Medical Teacher, Vol. 24, No.

1, 2002

TWELVE TIPS

Twelve tips for community-based medical education

AMANDA HOWE
School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK

Teaching and learning in primary care and

community settings is now a very common aspect of most
medical trainings, and there is a growing expertise and evidence
base related to the contribution of primary care practice to the
reform of medical education. This article in the 12 tips series
touches on both practical and political aspects of communitybased medical education, addressing the context in which this
contribution has developed, its impacts to date, and some core
essentials of effective educational practice.

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SUMMARY

Introduction
Motivated by the need for medical schools to reflect the
requirements of future healthcare systems, and to ensure
that doctors in training acquire appropriate aptitudes
(Boelen, 1993), there has been a worldwide trend to
reform medical education. One consistent aspect has been
the emphasis on balancing the university and hospital with
more use of community and primary care as learning
settings. Much is expected of this trend: Habbick & Leeder
(1996) suggest that community oriented programmes can:
create more appropriate knowledge, skills and attitudes;
deepen understanding of the whole range of health,
illness, and the workings of the health and social services;
deepen understanding of the contribution of social and
environmental factors to the causation and prevention of
illness;
promote a more patient-oriented perspective;
make better use of the expertise and availability of staff
and patients who are in primary care settings;
enhance multidisciplinary working;
offer a broader range of learning opportunities;
increase recruitment into primary care and generalist
specialties.
A multiplicity of models have now been described in the
literature, ranging from family case studies (McCrorie
et al., 1993), to development of professional attitudes
through early clinical exposure in primary care (Hampshire,
1998), acquisition of clinical skills (Murray et al., 1997),
and even parallel community-based clinical programmes
(Worley et al., 2000). In practice, the outcomes will depend
on the specific use to which the community setting is put,
and on the quality of the learners experience. Nevertheless,
there are some overarching guiding principles of good practice in community-based learning, which this article aims to
summarize. The first three tips set an evaluative context:
the next six consider different aspects of the learners

experience: and the last three address factors pertaining to

the tutor and their peer setting.
Tip 1
Consider how you can best convey the values for which you
have chosen to become involved in learning in the community
The discipline of family medicine is characterized by the
following:
a whole-person orientation, including social and family
context;
a clinical method that utilizes relationship skills;
longitudinal care;
generalist and integrated practice of medicine.
Whatever the specific learning objectives of the placement,
the learning experience of students while in primary care
should be used wherever possible to develop their understanding of health and illness in a broad context, and their
relationships with the practice-based staff and patients
used to assist the students professional development, as
well as their knowledge and skill base.
Tip 2
Be aware that community-based staff are seen as alternative
role models
Role modelling in medicine predominantly works at an
affective level, with caring respectful teaching and abusive
episodes both remembered (albeit not necessarily perpetuated) in the long term (Matthews, 2000). There is evidence
that students value the different approach of communitybased staff to both teaching and clinical care (Howe,
2001). Enthusiasm for teaching, and genuine effort to
assist students, may be as valuable as specific teaching
skills, and the importance of modelling the behaviour one
wishes them to adopt is crucial. For students who are not
attracted to secondary care as a culture, the potential to
develop a vision of a community-based career during a
primary care placement is considerable (Howe & Ives,
2001). Similarly, staff may find that students uncertain
about their professional identity are initially antagonistic to
the unfamiliar primary care world-view, because

Correspondence: Professor Amanda Howe, MD MEd FRCGP, School of

Medicine, Health Policy & Practice, University of East Anglia, Norwich NR4
7TJ, UK. Tel: 01603 593885; email: [email protected]

ISSN 0142159X (print)/ISSN 1466187X online/02/01000904 2002 Taylor & Francis Ltd
DOI: 10.1080/00034980120103423

