Time spent on clerkship activities by students in relation to their perceptions of learning environment quality

Learning strategies for the advanced trainee in specialist training

BACKGROUND

A significant factor of clinicians' learning is based on their ability to effectively transfer acquired knowledge, skills, and attitudes from specialty-specific clinical courses to their working environment.

MATERIAL AND METHOD

We conducted semi-structured interviews with 20 anaesthesiologist trainees (i.e. residents) in four group and five individual interviews using SRL principles as sensitizing concepts. Data were collected and analyzed iteratively using thematic analysis.

RESULTS

Advanced trainees are highly motivated to explore what they have learned in specialty-specific courses, but they often face several barriers in implementing their learning in the workplace environment. Four themes emerged from the interview data: 'Be ready to learn', "Take the 'take-home-messages' home', "Be ready to create your own opportunities', and "Face it, it's not entirely up to you'. Understanding the challenges regarding transferring knowledge from courses to the working environment is an important lesson for assisting trainees set their learning goals, monitor their progress, and re-evaluate their SRL processes.

CONCLUSION

Even for advanced trainees, successfully transferring knowledge from specialty-specific courses often requires adequate commitment and support. Medical supervisors and other relevant stakeholders must be aware of their shared responsibility for creating individual environments that support opportunities for trainees to self-regulate their learning.

Learning through connections: clinical participation and interpersonal relationships in longitudinal integrated clerkships and traditional block rotations in Taiwan

BACKGROUND

Longitudinal integrated clerkships (LICs) and traditional block rotations (TBRs) employ different designs that provide various learning experiences for students. In this study, we explored students' clinical participation and interpersonal interactions in LICs and TBRs at 2 metropolitan hospitals in Taiwan.

METHODS

In April 2018, we enrolled 15 LIC and 29 TBR students. We conducted a cross-sectional survey which required the students to outline a typical daily schedule during their internal medicine rotations and draw an ecomap of the clinical team members. With the patient in the center as a reference, the size of each circle in an ecomap indicated the importance of the member; the distances and number of connecting lines between two circles represented the relationship and frequency of interaction, respectively, between the corresponding members. We analyzed the results and compared the responses of the LIC and TBR students.

RESULTS

The LIC students spent more time on direct patient care and in the outpatient clinic/operation room, whereas the TBR students participated more in educational activities and in observation behind their seniors. In the ecomap analysis, the LIC students had a closer relationship with attending physicians and had better interactions with patients and preceptors than did the TBR students. Conversely, the TBR students felt closer to and interacted more frequently with interns and residents.

CONCLUSIONS

The LIC students had more opportunities to care for patients directly and engaged in interactions with patients and attending physicians more frequently than did the TBR students.

TRIAL REGISTRATION

Ethical approval for the study was obtained from the Institutional Review Board of Tri-Service General Hospital (TSGHIRB 2-106-05-018).

Mixed reality simulation for peripheral intravenous catheter placement training

BACKGROUND

Despite the advantages of simulation-based training, trainees are typically unable to view internal anatomical structures. This limitation can be overcome by using mixed reality (MR) wherein 3-D virtual anatomical images can be projected. This study was designed to evaluate the efficacy of an MR trainer for peripheral intravenous catheter (PIVC) placement.

METHODS

Sixty-two participants used projected images of arm veins to place a PIVC in a mannequin arm. Participants were evaluated using a checklist on their ability to successfully place the PIVC. Participants completed a survey to elicit demographic information and perceptions of the trainer. A follow-up survey at two-weeks assessed clinical experiences with PIVC placement since using the MR trainer.

RESULTS

First attempt catheter placement was successful in 48 (77.4%) cases. Only 11 (17.7%) and 3 (4.8%) of participants caused 'extravasation' and 'hematoma' formation on their first attempt, respectively. Fifty-nine participants (95.2%) agreed that ability to see internal structures was useful, and 58 (93.5%, respectively) agreed that the interactivity promoted learning and that MR should be included in training.

CONCLUSIONS

Results of this study showed that use of a novel MR trainer for PIVC placement appears to provide an environment conducive to successful learning. Most participants were successful at PIVC placement on their first attempt and an overwhelming number found it helpful in identifying landmarks and confirming correct needle angles for insertion. Given the increasing emphasis on simulation training, highly immersive MR tools appear to offer promise to close the gap between classroom instruction and clinical experience.

