Vol. 29, No. 4, pp. 377-381
Printed in Great Britain
Journal of Public Health Medicine
The clinical epidemiology ward round: can we
teach public health medicine at the bedside?
David H. Stone
Abstract
Background The clinical epidemiology ward round (CEWR)
is an educational tool for integrating the teaching of
epidemiology with clinical paediatrics. It aims to facilitate
the acquisition of the knowledge, skills and attitudes that
promote the effective application of epidemiological insights
into routine clinical practice. This paper describes experience
of the CEWR in a UK medical school and initial student
responses to it.
Methods Since 1995, the CEWR has formed an integral part
of the clinical teaching given to all final phase medical
students during their eight-week child health course at the
University of Glasgow. It took place in a general paediatric
ward of the Royal Hospital for Sick Children, Glasgow.
Groups of up to seven students were taught by a clinical
epidemiologist with a strong research interest, as well as
clinical experience, in child health. Each round lasted
approximately 90 minutes and the teaching style was
informal and interactive. At the end of the child health
course, students were asked a series of questions relating to
the CEWR's educational objectives.
Results The evaluation indicated that the CEWR had been
well received by students, 85 per cent of whom said it was an
excellent or good idea in principle, and 71 per cent of whom
said it worked well in practice. Most students seemed
unconvinced about its role in reinforcing epidemiological
knowledge or in clinical skill development.
Conclusion The CEWR requires further development but
offers a potentially inexpensive, effective and enjoyable
vehicle for integrating the teaching of two previously
separate components of the curriculum.
Keywords:
medicine
education,
epidemiology,
evidence-based
Introduction
This paper describes an integrated approach to the teaching of
epidemiology and clinical paediatrics to medical undergraduates in a Scottish medical school. Epidemiology is the study of
the distribution and determinants of health and disease in human
populations. Widely regarded as the 'basic science' of public
health, epidemiology is increasingly recognized as a key
element in both postgraduate and undergraduate education. Its
true significance is, however, often perceived by medical
students as marginal in comparison with general medicine,
surgery, obstetrics and gynaecology, paediatrics, and other
clinical specialties. In part, this reflects the separate career
structures and postgraduate training programmes pursued by the
public health physicians and clinicians who teach students.
More importantly, traditional undergraduate curricula include
epidemiology within public health courses or modules which in
turn tend to be taught separately from clinical subjects. The
damaging consequences of this compartmentalization have
been trenchantly criticized by the British General Medical
Council.1 At the University of Glasgow, an attempt has been
made in recent years to remedy this by having an introductory
session in child health, located at a children's hospital, as part of
the public health course for fourth (penultimate) year students.
Since October 1995, this philosophy has been extended further.
A population-based approach to child health has now been
incorporated into the clinical teaching of final year students in
the form of a clinical epidemiology ward round (CEWR).
The clinical epidemiology ward round
Aim and objectives
The aim and objectives of the CEWR are consistent with those
of the child health course as a whole.2 The general aim of
the CEWR is to facilitate the acquisition of the appropriate
knowledge, skills and attitudes that promote the effective
application of epidemiological insights to routine clinical
practice. Its specific objectives are:
(1) to reinforce and expand the students' knowledge and
understanding of the contrasting but complementary
approaches of public health and clinical practice, and of
the differing patterns of illness in the population and in the
ward;
(2) to enhance the students' clinical skills by enabling them
to apply explicit epidemiological principles and insights
to the process of diagnosis, management and follow-up
(including prevention of recurrent illness), with special
PEACH Unit, Department of Child Health, Yorkhill Hospital, Glasgow G3
8SJ.
David H. Stone, Director, Paediatric Epidemiology and Community Health
(PEACH) Unit
© Oxford University Press 1998
378
JOURNAL OF PUBLIC HEALTH MEDICINE
emphasis on the strengths and limitations of evidencebased medicine;
(3) to promote a positive attitude in the student towards the
need to incorporate an epidemiological and social perspective into clinical practice to optimize clinical effectiveness.
Content
The CEWR forms an integral part of the daily (and mandatory)
clinical teaching given to allfinalphase medical students during
their eight-week child health course. It takes place in a general
paediatric ward of the Royal Hospital for Sick Children,
Glasgow. Groups of up to seven students are taught by a clinical
epidemiologist with a strong research interest, as well as
clinical experience, in child health. The round lasts approximately 90 minutes and the teaching style is informal and
interactive. Students are encouraged to pose questions and offer
comments throughout the round.
