Tracking reflective practice-based learning by medical students during an ambulatory clerkship

A systematic scoping review of reflective writing in medical education

BACKGROUND

Reflective writing (RW) allows physicians to step back, review their thoughts, goals and actions and recognise how their perspectives, motives and emotions impact their conduct. RW also helps physicians consolidate their learning and boosts their professional and personal development. In the absence of a consistent approach and amidst growing threats to RW's place in medical training, a review of theories of RW in medical education and a review to map regnant practices, programs and assessment methods are proposed.

METHODS

A Systematic Evidence-Based Approach guided Systematic Scoping Review (SSR in SEBA) was adopted to guide and structure the two concurrent reviews. Independent searches were carried out on publications featured between 1st January 2000 and 30th June 2022 in PubMed, Embase, PsychINFO, CINAHL, ERIC, ASSIA, Scopus, Google Scholar, OpenGrey, GreyLit and ProQuest. The Split Approach saw the included articles analysed separately using thematic and content analysis. Like pieces of a jigsaw puzzle, the Jigsaw Perspective combined the themes and categories identified from both reviews. The Funnelling Process saw the themes/categories created compared with the tabulated summaries. The final domains which emerged structured the discussion that followed.

RESULTS

A total of 33,076 abstracts were reviewed, 1826 full-text articles were appraised and 199 articles were included and analysed. The domains identified were theories and models, current methods, benefits and shortcomings, and recommendations.

CONCLUSIONS

This SSR in SEBA suggests that a structured approach to RW shapes the physician's belief system, guides their practice and nurtures their professional identity formation. In advancing a theoretical concept of RW, this SSR in SEBA proffers new insight into the process of RW, and the need for longitudinal, personalised feedback and support.

A Best Evidence Medical Education (BEME) systematic review of: What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements? BEME Guide No. 52

BACKGROUND

Ingrained assumptions about clinical placements (clerkships) for health professions students pursuing primary basic qualifications might undermine best educational use of mobile devices.

QUESTION

What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements?

METHODS

A Best Evidence Medical Education (BEME) effectiveness-review of "justification" complemented by "clarification" and "description" research searched: MEDLINE, Educational Resource Information Center, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycInfo, Cochrane Central, Scopus (1988-2016). Reviewer-pairs screened titles/abstracts. One pair coded, extracted, and synthesized evidence, working within the pragmatism paradigm.

SUMMARY OF RESULTS

From screening 2279 abstracts, 49 articles met inclusion-criteria, counting four systematic reviews for context. The 45 articles of at least Kirkpatrick K2 primary research mostly contributed K3 (39/45, 86.7%), mixed methods (21/45, 46.7%), and S3-strength (just over one-half) evidence. Mobile devices particularly supported student: assessment; communication; clinical decision-making; logbook/notetaking; and accessing information (in about two-thirds). Informal and hidden curricula included: concerns about: disapproval; confidentiality and privacy; security;-distraction by social connectivity and busy clinical settings; and mixed messages about policy.

DISCUSSION AND CONCLUSION

This idiosyncratic evidence-base of modest robustness suggested that mobile devices provide potentially powerful educational support on clinical placement, particularly with student transitions, metalearning, and care contribution. Explicit policy must tackle informal and hidden curricula though, addressing concerns about transgressions.

Self-evaluation and peer-feedback of medical students' communication skills using a web-based video annotation system. Exploring content and specificity

OBJECTIVE

Self-evaluation and peer-feedback are important strategies within the reflective practice paradigm for the development and maintenance of professional competencies like medical communication. Characteristics of the self-evaluation and peer-feedback annotations of medical students' video recorded communication skills were analyzed.

METHOD

Twenty-five year 4 medical students recorded history-taking consultations with a simulated patient, uploaded the video to a web-based platform, marked and annotated positive and negative events. Peers reviewed the video and self-evaluations and provided feedback. Analyzed were the number of marked positive and negative annotations and the amount of text entered. Topics and specificity of the annotations were coded and analyzed qualitatively.

RESULTS

Students annotated on average more negative than positive events. Additional peer-feedback was more often positive. Topics most often related to structuring the consultation. Students were most critical about their biomedical topics. Negative annotations were more specific than positive annotations. Self-evaluations were more specific than peer-feedback and both show a significant correlation. Four response patterns were detected that negatively bias specificity assessment ratings.

CONCLUSION

Teaching students to be more specific in their self-evaluations may be effective for receiving more specific peer-feedback.

PRACTICE IMPLICATIONS

Videofragmentrating is a convenient tool to implement reflective practice activities like self-evaluation and peer-feedback to the classroom in the teaching of clinical skills.

How we use patient encounter data for reflective learning in family medicine training

INTRODUCTION

Consulting with patients is the core learning activity of Australian family medicine (general practice/GP) training, providing a rich source of reflective learning for trainees. We have developed a reflective learning program for postgraduate vocational trainees based on clinical encounters.

