Family Practice Vol. 19, No. 4, 416-421
© Oxford University Press 2002
Graduates' evaluation of a postgraduate Diploma Course in Family Medicine
Department of Community and Family Medicine, The Chinese University of Hong Kong, 4/F, Room 409, School of Public Health, Prince of Wales Hospital, Shatin, NT, Hong Kong.
Professor James Dickinson; E-mail: jad{at}cuhk.edu.hk
Dickinson JA, Chan CSY, Wun YT and Tsang KWK. Graduates' evaluation of a postgraduate Diploma Course in Family Medicine. Family Practice 2002; 19: 416–421.
Received 19 January 2001; Revised 6 September 2001; Accepted 2 November 2001.
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Abstract |
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Background. Postgraduate programmes offer an opportunity to learn family medicine for physicians in practice who were unable to obtain formal training in the immediate postgraduate phase of their career. Since 1985, the Chinese University of Hong Kong has provided a part-time 1-year diploma course at hours convenient for private practitioners. The curriculum has evolved, reducing public health components and increasing family medicine concepts. Between six and 16 students took the course each year until 1999, when formal recognition led to increased popularity.
Objective. The aim of this study was to evaluate the components and outcomes of the course as a prelude to further development.
Methods. Evaluation comprised a structured telephone interview conducted with two enrollees from each year of the course (total 28), selected randomly from class lists.
Results. Participants were mostly young doctors, with an average of 5 years in general practice. Many graduates are now prominent in training and development of family medicine in Hong Kong. Graduates rated most components favourably, but found the original research components too demanding, and not useful subsequently for most. Counselling, family dynamics, consultation and practice organization skills were valued. Conventional continuing education components, such as lectures by specialists, were evaluated poorly.
Conclusions. This course has proved useful in the Hong Kong context, being practical for physicians, and allowing them to study ideas they would not otherwise encounter. Critical appraisal and evidence-based medicine exercises now replace the former research components.
Keywords. Adult learning, diploma courses, family physicians, Hong Kong, postgraduate medical education, programme evaluation.
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Introduction |
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Many countries now have general practice vocational education programmes for new graduates, which will gradually change the face of the profession. However, large numbers of physicians in the community who had no opportunity to undertake such training, yet would like to upgrade their knowledge and skills,1 seek formal ways to do so, especially where the policy change to family medicine is being introduced. There is now a widespread development of such courses.2–5
In Hong Kong, the majority of practising community physicians left hospital work directly after internship, or after some years as a medical officer in specialty fields. Others have specialty qualifications, but largely practice primary care. With the development of the discipline of family medicine, many of them wanted a way to learn more about the insights of this newly defined discipline, and how to develop better practices.
In 1985, the Chinese University of Hong Kong Department of Community and Family Medicine established a course leading to a Diploma in Family Medicine that the Medical Council of Hong Kong formally recognized as a quotable qualification in 1999. Regular feedback sessions were part of the continuing quality improvement of the course, but we wished to undertake a formal evaluation to determine how best to develop. Therefore, we undertook a telephone survey of the opinions of graduates from the course, to determine which components of the course they had found valuable, and whether their medical practice has changed. The survey was wide ranging, covering all aspects of the course, but this paper selectively focuses on issues that may be helpful to other centres considering a similar approach.
Description of the course
Participants attend classes over 40 weeks for 2.5 hours per week on Thursday afternoons, a convenient time for doctors in private practice, who usually have a break between morning and evening consulting sessions. Table 1
shows the groups of topics covering family medicine theory and practice in early versions of the course, and in more recent years since Professor C Chan became course director in 1994. Originally, the course was designed to develop teachers and academics in family practice, following the pattern of the well-known Western Ontario course,6 so it emphasized research skills, and, until 1997–1998, students undertook a practice-based research project on their own or in groups. Teaching methods included lectures, but more often seminars, with pre-readings and discussion of problems, usually in groups with a class member as co-leader. A segment on working with families, consulting skills and counselling techniques included discussion of case reports and role-playing, though clinical supervision was not possible. Systematic clinical medical education dealt with topics that were not taught in depth in the undergraduate courses that most participants had attended. Various assignments included the submission of an essay in early years and a patient education project and a counselling case report in recent years. Other changes have been made to the course content over time, moving from theoretical teaching about disease, community medicine and research, towards critical appraisal based on the problems arising in family practice, with increased home assignments to encourage students to learn and reflect on their own. Table 2 shows how the evaluation methods have changed over the years, corresponding to the changed emphasis of teaching.
