 7: Diabetes

Preparatory work

In preparation students should have:

• researched the causes and treatments of Type 1 and Type 2 diabetes. The Diabetes UK website is a good starting point for information about diabetes; there are resources for patients and healthcare professionals so whatever your level of prior knowledge you should be able to find some useful information;
• reviewed some of the resources on healthtalk.org about type 2 diabetes, especially to get understand a patient’s perspective on living with diabetes, such as symptoms, diagnosis, controlling diabetes and impact on lifestyle.

Aims

To introduce students to the pathophysiology of diabetes; and to the impact diabetes has on the individual and society.

Learning Outcomes 

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

• describe the incidence and prevalence of Type 1 and Type 2 diabetes and the impact of diabetes on the general practice workload;
• discuss some factors that may be contributing to the rise in prevalence of Type 2 diabetes;
• describe the impact of diabetes on an individual;
• describe some health promotion interventions to reduce the prevalence of Type 2 diabetes;
• practise blood pressure monitoring, blood glucose testing, height and weight measurement.

Example timetable

Suggested ActivitieS

• Tutorial on diabetes – could include discussion around types of diabetes, incidence & prevalence statistics (national/local) and factors causing increased prevalence Type 2 diabetes, a quiz (either set by tutor or each student to contribute 1 or 2 questions), student presenting on students presenting pre-agreed topics based around preparatory work, ‘hot topics’ e.g. lifestyle medicine.
• Session with practice nurse/healthcare assistant to introduce students to the monitoring of patients with diabetes at the practice.
• Observe a consultation with a patient with diabetes; this could be a virtual diabetic review.
• Interview a patient with diabetes, with the possibility of a home visit if students are on site.
• Interview a health care professional involved with the care of the patients with diabetes.
• Group discussion after meeting patient/s and healthcare professionals to compare the patient’s and professional’s views on the management of diabetes and its impact on the patient’s life.
• Group debate e.g. Is Type 2 diabetes a reversible disease of lifestyle?
• Clinical skills teaching and practice e.g. blood pressure measurement, blood glucose testing, height and weight measurements and BMI calculations and interpretation. Discuss/observe how some diabetes monitoring is being carried out virtually.
• Students join practice/MDT meeting.
• Student-led research into local services and facilities for people with diabetes. This could include some students visiting local sites or conducting research on foot e.g. to local library/community centre if they are on site.

Questions for students to consider

• If you met a patient with diabetes – what did you learn about the impact the condition has on their day to day life?  Did anything they told you surprise you?  Did you think they could do anything to improve their own situation?  How can health care professionals help patients to help themselves?
• If type 2 diabetes is increasing because of our sedentary lifestyle and increasing weight (as a population) what is the role of the doctor in diabetes?  Should efforts be concentrated on prevention?  How far should we go to ‘encourage’ people to make healthy choices?  Or should doctors concentrate on treating the patients that present?

6.8. Day 8: 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 the report by The Mental Health Foundation has produced some guidance on wellbeing and nutrition; they also have a podcast episode discussing this topic.
• 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 watching Dr David Kessler's lecture “The End of Overeating - Taking Control of the Insatiable American Appetite” (it is a bit of a slow start).
• Thought about 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?
• 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?

6.9. Day 9: Mobility and Stroke

Preparatory work

In preparation students should have:

• Revised what they already know about the pathophysiology of stroke. 
• Looked at the NICE guideline for the diagnosis and initial management of stroke and transient ischaemic attack.
• Read the article “‘Me talk funny’: A stroke patient’s personal account”, which gives a personal account of stroke recovery from a linguist.
• Reviewed some of the information on the healthtalk.org website about both stroke and TIA, including lots of patient accounts.
• Looked at the Public Health England (PHE) Act-FAST campaign and considered what makes the posters 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 an interview schedule to use with a patient who has problems with mobility.  Include 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
• Visit a patient with impaired mobility at home or conduct meet patient virtually, but make sure questions about home modifications, travel, work and accessibility are covered.
• Session teaching clinical skills e.g. pulse checks, blood pressure measurement, examination of central and peripheral pulses and practise these. Possibility for students to observe new patient checks and/or work alongside practice nurse/HCA to complete initial examinations, including pulse, BP, weight, height. Also, consider how these parameters are being carried out remotely using telemedicine.
• 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

• 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? 
• 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?

