Patient perceptions of innovative longitudinal integrated clerkships based in regional, rural and remote primary care: a qualitative study

ABSTRACT: BACKGROUND: Medical students at the University of Wollongong experience continuity of patient care and clinical supervision during an innovative year-long integrated (community and hospital) clinical clerkship. In this model of clinical education, students are based in a general practice 'teaching microsystem' and participate in patient care as part of this community of practice (CoP). This study evaluates patients' perceptions of the clerkship initiative, and their perspectives on this approach to training 'much-needed' doctors in their community. METHODS: Semi-structured, face-to-face, interviews with patients provided data on the clerkship model in three contexts: regional, rural and remote health care settings in Australia. Two researchers independently thematically analysed transcribed data and organised emergent categories into themes. RESULTS: The twelve categories that emerged from the analysis of transcribed data were clustered into four themes: learning as doing; learning as shared experience; learning as belonging to a community; and learning as 'becoming'. Patients viewed the clerkship learning environment as patient- and student-centred, emphasising that the patient-student-doctor relationship triad was important in facilitating active participation by patients as well as students. Patients believed that students became central, rather than peripheral, members of the CoP during an extended placement, value-adding and improving access to patient care. CONCLUSIONS: Regional, rural and remote patients valued the long-term engagement of senior medical students in their health care team(s). A supportive CoP such as the general practice 'teaching microsystem' allowed student and patient to experience increasing participation and identity transformation over time. The extended student-patient-doctor relationship was seen as influential in this progression. Patients revealed unique insights into the longitudinal clerkship model, and believed they have an important contribution to make to medical education and new strategies addressing mal-distribution in the medical workforce.     

Student perceptions of a portfolio assessment process

Objectives  The objectives of this study were to identify and analyse students' attitudes to the portfolio assessment process over time.
Methods  A questionnaire containing statements and open questions was used to obtain feedback from students at the University of Dundee Medical School, Scotland. The responses to each statement were compared over 4 years (1999, 2000, 2002 and 2003).
Results  Response rates were 83% in 1999, 70% in 2000, 89% in 2002 and 88% in 2003. A major finding is that students perceived that portfolio building heightened their understanding of the exit learning outcomes and enabled reflection on their work. Student reactions to the portfolio process were initially negative, although they appreciated that senior staff took time to become familiar with their work through reviewing their portfolios. Student attitudes became more positive over the 4 years as the process evolved. Although portfolio assessment was recognised as supporting student learning, portfolio building was perceived to interfere with clinical learning as a result of the excessive amounts of paper evidence required.
Conclusions  Paperwork should be kept within manageable limits. A student induction process that highlights the importance of providing evidence for achieving all learning outcomes, not just theoretical knowledge and skills, may be helpful in allaying student concern over portfolio building and assessment and support preparation for lifelong learning and reflective clinical practice.     

Block versus longitudinal integrated clerkships: students’ views of rural clinical supervision

Context

Medical students undertaking longitudinal integrated clerkships (LIC s) train in multiple disciplines concurrently, compared with students in block rotations who typically address one medical discipline at a time. Current research suggests that LIC s afford students increased access to patients and continuity of clinical supervision. However, these factors are less of an issue in rural placements where there are fewer learners. The aim of this study was to compare rural LIC and rural block rotation students’ reported experiences of clinical supervision.

Methods

De‐identified data from the 2015 version of the Australian national rural clinical schools (RCS s) exit survey was used to compare students in LIC s with those in block rotations in relation to how they evaluate their clinical supervisors and how they rate their own clinical competence.

Results

Multivariate general linear modelling showed no association between placement type (LIC versus Block) and reported clinical supervision. The single independent predictor of positive perception of clinical supervisors was choosing an RCS as a first preference. There was also no association between placement type (LIC versus Block) and self‐rated clinical competence. Instead, the clinical supervision score and male gender predicted more positive self‐ratings of clinical competence.

Conclusions

The quality of clinical supervision in block placements and LIC programmes in rural Australian settings was reported by students as equivalent.

