There has always been a gap between the number of patients seen in primary care and how this is reflected in the curriculum of medical schools. To overcome this shortcoming, mandatory primary care clerkships are, to date, a component of most curricula. In the United States and the United Kingdom, for example, many schools already deliver a significant proportion of their curricula in the community [1
]. However, in Germany – like many other countries – general practice is still not fully established in most medical schools, and clerkships in primary care/general practice were not mandatory until recently. In early 2004, the 8th
amendment of the Federal Regulations for Medical Education in Germany instituted mandatory practical training in primary care [4
]. Clerkships in primary care in German medical schools range from 1 to 3 weeks. A 2-week clerkship in primary care in the 5th
year was introduced in 1999 at the University of Göttingen Medical School.
The core curriculum for this clerkship focuses both on general principles of teaching and on specific tasks of general practice. Some of the essentials are:
Communication skills, recognising patient expectations
Upper respiratory tract infections
Home visits and emergencies
Chronic disease, multi-morbidity and palliative care
Functional and psychosomatic complaints
Musculoskeletal disorders, e.g. low back pain
Preventive care in primary care
Some of these tasks also reflect learning objectives, e.g. recognising and treating upper respiratory tract infection or communications skills, which fall within the curricular responsibility of family medicine in our faculty.
Primary care practices are usually rather loosely attached to medical schools. The instructional quality of undergraduate medical education in the community setting has been described as a "black box" [5
] where the quality of teaching in some practices and the availability of time to teach and offer patient care are matters of concern [1
]. This is due to variation in practice structure as well as the large number of decentralised sites (compared to a hospital setting) and the high number of tutors. The biggest challenges are creating and maintaining a minimum level of standardisation and a system of quality assurance [6
]. Clerkship students are expected to learn from tutors, not usually trained in teaching, core concepts of primary care, such as "whole person" and "humanised health care" [8
], along with strategies for differential diagnosis, patient management and comprehensive care for chronic illness [9
]. Training programmes for general practitioners (GPs) with a special interest in medical education have been established elsewhere [10
] but are either not available in Germany or restricted to doctors who are highly motivated to take part in teach-the-teacher training courses [11
Although teaching general practices seem to perform better, for example, in prevention activities or prescribing indicators than non-teaching practices [13
], the quality of community-based education cannot be taken for granted [6
]. As early as 1999, Shipengrover and James [5
] complained about a lack of valid measures to monitor the quality of teaching during clerkships. Meanwhile, there are some measures to survey the students' most valued practice and preceptor characteristics and to evaluate instructional quality in ambulatory teaching sites [6
]. However, these measures lack a focus on characteristics unique to primary care.
A student assessment may provide exactly such data continuously, namely process data, which is needed to evaluate the quality of medical education. We therefore introduced a mandatory evaluation with a special focus on primary care characteristics that could form the basis of a subsequent benchmarking system. The aims of this study were to explore:
(1) Which expectations or preconceptions students had of a primary care clerkship.
(2) Which areas of teaching students did and did not appreciate to identify GPs' areas of strength and weakness in teaching.
(3) Correlations between the students' evaluation of the clerkship and their desire to pursue a career in primary care.
(4) Whether the data helped to identify practices with excellent or only moderate teaching performance.