Teaching and Learning Forum 99 [ Contents ]

Conflict in teaching between Medical School Departments: Teaching of the sore throat

Catherine Brooker, Max Kamien and Alison Ward
Department of General Practice
The University of Western Australia

ObjectivesTo determine whether differences exist between different departments' undergraduate teaching sessions in the medical course on what is taught and learnt about the acute sore throat. To determine correlation between what is taught and the evidence based literature.
DesignLectures on the acute sore throat were attended and recorded. Fifteen students were randomly selected from each teaching group and interviewed regarding learning from the lecture. Lecturers were interviewed regarding the basis of their teaching. The literature was reviewed for the evidence for correct diagnosis and treatment.
SettingThe University of Western Australia undergraduate medical course.
Main outcome measuresComparisons between classes on what was taught and what was learnt regarding diagnosis and management of the sore throat. Qualitative assessment on student perceptions of conflict within the course.
ResultsConflict existed between departments in what was taught. Significant differences existed between students from lectures in different departments on diagnosis and management.
ConclusionMedical students are left with confusion in this area due to discrepancies in teaching.


Introduction

In the undergraduate medical course many subject areas are covered by several different disciplines. Students often complain that differing advice is given and they are left in confusion.

Acute sore throat is the 4th most common reason for consulting a GP. [1]. There is controversy both in the literature and between branches of medicine regarding the most appropriate methods of diagnosis and management. Medical students at the University of Western Australia are taught the management of the acute sore throat by departments of microbiology, general practice, ENT and paediatrics.

This study examines what is taught and what is learnt by students in these departments, highlighting contrasting area of teaching. It also examines whether what is taught correlates with the evidence based literature.

Subjects

15 students were randomly selected from each teaching group using random number tables. Sample size of 15 was chosen as some teaching groups were small and only 20 students were eligible. Students were contacted by telephone and a questionnaire performed. All students who were asked, agreed to participate, hence response rate was 100%. However in three of the groups only 14 of the intended 15 were actually able to be contacted prior to the next teaching session on the subject. Overall responses were received from 86 of the 90 intended subjects = 95.6%.

Fifteen "subsequent term" trainees from the West Australian branch of the Royal Australian College of General Practitioners Training Program were randomly selected and administered the same telephone questionnaire. This group were included to represent the learning of R.A.C.G.P. registrars and as an end point of the distillation from undergraduate and postgraduate learning. Inclusion criteria for these trainees were that they were graduates from the University of Western Australia in the last 10 years.

Method

1. Observation of teaching

Each teaching session on the sore throat was observed by the author and the content recorded on dictaphone for transcript. These were classes in 3rd year microbiology, 4th year general practice, 4th year ENT and 5th year clinical microbiology. (There is no formal class teaching on the sore throat in the paediatrics terms, however most students reported being taught on this area in bed-side teaching sessions. These were not able to be observed.)

Formats and teaching methods differed between departments. Table 1 below describes the classes.

Table 1: Format of teaching sessions on the sore throat.

ClassNo. studentsDescription of class
3rd Yr Micro30Case discussion to launch topic discussion.
4th Yr GP20Perusal of selected articles from the literature by students followed by discussion of clinical application.
4th Yr ENT120Lecture on tonsillitis in conventional didactic format.
5th Yr Micro30Case discussion to launch topic discussion.

2. Assessment of student learning

a) quantitative comparisons between groups.

Two to four weeks after each teaching session (or after the paediatric term ended) telephone questionnaires were performed to ascertain current levels of knowledge on the area. The interview ascertained student knowledge on causes, diagnosis and management of the sore throat. Three brief case scenarios were described and students' diagnosis, investigation and treatment plans recorded.

The course is structured so that within each year different students study different subjects at different times. This meant that the 4th year students could be selected so that they had experienced either only ENT teaching or only GP teaching at the time of the questionnaire. Similarly 5th year students had experienced only the teaching from paediatrics or only the teaching from clinical microbiology.

