Medical Student Clinical Education. In: Norman GR, van der Vleuten CPM, Newble DI, Dolmans DHJM, Mann KV, Rothman A, Curry L, editors. International Handbook of Research in Medical Education. Dordrecht: Springer Netherlands; 2002. pp. 365-80. [DOI: 10.1007/978-94-010-0462-6_15]

Student-centred GP ambassadors: Perceptions of experienced clinical tutors in general practice undergraduate training

OBJECTIVE

To explore experienced general practitioner (GP) tutor perceptions of a skilled GP tutor of medical students.

DESIGN

Interview study based on focus groups.

SETTING

Twenty GPs experienced in tutoring medical students at primary health care centres in two Swedish regions were interviewed.

METHOD

Four focus-group interviews were analysed using qualitative content analysis.

SUBJECTS

Twenty GP tutors, median age 50, specifically selected according to age, gender, and location participated in two focus groups in Gothenburg and Malmö, respectively.

MAIN OUTCOME MEASURES

Meaning units in the texts were extracted, coded and condensed into categories and themes.

RESULTS

Three main themes emerged: "Professional as GP and ambassador to general practice", "Committed and student-centred educator", and "Coordinator of the learning environment".

CONCLUSION

Experienced GP tutors describe their skills as a clinical tutor as complex and diversified. A strong professional identity within general practice is vital and GP tutors describe themselves as ambassadors to general practice, essential to the process of recruiting a new generation of general practitioners. Leaders of clinical education and health care planners must understand the complexity in a clinical tutor's assignment and provide adequate support, time, and resources in order to facilitate a sustainable tutorship and a good learning environment, which could also improve the necessary recruitment of future GPs.

"I couldn't do this with opposition from my colleagues": a qualitative study of physicians' experiences as clinical tutors

BACKGROUND

Clinical contact in the early curriculum and workplace learning with active tutorship are important parts of modern medical education. In a previously published study, we found that medical students' tutors experienced a heavier workload, less reasonable demands and less encouragement, than students. The aim of this interview study was to further illuminate physicians' experiences as clinical tutors.

METHODS

Twelve tutors in the Early Professional Contact course were interviewed. In the explorative interviews, they were asked to reflect upon their experiences of working as tutors in this course. Systematic text condensation was used as the analysis method.

RESULTS

In the analysis, five main themes of physicians' experiences as clinical tutors in the medical education emerged: (a) Pleasure and stimulation. Informants appreciated tutorship and meeting both students and fellow tutors, (b) Disappointment and stagnation. Occasionally, tutors were frustrated and expressed negative feelings, (c) Demands and duty. Informants articulated an ambition to give students their best; a desire to provide better medical education but also a duty to meet demands of the course management, (d) Impact of workplace relations. Tutoring was made easier when the clinic's management provided active support and colleagues accepted students at the clinic, and (e) Multitasking difficulties. Combining several duties with those of a tutorship was often reported as difficult.

CONCLUSIONS

It is important that tutors' tasks are given adequate time, support and preparation. Accordingly, it appears highly important to avoid multitasking and too heavy a workload among tutors in order to facilitate tutoring. A crucial factor is acceptance and active organizational support from the clinic's management. This implies that tutoring by workplace learning in medical education should play an integrated and accepted role in the healthcare system.

Pedagogical strategies used in clinical medical education: an observational study

BACKGROUND

Clinical teaching is a complex learning situation influenced by the learning content, the setting and the participants' actions and interactions. Few empirical studies have been conducted in order to explore how clinical supervision is carried out in authentic situations. In this study we explore how clinical teaching is carried out in a clinical environment with medical students.

METHODS

Following an ethnographic approach looking for meaning patterns, similarities and differences in how clinical teachers manage clinical teaching; non-participant observations and informal interviews were conducted during a four month period 2004-2005. The setting was at a teaching hospital in Sweden. The participants were clinical teachers and their 4th year medical students taking a course in surgery. The observations were guided by the aim of the study. Observational notes and notes from informal interviews were transcribed after each observation and all data material was analysed qualitatively.

RESULTS

Seven pedagogical strategies were found to be applied, namely: 1) Questions and answers, 2) Lecturing, 3) Piloting, 4) Prompting, 5) Supplementing, 6) Demonstrating, and 7) Intervening.