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Participants pay full fees, since the course is not subsidized except for a few employees of the Department of Health.
Outcomes of the course
Between 1985 and 1999, there were 128 graduates with class sizes ranging from six to 16, and more had enrolled for subcomponents, as part of their higher training for the College of Family Physicians. None failed, though a small number did not complete all requirements to gain the diploma. Subsequently, one wrote a MD thesis, two obtained the MPH from our department, two the Master in Family Medicine degree by distance learning studies from Monash University, and some have obtained other qualifications such as MRCGP, DCH and Diploma in Dermatology. Forty-five have passed the Conjoint Fellowship Examination of the Hong Kong College of Family Physicians and Royal Australian College of General Practitioners. Of these, 26 have gained recognition from the Hong Kong Academy of Medicine as specialists in family medicine. Two are now full-time academic staff, while three are part-time. Two have gained Consultant status in the Department of Health, while another three are full-time trainers in family medicine in the Hospital Authority. Forty-one currently are adjunct teachers of our department, taking students for attachment in their clinics.
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Evaluation method |
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In order to obtain opinions about each version of the course, a random number table was used to select two physicians from each year group for a telephone interview. If either was unavailable, subsequent selections were substituted. A structured questionnaire was developed for interview, asking open-ended questions about major aspects of the course. The questions were developed in English, but translated into Cantonese.
A research assistant (KT) conducted the interviews, under the name of the recently arrived Professor of Family Medicine (JAD), rather than the course director (CC), so respondents would feel more free to comment. The research assistant phoned the doctors, explained the purpose of the survey and arranged a suitable time for a telephone interview, which lasted ~30 minutes, in the language preferred by the doctor.
Responses to open-ended questions were noted during the interview, and then entered directly as free text including verbatim quotations onto an Excel® database. Participants often were discursive, and revisited earlier comments as they reflected on related issues. After interviews were completed, KT grouped and summarized the data. Where appropriate, answers were classified and categorized to provide quantitative responses. More descriptive data were handled qualitatively. Two authors (JAD and CC) reviewed the data independently and each identified consistent issues that emerged. These were discussed, and the data were revisited repeatedly to develop agreement on their meaning.
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Results |
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Up until summer 1999, 138 physicians had taken the course: 22 (15.9%) female, and 85 (61.6%) in the private sector. Eighteen interviews were obtained on the first attempt. Up to four substitutes in a given year, 19 in all, were needed to obtain the full quota of 28 interviews: the main reason was out-of-date addresses. Only one contacted physician refused. Twenty were interviewed by telephone, but eight physicians were not willing to take time over the telephone, offering to comment on the questionnaire, which was mailed and returned with extensive comments.
One of the sampled physicians had dropped out of the course part way through. Twenty-five had completed the full diploma while two took parts of the course on a modular basis. Four (14.3%) of the respondents were female. The doctors had from 2 to 13 years experience in general practice at the time of entry to the course, with a mean of 5 years.
Questionnaire responses
Many of the participants found that the questionnaire gave them an opportunity to reflect upon their experience, and did not simply answer the questions, but roamed over a wide range of concepts. They went back to previous questions as later ones reminded them of particular issues, and elaborated on their responses.