Amanda Howe

Tip 3

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Community-based learning is a culture shock: induct students

into it
Whether students enter community settings early in their
course or after a number of years in training, they may
find the combination of undifferentiated clinical problems,
the less hierarchical environment and the emotional nature
of the patients world-view a considerable personal challenge. This is particularly the case if they have been
located away from their peer group or usual lifestyle: for
example, if an individual is attached to a primary care
team on a residential rural placement. Prior sensitization
training afforded to many professional workers entering
new cultural settings is often neglected by central curriculum planners, so the need to brief (and debrief) students
early in the attachment may make a considerable difference to their attitudinal adaptation, and to their
understanding of the factors influencing community staff
behaviour. The first contact with a community can be a
marvellous learning experience if well handled, and especially if the peer group can compare and contrast their
experiences within the learning setting, thus bringing
unsystematised personal experience under critical control
by developing greater awareness of how it is used, and reexamining taken for granted assumptions (Eraut, 1994).
This does not imply a need to convert the students to your
own values, but to be open and reflective about their
developing understanding.
Tip 4
The curriculumknow why the learners are there
Many medical staff in primary care have not adjusted to
the changes in community-based teaching since they were
sent to a GP for a two-week sit in and see what we do
course of the opportunistic (and often counterproductive)
kind. Although learners differ, there is a clear educational
imperative to understand the nature of the curriculum,
and to arrange the learning opportunities accordingly. It is
essential that staff and students establish a common view
of their learning needs; that tutors appreciate any core
objectives for the community placements; that they know
something of where the placement fits within the broader
curriculum; and that the basic facts are also conveyed to
other staff who play a role in the learners experience.
While structured teaching may be challenging to
the vagaries of the clinical setting, it is known that
community-based teaching can both be valued for this
(Howe, 2000) and criticized if the placement opportunities
appears to depart from the placements goals (Roberts
et al., 2000).
Tip 5
Ensure some precious protected timeit is essential to teaching
and learning
Each course organizer should specify the extent to which
learners can work unsupervised (senior student clinic), in
conjunction with you (shared learning), or need 100%
commitment (group tutorial). In any placement, the
10

learner(s) will require some protected time with the lead

tutor, and this will require preparation by both parties,
especially if the course objectives are complex or require
technical equipment. Students will also need protected
time with appropriate and consent-given patients, and the
tutoring staff will themselves need protected time to
develop their skills, plan teaching sessions, and evaluate
their impact. With a small team in a community setting,
there will be little likelihood that staff can teach at short
notice, so forward planning and resource input are both
essential for genuine availability of protected time.
Community staff therefore need to be proactive in their
approach to the learning programme, in order to assure its
quality.
Tip 6
Support and guidancemake the most of the exceptional potential of community-based learning for pastoral care and personal
mentoring
The clinical method of primary care-based staff lends itself
to the use of relationships to extend learners potential.
They often see students in smaller cohorts, making the
learners needs and abilities more visible. Students value
personal feedback on their performance greatly, often
having unwarranted concerns about their own abilities.
Community staff should make the most of their considerable interpersonal skills to develop student insight into
their performance (both strengths and weaknesses), and
can also be valuable to central staff in picking up students
with problems.
Many community staff have responded to their new role
with a touching concern for the personal well-being of the
students (Howe et al., 2001). A tendency to advocate on
behalf of students may need to be moderated in discussion
with central faculty, who will have a broader view of both
the statutory regulations and the need to be equitable
across the peer group. Nevertheless, taking up issues on
behalf of individuals and the group may be immensely
valuable, and can bring about important quality
improvements.
Tip 7
Assessmenttake it seriously
There are many developments in medical education
designed to make assessment both an adequate reflection
of the eventual professional role, and reliable across
different settings and assessors. It is, of all the key elements
of a medical curriculum, the one that is particularly scrutinized by external bodies such as the General Medical
Council. One of the biggest challenges to face communitybased tutors and their academic colleagues is the role of
such a dispersed group in assessment, given the challenges
that this brings to reliability. Community-based staff,
unlike hospital or university staff, rarely get together, and
are often even more diverse as individuals than those operating in secondary care. The tip here is to ensure that you
understand what your role is in assessment. Faculty should
train you for this task as much as for the teaching, as the
consequences of an inaccurate or unjustifiable summative

Twelve tips for community-based medical education

assessment are considerable, and the role of formative

assessment an essential one for the students efficacy. It is
perfectly legitimate to ask for advice on this, and it is good
practice for novice assessors to be double marked until
the consistency of their assessments is established. So make
sure you do understand the assessment model and your
role within it, and use more experienced colleagues to
develop your expertise in this area. Although inclusivity
may favour asking all the team their opinion of the student,
this should not form part of the feedback to the medical
school unless both requested and systematized. It may
also be daunting for more junior students, and any feedback from staff needs to be given via the filter of an
experienced tutor.

