Pre-medicine summer school for pupils from underprivileged backgrounds: action research study

Nick Dunn takes you through a study about trying to motivate school pupils to apply to medical school by sending them to summer school

This month's paper is Greenhalgh T, Russell J, Boynton P, Lefford F, Chopra N, Dunkley L. “We were treated like adults”-development of action research study from deprived socioeconomic backgrounds: a pre-medicine summer school for 16 year olds. BMJ 2006;332: 762-7.

Doctors are often accused of being middle class, paternalistic, and narrow minded. There may be an element of truth in this, in that most doctors do come from higher socioeconomic classes and are often from families with doctoring traditions. Strictly speaking, “paternalistic” is no longer true, as increasing numbers of doctors nowadays are women. In an attempt to move away from this stereotyping, and in response to government initiatives, several medical schools in the United Kingdom are now making efforts to draw in pupils from non-traditional backgrounds for medical courses. These are known as “widening access” programmes. They are meeting with mixed success and have perhaps got off to a slow start.

The study drew on the principles of action research. This is a dynamic process, in which the study is divided into different phases, and an analysis of data from the previous phase informs the development of the next phase. The data used are all qualitative, so that there are no statistics anywhere in the paper. Qualitative research, a technique developed in the social sciences, is of wide relevance to the healthcare world and seeks to identify the meanings people attach to their experiences of the world, and how people make sense of that world. It seeks to answer questions such as, “What is X, and how does X vary in certain circumstances, and why?” but is not concerned with quantifying X (the province of quantitative research and statistics). Typical applications of qualitative research in health care are the following.

Firstly, as a preliminary exploration, before using qualitative methods-that is, what exactly is “X”? For example, what is it that concerns patients most about recovery from surgery in hospital-control of pain and loss of dignity might seem obvious, but perhaps loss of contact with family is important, etc.

Secondly, to provide explanations for puzzling results from quantitative work-for example, why is control of diabetes apparently more difficult to achieve in certain ethnic groups? This may be due to cultural and dietary customs not revealed by numeric results.

Thirdly, “standalone” qualitative research can reveal valuable insights into the effects of structural and organisational changes in the health service. The viewpoint of patients, health professionals, and managers will all be important in this scenario.

This study, an example of the third category above, had five phases: school liaison, recruitment of pupils, design, delivery, and evaluation. These took place over a period of 16 months. The end product was the delivery of a one week summer school.

Pupils involved
The study was based on the medical school of University College London. Pupils were drawn from 16 year olds at inner city schools already classified as “partnership” schools to the medical school. There were strict criteria for identifying pupils who might benefit from the study programme. Such pupils needed to be recommended by a teacher at the school on the basis of motivation and ability, and students from the most deprived backgrounds were prioritised. This was based on the index of multiple deprivation score, derived from the pupil's address postcode, which categorises districts according to a number of indicators within several domains-such as type of housing or level of unemployment. Their parents should not have gone to university. In the end, 70 pupils were nominated, of whom 41 were offered places on the course, because they conformed most closely to the inclusion criteria. All 41 pupils accepted the offer of a place. These pupils were predominantly first or second generation immigrants to the UK, who came from 19 different countries of origin and spoke 16 ethnic languages. The hope is that if such pupils were to go on and become doctors, they might return to deliver effective healthcare to the exact communities which are most in need: poor, inner city areas with relatively high morbidity and mortality rates.

Planning the course
The course was designed on the basis of findings from interviews with the 41 pupils and also of liaison with parents of pupils as regards what they would like to see in the summer school. In order to meet the pupils' perceptions and expectations, the course was arranged based on small groups with a high ratio of staff to pupil and an emphasis on high technology type specialties as learning tools-for example, surgery and accident and emergency (although pupils were also informed about the less glamorous specialties, such as pathology and preventive care). An important feature was the use of existing medical students as “buddies” for each group of pupils. Considerable emphasis was put on making the small groups as friendly and interactive as possible, in order to promote self esteem and confidence and motivation among the pupils.

Delivering and evaluating the course
Most teaching was done in the small group format, taken by selected guest tutors, who were chosen for their friendliness and inspirational ability. Each student had the opportunity to observe a surgical operation during the course of the week. Medical student “buddies” evidently spent time during the week simply talking to the pupils about the experience of being a medical student. On the final day of the course a “grand round” was held, where each group of pupils made a presentation on a real patient in front of their peers (see original article).

The grand round entailed pupils trawling information from various parts of the hospital and collating it, to produce a coherent whole at the end of the week. This part of the course was apparently very popular. During the course of the week ethnographic observations (close observations of the daily function of the pupils in their groups) were made by qualitative researchers. All pupils were debriefed at the end of each day. At the end of the course, pupils and parents filled in evaluation forms and a semistructured survey of teachers and guest tutors were made. Staff and medical student assistants were interviewed in focus groups.

The course seems to have been very popular and produced good feedback from the pupils, staff, and medical students involved. Numerous very positive quotes are reproduced in the results section. Small group work with medical student “buddies,” and the “grand round” were identified as particularly successful. Most pupils seem to have gained in confidence and the majority found it “fun” and “motivating.” However, it should be noted that three pupils stated that they did not gain in confidence, and two withdrew from the course. Equally, there does not seem to be any quoted example of dissent in the course, and it is perhaps difficult to believe that everything went quite so well as portrayed. The evaluators identified four critical success factors: the fostering of respect, the input of medical student assistants, the value of working in small groups, and the vision and leadership of senior staff. However, at the end of the results section we are told that the evaluation also identified many suggestions (mostly operational and administrative) for improving the course. We are not told much about what these potential weaknesses in the course were, but one can surmise that this might have been due to the length of time necessary to prepare for the provision of such a course, the tying up of considerable numbers of staff, and the costs of laying on such a course. All of these factors have to compete against other interests, and some might not give such a project high priority in the absence of a guaranteed return (high quality input of medical students to the medical school). We are told the course was funded by three sponsors: will they be willing to carry on with such support in the future?

There can be little doubt from this paper that the one week summer school course was a success. It is impressive that children from underprivileged backgrounds in deprived inner city areas can show so much promise in an area that would be traditionally alien to them. Most of the pupils involved in the course seem to have gained much, although as the authors state, the long-term effects of this course are yet to be seen (will these pupils go on to become medical students and successful doctors?). These pupils were given very close attention, both in the planning stages and actually during the course itself; something that they might find less evident when, and if, they enter medical school proper, and have to learn to find their own way. Also, they were highly selected since the selection process weeded out those 16-year-olds with anything less than high motivation, as identified by teachers and their schools. Delivery of the course sounds to have been labour intensive, with a high staff:pupil ratio, teaching in small groups, and the use several specially chosen guest tutors. This may not be possible to reproduce in other medical schools.

This is an unusual piece of research, focused on the delivery of a novel educational course. The authors are to be congratulated for managing to write this up as an enjoyable and well written article. A large amount of work has been compressed into a relatively short piece of writing, and this has disadvantages. Some of the detail from the qualitative research has undoubtedly been missed out. This may be at the expense of producing a balanced picture of how the course went. Also, I would have liked to have seen more detail on how the medical students and teaching staff were selected, as this process must have played a big part in the success story. Nevertheless, one cannot help but be carried away by the enthusiasm of the authors, and hopefully this sort of course will appear elsewhere in the country, with equal success.

Competing interests: None declared.

studentBMJ 2006;14:265-308 July ISSN 0966-6494