Results of the responses by the students in each of the 5 teaching groups and the postgraduate trainees were compared.

b) qualitative results regarding student views on teaching and learning

In addition to asking about their current knowledge on the subject, students were asked if there was any conflict with previous teaching in the medical course. Trainees were asked a similar question regarding conflict in teaching in this area during the medical course.

Results

1. Observation of teaching sessions

Differences in what was taught were found in areas of causation, diagnosis and management of the acute sore throat (table 2).

Table 2: Teaching of causes, investigation and management of the acute sore throat

ClassRanked causesInvestigation
mentioned
Recommended
management
3rd Yr Micro1. Group A Strep
2. Epstein Barr Virus (EBV)
Throat Swab [a]
Full blood picture[b]
EBV Serology [c]
Mycoplasma Serology [c]
Viral Culture [c]
Management not discussed
4th Yr GP1. "Other Viruses"
2. Streptococcus
3. EBV
Throat Swab [c]
EBV Serology [c]
INFREQUENT use of antibiotics recommended
4th Yr ENT1. Streptococcus
2. EBV
3. Acute Leukemia
4. Agranulocytosis
5. Other Viruses
6. Diphtheria
Throat Swab [d]
Full blood picture[e]
EBV Serology [c]
Penicillin for management of streptococcal sore throat (and relevant surgical management)
5th Yr Micro1. Group A Strep
2. Other Strep
3. EBV
4. Other Viruses
Throat Swab *
EBV Serology [c]
Strep Serology [c]
"Streptococcal pharyngitis must be treated with oral penicillin".
[a] Recommended in investigation of all cases.
[b] Stated to be "vital" for investigation.
[c] Recommended in selected cases.
[d] Use discouraged in initial investigation.
[e] Use encouraged in initial investigation.

All classes mentioned the group A beta haemolytic streptococcus (Group A Strep), which some lecturers differentiated from other streptococci that may be implicated in causation. Epstein Barr Virus (EBV) was mentioned as a cause in all lectures. Some classes emphasised rarer causes, with more than 26 different causative organisms mentioned in the 3rd year microbiology class and more than 15 in the 5th year microbiology class. "Other viruses" were mentioned in all teaching groups however it was only in general practice that emphasis was given to this as the commonest cause of an acute sore throat.

Differences were noted in the teaching of when it is appropriate to use particular investigations in cases of the acute sore throat. Advice ranged from the 3rd year microbiology lecturer who recommended a throat swab in ALL cases, to the ENT lecturer who recommended avoiding the throat swab but using a full blood count, to the GP lecture where teaching emphasised that throat swabs are rarely useful. While the 5th year microbiology lecturer recommended that ALL patients have throat swab cultures performed, he did concede that many GPs don't perform the culture.

Regarding management, advice also differed. In particular the ENT lecturer and 5th year microbiology lecturer emphasised the use of penicillin for all cases of suspected streptococcal pharyngitis, whereas the GP lecturer, having given students an article by Del Mar [2] for perusal, suggests that avoiding antibiotics is often reasonable even when streptococcus is the suspected cause.

2. Assessment of student learning

a. Quantitative comparisons between teaching groups

In the telephone interview students were asked for the 3 commonest causes of an acute sore throat, and what investigations, if any, are usually useful initially. Frequencies of responses were compared between students from the different teaching groups and the postgraduate trainees. Areas of difference in student knowledge were found in each of these areas (Table 3).

All groups emphasised streptococcus as a cause. Only half of the ENT group nominated viruses as a common cause, whereas the majority in all other groups did.

Regarding investigations, marked differences were noted between groups in the use of throat swabs and blood tests. Throat swabs were more likely to be nominated as being appropriate by students following the 3rd year and 5th year microbiology classes. Full Blood Count (FBC) was more likely to be nominated by students following the ENT lecture.

Table 3: Nominated 3 commonest causes of an acute
sore throat and initial useful investigations.


