Student perspectives on primary care preceptorships: enhancing the medical student preceptorship learning environment

Long-term mentoring relationships in undergraduate longitudinal general practice tracks - a qualitative study on the perspective of students and general practitioners

BACKGROUND

Longitudinal general practice tracks have been established in medical faculties in Europe and worldwide to attract more graduates to general practice careers. In many programs, long-term mentoring relationships play an important role in providing students with positive role models, regular practical experiences, and acquisition of clinical skills in a community context. However, little is known about students' and general practitioner mentors' expectations, experiences, challenges, and ideas for improvement within these long-term mentoring relationships in general practice in our medical education system.

METHODS

Qualitative study based on semi-structured interviews with 15 students and 13 mentors. Interviews were audio-recorded and transcribed verbatim. MAXQDA was used for data analysis, following a mixed deductive/inductive approach.

RESULTS

Both groups had few and rather unstated expectations, particularly regarding their relationships. Consequently, expectations were often not clearly communicated. Nevertheless, a high level of satisfaction and good opportunities for teaching were achieved for both sides. The evolving familiarity facilitated a positive learning environment. Students valued independent medical tasks continuously adjusted to their current abilities. However, some felt a reluctance to demand their mentor's time and consideration. Conversely, the mentors criticized a lack of initiative from some of the students and wished that they would get more actively involved. Students, in contrast, wished for more guidance at the start of the project and joint events to deepen the relationship.

CONCLUSIONS

With this study, we gained detailed insights into and understanding of the nature of long-term relationships between students and mentors. Points for improvement revealed included: 1) education of both participating groups on the goals and benefits of mentoring, including binding expectations for the participants; 2) intensified support and training of teaching physicians; 3) structured and accompanied establishment of initial contact between mentor and mentee; and 4) encouraged additional shared (teaching) time, individualized timing, and intensification, if desired.

When and why do medical students drop out of extracurricular longitudinal general practice tracks? A cross-sectional study from two German medical faculties

OBJECTIVES

To explore when and why undergraduate medical students drop out of longitudinal extracurricular general practice (GP) tracks and to describe their future career plans.

DESIGN

Cross-sectional online survey and descriptive analysis of routine data.

SETTING

GP tracks at two German medical faculties, data collection took place between September 2020 and April 2021.

PARTICIPANTS

Of 111 students who had taken part in one of the two GP tracks and dropped out prematurely, 101 were contactable via email. Overall, the response rate was 72.3% with 73 completed questionnaires and 75.3% of the participants were female.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reasons for leaving the GP track (closed and free-text answers), attitudes towards a career in GP and future career plans.

RESULTS

Students left the tracks predominantly during the first 2 years of study. Students most frequently stated that structural reasons such as the distance to the GP teaching practice (74.2%), interest in another medical discipline (66.1%), private reasons (58.1%) and the GP mentor (53.1%) influenced their decision to drop out. However, 87.1% of the students indicated that their exit could not have been prevented by the project administration.

CONCLUSIONS

Reasons for dropping out differ between GP tracks and not all reasons are within reach of programme design and staff. Addressable issues include student selection with regard to career plans, support and strengthening of student-mentor relationships, the location of GP practices, and/or travel and accommodation support.

An innovative clinic model for student learning

BACKGROUND

Ambulatory rotations are a key part of medical student education, but there are few educational initiatives aimed to improve student experience.

APPROACH

This initiative implemented a new model for an urgent care clinic, based on Erickson's framework for learning, designed to provide students with more autonomy, and more time for teaching, discussion, feedback and patient encounters. Participants were fourth year medical students in their ambulatory rotation who were randomly assigned to participate in the urgent care clinic. Students were asked to respond to a survey at the end of the rotation.

EVALUATION

A total of 59 fourth-year medical students participated in the ambulatory care rotation, of which 40 students responded to the survey. Students who participated in the urgent care clinic reported more autonomy, feedback, learning and time to see patients. They were happier overall with their experience and felt more prepared for their intern year of residency.