CONCLUSIONS

This study contributes to previous research in describing a repertoire of pedagogical strategies used in clinical education. The findings showed that three superordinate qualitatively different ways of teaching could be identified that fit Ramsden's model. Each of these pedagogical strategies encompass different focus in teaching; either a focus on the teacher's knowledge and behaviour or the student's behaviour and understanding. We suggest that an increased awareness of the strategies in use will increase clinical teachers' teaching skills and the consequences they will have on the students' ability to learn. The pedagogical strategies need to be considered and scrutinized in further research in order to verify their impact on students' learning.

'They've all got to learn'. Medical students' learning from patients in ambulatory (outpatient and general practice) consultations

BACKGROUND

The dynamics of effective teaching consultations need to be better understood.

AIM

Find from medical students, patients and doctors how to optimize learning in ambulatory consultations.

METHODS

Patients and students independently gave semi-structured exit interviews after 25 ambulatory teaching consultations during a clinical attachment set up experimentally to strengthen students' ambulatory learning. The results of an abbreviated grounded theory analysis were checked in three focus group discussions with teachers and students.

RESULTS

Patients and students identified strongly with one another and benefited from teaching consultations in parallel ways yet defaulted to passive roles. Patients deferred to professional expertise whilst students were uncertain what was expected of them, feared harming patients and feared being showed up as ignorant. The educational value of consultations was determined by doctors' ability to promote student-patient interaction.

CONCLUSIONS

In the most effective teaching consultations, doctors promoted a level of participation that realized patients' and students' mutual sense of responsibility by orientating them to one another, creating conditions for them to interact, promoting and regulating discourse, helping students to perform practical tasks and debriefing them afterwards. Those broad conclusions translate into 18 practical recommendations for supervising a medical student in an outpatient clinic or surgery.

The power of one: looking beyond the teacher in clinical instruction

BACKGROUND

Research on clinical teaching in medicine tends to focus on preceptors and senior attending physicians as the primary source of learning for medical students. As a result, there is an artificial separation of 'teacher' from context in much of the research on clinical teaching in medicine.

AIMS

The central aim of this study was to challenge the taken-for-granted assumption that student learning can be attributed primarily to a preceptor or attending physician on a rotation.

METHODOLOGY

Twenty-two medical students and forty-one clinical faculty members generated explanations for a study that showed a positive effect on NMBE results for 3rd year clerkship students who had at least one highly effective clinical teacher during their clinical rotation in medicine.

RESULTS

Student and faculty explanations resulted in fourteen factors and six propositions describing the nature of highly effective clinical teaching. Students believed contextual factors influenced their own learning, but did not comment on that possibility in the study (Griffith CH, Georgesen JC, Wilson JF. 2000. Six-year documentation of the association between excellent clinical teaching and improved student examination performance. Acad Med 75(10): October Supplement). Most clinical faculty did question the assumption that one teacher could have that effect.

CONCLUSIONS

We recommend refocusing research on clinical instruction toward engagement within a community of professionals, rather than attributing 'power' to a single clinical teacher.

Instructiveness of feedback during clerkships: influence of supervisor, observation and student initiative

BACKGROUND

Several authors assume that the supervisor's role, observation of behaviour and students' active participation are important factors in the instructiveness of feedback.

AIM

This study aims to provide empirical evidence for these expectations.

METHODS

For two weeks, 142 clerks from eight hospitals recorded for each individual feedback event: who provided the feedback, whether the feedback was based on observation of behaviour, who initiated the feedback moment and the perceived instructiveness of the feedback. Data were analysed with multilevel techniques.

RESULTS

The perceived instructiveness of feedback provided by specialists and residents did not differ significantly. However, both were perceived to be more instructive than feedback from nursing and paramedical staff (beta(specialists) = 0.862, p < 0.01; beta(residents) = 0.853, p < 0.01). Feedback on behaviour that had been directly observed was reported to be more instructive than feedback on behaviour that had not been observed (beta(observed) = 0.314, p < 0.001). Feedback which stemmed from student initiative or a joint initiative was experienced to be more instructive than feedback which ensued from the supervisor's initiative (beta(student) = 0.441, p < 0.01; beta(joint) = 0.392, p < 0.01).