Tip 10
Make the most of the multidisciplinary community team
Not only can education bring team members together, it
can also make their skills and roles more visible to each
other and to the students, whose view of the larger intersecting teams in hospital settings is often partial and
fragmented. The community setting provides great opportunity to see the whole patient care pathway across all
agencies (Lennox & Petersen, 1998), and for students to
experience teaching by staff who hold non-medical qualifications (Howe et al., 2000). Community-based staff should
be able in the longer term to extend the impact of the
multiprofessional team on medical students to supporting
courses for an interprofessional student body.

Tip 8
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Practical resourcesget your kit in

The central course organizer should inform communitybased staff very clearly as to what information technology,
texts, CD-ROMs, cameras and technical equipment are
needed, and should tell you about any learning resources
available to staff to assist learning. Community-based staff
need to be proactive about familiarizing themselves with
the material available to students that is relevant to the
placement, and to be demanding of resources that may be
needed to invest in the required infrastructure.
Many community practices will be too small to accommodate large numbers of students but it is rare that the
building of new additional premises can be justified, especially in settings that are owned by the doctors rather than
the health service or university. Successful teaching can
occur in other locations (e.g. a community hospital) if they
are easy and safe to access, familiar to patients, and similarly equipped.
Tip 9
Learning from experiencethe value of being involved in
education for the tutors own professional development
All key community staff who take responsibility for medical
education should be given appropriate staff training and
regular updates, with provision of guidance for other staff
who make an occasional contribution. If this is not available, the programme organizers should be reconsidering
their position! Staff training, new contact with ones peer
group, the constant stimulus of being involved with
students, and the role of reflection and evaluation in
developing ones own skills are all valuable opportunities
for continuing professional development, and can be
accredited towards revalidation. The quality uplift of practitioners skills by becoming involved in teaching is well
established (Murray et al., 1997), and the policy of using
active educational environments as an incentive to recruitment of staff is widespread in Europe and Australasia
(Worley et al., 2000). The cycle of satisfaction experienced by community-based tutors (Howe, 2000) is a
potential protection against burnout, because it reduces the
professional isolation inherent in community practice, and
can also unite teams in a new common task. Which relates
to the need to

Tip 11
Celebrate working at the margins and being leading edge
Community-based courses have been almost universally
acclaimed in peer-reviewed settings, and the number of
general practitioners active in medical education is disproportionately high compared with the amount of time in
medical courses that is devoted to community settings.
Primary care not only offers new clinical opportunities but
has also been a major player in achieving a modern curriculum for communication skills, medical humanities and
population health (to name but a few). To the author, the
current crisis in professional confidence is harsh for all
disciplines, but undermining the motivation of primary
care teams to teach would be an unjustifiable outcome
given the burgeoning evidence base of good practice by this
sector. Nevertheless, there continues to be a sense in which
community-based courses are marginal to the positivist
bioscience that dominates most medical schools, and the
pendulum of power may swing the other way. This may
sound overly political, but there is an international agenda
for medical schools about their
Tip 12
Social accountabilitycommunity-based learning is in the front
line
The moral imperative to move medical schools from ivory
tower to public reciprocity is one with which the majority
of primary care staff will have some sympathy. As patient
advocates, and with the daily experience of our patients
socioeconomic sufferings, family medicine has been key to
confronting the dehumanizing aspects of both medical
care and medical education. One of the key roles that
community-based learning can play is to show students
real life; for staff, this means supporting students in their
dawning awareness that doctors should be socially
accountable (and ensuring that this leads to a moral challenge rather than despair!). Staff often cannot articulate
why it is that they feel students should have more community exposurebut it may be that it is only when exposed
to the humour and courage of people in their everyday
interactions with health and illness that we can truly see
the limits and the great opportunities which becoming a
doctor affords to us.
11

Amanda Howe

In conclusion
Community-based medical education is not the solution to
all the ills of a clinical culture that does not integrate and
manifest the same values as many primary care staff.
Nevertheless it is an essential component of the modern
medical course, and by and large community staff have
been successful in delivering effective learning. These
twelve tips are a brief guide onlythe rest is a question of
learning from experience (Kolb, 1984).

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