Quality Assurance of Undergraduate Medical Education in Israel by Continuous Monitoring and Prioritization of the Accreditation Standards

External accreditation reviews of undergraduate medical curricula play an important role in their quality assurance. However, these reviews occur only at 4-10-year intervals and are not optimal for the immediate identification of problems related to teaching. Therefore, the Standards of Medical Education in Israel require medical schools to engage in continuous, ongoing monitoring of their teaching programs for compliance with accreditation standards. In this paper, we propose the following: (1) this monitoring be assigned to independent medical education units (MEUs), rather than to an infrastructure of the dean's office, and such MEUs to be part of the school governance and draw their authority from university institutions; and (2) the differences in the importance of the accreditation standards be addressed by discerning between the "most important" standards that have been shown to improve student well-being and/or patient health outcomes; "important" standards associated with student learning and/or performance; "possibly important" standards with face validity or conflicting evidence for validity; and "least important" standards that may lead to undesirable consequences. According to this proposal, MEUs will evolve into entities dedicated to ongoing monitoring of the education program for compliance with accreditation standards, with an authority to implement interventions. Hopefully, this will provide MEUs and faculty with the common purpose of meeting accreditation requirements, and an agreed-upon prioritization of accreditation standards will improve their communication and recommendations to faculty.

Lower Frequency of Call Shifts Leads to Higher Attendance, Higher Academic Performance, and Less Burnout Syndrome in Surgical Clerkships

OBJECTIVE

Clinical clerkships are a fundamental component of medical education where students' learning is aided by exposure to real patients in diverse practical settings. Countless programs use overnight call shifts as an essential part of their clerkships. There has been concerns about the negative effects these shifts have on students. The study aims to determine relations between call schedule, lecture attendance, and academic and clinical performance.

METHODS

One hundred and eight medical students were followed during their surgery clerkship. Students on a Q3 schedule had an on-call shift once every 3 nights, while students on a Q4 schedule once every 4 nights. Their academic performance was evaluated using their exams grades, while their clinical performance was evaluated by their attending physicians. Burnout syndrome was measured using Maslach Inventory.

RESULTS

A total of 108 medical students attended their surgical clerkship. Sixty-nine students were under the Q3 call schedule while 39 students in the Q4 call schedule. Mean lecture attendance for students in Q3 was 82.7% (17.3%) compared to 90% (11.2%) (p = 0.020). Final exam grades were different between groups, with Q3 scoring a mean 71.55 (9.3) compared to Q4 85.07 (9.8) (p = 0.001). Clinical performance score means were similar between groups (p = 0.777). Q4 had 74% and Q3 had 49.3% of the students with >90% of attendance (p = 0.008). Q4 had 2.6% students with <70% attendance compared to Q3 with 23.2% (p = 0.008). Students with >90% attendance regardless of call schedule, scored higher in both midterms and final exams (p = 0.002; p = 0.001). Burnout prevalence was higher in students on the Q3 schedule with 28.6% compared to 4.7% of those on the Q4 schedule (p = 0.003).

CONCLUSIONS

Students with less call frequency were associated with an improvement in lecture attendance and academic performance, and a lower burnout syndrome rate, without impacting clinical performance. Students with higher attendance regardless of call schedules performed higher academically. Further studies should evaluate the impact on clinical performance and exposure more thoroughly.

A mandatory Emergency Medicine clerkship influences students' career choices in a developing system

BACKGROUND

Attracting medical students for a front-line specialty, Emergency Medicine, is challenging in many countries. The available literature is scarce and bounded to the mature emergency care and education systems. In the countries where emergency medicine is a new specialty and has different contextual needs, the perception of the students and their career interest in emergency medicine specialty is an unanswered question.

OBJECTIVE

We aimed to study the effects of a mandatory Emergency Medicine (EM) clerkship on students' perceptions and their future career choice to be emergency physicians.

METHODS

A voluntary de-identified survey was prospectively collected before and after the EM clerkship to capture students' perceptions in four domains (EM clerkship, EM physicians, EM patients, and EM specialty as a career choice). The survey included 24 statements having five-point Likert scale for each statement. Non-parametric Wilcoxon signed rank test was used for statistical analysis.

