Problems with curriculum implementation in in-service clinical education.

We report a hitherto poorly documented cause of failure of curriculum implementation. The case of the clinical training of foreign medical graduates (externs) in Hong Kong is used to illustrate problems that may arise in professional education where in-service work in institutions is part of the educational process. The example is particularly relevant to health professional education which generally involves a significant in-service component. We used participant observation, questionnaires and brief interviews to obtain data from 97 externs and 48 supervisors. The results indicated that between a third and a half of the externs did not receive experiences as designated in the curriculum. Apart from age, individual characteristics of the externs did not show statistically significant relationships to the kind of experience obtained. The major significant variable (P less than 0.01) was the type of hospital where the exposure was gained. In one type of hospital the externs shared the work-load, whilst in the other type they were largely used as observers with minor technical duties. The supervisors' perception of the externs' professional capabilities varied according to the hospital. We believe that the failure of curriculum implementation was related to conflict between institutional needs, which must be safeguarded by the supervisors, and the educational needs of the learners. This conflict affects the perceptions of the supervisors and without their full cooperation the curriculum cannot be delivered. The roles and perceptions of supervisor and learner must overlap sufficiently for the system to be effective and this must be taken into account by curriculum planners.