Student learning experiences in a longitudinal clerkship programme

Objective  To identify how medical student learning experiences in a new longitudinally integrated clinical clerkship (LICC) programme impacted students' learning.
Methods  We conducted semi-structured interviews with 12 medical students at three points in their training. We used an inductive, thematic analytic approach to data. Interviews ( n  = 35) were iteratively and independently coded by research team members to identify and corroborate key emergent themes.
Results  Students in the LICC programme reported slow but ongoing increases in patient responsibility, examination-driven learning, programme flexibility to address educational gaps, and a strong and positive perception of educational continuity through a longitudinal primary care educator and similar case mix throughout the year.
Conclusions  Student learning experiences in an LICC programme are both similar to and different from those in a traditional rotational clerkship programme. Students in the integrated clerkship were clear and unequivocal about the benefits of working with one teacher across time and caring for patients at different stages of the same disease in multiple settings. These findings have implications for clinical education development and design.     

Medical students’ professional identity development in an early nursing attachment

Medical Education 2010: 44 : 674–682 Objectives The importance of early clinical experience for medical training is well documented. However, to our knowledge there are no studies that assess the influence of very early nursing attachments on the professional development and identity construction of medical students. Working as an assistant nurse while training to be a doctor may offer valuable learning experiences, but may also present the student with difficulties with respect to identity and identification issues. The aim of the present study was to describe first‐year medical students’ perceptions of nurses, doctors and their own future roles as doctors before and after a nursing attachment. Methods A questionnaire containing open questions concerning students’ perceptions of nurses, doctors and their own future roles as doctors was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in hospitals and nursing homes. We carried out two confirmatory focus group interviews. We analysed the data using qualitative and quantitative content analyses. Results The questionnaire was completed by 316 students (response rate 91%). Before starting the attachment students regarded nurses as empathic, communicative and responsible. After the attachment students reported nurses had more competencies and responsibilities than they had expected. Students’ views of doctors were ambivalent. Before and after the attachment, doctors were seen as interested and reliable, but also as arrogant, detached and insensible. However, students maintained positive views of their own future roles as doctors. Students’ perceptions were influenced by age, gender and place of attachment. Conclusions An early nursing attachment engenders more respect for the nursing profession. The ambivalent view of doctors needs to be explored further in relation to students’ professional development. It would seem relevant to attune supervision to the age and gender differences revealed in this study.     

The effect of a psychiatric attachment on students' attitudes to and intention to pursue psychiatry as a career

OBJECTIVES: This study examined determinants of students' attitudes to psychiatry and intentions to pursue psychiatry as a career, considering: (1) experiences during the clinical attachment; (2) type of curriculum (traditional or problem-based), and (3) student characteristics (age and gender). The relationships between attitudes, career intentions and academic performance were examined. METHOD: Fourth year medical students (n = 379) completed questionnaires at the beginning and end of an 8-week psychiatry attachment to assess their attitudes to psychiatry, career intentions and experiences during the attachment. Students completed two assessments consisting of a multiple choice paper and a clinical viva. Consecutive cohorts of students receiving a traditional curriculum (n = 188) and a problem-based curriculum (n = 191) were compared. RESULTS: Students' attitudes to psychiatry improved and intentions to pursue psychiatry as a career increased during the attachment. These changes were predicted by specific experiences during the attachment, such as receiving encouragement from consultants, seeing patients respond well to treatment and having direct involvement in patient care. There was no difference in change in attitudes or career intentions between the two cohorts. Students with more favourable attitudes or career intentions at the outset did not report more favourable experiences during the attachment. Attitudes and career intentions were unrelated to performance in psychiatry assessments. Improvement in attitudes was related to an increased intention to pursue psychiatry as a career. CONCLUSIONS: Change in attitudes and career intentions was dependent on the actions of the clinical teachers. Undergraduate teachers may have an important influence on the numbers of doctors who choose this specialty as a career.     