3rd Yr Micro (N=14)4th Yr GP (N=14)4th Yr ENT (N=14)5th Yr Paeds (N=15)5th Yr Micro (N=14)Postgrad (N=15)

Causes
Group A Strep 71.4%14.3%0%33.3%35.7%26.7%
Strep (Other) 35.7%85.7%85.7%66.7%57.1%60.0%
EBV 35.7%28.6%42.9%33.3%50.0%26.7%
Viral 78.6%100%50.0%86.7%100%93.3%
Bacterial (Unspecified) 7.1%57.1%14.3%6.7%0%26.7%
Trauma 0%0%14.3%0%0%0%
Haemophilus Influenza 35.7%0%7.1%20%0%40%
Staphylococcus 14.3%7.1%0%6.7%0%6.7%
Mycoplasma 0%0%0%0%0%6.7%

Investigations
Throat Swab 57.1%7.1%21.4%33.3%42.9%20.0%
FBC 7.1%0%71.4%26.7%21.4%13.3%
EBV Test 35.7%0%35.7%20.0%14.3%26.7%
Sputum Culture 28.6%0%7.1%13.3%0%0%
Other investigations 21.4%7.1%14.3%13.3%0%6.7%

Students were then read the following case scenario, designed to illustrate a typical case of a viral sore throat:

A 19 year old barman presents with a 24 hour history of sore throat and elevated temperature. He has rhinorrhoea and pharyngeal injection. His girlfriend had similar symptoms last week and antibiotics were prescribed and she recovered in 2 days.

What is the most likely diagnosis? How would you choose to investigate and/or treat this patient?

Responses to this question varied markedly between the groups (table 4). In particular the third year microbiology students and the ENT students were unlikely to consider a viral aetiology. Regarding investigations, third year microbiology students were much more likely to perform a throat swab and ENT students were much more likely to perform blood tests. Regarding treatment, all of the third year microbiology students would have given antibiotics as would 70% of the ENT students. This compares with the majority of other subjects who would not have given antibiotics.

Table 4: Diagnosis, investigation and treatment in "viral" case


3rd Yr Micro (N=14)4th Yr GP (N=14)4th Yr ENT (N=14)5th Yr Paeds (N=15)5th Yr Micro (N=14)Postgrad (N=15)

Diagnosis
Group A Strep 35.7%0%0%6.7%0%0%
Strep (Other) 50.0%7.1%42.9%6.7%28.6%6.7%
EBV 7.1%0%21.4%6.7%7.1%0%
Viral 0%57.1%14.3%73.3%57.1%93.3%
Bacterial 7.1%35.7%14.3%6.7%7.1%0%
Unknown 0%0%7.1%0%0%0%

Investigations
Throat Swab 78.6%0%21.4%13.3%14.3%6.7%
FBC 0%0%50%0%0%0%
EBV Test 7.1%0%28.6%26.7%21.4%6.7%
Other investigations 21.4%0%7.1%0%0%0%
No investigation 7.1%100%42.9%73.3%71.4%86.7%

Treatment
Penicillin 50.0%7.1%42.9%13.3%14.3%6.7%
Amoxicillin 7.1%7.1%7.1%0%14.3%0%
Other Antibiotic 42.9%28.6%21.4%6.7%7.1%0%
No Antibiotic 0%57.1%21.4%80.0%64.3%93.3%
Unknown 0%0%7.1%0%0%0%

3. Qualitative analysis of student's views on consistencies and discrepancies of teaching

Students were asked:
Was the teaching in this lecture on the sore throat knowledge you already had from previous lectures in other disciplines?
All of the 3rd year students replied "no".

About half of the fourth year students replied yes and most (86%) of the 5th years recognised some overlap. Of those that did identify overlap more than half identified a different emphasis with most noting the greater clinical emphasis as the course progressed. None of the students complained about the overlap, with most being appreciative of the revision, as evidenced by the comments from a fourth year GP student:

It was supposed to be knowledge I already had but I hadn't integrated it...
And from two of the 5th year micro students:
Yes it was old knowledge but this tied it in more and had a different emphasis.
and:
Yes it was knowledge I already had but I relearned a lot in this lecture and the clinical side is new.
Students were then asked:
Did the teaching in this lecture disagree with anything you've previously been taught? Please specify...
All the 3rd year students replied "no".