RESULTS

Sixty-seven students responded to both surveys (response rate of 85%). Students' perceptions have significantly improved on the EM physicians, and their job after attending the clerkship (p < 0.001). They found EM a respected (p = 0.038), flexible (p < 0.001), secure (p < 0.001), satisfying, and prestigious (p = 0.006) job. They found EM physicians compassionate (p < 0.011), have adequate patient contact (p < 0.045) and control on their time (0.004). Choosing EM as a future career has significantly increased after clerkship (p < 0.001).

CONCLUSIONS

Our mandatory EM clerkship significantly improved students' perceptions on EM specialty as a future career choice. A well-structured and mandatory EM clerkship can attract more students to be trained in the EM.

The education avenue of the clinical learning environment: A pragmatic approach

Aim: This perspective is part of a series of articles that are outcomes of a consensus conference, that seek to offer a comprehensive examination of the clinical learning environment (CLE), using different academic disciplines and areas of focus termed "avenues." The education dimensions of the CLE are discussed in detail in this perspective, along with critical linkages to the other avenues. Methods: Using iterative presentations, discussion and small group work, in October 2018, the consensus conference participants explored the education, psychological, sociocultural, diversity and inclusion, digital and architectural aspects of the CLE. Results: The education avenue of the CLE includes elements of teaching and learning such as the curriculum, clinical experiences, the assessment system, educational program governance, trainee selection, faculty development, and program evaluation and improvement. Within the educational domain, we focus on organizational and personal/social aspects of the CLE, including (1) curriculum design and deployment, including placement of trainees in clinical settings, organizational culture, practices and policies, and accreditation and regulatory requirements from the organizational domain (2) the education system, including assessment, program evaluation and organization and governance; and (3) elements from the personal and social domains, including peer-to-peer, trainee-faculty, and trainee-patient relationships that influence how and what postgraduate trainees learn, trainee selection, informal and hidden curricula, and trainees' perceptions of their learning environment. Conclusions: We provide suggestions for further research and recommendations for addressing challenges and facilitating improvement in the educational aspects of the CLE, along with actionable practice points.

Mapping scientific research on the negative aspects of the medical school learning environment

OBJECTIVE

We sought to understand the landscape of published articles regarding medical schools' learning environments (LE) worldwide, with an explicit focus on potentially harmful aspects of the LE as an effort to identify areas specifically in need of remediation or intervention that could prevent future unprofessional behaviors, burnout, violence and mistreatment among students and physicians.

METHODS

A bibliometric analysis was conducted in six electronic databases (PubMed/Medline, Web of Science, Cochrane Library, SCOPUS, ERIC-ProQuest, and PsycINFO) up to December 31, 2016, including 12 themes: learning environment - general, hidden curriculum (harmful), unethical behaviors, bullying/hazing, violence, sexual discrimination, homophobia, racism, social discrimination, minorities discrimination, professional misconduct, and other negative aspects.

RESULTS

Of the 9,338 articles found, 710 met the inclusion criteria. The most common themes were general LE (233 articles), unprofessional behaviors (91 articles), and sexual discrimination (80 articles). Approximately 80% of articles were published in the 21st century.

CONCLUSION

There is a definite increase in scientific articles on negative aspects of the medical school LE in high-quality journals, especially in the 21st century. However, more studies are needed to investigate negative LE aspects with greater attention to experimental, longitudinal, and cross-cultural study designs.

Mapping the scientific research on the negative aspects of the medical school learning environment

OBJECTIVE

We sought to understand the landscape of published articles regarding medical schools' learning environments (LE) worldwide, with an explicit focus on potentially negative aspects of the LE as an effort to identify areas specifically in need of remediation or intervention that could prevent future unprofessional behaviours, burnout, violence and mistreatment among students and physicians.

METHODS

A bibliometric analysis was conducted in six electronic databases (PubMed/Medline, Web of Science, Cochrane Library, SCOPUS, ERIC-ProQuest and PsycINFO) through December 31, 2016, including 12 themes: learning environment - general, hidden curriculum (negative), unethical behaviours, bullying/hazing, violence, sexual discrimination, homophobia, racism, social discrimination, minorities' discrimination, professional misconduct, and "other" negative aspects.