IMPLICATIONS

Our intervention was able to achieve our goals of improving student satisfaction in their ambulatory experience at our institution. This model could be used to design a more effective teaching experience for medical students in other rotations at our institution, as well as at other institutions.

A Practical Approach to Integrating Communication Skills and Early Clinical Experience into the Preclinical Medical School Curriculum

BACKGROUND

Effective integration of early clinical experiences (ECE) with preclinical curricula is challenging, given the limited knowledge-base of students and the unpredictability of clinical environments. Integration of ECE with communication skills (CS) training presents an attractive opportunity since CSs apply to all types of clinical encounters and are independent of students' medical knowledge. We present an ECE program that integrates formal CS training with the realities of clinical practice.

METHODS

Five ECE sessions occur throughout the first year of medical school, each focusing on a specific set of CSs previously introduced in class. Students actively observe preceptors use these skills, briefly practice them, write a critical analysis on each experience, and discuss these in small groups. To identify the perceived usefulness and impact of the ECE on students' CS learning, we analyzed the critical analyses and post intervention evaluations from students and preceptors. Descriptive analyses used SAS for Windows. Thematic content analysis using constant comparison was used to review and code narrative data, and the most commonly referred to impacts, strengths, and limitations of ECE were identified.

RESULTS

Analysis of the students' critical analyses identified the following main themes: (1) integration between ECE and formal CS teaching, (2) importance of effective CS to the delivery of good patient care, and (3) adaptability of CS to specific clinical contexts. Preceptors did not perceive the program as an added burden.

CONCLUSIONS

ECE with focused goals, critical analyses, and small group debriefing can be used to effectively teach and reinforce formal classroom CS training.

Comparing Medical Students' and Preceptors' Views of a Longitudinal Preclerkship Family Medicine Course

Introduction

Despite the increasing popularity of longitudinal primary care experiences in North America and beyond, there is a paucity of work assessing these medical undergraduate experiences using reliable and valid questionnaires. Our objective in this study was to evaluate a new preclerkship longitudinal family medicine experience (LFME) course at McGill University by assessing family physician preceptors' self-reported ratings of the perceived effects of this course, and to compare their responses with ratings provided by medical students who completed the course.

Methods

This study is part of a larger evaluative research project assessing the first edition of the LFME. Students (N=187) and preceptors (N=173) of the 2013-2014 cohort were invited to complete separate online questionnaires in the spring through summer of 2014. The preceptor survey contained 53 items, 14 of which were nearly identical to items in the student survey (published elsewhere) and served as the basis for comparing preceptor and student ratings of the LFME.

Results

Ninety-nine preceptors (57% response rate; 55% female) and 120 students (64% response rate; 58% female) completed the surveys. Preceptors and students did not significantly differ in their overall ratings of the course, as both groups were satisfied with the quality of the LFME and felt it was an appropriate and valuable educational experience. However, preceptors had more positive ratings regarding their role and the benefits of the course than did medical students.

Conclusion

This study corroborates prior work showing extensive perceived benefits of longitudinal preclerkship exposure to primary care; however, preceptors were found to report more positive reviews of the course than students. This study also provides new innovative tools to assess students' and preceptors' perceptions of longitudinal, preclerkship family medicine courses available for use over time and in different educational contexts.

Lived experiences of multimorbidity: An interpretative meta-synthesis of patients', general practitioners' and trainees' perceptions

OBJECTIVES

Multimorbidity is an increasing challenge. Better understanding of lived experiences of patients, general practitioners and trainees, may advance patient care and medical education. This interpretative meta-synthesis sought to (i) understand lived experiences of patients, general practitioners and trainees regarding multimorbidity, (ii) identify how similarities and differences in experiences should shape future solutions.

METHODS

Empirical studies containing qualitative data and pertaining to lived experiences from our recent realist synthesis (PROSPERO 2013:CRD42013003862) were included. Following quality assessment, data were extracted from key studies to build an integrated analytic framework. Data from remaining studies were utilised to expand and refine the framework through thematic analysis of concepts within and between perspectives.