Student perceptions of assessment and feedback in longitudinal integrated clerkships

Objectives This study was conducted to elucidate how the learning environment and the student–preceptor relationship influence student experiences of being assessed and receiving feedback on performance. Thus, we examined how long‐term clinical clerkship placements influence students’ experiences of and views about assessment and feedback. Methods We took a constructivist grounded approach, using authentic assessment and communities of practice as sensitising concepts. We recruited and interviewed 13 students studying in longitudinal integrated clerkships across two medical schools and six settings, using a semi‐structured interview framework. We used an iterative coding process to code the data and arrive at a coding framework and themes. Results Students valued the unstructured assessment and informal feedback that arose from clinical supervision, and the sense of progress derived from their increasing responsibility for patients and acceptance into the health care community. Three themes emerged from the data. Firstly, students characterised their assessment and feedback as integrated, developmental and longitudinal. They reported authenticity in the monitoring and feedback that arose from the day‐to‐day delivery of patient care with their preceptors. Secondly, students described supportive and caring relationships and a sense of safety. These enabled them to reflect on their strengths and weaknesses and to interpret critical feedback as supportive. Students developed similar relationships across the health care team. Thirdly, the long‐term placement provided for multiple indicators of progress for students. Patient outcomes were perceived as representing direct feedback about students’ development as doctors. Taking increasing responsibility for patients over time is an indicator to students of their increasing competence and contributes to the developing of a doctor identity. Conclusions Clerkship students studying for extended periods in one environment with one preceptor perceive assessment and feedback as authentic because they are embedded in daily patient care, useful because they are developmental and longitudinal, and constructive because they occur in the context of a supportive learning environment and relationship.     

Community hospitals and general practice: extended attachments for medical students

The first year experience of an innovative experiment in undergraduate medical education is described. The study investigated the educational effectiveness of prolonged clinical attachments for medical undergraduates in community hospital-based general practice. It has also assessed the ability of students to take some responsibility for their own learning in a clinically challenging environment. A retrospective evaluation of the experience obtained during the 3 month attachments for a self-selected group of fourth year Dundee medical school undergraduates was made. These undergraduates were placed in 10 mainly rural Scottish general practices with attached community hospitals providing a wide spectrum of inpatient and outpatient medical and surgical care. Students were assessed on the satisfactory completion of a portfolio of learning experiences and a practical clinical skills list. They were also required to submit a clinical project based on some aspect of their work during the attachment. The initial results showed a high degree of student and tutor satisfaction with the attachments. The assessment of all 10 of the students' educational achievements in their attachment were regarded as satisfactory and two were assessed as outstanding. Tutor assessment confirmed the validity of the initiative. Prolonged attachments in community hospital-based general practice for medical undergraduates have proved educationally valid and popular with both students and tutors. The development and dissemination of this model on a wider scale has resource issues which require to be addressed.     

Medical students' perceptions of their learning about the doctor-patient relationship: a qualitative study

Objective To describe and discuss Year 5 medical students' perceptions of their own learning about the doctor?patient relationship. Methods We carried out a qualitative study of semi‐structured interviews with 16 Year 5 medical students using 3‐way analysis at the School of Medicine, Federal University of São Paulo, São Paulo, Brazil. Results For experiences at the pre‐clinical stage, the subcategories were: positive aspects of the medical psychology course; great distance between theory and reality, and strong desire for clinical practice. For experiences at the clinical stage, the subcategories were: demand for opportunities to discuss the doctor?patient relationship; teachers as either role models or anti‐models; clinical situations favourable for developing empathic relationships, and clinical situations unfavourable for developing empathic relationships. For views about future experiences, the subcategories were: apprehension about ethical behaviour; anxiety about handling patients' psychosocial characteristics, and fear of professional ethics cases or legal action. Discussion To compensate for the lack of practical activities during the pre‐clinical stage, students search for extracurricular activities that often overload them. Because teachers function as professional role models, their attitudes towards patients have great importance. Students fear not being able to maintain their empathic capacity in the future because of work‐related issues. Knowledge of the psychological aspects of the doctor?patient relationship helps students to comprehend their experiences. Gradual contact between student and medical practice from the beginning of the course is advised. It should be followed by interdisciplinary discussions that deal with the technical aspects of cases and the doctor?patient relationship.     