RESULTS

Of 9,338 articles found, 710 met the inclusion criteria. The most common themes were general LE (233 articles), unprofessional behaviours (91 articles), and sexual discrimination (80 articles). Approximately 80% of articles were published in the 21st century.

CONCLUSION

There is a clear increase in scientific articles on negative aspects of the medical school LE in high-quality journals, especially in the 21st century. However, more studies are needed to investigate negative LE aspects with greater attention paid to experimental, longitudinal, and cross-cultural study designs.

Interventions Designed to Improve the Learning Environment in the Health Professions: A Scoping Review

This article was migrated. The article was marked as recommended. Purpose: To identify and describe interventions designed to affect the learning environment (LE) in health professions education, summarize factors that influence the LE, and determine gaps that require additional research. The LE can be thought of as a dynamic and complex construct co-created by people in a particular setting. A positive LE represents a welcoming climate for learning, which enhances satisfaction, well-being, academic performance and collaboration, while a negative LE restricts participation and learning, leading to emotional exhaustion, depersonalization and burnout. Method: A six-step scoping review methodology was followed to identify and report on literature that describes interventions affecting the LE in the health professions education: 1. Identify the research question, 2. Identify relevant studies, 3. Select studies to be included, 4. Chart the data, 5. Collate, summarize and report results, and 6. Consult with stakeholders. Results: 2,201 unique citations were identified and reviewed using titles and abstracts. 240 full-text articles were retained for detailed review, resulting in the inclusion of 68 articles. Study results are reported in relation to essential components of the LE: personal, social, organizational, physical and virtual spaces. Results of four different types to the studies of the LE are described: specific interventionsimpacting the LE, comparisonsof perceptions of the LE by two or more different groups, associations with other variable such as well-being with the LE, and descriptivestudies of the LE. Major influences included accreditation regulations, curricular interventions, faculty/staff development grading practices, instructional interventions, placements, physical and virtual spaces, and support services; and are reported along with specific interventions. Conclusion: These results reflect the complexity of the LE and the need for conceptual clarity. Since the quality of the evidence was not evaluated, the identified influences should be viewed as potential opportunities to improve the LE.

How characteristic routines of clinical departments influence students' self-regulated learning: A grounded theory study

BACKGROUND

In clerkships, students are expected to self-regulate their learning. How clinical departments and their routine approach on clerkships influences students' self-regulated learning (SRL) is unknown.

AIM

This study explores how characteristic routines of clinical departments influence medical students' SRL.

METHODS

Six focus groups including 39 purposively sampled participants from one Dutch university were organized to study how characteristic routines of clinical departments influenced medical students' SRL from a constructivist paradigm, using grounded theory methodology. The focus groups were audio recorded, transcribed verbatim and were analyzed iteratively using constant comparison and open, axial and interpretive coding.

RESULTS

Students described that clinical departments influenced their SRL through routines which affected the professional relationships they could engage in and affected their perception of a department's invested effort in them. Students' SRL in a clerkship can be supported by enabling them to engage others in their SRL and by having them feel that effort is invested in their learning.

CONCLUSIONS

Our study gives a practical insight in how clinical departments influenced students' SRL. Clinical departments can affect students' motivation to engage in SRL, influence the variety of SRL strategies that students can use and how meaningful students perceive their SRL experiences to be.

The impact of students and curriculum on self-study during clinical training in medical school: a multilevel approach

BACKGROUND

In higher education, the focus has shifted from the acquisition of knowledge to learning objectives and skills. This means that, the majority of student learning time is spent independently working outside the classroom. Students take an active role in setting goals, deciding how to achieve them, and planning individual study time. Although extensive research has recognized the importance of curriculum and students' characteristics in time devoted to self-study, it is still unclear to what extent these variables affect time to study. Due to the growing reliance on self-directed learning in medical education, and in an attempt to elucidate this issue, this research aims to evaluate self-study time during clinical training and assess whether this is more influenced by the student or the curriculum.

METHODS

A questionnaire was given to 1220 medical students (43.3% of the enrolled students). The students were asked to indicate the average number of study hours per week beyond the time allocated to classes for each clerkship (rotation) attended. Variation and generalizability of students' self-study were estimated using linear mixed models.