CONCLUSIONS

The expectations concerning the influence of observation and student initiative on the instructiveness of feedback were confirmed in this empirical study. Expected differences in instructiveness between feedback from specialists and residents were not confirmed.

Factors determining students' global satisfaction with clerkships: an analysis of a two year students' ratings database

Clerkships would benefit from teachers' improved understanding of the didactic aspects of their task. The purpose of this study is to identify factors that determine the teaching quality of clerkships and to examine the predictive value of these factors for students' global satisfaction. Thus, results would be further reflected to clinical teachers' tasks. These factors could then be taken into account in future clinical teaching. In this paper, a medical faculty's 2 year data set of student feedback from a systematic programme evaluation project was used. A factor analysis was performed on 11,780 student questionnaires. Factor loads, and the Cronbach's alpha coefficients of the questionnaire and factors were calculated. In order to examine the contributions of the factors to the students' global satisfaction, the study included a multivariate stepwise regression analysis. The analysis revealed four factors, which together explained 60.24% of the variance: Structure & Process (44.66%); Time (5.8 %); Outcome (5.35%) and Input (4.39%). The Structure & Process factor was found to be the best predictor of students' global satisfaction (R2 =( ).537). Our conclusion is that "efforts to improve clerkship quality should focus on students' learning processes and clerkship structure".

Experience-based learning: a model linking the processes and outcomes of medical students' workplace learning

OBJECTIVE

To develop a model linking the processes and outcomes of workplace learning.

METHODS

We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students.

RESULTS

To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning.

CONCLUSIONS

The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Curriculum development in anesthesia: Basic theoretical principles

PURPOSE

Educational theories provide a guiding basis for coherent medical curriculum development and instruction in a similar way that evidence-based medicine provides a rational basis for medical treatment. The purpose of this review is to provide general organizational, theoretical and educational principles for developing or modifying an anesthesia curriculum.

SOURCE

This paper draws from the general educational and cognitive psychology literature, the medical educational literature from the period 1996-2006, as well as our experience in renewing the anesthesia clerkship curriculum at McMaster University.

PRINCIPAL FINDINGS

Successful curriculum development includes the consideration of stakeholder needs, organizational issues, funding and sustainability, curriculum design, implementation and evaluation. Curriculum design includes the development of curricular goals and objectives, determination of the content and its organization, instructional methods and strategies, and assessment of the learners. Curriculum evaluation is used to judge the curriculum's merit and worth. The findings and recommendations from these evaluations feed back into the curriculum development cycle for further curricular improvements or modifications.

CONCLUSION

The current medical environment requires a responsive and efficacious curriculum that is able to keep up with its rapid pace of change. By providing a discussion of the educational and theoretical principles which underpin coherent curriculum development, this paper advocates a rational, theory-based approach to curriculum development.

Faculty views of reimbursement changes and clinical training: a survey of award-winning clinical teachers

BACKGROUND

Prominent authorities believe that managed care and governmental policies are compromising the clinical education of future physicians.

PURPOSE

This study sought the views of clinical teachers to quantify the extent to which managed care and governmental policies have changed clinical education.

METHODS

Questionnaires were mailed to faculty that U.S. medical schools had recognized for clinical teaching excellence. Measures included reports of change in quality of clinical teaching due to payment regulations, Liaison Committee on Medical Education (LCME) and Residency Review Committee (RRC) requirements, and institutional support for teaching; change in numbers of students-trainees in clinics; need to generate more clinical revenue; and change in enjoyment of teaching. Other measures about clinical teaching included faculty attitudes, institutional rewards, and teaching different levels of students. Characteristics of the respondents also were measured.

RESULTS

Faculty reported that payment regulations have affected clinical teaching negatively and that faculty need to generate more clinical revenue. Institutions tend to provide a supportive teaching environment but do not reward teaching financially. Intrinsic incentives for teaching increase as the level of student increases. Faculty reports did not differ by medical specialty or other faculty characteristics. Differences among medical schools occurred on all measures.

CONCLUSIONS

Clinical education is being negatively affected, but not yet critically. Continued clinical financial pressures on faculty will affect all levels of clinical education, particularly for medical students. Differences among institutions indicate that individual schools can moderate or exacerbate the impact of external forces on the teaching faculty. Medical schools should monitor increasing pressures on faculty and ensure that goals, processes, support, and rewards for clinical teaching are proportionate to those for clinical care.