Every round is different, but a typical pattern is as follows:
preliminary round table discussion (30 minutes); ward round
proper (45 minutes); a concluding session (15 minutes).
Preliminary discussion
The tutor starts the session in a tutorial room adjacent to a
general paediatric medical ward. After initial introductions, the
purpose of the CEWR is explained. The students are invited to
suggest ways in which epidemiology may be useful in clinical
diagnosis, management and follow-up. The ensuing discussion
covers the definition of epidemiology, the contrasting perspectives of epidemiology and clinical practice and the overlap
between the two. The interrelationship between individual and
population perspectives is emphasized using the analogy of
pointillisrn in painting.3
The tutor then focuses on specific clinical tasks, starting with
diagnosis. The way that both symptomatology and epidemiology are necessary to reach a diagnosis is discussed with
reference to a hypothetical example. A child aged 5 presents to
the accident and emergency department with symptoms of
fever, vomiting and intermittent abdominal pain. Students are
invited to make a tentative diagnosis at this stage; gastroenteritis is usually proposed. The teacher then adds a further
item of information: the child is of Greek Cypriot origin. Other
possibilities, such as thalassaemia or Familial Mediterranean
Fever, now have to be considered, based on the students'
knowledge of ethnic variation in disease risk. Other examples
relating to the epidemiological or clinical variables of
geography, age, gender, season of the year and social class
are discussed.
As well as contributing to the differential diagnosis, the
students are asked to consider how epidemiology might throw
light on aetiology. Asthma provides a good model: the
pathophysiological diagnosis may be elaborated with reference
to causal or exacerbating factors such as atopy, allergy, exercise
and infection. The aetiological significance of these factors has
been investigated by epidemiological studies using crosssectional, case-control and cohort designs. These data are
clinically helpful in making an aetiological diagnosis and in
deciding on appropriate management.
At this point, the tutor interrupts the discussion and takes the
students into the ward.
The ward round proper
Immediately upon entry to the ward, the students are urged to
comment on physical or environmental features that may be
epidemiologically important. Isolation cubicles are noticed and
discussed, as are the types of conditions the occupants are likely
to suffer (e.g. respiratory syncitial virus or meningitis in winter
and spring, gastro-enteritis in summer and autumn).
The tutor emphasizes that the ward is a small community in
itself rather than merely a repository for patients. It has a high
street, residential units, work stations and utilities. There is
constant traffic and a flow of people (patients, staff, visitors),
materials and equipment in and out of the ward. These features
result in the ward population being exposed to several public
health risks including nosocomial infection, accidental injury,
overcrowding, pollution and stress.
One or two patients (and, usually, a parent) are selected
(having sought their prior permission) for group bedside
teaching. Students are asked to elicit a brief history and to try
to elucidate aetiological factors that might be relevant both to
diagnosis and management. This provides an opportunity to
discuss clinical data quality issues such as the validity and bias
of patient responses to questions about, for example, cigarette
smoking. The epidemiological fallacy, whereby an association
between two variables at a population level is wrongly
atttibuted to causation in an individual patient, is noted as a
potential pitfall. The selection of appropriate therapies is
touched upon briefly and flagged for further discussion later.
Finally, follow-up strategies are covered, including the
responsibility of the doctor to seek to prevent recurrent illness
following discharge from hospital.
Before leaving the ward, the tutor draws the students'
attention to a poster describing children's rights and relates
this to the UN Convention on the Rights of the Child. The
implications of the Convention for clinical practice (especially
the obtaining of consent) are briefly mentioned.
The concluding session
The subject of evidence-based medicine is the theme of the
concluding session, which is held in the tutorial room. In
particular, students are invited to describe how they critically
appraise evidence of the therapeutic efficacy of medical
interventions. The techniques, strengths and limitations of
randomized controlled trials, systematic reviews and metaanalyses are discussed. The difference between efficacy
(research-based knowledge) and effectiveness (audit-based
knowledge) is emphasized. A single-page handout on the
hierarchy of evidence (see Table 1) is distributed.