Similarly the 4th year ENT group identified no discrepancies with previous teaching. 7/14 (50%) 4th year GP students replied "no". In the 5th year paediatrics group 10/15 (66%) indicated no area of discrepancy. In the group of trainees 5/15 (33%) commented there was little discrepancy, or too little undergraduate teaching in this area to comment.

Several students commented that there was relatively little discrepancy in this area compared with very marked discrepancies in other subject areas taught in the medical school.

Regarding investigations, the commonest identified discrepancies related to whether or not to investigate: 10/26 (38%). A frustrated 4th year GP student commented:

In 3rd year micro we were taught that antibiotics must be used for ALL bacterial infections and that swabs are essential. Now in GP we are taught the opposite.
One student, following the 5th year microbiology tutorial commented:
some departments say to do throat swabs and some don't - it's really hard to know what to do.
Students and trainees noted discrepancies in teaching about the clinical diagnosis of the sore throat. After the GP teaching one student said:
the differential diagnosis part was different - I had the impression that bacterial infections had other clinical signs.
And one trainee commented:
newer information indicates that pus is not the only sign of bacterial infection.
Many subjects also identified a marked discrepancy between what students are taught and what they see being done. A 5th year student commented:
With respect to prescribing of antibiotics - [Univ dept of] GP SAY that even for streptococcus, antibiotics are of little benefit, but we SEE GPs and paediatricians prescribing - I guess they believe it'll change the course of the illness.
One trainee identified:
a significant difference between what you get taught at Uni and what GPs teach you : Uni - mostly viral - avoid antibiotics unless systemically unwell, GPs more free to use antibiotics.

Discussion

This study has identified specific instances of discrepancy in teaching between departments. It has also shown that what is learned by students reflects this discrepancy, but is of a lesser degree. Of interest is the finding regarding students' perception of discrepancy, with a minority identifying that there had been any conflict regarding what is taught.

The study has several limitations. The first is that the actual subject of lectures was slightly different, meaning that the content will inevitably be different. This particularly applies to the ENT lecture which was specifically on tonsillitis rather than pharyngitis.

Secondly, the telephone interviewer identified herself as a member of the staff of the department of General Practice, hence responses may have been biased in favour of teaching in that department.

Thirdly, it is recognised that in all subject areas a large part of medical school teaching is done in small groups or one-to-one in bedside teaching and out-patient sessions. None of these teaching sessions were observed or included in analysis. A gradual drift of opinion of students as they progressed through the course and reached post-graduate level can be seen in the results. In particular students became more aware of the probability of a viral diagnosis and less likely to perform test. The difference stands out in the different results from the two microbiology groups, despite very similar teaching content in the 3rd and 5th year lectures.

Conclusions

Teaching across the departments in the medical school is not consistent. This was evident from observing teaching on the acute sore throat, and from analysis of what students learnt from these sessions. In particular students are left with different ideas regarding cause - (some student groups unable to identify a typical viral case), diagnosis - (whether or not to swab throats, and blood tests), and management - (in particular the place of antibiotics).

Departments at UWA involved in teaching in this area do not currently communicate regarding who is teaching what and when and the content of teaching.

Teaching of the sore throat is probably only one of many areas of inconsistency between medical school departments.

References

  1. Bridges-Webb, C. (1993). Morbidity and treatment in General Practice in Australia. Australian Family Physician, 22(3, March), 336-339, 442-446.

  2. Del Mar, C. (1992). Managing sore throat: a literature review II. Do antibiotics confer benefit? Med J Aust, 156, 644-649.
Please cite as: Brooker, C., Kamien, M. and Ward, A. (1999). Conflict in teaching between Medical School Departments: Teaching of the sore throat. In K. Martin, N. Stanley and N. Davison (Eds), Teaching in the Disciplines/ Learning in Context, 49-55. Proceedings of the 8th Annual Teaching Learning Forum, The University of Western Australia, February 1999. Perth: UWA. http://lsn.curtin.edu.au/tlf/tlf1999/brooker.html


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