A longitudinal integrated placement and medical students' intentions to practise rurally

Medical Education 2012: 46 : 179–191 Context Integrated longitudinal rural placements are designed to promote favourable student attitudes towards and facilitate return to rural practice upon graduation. We explored the impact of an integrated placement on medical students’ attitudes towards rural practice. Methods Data were available from interviews with 10 medical students, 15 clinical supervisors and teachers, three community health staff, and focus groups made up of medical students. Socio‐cognitive career theory gave insight into the personal, contextual and experiential factors, as well as the career barriers, that influence students’ rural practice intentions. Framework analysis was used to develop a thematic framework illustrating the key findings. Results The longitudinal placement enabled students to achieve personal goals, and enhanced self‐efficacy beliefs and orientation towards the complex personal and professional demands of rural practice. The informal curriculum, including multifaceted interactions with patients and their families, clinical teachers and other health care staff, was a vital experiential component. Students assimilated these rich experiences into their practice and evolving notions of professional identity as rural practitioners. Some students had little intention of practising rurally, partly as a result of contextual barriers such as geographic isolation, family and relationship needs, restricted postgraduate training opportunities and limited opportunities for specialist practice. Conclusions The richness of the informal curriculum in a longitudinal rural placement powerfully influenced students’ intentions to practise rurally. It provided an important context for learning and evolving notions of professionalism and rural professional identity. This richness could be reinforced by developing formal curricula using educational activities based around service‐led and interprofessional learning. To overcome the contextual barriers, the rural workforce development model needs to focus on socialising medical students into rural and remote medicine. More generic issues include student selection, further expansion of structured vocational training pathways that vertically integrate with longitudinal rural placements and the maintenance of rurally focused support throughout postgraduate training.     

RURAL ATTACHMENTS FOR STUDENTS IN THE HEALTH PROFESSIONS: ARE THEY WORTHWHILE?

ABSTRACT: In the period 1991–96, 156 undergraduates from 14 health disciplines at the University of Sydney completed rural attachments in rural and remote areas of Australia as part of the Rural Careers Project. On return from their attachment, students were encouraged to write a brief report of their experiences. Ninety-two available reports were analysed as one means of assessing the success of the attachments with respect to informing students about rural health issues and stimulating their interest in rural careers after graduation. A content analysis of the students' written comments about their perceptions and experiences was completed. Students were extremely positive about the value of the attachments and expressed more positive than negative comments regarding their perceptions of rural life and work. The results show that rural attachments are indeed worthwhile learning opportunities.     

A prospective randomized trial of an urban general practice attachment for medical students

A randomized controlled trial was undertaken to evaluate the effectiveness of a new model for providing urban general practice attachments for final-year medical students at the Flinders University of South Australia. All the student groups in that year were randomized prospectively to either the standard student attachment, as run by the university, or to an attachment organized by a project team from a local network of general practitioners. Students in the intervention group had their personal learning goals assessed and matched with their general practice preceptors, and the students were set a task that developed their contact with other health resources in the community. Results from an evaluation questionnaire completed by the students at the end of their terms showed that the students in the intervention group rated their general practice preceptors more highly, had more contact with allied health and community organizations, felt that they had met their own learning goals to a greater extent, and enjoyed their term more. Student examination results showed that the students in the intervention group did not perform as well in one of the four areas of their end of term examination as did the students in the standard attachment. The additional cost of providing the intervention was estimated to be A$340 per student. We conclude that long-term decisions about adopting this new model of organizing general practice attachments on a wider scale will need to balance the apparent benefits against the increased resources required.     

Phenomenological analysis of patient experiences of medical student teaching encounters

Medical Education 2012: 46 : 963–973 Context It is important to know how patients are affected by becoming opportunistically involved in medical student education. In previous studies, researchers rather than patients set the research agenda and expert patients or people well known to teachers were more often involved than ordinary people. Objectives This study aimed to explore how ordinary patients experience undergraduate medical teaching when they become involved in it opportunistically and to derive practical insights from the lived experiences of these patients. Methods The research was conducted in line with a conceptual orientation towards communities of practice theory and used phenomenology as a way of exploring patients’ lived experiences in depth. Minimally structured interviews were carried out with 10 patients following ordinary out‐patient or general practice appointments in which students were being taught. Template analysis was used to generate provisional themes and a process of phenomenological reduction was used to distil individual respondents’ lived experiences to their essence. Results The presence of students in ambulatory consultations was normal. Nine respondents described transactional relationships in which they remained outside the community of practice of which the doctor and student were members. Only an intimate problem would engage them deeply enough for a student’s presence to ‘bother’ them. One patient’s personal and professional background led her to regard doctors’ handling of consultation dynamics as factors contributing to whether teaching consultations were negative or positive experiences. When doctors’ sensitive and inclusive behaviour drew her into a triadic relationship with the student and doctor, she experienced mutual benefits with students. When it did not, she felt objectified and alienated. Conclusions Provided they receive the clinical care for which they are attending a consultation and are treated respectfully, patients may sometimes willingly become ‘objects’ from which students learn. They may, however, become more deeply engaged in teaching consultations in which they participate actively in a triadic relationship of mutual benefit with a doctor and student. Teaching consultations call for doctors to be sensitive and adaptable.     