6.10. Day 10: 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.
• Read this article on mental health perspectives from The Guardian, which has recommendations on mental health services from service users.
• Looked at the NHS website pages on addiction, which has information on different addictions, treatment options and patient stories.
• Considered how the COVID-19 pandemic, and especially the lockdown measures, have affected people’s mental health and addiction problems; there is an episode of ‘Hooked: The unexpected addicts’ that focuses on Lockdown.
• Thought about how healthcare professionals, including medical students, need to be aware of their own mental health and wellbeing; there are a number of GP wellbeing resources signposted on the RCGP website.

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; quiz e.g. mental health quiz from the time to change website; hot topics e.g. impact of COVID-19 pandemic on people’s mental health and addiction.
• Practising self-compassion: looking after ourselves as well as our patients – could watch the TEDx Talk ‘Our healthcare systems are making doctors mentally ill’; 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.
• Online research and/or visit to 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?

6.11. Day 11: 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 birthrights and national childbirth trust (NCT) websites are a good staring points for some of these questions.
• Read this newspaper article regarding the drop in teenage pregnancy rates in the UK and this summary of teenage pregnancy statistics.
• Looked at the MMRACE-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 and local area;
• 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? Could include any current 'hot topics' e.g. occupational health for pregnant women during COVID-19 (see RCOG advice).
• 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 e.g. these graphic 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?

6.12. Day 12: Mother and Baby

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

Student Assessment

There are three components to the student assessment for Medicine in Society:

• Reflective pieces (2)
• Health promotion poster 

At the end of the year your tutor will be asked to submit your attendance record, a numerical mark for the reflective pieces and a numerical mark for your poster.

Attendance

Student attendance is recorded at each placement. Tutors must inform us at the time of any non-attendance.

Any student unable to attend must submit a self certificate form to the University. (Available on QMPlus)

Please click here for link to the self certificate form.

There may be occasions during the year when students have an in-course assessment exam on the Friday after a MedSoc day; these exams contribute only in a relatively small way to the students’ end of year marks. Students must attend their placement as usual. If tutors have any concerns about a student’s attendance, behaviour, health etc. they should contact the unit convenor as soon as possible.

7.1. Reflective Pieces (70%)

7.2. Health Promotion Poster (30%)

7.3. Professional Assessment

8. Appendices

These are the appendices.

8.1. COVID-19 and Virtual teaching

Due to the COVID-19 pandemic, primary care teaching will be delivered virtually by GP tutors in 2021/22

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:

http://www.nhs.uk/england/

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 virtually 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 on subsequent days, especially if you are able to attend the practice in person and explore the local area on foot, and you should use this to supplement your initial observations. After your virtual 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 locallyor 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, take-aways
• 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, job centre, 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. Reading Resources

The core texts recommended for the Medicine in Society course are:

• Patrick DL and Scambler G (eds.) (2008) Sociology as applied to Medicine. 6th edn. London: W.B. Saunders
• Dowrick C (ed.) (2001) Medicine in Society: Behavioural Sciences for Medical Students. London: Arnold (ISBN 0 340 76127 3)

Electronic Resources

For each placement day the links to the recommended reading are embedded in the text  - click on the link to take you to the website or the full text article.

8.5. Internet Resources

Access to websites and e-mail facilities from remote sites is useful throughout a student’s training in general practice. It can be used for study and research purposes as well as maintaining contact with the college. Any urgent messages and changes of venues etc that require notification will be done electronically.

Students and tutors need to ensure they can regularly check for such messages.

Each practice should provide a PC for students to use. The PC will either be free-standing and connect via a dial up modem or via the local practice network (NHS Net). The practice will need to provide a login and password for student use whilst at the practice. 

Please be aware of confidentiality issues and that inappropriate use of the computer and/or internet access will be taken as a disciplinary matter and should be brought to the attention of the unit convenor.