RESULTS

Findings showed that the intrinsic differences within students were a greater source of variation in self-study time than differences within clerkships (56.0% vs. 6.9%). If the amount of self-study dedicated to an individual clerkship is to be determined, at least 32 students are needed to achieve acceptable reliability. However, this data with two clerkships per student can used to retrospectively measure the self-study reported by students in clinical training.

CONCLUSIONS

The findings suggest that, both, curriculum and student characteristics influence self-study in undergraduate clinical training. Indeed, students' characteristics play a significant role in time devoted to study. Further research should be undertaken to investigate students' characteristics that may predict self-study during undergraduate medical training.

Identifying Opportunities for Peer Learning: An Observational Study of Medical Students on Clinical Placements

Phenomenon: Peer assisted learning (PAL) is frequently employed and researched in preclinical medical education. Fewer studies have examined PAL in the clinical context: These have focused mainly on the accuracy of peer assessment and potential benefits to learner communication and teamwork skills. Research has also examined the positive and negative effects of formal, structured PAL activities in the clinical setting. Given the prevalence of PAL activities during preclinical years, and the unstructured nature of clinical placements, it is likely that nonformal PAL activities are also undertaken. How PAL happens formally and informally and why students find PAL useful in this clinical setting remain poorly understood.

APPROACH

This study aimed to describe PAL activities within the context of clinical placement learning and to explore students' perceptions of these activities. An ethnographic study was conducted to gather empirical data on engagement in clinical placement learning activities, including observations and interviews with students in their 1st clinical year, along with their supervising clinicians. Thematic analysis was used to interrogate the data.

FINDINGS

On average, students used PAL for 5.19 hours per week in a range of activities, of a total of 29.29 hours undertaking placements. PAL was recognized as a means of vicarious learning and had greater perceived value when an educator was present to guide or moderate the learning. Trust between students was seen as a requirement for PAL to be effective. Students found passive observation a barrier to PAL and were able to identify ways to adopt an active stance when observing peers interacting with patients. For example, learners reported that the expectation that they had to provide feedback to peers after task observation, resulted in them taking on a more critical gaze where they were encouraged to consider notions of good practice. Insights: Students use PAL in formal (i.e., tutorial) and nonformal (e.g., peer observation and feedback on the ward; discussion during lunch) situations in clinical education and find it useful. The educator is crucial in fostering PAL through providing opportunities for learners to practice together and in helping to moderate discussions about quality of performance. Student engagement in PAL may reduce passivity commonly reported in clinical rotations. Further directions for research into PAL in clinical education are identified along with potential strategies that may maximize the benefits of peer to peer learning.

Adoption and correlates of Postgraduate Hospital Educational Environment Measure (PHEEM) in the evaluation of learning environments - A systematic review. MEDICAL TEACHER 2016;38:1248-1255. [PMID: 27564848 DOI: 10.1080/0142159x.2016.1210108]

BACKGROUND

The Postgraduate Hospital Educational Environment Measure (PHEEM) is a highly reliable and valid instrument to measure the educational environment during post graduate medical training. This review extends earlier reports by evaluating the extant adoption of PHEEM in various international clinical training sites, and its significant correlations in order to expand our understanding on the use of PHEEM and facilitate future applications and research.

METHOD

A systematic literature review was conducted on all articles between 2005 and October 2015 that adopted and reported data using the PHEEM.

RESULTS

Overall 30 studies were included, encompassing data from 14 countries internationally. Notable differences in the PHEEM scores were found between different levels of training, disciplines, and clinical training sites. Common strengths and weaknesses in learning environments were observed and there were significant correlations between PHEEM scores and In-Training Exam (ITE) performance (positive correlation) and level of burnout (negative correlation), respectively.

CONCLUSIONS

PHEEM is widely adopted in different learning settings, and is a useful tool to identify the strengths and weaknesses of an educational environment. Future research can examine other correlates of PHEEM and longitudinal changes in interventional studies.

Does academic performance or personal growth share a stronger association with learning environment perception?

OBJECTIVES

This study was conducted to characterize the relative strength of associations of learning environment perception with academic performance and with personal growth.