Early clinical experience: do students learn what we expect?

Medical Education 2011: 45 : 731–740 Context Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged. Objectives This study describes students’ learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment. Methods A questionnaire containing open‐ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4‐week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses. Results Students’ learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self‐reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes. Conclusions Students’ learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under‐represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students’ professional development are neglected in the first year of medical education.     

The feminisation of Canadian medicine and its impact upon doctor productivity

Objective  We examined the differences in work patterns between female and male doctors in Canada to gain insight into the effect of an increased number of female doctors on overall doctor productivity.
Methods  Data on the practice profiles of female and male doctors across Canada were extracted from the 2007 National Physician Survey. A doctor productivity measure, 'work hours per week per population' (WHPWPP), was created, based on the number of weekly doctor hours spent providing direct patient care per 100 000 citizens. The predicted WHPWPP was calculated for a hypothetical time-point when the female and male doctor populations reach equilibrium. The differences in current and predicted WHPWPP were then analysed.
Results  Female medical students currently (2007) outnumber male medical students (at 57.8% of the medical student population). The percentage of practising doctors who are women is highest in the fields of paediatrics, obstetrics and gynaecology, psychiatry and family practice. Female doctors work an average of 47.5 hours per week (giving 30.0 hours of direct patient care), compared with 53.8 hours worked by male doctors (35.0 hours of direct patient care) ( P  < 0.01, χ² test). Female doctors tend to work less on call hours per week and see fewer patients while on-call. Female doctors are also more likely to take parental leave or a leave of absence ( P  < 0.01, χ² test). The difference in current and predicted WHPWPP was found to be 2.6%, equivalent to 1853 fewer full-time female doctors or 1588 fewer full-time male doctors.
Conclusions  Gender appears to have a significant influence on the practice patterns of doctors in Canada. If the gender-specific work patterns described in the present study persist, an overall decrease in doctor productivity is to be anticipated.     

Challenges to rural medical education: a student perspective

ABSTRACT: The key feature of the Greater Murray Clinical School model is the attachment of students to patients. Students follow their patients through the health care system, in contrast to the standard approach where students are attached to doctors or speciality based clinical units. The patient/student coupling occurs at the primary care level, which mostly but not exclusively will occur in the GP's office. Students anchor their knowledge by seeing the natural progression of common illnesses, the impact of behavioural aspects on health and disease, and by experiencing continuity of care. Along their path they develop good problem solving skills and learn to understand the health care system they will become part of. The main obstacle in teaching a medical undergraduate curriculum in a rural setting is that large geographical distances separate students, teachers and resources. Consequently, information technology will play an important role in terms of delivery of the GMCS curriculum. Moreover, there is potential for flow-on benefits to the community following integration of new information technology into the local health infrastructure.     

How do supervising doctors construe the medical student in clinical training?

Basing the prediction of student performance in medical school on intellective-cognitive abilities alone has proved to be more pertinent to academic achievement than to clinical practice. A major obstacle to the development of adequate measures has been the elusive nature of requirements for successful clinical performance. The present study aimed at defining the relevant variables through an analysis of the concept of the medical student held by supervising doctors. With the aid of a methodology derived from cognitive-social psychology, the components of how training doctors of a large medical school evaluate their students were first explicated in structured interviews. In a second phase of the research, 18 supervisors in five major clinical departments rated their student-supervisees on 15 obtained traits. Findings of trait correlations with an overall evaluation, as well as Guttman's 'Smallest Space Analysis' (1968), indicated a clear priority of cognitive-motivational traits in supervisors' judgements and reduced relevance of personal and interpersonal variables. Certain inconsistencies between avowed ideology of medical training and actual supervising practice could be detected.     