METHODS

The Registrar Clinical Encounters in Training (ReCEnT) program is an educational program documenting GP trainees' consultations in five Australian GP training providers. Trainees record patient demographics, consultation details, problems managed, management practices and educational factors from sixty consecutive consultations per six-month training term. Trainees receive a detailed feedback report comparing individual data to aggregated trainee data and national GP data.

RESULTS

The patient encounter system provides multiple opportunities for reflective learning across a number of domains of exposure and practice. Reflection can occur during completion of the encounter form; as self-reflection on the feedback report; as facilitated reflection with the GP trainer and medical educator; and as part of integration of data into teaching. We have identified areas for further development, including enhancing the reflective skills of trainees and trainers.

CONCLUSION

The ReCEnT patient encounter program provides a rich platform for reflective learning for vocational trainees and supports development of skills in lifelong learning.

An innovative OSCE clinical log station: a quantitative study of its influence on Log use by medical students

BACKGROUND

A Clinical Log was introduced as part of a medical student learning portfolio, aiming to develop a habit of critical reflection while learning was taking place, and provide feedback to students and the institution on learning progress. It was designed as a longitudinal self-directed structured record of student learning events, with reflection on these for personal and professional development, and actions planned or taken for learning.As incentive was needed to encourage student engagement, an innovative Clinical Log station was introduced in the OSCE, an assessment format with established acceptance at the School. This study questions: How does an OSCE Clinical Log station influence Log use by students?

METHODS

The Log station was introduced into the formative, and subsequent summative, OSCEs with careful attention to student and assessor training, marking rubrics and the standard setting procedure. The scoring process sought evidence of educational use of the log, and an ability to present and reflect on key learning issues in a concise and coherent manner.

RESULTS

Analysis of the first cohort's Log use over the four-year course (quantified as number of patient visits entered by all students) revealed limited initial use. Usage was stimulated after introduction of the Log station early in third year, with some improvement during the subsequent year-long integrated community-based clerkship. Student reflection, quantified by the mean number of characters in the 'reflection' fields per entry, peaked just prior to the final OSCE (mid-Year 4). Following this, very few students continued to enter and reflect on clinical experience using the Log.

CONCLUSION

While the current study suggested that we can't assume students will self-reflect unless such an activity is included in an assessment, ongoing work has focused on building learner and faculty confidence in the value of self-reflection as part of being a competent physician.

Study protocol: the Registrar Clinical Encounters in Training (ReCEnT) study

BACKGROUND

Patient encounters are the core learning activity of Australian general practice (family practice) training. Exposure to patient demographics and presentations may vary from one general practice registrar (vocational trainee) to another. This can affect comprehensiveness of training. Currently, there is no mechanism to systematically capture the content of GP registrar consultations. The aim of the Registrar Clinical Encounters in Training (ReCEnT) study is to document longitudinally the nature and associations of consultation-based clinical and educational experiences of general practice registrars.

METHODS/DESIGN

This is an ongoing prospective multi-site cohort study of general practice registrars' consultations, entailing paper-based recording of consultation data. The study setting is general practices affiliated with three geographically-based Australian general practice regional training providers. Registrars record details of 60 consecutive consultations. Data collected includes registrar demographics, details of the consultation, patient demographics, reasons for encounter and problems managed. Problems managed are coded with the International Classification of Primary Care (second edition) classification system. Additionally, registrars record educational factors related to the encounter. The study will follow the clinical exposure of each registrar six-monthly over the 18 months to two years (full-time equivalent) of their general practice training program.

CONCLUSIONS

The study will provide data on a range of factors (patient, registrar and consultation factors). This data will be used to inform a range of educational decisions as well as being used to answer educational research questions. We plan to use ReCEnT as a formative assessment tool for registrars and help identify and address educational needs. The study will facilitate program evaluation by the participating training providers and thus improve articulation of educational programs with practice experience. From the research point of view it will address an evidence gap - the in-practice clinical and educational experience of general practice trainees, determinants of these experiences, and the determinants of registrars' patterns of practice (for example, prescribing practice) over the course of their training.

Understanding the educational value of first-year medical students' patient encounter data

BACKGROUND

Many medical schools use patient-encounter logs to track students' clinical experiences, but few have investigated the student-user perspective to understand how students enter, review, and use patient-encounter information.

AIMS

This study examines first-year medical students' use of a web-based tracking system and whether students thought logging patient-encounters was educationally valuable.

METHODS

This mixed-methods study uses data from student encounter log entries, a focus group with first-year students, and a survey. Data analysis involved descriptive statistics for quantitative data, qualitative content analysis of students' free-response entries in the logs, and thematic analysis for focus group and survey responses.

RESULTS

Most students logged at least one encounter (90%), but used the system substantially less than expected. Focus group and survey data indicated that students found minimal educational value in the encounter tracking system as designed, but identified several ways in which the system could be improved to better support their learning. Suggestions included clearer guidelines for use, better integration into the curriculum, a mentoring process, and provision of benchmarks or target number of specific encounter types.

CONCLUSION

Student-user perspectives are crucial in optimizing information collected through patient-encounter tracking systems, and can improve both the functionality and the educational value of such systems.