METHODS

In 2012-2014 second and third year students at Johns Hopkins University School of Medicine completed a learning environment survey and personal growth scale. Hierarchical linear regression analysis was employed to determine if the proportion of variance in learning environment scores accounted for by personal growth was significantly larger than the proportion accounted for by academic performance (course/clerkship grades).

RESULTS

The proportion of variance in learning environment scores accounted for by personal growth was larger than the proportion accounted for by academic performance in year 2 [R(2)Δ of 0.09, F(1,175) = 14.99,  p < .001] and year 3 [R(2)Δ of 0.28, F(1,169) = 76.80, p < .001]. Learning environment scores shared a small amount of variance with academic performance in years 2 and 3.  The amount of variance between learning environment scores and personal growth was small in year 2 and large in year 3.

CONCLUSIONS

Since supportive learning environments are essential for medical education, future work must determine if enhancing personal growth prior to and during the clerkship year will increase learning environment perception.

How clinical reasoning is taught and learned: Cultural perspectives from the University of Melbourne and Universitas Indonesia

BACKGROUND

The majority of schools in the Asia-Pacific region have adopted medical curricula based on western pedagogy. However to date there has been minimal exploration of the influence of the culture of learning on the teaching and learning process. This paper explores this issue in relation to clinical reasoning.

METHOD

A comparative case study was conducted in 2 medical schools in Australia (University of Melbourne) and Asia (Universitas Indonesia). It involved assessment of medical students' attitudes to clinical reasoning through administration of the Diagnostic Thinking Inventory (DTI), followed by qualitative interviews which explored related cultural issues. A total of 11 student focus group discussions (45 students) and 24 individual medical teacher interviews were conducted, followed by thematic analysis.

RESULTS

Students from Universitas Indonesia were found to score lower on the Flexibility in Thinking subscale of the DTI. Qualitative data analysis based on Hofstede's theoretical constructs concerning the culture of learning also highlighted clear differences in relation to attitudes to authority and uncertainty avoidance, with potential impacts on attitudes to teaching and learning of clinical reasoning in undergraduate medical education.

CONCLUSIONS

Different attitudes to teaching and learning clinical reasoning reflecting western and Asian cultures of learning were identified in this study. The potential impact of cultural differences should be understood when planning how clinical reasoning can be best taught and learned in the changing global contexts of medical education, especially when the western medical education approach is implemented in Asian contexts.

Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills--a controlled study

BACKGROUND

The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills.

METHODS

All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test.

RESULTS

At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2.

CONCLUSIONS

Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.

Learning opportunities in 'student assistantships'

BACKGROUND

In order to gain experience of the skills required when they begin practice, all final-year medical students in the UK undertake a 'student assistantship', working alongside first-year postgraduate doctors. In this study, we examined the learning opportunities open to students in one locality during two periods of assistantship: one in medicine; one in surgery.

METHODS

Final-year students and their supervisors completed online questionnaires. The students' questionnaire explored general perceptions of the placement, and whether 15 potential learning opportunities (identified as 'desk-' or 'patient-oriented') had been 'taken', 'missed' or were 'not available'. The supervisors' questionnaire explored their perceptions of students' learning during the assistantship.

RESULTS

Overall, 86 student questionnaires and 17 supervisor questionnaires were returned (response rates of 57 and 63%, respectively). Students reported more desk-based learning opportunities, of which more were taken up, than patient-oriented learning opportunities. Surgical placements were associated with more 'missed' opportunities than medical placements. Across all tasks, many students felt that some learning opportunities were not present in their assistantship. By contrast, supervisors felt students 'made the most' of assistantships. Students' overall perceptions of the assistantship were positively related to the level of experience that they had attained (r = 0.40-0.54).

DISCUSSION

The assistantship fulfils its aims for many students, but individual experience gained varies considerably. Some opportunities are not being taken, with 'patient-oriented' opportunities more likely to be missed, whereas others are not available during placements. Supervisors may overestimate the educational value of the assistantship, with implications for its management and delivery.

How clerkship students learn from real patients in practice settings

PURPOSE

To explore how undergraduate medical students learn from real patients in practice settings, the factors that affect their learning, and how clerkship learning might be enhanced.