A model of clinical problem-based learning for clinical attachments in medicine

Context  Problem-based learning (PBL) has been widely adopted in medical curricula for early-years training, but its use during clinical attachments has not been extensively explored.
Objectives  This study aimed to develop and evaluate a new model, 'clinical problem-based learning' (CPBL), to promote learning skills, attitudes and knowledge during clinical attachments.
Methods  The CPBL model takes the principles of PBL and applies them to learning during clinical attachments. Real patient encounters are guided by a list of broadly defined case types to ensure curriculum coverage. By discussing history taking and examination in the context of differential diagnosis and problem listing, students generate learning objectives relating to clinical skills, disease mechanisms and clinical management. These are explored through self-directed learning before the second tutorial, in which the tutor takes the role of 'expert', demonstrating how learned material translates into clinical practice. We evaluated which components contributed most to the success of the model using semi-structured questionnaires, focus groups and a consensus (Delphi process) method.
Results  Students found CPBL a positive learning experience. Identification of suitable cases for discussion was readily achieved, although follow-up was sometimes difficult. The tutor's level of expertise and a non-threatening learning environment, conducive to student questioning, were highly rated contributors to successful CPBL. Comments reinforced the view that CPBL is a parallel teaching approach that helps structure the teaching week, but does not replace traditional bedside teaching.
Conclusions  Clinical problem-based learning was well received in clinical placements. Key elements were the learning interval, the involvement of expert tutors and a non-threatening learning environment.     

Creating pedagogical spaces for developing doctor professional identity

Objectives  Working with doctors to develop their identities as technically skilled as well as caring, compassionate and ethical practitioners is a challenge in medical education. One way of resolving this derives from a narrative reflective practice approach to working with residents. We examine the use of such an approach.
Methods  This paper draws on a 2006 study carried out with four family medicine residents into the potential of writing, sharing and inquiring into parallel charts in order to help develop doctor identity. Each resident wrote 10 parallel charts over 10 weeks. All residents met bi-weekly as a group with two researchers to narratively inquire into the stories told in their charts.
Results  One parallel chart and the ensuing group inquiry about the chart are described. In the narrative reflective practice process, one resident tells of working with a patient and, through writing, sharing and inquiry, integrates her practice and how she learned to be a doctor in one cultural setting into another cultural setting; another resident affirms her relational way of practising medicine, and a third resident begins to see the complexity of attending to patients' experiences.
Conclusions  The process shows the importance of creating pedagogical spaces to allow doctors to tell and retell, through narrative inquiry, their stories of their experiences. This pedagogical approach creates spaces for doctors to individually develop their own stories by which to live as doctors through narrative reflection on their interwoven personal, professional and cultural stories as they are shaped by, and enacted within, their professional contexts.     

Help,I’m losing patient‐centredness! Experiences of medical students and their teachers

Medical Education 2010: 44 : 662–673 Objectives Despite all educational efforts, the literature shows an ongoing decline in patient‐centredness during medical education. This study explores the experiences of medical students and their teachers and supervisors in relation to patient‐centredness in order to gain a better understanding of the factors that determine its development. Methods We conducted 11 focus groups on the subject of learning and teaching about patient‐centredness. We then carried out a constant comparative analysis of prior theory and the qualitative data collected in the focus groups using the ‘sensitising concepts’ provided by the Attitude–Social Influence–Self‐Efficacy (ASE) model. Results Although students express positive attitudes towards patient‐centredness and acquire patient‐centred skills during medical education, this study indicates that these are not sufficient to attain the level of competent behaviour needed in today’s challenging hospital environment. Clinical clerkships do provide students with ample opportunity to encounter patients and practise patient‐centred skills. However, when students lack self‐efficacy, when they face barriers (time pressure, tiredness) or when they are surrounded by non‐patient‐centred role models and are overwhelmed by powerful experiences, they lose their patient‐centred focus. The study suggests that communication skills training protects students from negative social influences. Moreover, personal development, including developing the ability to deal with emotions and personal suffering, self‐awareness and self‐care are important qualities of the central phenomenon of the ‘doctor‐as‐person’, which is identified as a missing concept in the ASE model. The student–supervisor relationship is found to be key to learning patient‐centredness and has several functions: it facilitates the direct transmission of patient‐centred skills, knowledge and attitudes; it provides social support of students’ patient‐centred behaviour; it provides support of the ‘student‐as‐person’; it mirrors patient‐centredness by being student‐centred, and, lastly, it addresses supervisor vulnerability. Finally, participants recommend that student‐centred education and guidance be offered, self‐awareness be fostered and more opportunities to encounter patients be created, including more time in general practice. Conclusions Supportive student–doctor relationships, student‐centred education and guidance that addresses the needs of the doctor‐as‐person are central to the development of patient‐centredness. Medical education requires patient‐centred, self‐caring and self‐aware role models.