To learn about general practice/family medicine

A primary care, general practice or family medicine rotation is the most common clinical CBME attachment and appears in most contemporary medical curricula. It occurs either in a short, discrete block of time or in a continuity rotation of perhaps a full or half day per week for a semester, a year or more. There are advantages and disadvantages with both models (Table 13.1).

Whichever structure is chosen, it is essential to have a well-planned orientation to the rotation, the practice and the community. This may also involve intensive instruction in relevant clinical skills and in the structure of healthcare delivery in the local community, especially if this is the first such exposure for students. Many additional useful tasks may be linked to these rotations, such as doing home visits, developing an ecomap of local resources or health facilities available to patients, meeting with community-based organizations or support groups, and visits to other health workers in the area. An opportunity to debrief and reflect on their experiences is also helpful to consolidate students’ learning and conduct course evaluation. These suggestions are relevant to both undergraduate and postgraduate learning.

To learn about a particular specialty other than general practice/family medicine

There are a number of good examples of this type of CBME. At University College London, students spend 4 weeks in a tertiary hospital and 4 weeks based in a general practice with the specific aim of learning about internal medicine (Murray et al 1997). Evaluation of this model indicates that the student learning at both sites was complementary and students valued the CBME component highly. At the University of Pretoria in South Africa, students spend part of a 7-week community-based rotation specifically developing obstetric skills. In addition to such undergraduate models, postgraduate training programmes in disciplines traditionally taught in hospitals, for example, paediatrics, psychiatry and internal medicine, are creating CBME learning experiences as they seek to prepare their residents appropriately for current and future practice.

To learn about primary care

In this model, the tertiary hospital is still the primary learning area, but community sites are used to fill in the gaps in the curriculum, because of a mismatch between curriculum goals and what is achievable in the hospital context. Important areas covered may be in relation to learning about primary healthcare, community-based practice, team-based care and working with communities. The primary care context can be used to integrate learning from a range of disciplines, for integrating clinical practice and public health and for interprofessional and multidisciplinary learning.

The Integrated Primary Care (IPC) block at the University of the Witwatersrand, Johannesburg is an example of this. Students complete a 6-week rotation in primary care clinics and community hospitals, applying the knowledge and skills acquired from the major specialties (from internal medicine to public health) to undifferentiated patients, their families and communities, in an integrated programme that is jointly managed and examined by representatives from the major disciplines, and are orientated to the importance of primary healthcare (Nyangairi et al 2010).

To learn multiple disciplines concurrently

In this case, the whole curriculum is based on community practice, whether this be for 1 year or for the entire period of training. This might be the orientation of a whole medical school, such as Walter Sisulu University in South Africa, University of Wollongong in Australia, Ateneo de Zamboanga University in the Philippines, and the Northern Ontario School of Medicine in Canada, or an option for a subgroup of students, such as the Flinders Parallel Rural Community Curriculum (PRCC) at Flinders University in Australia.

This concept takes advantage of the broad patient base in primary care and, with some exceptions, has mostly been situated in rural communities. There are two principal reasons for this that relate to educational opportunities and health policy agendas.

Rural practice, in most countries, has a broader range of patients, involves fewer referrals, and the clinicians are more likely to have significant roles in primary care, emergency medicine, obstetrics and inpatient care. Thus, it is relatively simple for the rural preceptor to give students access to continuity of care through initial diagnosis, investigation, initial management (including as an inpatient) and ongoing care of a range of patients.

Extended rotations of this type have also been shown to be associated with a high number of students choosing a career in rural practice (Worley et al 2008) and thus have been supported financially by government authorities as a significant long-term strategy with regard to the rural medical workforce. Evaluation of this programme has shown that students in the Flinders PRCC perform better in examinations than their hospital-based peers (Worley et al 2004) and develop the skills and personal qualities required to practise in areas of need (Couper & Worley 2010). Based on the Flinders experience, the contrasts between this extended form of CBME and multiple tertiary hospital rotations, combining inpatient and ambulatory outpatient experience, are summarized in Table 13.2.

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