Friday, October 24, 2008

The SPICES Model: C. Community-Based Education vs. Hospital-Based Education

Furthering our examination of Harden’s SPICES model (1), the C models 2 different methods of clinical training, one based more on working within community-based systems and the other surrounding hospital-based systems. A corollary to this question inside chiropractic education would be a chiropractic college clinic education for interns vs. a preceptor-based education which places the student intern into a chiropractic office located in an external community-based setting. As Harden notes, one of the criticisms of medical education is that it’s hospital-based approach has “fostered an ‘ivory tower’ approach to medicine in which students during their training have little contact, if any, with the community which they are being trained to serve.” While this is certainly less an acute problem in chiropractic education, there remains a kernel of truth here.

In the normal course of medical training, many colleges center their teaching on their main teaching hospital. The staff of those hospitals are the teachers for medical students. And students then attend lectures, tutorials and see patients who were admitted as in-patients to the hospital. They do not see patients in the manner they would were they a general practitioner seeing them in a community office or even in the patient’s own home. One criticism of this approach is that it focuses excessively on specialists and specialization, and students only see therefore a narrow view of patients with medical needs.

On the other hand, those working in community settings see patients that truly represent the community. In medicine, this might be through a community clinic, a family planning center, a patient’s home or in a rural clinic- which is one area where chiropractic experience mimics that of medicine. Students learn a great deal more about the social and economic aspects of illness and patient care, and they learn a great deal more about community values. Health promotion, an area where chiropractic excels, is enhanced in such settings.

Factors that support community-based approaches include: (1) Providing community orientation. This works far better to rain doctors in the delivery of primary care. And doctors will be better understand their role in their community. (2) The community provides useful learning experiences. Continuity of care can be better demonstrated and taught in a community setting. (3) It makes use of untapped resources. It increases the pool of physicians serving the public outside the teaching hospital setting. (4) It encourages active learning. This is more motivating to students. (5) It avoids “student-wise” patients, who know the system and manipulate it. (6) It is a perfect introduction to what “real life” as a physician- in this case, a chiropractic physician- is all about.

Factors that support a hospital or clinic-based system include: (1) There are organizational problems with community-based systems. For example, we need to vet preceptors to make sure students will be properly trained. (2) Chiropractic college clinicians have a wealth of expertise and are trained teachers. (3) Which also means that students gain wide exposure to care management. (4) Some students may wish to enter specialty training as a result of the exposure they receive in the clinical or hospital setting.

One final comment would be to find ways to combine elements of both in clinical training. This remains very much a work in progress.

I will be gone, as many of us are, from October 25 to November 3, so the next post will occur shortly after my return. Please have a great break!


1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297

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