     

Perceptions of evaluation in longitudinal versus traditional clerkships

Medical Education 2011: 45 : 464–470 Objectives Methods for evaluating student performance in clerkships traditionally suffer shortcomings, partly as a result of clerkship structure. The purpose of this study was to compare preceptors’ and students’ perceptions of student evaluation in block clerkships and longitudinal integrated clerkships (LICs). Methods From 2007 to 2009, preceptors who taught on both block clerkships and an LIC were surveyed on their perceptions of clerkship evaluation. Year 3 students were surveyed on their perceptions of clerkship evaluation at the year end. Responses from preceptors who completed both block clerkship and LIC surveys were compared using paired‐samples t‐test; student responses were compared using independent‐samples t‐test. Results Overall, 66% (67/102) of block clerkship and 75% (77/102) of LIC preceptors responded; 44% of preceptors (45/102) completed both block and LIC surveys. In total, 62% (68/110) of block clerkship and 83% (19/23) of LIC students responded. Both preceptors and students favoured evaluation in the LIC on three factors (p ≤ 0.01): validity of evaluation process, quality of clinical skill evaluation, and willingness to provide constructive feedback. Conclusions Preceptors and students perceived evaluation in an LIC more favourably than evaluation on block clerkships. For educators working to improve student evaluation, further examination of the LIC structure and evaluation processes that seem to enhance both formative assessment and summative evaluation may be useful to improve the quality of evaluation and feedback.     

Student perceptions of a new integrated course in clinical methods for medical undergraduates

CONTEXT: In line with recent General Medical Council recommendations a new, 8-week integrated course in clinical methods has been introduced into the undergraduate curriculum at Leicester University. OBJECTIVES: To describe student perceptions of the course and to identify areas for improvement. DESIGN: A questionnaire survey. SETTINGS: These were 50 general practices, three teaching hospitals and the academic Department of General Practice and Primary Health Care. SUBJECTS: A total of 180 third- and fourth-year medical students. RESULTS: The questionnaires were completed by 93% of students. The latter expressed higher satisfaction with practice teaching compared with hospital teaching, on a 5-point scale, with regard to questions on 'teaching content' (4.0 vs. 2.7, P < 0.0001) and 'teaching process' (4.1 vs. 2.7 P < 0.0001), which was reinforced by free text comments. Of the respondents, 92% agreed that their teaching practice had satisfied the required teaching timetable and 87% of students found their departmental tutor enthusiastic and stimulating. CONCLUSION: It is possible to deliver an integrated course in clinical methods, teaching generic clinical skills, in a mix of hospital and practice settings. Nevertheless there were substantial differences in student perceptions of the relative quality and impact of teaching in the two settings. This may be related to the more detailed programme of preparation of practice teachers and the greater extent to which practice teachers were required, and able, to create protected time for the teaching task. These differences should be minimized if hospital teachers undergo similar preparation for the teaching task and have similar levels of protected teaching time.     

Changes in students' perceptions of clinical teaching as a result of general-practice clerkships

This study investigated whether a 3-week clerkship for third-year medical students in general-practice doctors' offices changed the students' perceptions of clinical teaching. The Preceptor Evaluation Questionnaire was administered to 138 junior medical students before and after their clerkships. The result of the study indicated that the clerkship had a positive effect on the students' perceptions. This finding was not related to their experiences in other clerkships nor to the grades they received for the clerkship.
The results indicate that the teaching relationship established between student and family doctor significantly affects students' perceptions of aspects of effective clinical teaching.     

Student perceptions of effective small group teaching

PURPOSE: The goal of this study was to assess student perceptions of effective small group teaching during preclinical training in a medical school that promotes an integrated, systems-based undergraduate curriculum. In particular, students were asked to comment on small group goals, effective tutor behaviours, pedagogical materials and methods of evaluation. METHODS: Six focus groups were held with 46 Year 1 and 2 medical students to assess their perceptions of effective small group teaching in the 'Basis of Medicine' component of the undergraduate curriculum. Ethnographic content analysis guided the interpretation of the focus group data. RESULTS: Students identified tutor characteristics, a non-threatening group atmosphere, clinical relevance and integration, and pedagogical materials that encourage independent thinking and problem solving as the most important characteristics of effective small groups. Tutor characteristics included personal attributes and the ability to promote group interaction and problem solving. Small group teaching goals providing included opportunities to ask questions, to work as a team, and to learn to problem solve. CONCLUSION: This study highlighted the benefits of soliciting student impressions of effective small group teaching. The students' emphasis on group atmosphere and facilitation skills underscored the value of the tutor as a 'guide' to student learning. Similarly, their comments on effective cases emphasised the importance of clinical relevance, critical thinking and the integration of basic and clinical sciences. This study also suggested future avenues for research, such as a comparison of student and teacher perceptions of small group teaching as well as an analysis of perceptions of effective small group learning across the educational continuum, including undergraduate, postgraduate and continuing professional education.     