METHOD

In 2009, 22 medical students in the three clerkship years of an undergraduate medical program in the United Kingdom made 119 near-contemporaneous audio diary entries reflecting how they learned from real patients. Nineteen attended focus groups; 18 were individually interviewed. The authors used a qualitative theory-building methodology with a conceptual orientation toward Communities of Practice theory. A learning theorist guided selective coding of a constant-comparative analysis.

RESULTS

Participants learned informally by participating in the communicative practices of workplaces. Two overlapping practices, patient care and education, were identified. Patient care created learning opportunities, which were enriched when practitioners intentionally supported participants' learning. Education, however, was not always coupled with patient care. So, talk positioned the boundaries of two practices in three configurations: education without patient care, education within patient care, and patient care without education. The nature and quality of participants' learning depended on how practitioners entered dialogue with them and linked the dialogue to authentic patient care.

CONCLUSIONS

Findings strongly suggest that medical students learn from real patients by participating in patient care within an educational practice. Their learning is affected by clinicians' willingness to engage in supportive dialogue. Promoting an informal, inclusive discourse of workplace learning might enhance clerkship education. This approach should take its place alongside-and perhaps ahead of-the currently dominant discourse of "clinical teaching."

Development and psychometric evaluation of the Undergraduate Clinical Education Environment Measure (UCEEM)

BACKGROUND

There is a paucity of instruments designed to evaluate the multiple dimensions of the workplace as an educational environment for undergraduate medical students.

AIM

The aim was to develop and psychometrically evaluate an instrument to measure how undergraduate medical students perceive the clinical workplace environment, based on workplace learning theories and empirical findings.

METHOD

Development of the instrument relied on established standards including theoretical and empirical grounding, systematic item development and expert review at various stages to ensure content validity. Qualitative and quantitative methods were employed using a series of steps from conceptualization through psychometric analysis of scores in a Swedish medical student population.

RESULTS

The final result was a 25-item instrument with two overarching dimensions, experiential learning and social participation, and four subscales that coincided well with theory and empirical findings: Opportunities to learn in and through work & quality of supervision; Preparedness for student entry; Workplace interaction patterns & student inclusion; and Equal treatment. Evidence from various sources supported content validity, construct validity and reliability of the instrument.

CONCLUSION

The Undergraduate Clinical Education Environment Measure represents a valid, reliable and feasible multidimensional instrument for evaluation of the clinical workplace as a learning environment for undergraduate medical students. Further validation in different populations using various psychometric methods is needed.

Expectations for medical student work hours in inpatient clinical clerkships

BACKGROUND

No standards regarding what should be learned during medical school exist.

PURPOSE

We investigated what medical students and clerkship directors (CDs) believe students are, and should be, doing during clerkships.

METHODS

From January to June 2011, Mount Sinai School of Medicine CDs (n = 4) and 3rd-year students (n = 132) estimated how students spend time and should spend time during clerkships. Mann-Whitney U-tests compared students' and CDs' replies.

RESULTS

All CDs and 105 of 132 students (79.5%) participated. Medicine CDs believed that students did more rounding and studying, and surgery CDs perceived that students did more note writing and studying and less waiting than students reported. Medicine CDs felt students should round more, whereas surgery CDs felt students should spend more total time in the hospital as well as in educational activities and studying than students did ( p < .05).

CONCLUSIONS

Students and CDs disagree about how students allocate (and should allocate) time during clerkships.

Manchester Clinical Placement Index (MCPI). Conditions for medical students' learning in hospital and community placements

The drive to quality-manage medical education has created a need for valid measurement instruments. Validity evidence includes the theoretical and contextual origin of items, choice of response processes, internal structure, and interrelationship of a measure's variables. This research set out to explore the validity and potential utility of an 11-item measurement instrument, whose theoretical and empirical origins were in an Experience Based Learning model of how medical students learn in communities of practice (COPs), and whose contextual origins were in a community-oriented, horizontally integrated, undergraduate medical programme. The objectives were to examine the psychometric properties of the scale in both hospital and community COPs and provide validity evidence to support using it to measure the quality of placements. The instrument was administered twice to students learning in both hospital and community placements and analysed using exploratory factor analysis and a generalizability analysis. 754 of a possible 902 questionnaires were returned (84% response rate), representing 168 placements. Eight items loaded onto two factors, which accounted for 78% of variance in the hospital data and 82% of variance in the community data. One factor was the placement learning environment, whose five constituent items were how learners were received at the start of the placement, people's supportiveness, and the quality of organisation, leadership, and facilities. The other factor represented the quality of training-instruction in skills, observing students performing skills, and providing students with feedback. Alpha coefficients ranged between 0.89 and 0.93 and there were no redundant or ambiguous items. Generalisability analysis showed that between 7 and 11 raters would be needed to achieve acceptable reliability. There is validity evidence to support using the simple 8-item, mixed methods Manchester Clinical Placement Index to measure key conditions for undergraduate medical students' experience based learning: the quality of the learning environment and the training provided within it. Its conceptual orientation is towards Communities of Practice, which is a dominant contemporary theory in undergraduate medical education.