Their hopes for the course were expressed mainly in terms of becoming a better family doctor, and to learn more about the theoretical concepts that would help them to improve, especially in doctor–patient relationships. Some undertook the course initially as preparation for examinations and Fellowship of the Academy of Medicine. Most of their expectations were met: "the course was well-run, based on group discussions with exchanges of ideas and practical experiences among doctors working in the community setting." Most liked the wide range of topics, small group approach to learning, assignments and presentations by students. They felt it was very relevant and applicable to daily practice. This group tended to criticize "continuing education lecture" components: "because a single lesson is not enough, it is like being given the contents of a book; unless the topics fit into daily practice."
There is a dichotomy between those who were pleased with the free-ranging ideas and philosophical approach, and a few who remained focused on learning specific clinical knowledge, and were impatient of the theoretical concepts. Time pressure and the lack of opportunity to explore in depth were mentioned repeatedly, though each such respondent provided different examples of what they would have liked more of. For example: "the course covered too many topics, was too ambitious, and too much time was spent on the research project." These doctors were disappointed, seeing the course as focusing on ideals, not the practicalities of Hong Kong practice, and not providing enough specific information. The lack of fixed curriculum content disturbed several with concerns that it was not decided by experts: "each student was given a topic then did reading and research and presented it. How well the topic was covered depends on the students' effort."
When asked the most important things they gained from the course, most focused on better understanding of family medicine concepts, and being a better primary care doctor. An unexpected finding was that many mentioned the friendship and peer support gained from the other members of the class, which broke down the loneliness of the solo practitioner working long hours.
As a result of the course, most described changes they had made to their practice. These include structural changes such as improved records with problem orientation, prevention records or better ways to work with their staff. They changed practice processes, such as setting aside time for counselling and establishing appointment systems. Others complained that they could not, because they work in institutions, and "there is no way to change the organization of the practice."
Most importantly, all but five stated that they were better doctors, describing better understanding of the diagnostic process, changed consultation style, focus on patients' concerns and psychological problems. They also changed to be more patient-focused: "more initiative to ask about relevant family background", or "giving patients the choice of making changes." Comments were made about considering the "whole person, with more emphasis on psychosocial factors and not just the disease, seeing patients in the context of the family." "Provide more comprehensive service, ... willing to tackle more difficult clinical problems." They prescribe less medication, and are more critical analysts of information from specialists and pharmaceutical companies. The skills in self-directed learning and critical analysis were specially commended, and several have continued the habit of literature searching, allowing them to go deeper into particular topics, and maintain their knowledge more effectively.
The research project was regarded as a good experience, especially since they worked in teams and had to co-operate, but was criticized as inefficient by some. Statistics and research method teaching was too rushed and superficial. Moreover, only three had gone on to publish their projects or do more research themselves. They are willing to assist others to do research, but feel that the constraints of practice prevent them from doing their own.
While most appreciated the sections on communication skills, they would have preferred approaches more usable in their context, with opportunity for practice. Several commented that counselling needs time, so these skills are not easily usable in their setting "... because only seven minutes per consultation ... now can only identify patients' problems and become more aware of them but can't deal with them." However, others felt that they are usable, even if not formally: "they can be used subtly in nearly every case in practice."
Although some graduates have gone on to further studies, especially through the distance-learning course offered by Monash University, most have not, giving pragmatic reasons for not doing so. Their interest in the course was shown by the positive and practical series of suggestions for improvement from 20 of the 28 interviewed. These were contradictory in some aspects, especially the distinction between the small number who wanted more of ‘factual’ continuing education programmes, and the large number who recommended more emphasis on principles of family medicine and evidence-based appraisal, with reduced specific specialist topics or other material that can be learned from conventional programmes and books.
Overall, many described how they have enhanced their self-esteem as family doctors, through being confident and proud of what they do. "I used to feel that family medicine is a second grade doctor, but now consider that I am an expert in my specialty." "... to know and understand the importance of family medicine. (I used to think) that family medicine was a mixture of specialties and didn't think family medicine was important." One used slightly overblown language in his attempt to express this transformation: "The course is good for the self-esteem of general practitioners, to elevate them from the lowest stratum of all medical disciplines to the lofty height of family physician, a specialty on an equal par with all other specialties."
