We studied the influence of undergraduate primary care teaching components on students’ perception of primary care as a specialty at the medical faculties in Geneva and Lausanne. We found that primary care teaching overall had a positive impact on students’ image of primary care, but, in Lausanne, primary care curricular components were rated more positively than in Geneva. Curricular components that were not part of the primary care teaching, but were nevertheless cited by some students, were also frequently perceived as having a negative impact.
Our results highlight a clear difference between the two medical faculties. Students in Lausanne cited components that belonged more specifically to primary care and which appeared to have a more positive impact on students’ perception of the specialty. This difference was expected and can in part be explained by structural differences between the curricula in each site. In Lausanne, the primary care curriculum is clearly labelled “Generalism”, is more continuous, and there is a clear identification of the sessions taught by the lecturers who are part of the Institute of Family Medicine. In Geneva, the primary care curriculum is mostly taught in a seminar format, by a larger number of teachers affiliated with various structures, one from the Faculty of Medicine, and the other from the University Hospital. Longitudinal, well-structured primary care teaching programs are more susceptible to effectively increase the number of students choosing a primary care specialty . We hypothesize that, in Geneva, the involvement of two units—and a multitude of teachers from private and hospital practice—leads to a less clearly structured curriculum and more difficulties for Geneva students to identify primary care teaching components. On the contrary, in Lausanne the lecture format, with a limited number of lecturers identified as family doctors and from the same institute of family medicine, allows for clearer identification. The structural differences between the two sites can be explained by the fact that Lausanne’s entire primary care curriculum was launched in 2009 as part of an educational reform favouring primary care, whereas in Geneva the primary care components were gradually added to the curriculum from the early 1990s, without a true longitudinal and global perspective.
Interestingly, a fair number of students cited curricular components that are not part of the primary care curriculum and are not taught by primary care faculty. A majority of these components were rated as having a negative impact on the image of primary care. Several hypotheses may explain these findings:
Students may have taken the opportunity to express their general dissatisfaction with specific components (not specifically linked to their impact on the image of primary care).
Students may have falsely attributed certain components to primary care; this may be due to an imperfect understanding of the field of primary care.
Students may have misunderstood the question and spontaneously listed all curricular components they remembered having a negative impact on their image of primary care. For example, students cited surgery or hospital-based internal medicine clerkships as having a negative impact.
Several studies have highlighted the influence of a hidden and informal curriculum introducing a culture of misconceptions and downgrading of primary care among specialists [22–24]. Our results are consistent with these studies. They also show that a negative image of primary care can be transmitted through the formal curriculum, or at least perceived as formal by students.
Our results also show an imbalance in students’ perceptions of how different aspects of primary care are taught. Students seem to think that the psychosocial aspects of primary care and providing comprehensive care are adequately covered in class, while more technical aspects such as managing uncertainty and clinical reasoning in an outpatient context are not. Previous studies have shown that students see primary care as a specialization focused on human aspects . Giving the curriculum a more coherent structure—especially by implementing a longitudinal structure within the curriculum—may help improve the image of primary care . In the future it will be interesting to study the influence of introducing a stronger focus on more clinical aspects and clinical reasoning on students’ perception of primary care.
Strengths and weaknesses
Our study’s main limitation is the response rate, which was under 50 %. The respondents’ mean age and gender were representative of the student population in the two faculties. However, we cannot exclude a selection bias, especially in the Geneva group, where the proportion of students planning a primary care career was higher than observed in previous years. Alternatively, this higher proportion could in part reflect a true increase in this career choice in relation to recent social and political focus on primary care in our country. Yet we have no recent data to confirm this. The retrospective nature of our questions may have introduced a recall bias. Due to the open-ended questioning method, students may have more willingly cited the more recent curriculum components. Nevertheless, the fact that students listed all the main primary care curricular components given over the whole study program suggests that this bias had a weak influence. The seven student pilot testers were not removed from the sample and received the questionnaire. As their answers were anonymous, we do not know whether they participated.
A more complete view of students’ perspective on the entire curriculum could have been obtained by surveying sixth year students. Due to their final year clerkships, these students are difficult to reach, and we therefore decided to limit our sample to fifth year students. Thus we cannot draw conclusions on elements that students may have encountered during their final study year. Our data were collected before the launch of the primary care education reform currently under way in Switzerland [17, 26]. Our findings thus reflect students’ views on an evolving curriculum. Yet they form a useful base for future comparisons. Replication of our study in the future may contribute to measure, to some extent, the impact of changes made to the curriculum as part of this reform.
The main strength of our study is the focus on two closely situated medical schools in the French-speaking part of Switzerland, which limited variations due to cultural differences. This also allowed us to compare and interpret our findings in light of the differences between the two curricula. However, cultural and political differences between the two regions (the urban setting of Geneva and the more rural setting of Lausanne and its surroundings) may also play a role in explaining some of our findings. Asking participants which courses they thought were related to primary care in the open-ended questions helped avoid the measurement bias that would have been introduced if we had provided them with pre-defined course lists. This method encouraged students to list curricular components that had made a strong impression on them, and unexpectedly revealed other components that seem to have had a more negative impact on their image of primary care. Thus, we were able to study the impact of the entire primary care curriculum from the first to the fifth year and its “real-life” impact on the students. In the UK, in a post-graduate junior doctor population, an association was observed between socio-economic factors and general practice choice . It would be interesting to see whether these results can be replicated in an undergraduate population and in a country such as Switzerland.
The questionnaire-based format and electronic distribution method present the advantage of being easily reproducible over time and at other medical schools. It would be interesting to observe to what extent our findings can be reproduced at other medical schools in Switzerland and in other countries.