CLINICAL EPIDEMIOLOGY WARD ROUND
Table 1 Evidence-based clinical practice; hierarchy of
evidence of efficacy
Level 1
Strong evidence from at least one systematic review or meta-analysis
of multiple well-designed randomized controlled trials
Level 2
Strong evidence from at least one properly designed randomized
controlled trial of appropriate size
Level 3
Evidence from well-designed trials without randomization, single
group pre-post, time series or matched case-control studies
Level 4
Evidence from well-designed non-experimental studies from more
than one centre or research group
Level 5
Opinions of respected authorities, based on clinical evidence,
descriptive studies or reports of expert committees
Source' Anglia and Oxford Regional Health Authority. Bandolier1995; 2:1
(modified from US Agency for Health Care Policy and Research 1992)
The key points arising from the CEWR are summarized. The
role of epidemiology in diagnosis, treatment and follow-up
(including prevention) is reviewed. Students are urged to apply
these epidemiological principles in all of their ensuing clinical
sessions, and to challenge the evidence base for questionable
clinical decisions that they observe throughout their careers.
As a parting thought, they are reminded that until relatively
recently leeches were widely believed by the leaders of the
medical profession to be valuable in the treatment of
innumerable diseases from infection to psychosis. All doctors
should ask themselves the question: what are the leeches of the
1990s?
Evaluation
A combination of formal and informal feedback from the
students, obtained at the end of their child health course, was
used to assess the impact of the CEWR in itsfirstyear, by which
time approximately 90 students had experienced it. The
informal comments were generally enthusiastic, although a
small minority of students expressed negative views (e.g. 'a
waste of time', 'already covered it in public health course', 'too
vague').
The results of the formal evaluation, based on a series of
questions broadly relating to the CEWR's educational objectives, are shown in Table 2. A large majority (85 per cent) felt it
was a 'good' or 'excellent' idea in principle, and 71 per cent
thought it worked 'quite well' or 'extremely well' in practice.
More than half (54 per cent) felt that it had 'raised their
awareness of the social and environmental content of paediatric
practice' (with 22 per cent unsure). About half (49 per cent)
responded that it had 'reinforced existing knowledge of
epidemiology and public health' (with another 20 per cent
unsure), and just under half (42 per cent) said that the CEWR
379
Table 2 Evaluation of clinical epidemiology ward round,
1995-1996
No.
%
What do you think of this idea in principle?
Excellent idea
Good idea
Poor idea
Extremely bad idea
Total
11
63
4
9
87
13
72
5
10
100
How do you think the idea worked in practice?
Extremely well
Quite well
Not well
Very badly
Total
3
56
19
5
83
4
67
23
6
100
Did the CEWR increase your knowledge of the pattern
and causes of childhood illness in the population?
Yes
Not sure
No
Total
29
23
31
83
35
28
37
100
Did the CEWR raise your awareness of the social and
environmental content of paediatric practice?
Yes
45
Not sure
18
20
No
Total
83
54
22
24
100
Did the CEWR improve your clinical skills'
Yes
Not sure
No
Total
5
18
61
84
6
21
73
100
41
17
25
83
49
20
30
100
35
22
26
83
42
27
31
100
Did the CEWR reinforce your existing knowledge of
epidemiology and public health?
Yes
Not sure
No
Total
Did the CEWR stimulate your thinking about
paediatrics in new directions?
Yes
Not sure
No
Total
had 'stimulated thinking about paediatrics in new directions'
(with 27 per cent unsure). The students' knowledge of 'the
pattern and causes of childhood illness in the population' was
perceived to have been improved in only 35 per cent (with 28
per cent unsure). Only a small minority (6 per cent), however,
thought it had 'improved clinical skills' (with 21 per cent
unsure).
A further 45 students were asked, immediately before and
immediately after the CEWR, to agree or disagree (on a fivepoint scale) with the statement: 'Epidemiology is essential to
high quality medical practice in the 1990s.' Before the round,
380
JOURNAL OF PUBLIC HEALTH MEDICINE
60 per cent agreed or strongly agreed with the statement, the
remainder being unsure; after the round, all agreed.
Discussion
Epidemiology is essential to the understanding of disease
aetiology (causation) and hence its avoidance by means of
specific preventive measures such as immunization and
population screening. This focus on prevention, a neglected
topic in most medical schools, is the main justification for the
inclusion of epidemiology in the undergraduate curriculum.