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Discussion |
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The course has been successful, as shown by the continuing interest of these graduates and its recent recognition as a ‘quotable qualification’ by the Medical Council of Hong Kong, in 1999. Hong Kong experienced very high mobility among doctors in the years leading up to 1997, so the failure to find some doctors is probably due to their going overseas. We are confident that we obtained almost complete response from those still in Hong Kong. The interviewer was a research assistant, calling on behalf of the newly arrived professor, rather than the director of the course, to distance the evaluation from the previous teachers, and therefore give more independence in response. The evaluation proved successful, with a high response rate, and enthusiastic responses: many were willing to spend a long time discussing and critically assessing the course.
Participants in the course were volunteers: those most interested and willing to pay for intellectual development. At the time they did the course, they were mostly young doctors getting established in practice, or in the clinics of the Department of Health, who were looking for more intellectual background to their work. Most of them had very little hospital experience or other training, and therefore felt insecure about their skills and knowledge, and needed to develop. As the Diploma only gained formal recognition in 1999, none of these took it for the purpose of obtaining a quotable qualification. Many are now in senior positions of influence in the medical world in Hong Kong, and this may in part be due to the confidence they gained during the course.
The goal of developing researchers in the community has not succeeded, since front-line working GPs have insufficient time and energy nor funding for research. However, some academic teachers have developed, as have community practitioners who teach our students in their own clinics.
The course had high goals, which generated expectations that could not be fulfilled, since time was limited. The course left out or had to skim over many interesting issues. However, even when topics could not be examined in depth, their introduction led students to greater awareness of what they could do for themselves. The responses show the value especially of introducing ideas that were not previously taught in undergraduate courses, nor in conventional continuing medical education, which is largely focused on specific clinical topics that are treated by drugs, since these obtain sponsorship from pharmaceutical companies. The contradictory responses about the amounts of some material show that the designers may have balanced the programme effectively.
Postgraduate courses in family medicine have different targets and design. Some have direct clinical focus and supervision, such as those used for family medicine certification in some countries. Others are for faculty development.6–10 Such academic programmes focus on developing research and publication skills. Originally, our programme was like these, with strong influence from the Western Ontario model. 6,11 However, few of our graduates have used research skills subsequently, showing that such components will not be used unless greater opportunities and support are available. Even audits have not been used. Since few Hong Kong practitioners can enter an academic career in a city with only eight academic family medicine positions, and where practice research is not prized, it is more appropriate to provide the family medicine knowledge that they will use daily but have difficulty obtaining through other means. From 1998–1999 onwards, we had decided to concentrate on critical analysis, understanding evidence-based medicine and consultation skills. The evaluation has given us confidence that these were the right decisions. Those who are excited by ideas and wish to go further, especially into research, can undertake further studies either in Public Health or Epidemiology programmes recently developed within the Department, or distance-learning courses, for example from Monash University, which regularly runs tutorials in Hong Kong.
In Hong Kong, formal recognition of the course in the form of ‘quotability’ means that doctors may advertise the qualification on their signs and stationery. In addition, in the past 2 years, training for family medicine has become more institutionalized, so that the number of new graduates formally trained in family medicine will increase, thus increasing competition of well-trained doctors in primary care. Since then, we have experienced an influx of new applicants with expansion to 80 in 2000–2001. The new challenge for us is how to preserve the small group atmosphere, and the relationships between participants and with their teachers that were praised and found most valuable in the context of a much smaller course.
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Acknowledgments |
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We thank the doctors who responded to our questionnaire. We acknowledge the academic staff who established the course and directed it, especially in the early years: Professor SPB Donnan, Dr NF Chan, Dr D Chan and Professor D Watson, and those who have taught it over the years.
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References |
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