Development of clinical reasoning from the basic sciences to the clerkships: a longitudinal assessment of medical students' needs and self-perception after a transitional learning unit

BACKGROUND: To facilitate students' transition from basic, science-oriented, problem-based learning (PBL) to clinical reasoning-oriented PBL, the University of Geneva School of Medicine introduced a 12-week unit of Introduction to Clinical Reasoning (ICR) at the beginning of its fourth or clerkship year. PURPOSE: The aims of the present study were to determine, after 12 weeks in the ICR unit, to what extent students had: (1) identified the learning content set by the faculty while adapting to the hypothetico-deductive reasoning approach; (2) familiarised themselves with the clinical reasoning-oriented learning process, and (3) transferred and further developed this process during the clinical years. METHOD: Students' derived objectives from the problems were compared to the objectives preset by the faculty to determine acquisition of intended learning content. To assess their adaptation to the clinical reasoning-oriented PBL approach, students (n = 124) were asked to list and freely comment on aspects of the unit they felt most at ease with or had difficulty with, and to complete a questionnaire on the clinical reasoning process (CRP). The same questionnaire was administered 6 and 12 months later to assess the evolution of the students' self-perception during clerkships. RESULTS: On average, student objectives matched 62% of faculty objectives. Half of the missed (38%) objectives were in basic sciences. Students generated 16% additional objectives, also predominantly in the basic sciences category (41%). Free comments indicated that the difficulties perceived by students were very similar to those previously reported in studies on reasoning and errors, such as difficulty in gathering, interpreting and weighting relevant data, synthesising information, and organising it hierarchically. These results were confirmed with the CRP questionnaire administered at the end of the unit. For most of the competencies assessed on the CRP questionnaire, a gradual improvement was seen to have occurred by 6 and 12 months after the unit. CONCLUSIONS: To ease students' transition from the preclinical to clinical years, a learning unit should give them the opportunity to train their clinical reasoning processes on standardised and prototypical problems, before encountering real patients with more ill-structured problems during clerkships. Such a transitional structure should particularly emphasise a developed repertoire of problem representations, recognition of key findings and a hierarchical classification of working hypotheses. It should foster the creation of links between the acquired basic clinical knowledge and the diagnostic, management and therapy steps of problem solving.     

Student perceptions of tutor skills in problem-based learning tutorials

OBJECTIVE: The problem-based learning (PBL) tutor plays a role that is different from the role of a teacher in a conventional teaching format. In the Faculty of Medicine and Health Sciences, United Arab Emirates, all students are Arab nationals and tutors are expatriates with different sociocultural backgrounds from the students. This study was designed to investigate how students evaluate tutors in PBL tutorials and whether student evaluations of tutors change with the progress of students in PBL tutorials. METHODS: Differences in tutor performance evaluation by male and female students were also analysed. The students evaluated 12 tutor skills in a scale of 1-3, 1 being 'below average' and 3, 'outstanding'. Student responses from a total of 314 (98.1%) completed forms collected over 2 academic years were analysed statistically. A total of 14 tutors participated in the PBL programme. RESULTS: The analysis revealed that tutors as a group were rated as having average to outstanding tutor skills in 10 items of the evaluation form. Students and faculty perceptions were different for the tutor skills of guiding students for information management. The students expected more support from tutors, whereas the tutors tried to emphasize self-learning in the PBL curriculum. Lower scores to the tutors in the 'problem' bringing sociocultural and religious issues for discussion showed that a gap in sociocultural/religious understanding between students and tutors might influence tutor skills. CONCLUSIONS: Differences in tutor evaluation by male and female students indicate necessity of adopting different strategies by tutors in a different sociocultural background. The results of the study have direct implications for faculty development.     

Maturational differences in undergraduate medical students' perceptions about feedback

Medical Education 2012: 46: 711–721 Context Although medical students receive varied feedback throughout their training programmes, research demonstrates that they frequently perceive it as insufficient. However, supervisors tend to perceive that it is adequate. Students’ responses to, and use of, feedback are not clearly understood. The purposes of this study were to investigate how medical students recognise, respond to and utilise feedback, and to determine whether there are maturational differences in understandings of the role of feedback across academic years in medical school. Methods This was a mixed‐methods study collecting qualitative (focus group and open‐ended questionnaire items) and quantitative (questionnaire) data across the 5 years of an undergraduate programme. Results A total of 68 students participated in 10 focus groups. The questionnaire response rate was 46% (564/1233). Data analysis investigated the students’ perceptions of feedback and explored patterns of responses across the continuum of undergraduate medical school stages. Maturational differences among the year cohorts within the programme emerged in three general areas: (i) student perceptions of the purpose of feedback; (ii) student recognition of feedback, and (iii) student perceptions regarding the credibility of feedback providers. Conclusions Junior students generally perceived the receiving of feedback as a passive activity and preferred positive feedback that confirmed their progress and provided reassurance. More senior students viewed feedback as informing their specific learning needs and personal development. They valued immediate informal verbal feedback and feedback from peers and others, as well as that from senior teachers. Exploring students’ progressive degrees of engagement with feedback and its relationship with self‐esteem are subjects for further study.