In addition, epidemiology has been thrust to the fore in
recent years with the advent of 'evidence-based medicine'
(EBM), that is, clinical decision-making based on knowledge
gained through systematic reviews of health services research,
much of which (such as randomized controlled trials) is
epidemiological in nature. Detailed strategies, including ward
rounds, for the practice and teaching of EBM have been
described by Sackett and his colleagues from McMaster
University, Canada.4 Their pioneering efforts have undoubtedly
exerted an increasing influence on medical education around
the world.
In the United Kingdom, EBM was forcefully advocated by
Archie Cochrane,5 a visionary epidemiologist whose ideas
are currently achieving practical realization through the
establishment of so-called Cochrane Centres and Cochrane
Collaborations throughout the world dedicated to the analysis,
documentation and dissemination of EBM, specialty by
specialty. In 1993, the Education Committee of the General
Medical Council (GMC), recognizing the growing significance
of epidemiology and public health, called for a major
realignment of the undergraduate medical curriculum to
ensure that students receive greater exposure to these subjects.
Its groundbreaking report' Tomorrow's doctors highlighted the
resurgence of public health: 'whereas the focus of medical
education during the present century has been mainly on the
understanding of disease processes in individuals and on their
diagnosis and management, there is an evident reawakening
of the wider interest of our forebears in the health of
populations, the epidemic and environmental hazards that
affect them and the means whereby diseases may be controlled
or prevented. Public health, temporarily lost from the
vocabulary, has been firmly reinstated as a priority in the
planning of medical services in this country and abroad, and the
undergraduate curriculum must reflect this important change of
emphasis.'
In its recommendations to British medical schools, the GMC
proposed a greatly increased role for public health in the
curriculum, but in a manner consistent with the underlying aim
of interdisciplinary integration in teaching: 'The theme of
public health medicine must figure prominently in the curricula
of the future. The study of diseases in the context of their impact
on populations as well as on individuals requires additional
dimensions of thought and the deployment of measurement
techniques with which the student should be familiar. The
assessment of population needs in relation to the provision of
services, the targeting of special areas of concern, the influence
of environment and social factors, the prevention of illness and
the promotion of health, will be relevant to many parts of the
curriculum and should not be seen by the student as comprising
the content of a compartmentalised course.'
The introduction of the CEWR to clinical teaching is an
appropriate response to the GMC's strictures. Our students
seem reasonably receptive to the idea of integrated teaching at
the bedside in principle and in practice, an experience shared by
others.6 Evaluation of the CEWR is continuing, and its format
and content will be continuously reviewed and refined in the
light of experience. Overall, the evaluation suggests that the
CEWR has been a successful innovation, although the students
seem unconvinced about its role in reinforcing existing
epidemiological knowledge or its potential impact on clinical
skill development. On the other hand, it is probably unrealistic
to expect a single session of 90 minutes out of a total course
lasting eight weeks to fulfil all its wide-ranging objectives.
What of the future? The CEWR has become a firmly
established part of the clinical teaching of child health to
medical undergraduates at the Glasgow medical school. It
epitomizes two central themes of the GMC recommendations
on medical education (integrated teaching and an emphasis on
public health) that are likely to preoccupy medical educationists
over the coming decades. Its continued success will, however,
be contingent upon the availability of suitably skilled and
highly motivated teachers.
In conclusion, experience in Glasgow to date suggests that
the CEWR offers a potentially inexpensive, effective and
enjoyable vehicle for synthesizing concepts and information
derived from two traditionally separate parts of the undergraduate medical curriculum. The CEWR could be regarded as
a model for similar educational experiments designed to
achieve progress towards the ultimate aim of achieving the
total integration of population and clinical perspectives
throughout medical training.
Acknowledgements
I am indebted to Professor Walter Holland, whofirstintroduced
me to the concept of teaching epidemiology at the bedside at St
Thomas' Hospital, London, in the 1970s. I am also grateful to
many members of the Department of Child Health of the
University of Glasgow for their contribution to the success of
the CEWR. Special thanks are due to: Dr J. Paton, coordinator
of the final year child health course, for his vision in granting
permission for the launching of this educational experiment; Dr
D. Tappin for assisting with the teaching of the CEWR;
Professors F. Cockburn and L. T. Weaver for their unstinting
enthusiasm and support; and the patients and staff of Ward 6B,
Royal Hospital for Sick Children, Yorkhill, Glasgow, for their
good-natured co-operation.
CLINICAL EPIDEMIOLOGY WARD ROUND
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Accepted on 7 April 1998