Students' workplace learning in two clerkship models: a multi-site observational study

CONTEXT

Longitudinal integrated clerkships (LICs) are established, rapidly growing models of education designed to improve the core clinical year of medical school using guiding principles about workplace learning and continuity. This study is the first to report data from direct observations of workplace learning experiences of students on LICs and traditional block clerkships (BCs), respectively.

METHODS

This multi-institution study used an observational, work-sampling methodology to compare LIC and BC students early and late in the core clinical year. Trained research assistants documented students' activities, participation (observing, with assistance, alone), and interactions every 10 minutes over 4-hour periods. Each student was observed one to three times early and/or late in the year. Data were aggregated at the student level and by in-patient or out-patient setting for BC students. One-way analysis of variance (anova) was used to compare two groups early in the year (LIC and BC students) and three groups late in the year (LIC, out-patient BC and in-patient BC students).

RESULTS

Early-year observations included 26 students (16 LIC and 10 BC students); late-year observations included 44 students (28 LIC, eight out-patient BC and eight in-patient BC students). Out-patient activities and interactions of LIC and BC students were similar early in the year, but in the later period LIC students spent significantly more time performing direct patient care activities alone (25%) compared with out-patient (12%) and in-patient (7%) BC students. Students on LICs were significantly more likely to experience continuity with patients as 34% of their patients returned to them, whereas only 5% of patients did so for out-patient BC students late in the year.

CONCLUSIONS

By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.

Workplace learning

This critical review found Dutch research to be strong at the undergraduate and residency levels and more or less absent in continuing medical education. It confirms the importance of coaching medical students, giving constructive feedback, and ensuring practice environments are conducive to learning though it has proved hard to improve them. Residents learn primarily from experiences encountered in the course of clinical work but the fine balance between delivering clinical services and learning can easily be upset by work pressure. More intervention studies are needed. Qualitative research designs need to be more methodologically sophisticated and use a wider range of data sources including direct observation, audio-diaries, and text analysis. Areas for improvement are clear but achieving results will require persistence and patience.

Effect of medical students' experiences with residents as teachers on clerkship assessment

BACKGROUND

We assessed the impact of resident teaching in medical students' overall assessment of an obstetrics and gynecology clerkship.

METHODS

Between September 2007 and March 2010, third-year medical students completed a questionnaire at the end of their clerkship. Questions covered the number of topics they recalled learning about from residents, perceptions of the quality of education received from residents, perceptions of the experience with the residents as teachers, and overall rating of the obstetrics and gynecology clerkship.

RESULTS

Questionnaires were completed by all medical students (N  =  74), with 63 students returning complete surveys. There was a small correlation between the number of topics students recalled learning about from residents and ratings of quality of education (r  =  0.249, P  =  .03), a small correlation between the number of topics students recalled learning about from residents and level of satisfaction with the clerkship (r  =  0.262, P  =  .04), and a larger correlation between assessment of the overall experience with residents as teachers and ratings of quality of education received from residents (r  =  0.687, P < .001). Overall experience with residents as teachers and perceived quality of education from residents were both associated with satisfaction with the clerkship (r  =  0.756, P < .001 and r  =  0.603, P < .001, respectively). A regression model with these variables accounted for 58% of the variability in students' ratings of the clerkship (F  =  27.103, P < .001, R  =  .761, R(2)  =  .579). The only significant independent variable was assessment of the overall experience with residents as teachers (t  =  5.350, P < .001).

CONCLUSION

Quality of interactions between residents and medical students is a key factor in medical students' assessment of their clerkship.