RESULTS

Twenty-one papers were included in the meta-synthesis. Analysis of 70 concepts produced five themes: (1) goals of care and decision making, (2) complexity, (3) meeting expectations, (4) logistics and (5) interpersonal dynamics. The complexities of multimorbidity lead to shared feelings of vulnerability, uncertainty and enforced compromises. Barriers to optimal care-education included system constraints, inadequate continuity and role uncertainty.

DISCUSSION

There was little evidence of shared discussion of these challenges. Addressing these issues and more explicit exploration of the experiences of each group during interactions may improve delivery and satisfaction in care and education.

Hidden benefits of a peer-mentored 'Hospital Orientation Day': first-year medical students' perspectives

BACKGROUND

Entering the clinical environment is potentially stressful for junior medical students.

AIMS

We evaluated first-year medical student feedback on a peer-mentored 'Hospital Orientation Day' designed to provide insight into future clinical training.

METHOD

Using a mixed methodology approach data were collected from first-year medical students. Responses to a questionnaire were used to develop a topic guide for focus groups held the next academic year. The questionnaire was completed by 230 first-year students and 32 second years participated in the interviews. Thematic analysis was used to draw conclusions.

RESULTS

Analysis of questionnaire responses indicated that students gained insight into future learning. Focus groups then generated five themes: (1) entering the hospital without fear, (2) linking the present with the future, (3) understanding the culture of learning in the clinical years, (4) a 'Backstage Pass' to the clinical world and (5) peer mentors make or break the day.

CONCLUSIONS

Using peer mentors during the Hospital Orientation Day allowed insight into future learning. We highlight the importance of student Mentors in the success of hospital orientation. To maximise the benefits for first years, we recommend a mentor selection procedure, mentor training opportunities and incentives to optimise mentor performance.

Workplace learning from a socio-cultural perspective: creating developmental space during the general practice clerkship

Workplace learning in undergraduate medical education has predominantly been studied from a cognitive perspective, despite its complex contextual characteristics, which influence medical students' learning experiences in such a way that explanation in terms of knowledge, skills, attitudes and single determinants of instructiveness is unlikely to suffice. There is also a paucity of research which, from a perspective other than the cognitive or descriptive one, investigates student learning in general practice settings, which are often characterised as powerful learning environments. In this study we took a socio-cultural perspective to clarify how students learn during a general practice clerkship and to construct a conceptual framework that captures this type of learning. Our analysis of group interviews with 44 fifth-year undergraduate medical students about their learning experiences in general practice showed that students needed developmental space to be able to learn and develop their professional identity. This space results from the intertwinement of workplace context, personal and professional interactions and emotions such as feeling respected and self-confident. These forces framed students' participation in patient consultations, conversations with supervisors about consultations and students' observation of supervisors, thereby determining the opportunities afforded to students to mind their learning. These findings resonate with other conceptual frameworks and learning theories. In order to refine our interpretation, we recommend that further research from a socio-cultural perspective should also explore other aspects of workplace learning in medical education.

Engagement and opportunity in clinical learning: findings from a case study in primary care

BACKGROUND

This article explores in a primary care setting how clinical learning occurs across a range of professional groups and levels of learner experience, both undergraduate and postgraduate.

AIM

To explore how clinical learning occurs in a primary care workplace from a socio-cultural perspective.

METHOD

A single case study approach using interview data from 33 participants and strengthened through direct and indirect observations and documentary evidence.

RESULTS

Clinical learning occurs through engagement and opportunity. Engagement in learning appeared to be developed through four elements: recognition, respect, relevance and emotion. Opportunity includes the availability of patient encounters (made meaningful through the immediacy of hearing patient narratives de novo and the authenticity arising from the social context of illness) and the ability to learn with peers and professional colleagues.

CONCLUSION

These findings support and develop existing literature on learning in other clinical settings. They are consistent with socio-cultural theories of learning, but develop this literature within the context of clinical education. Engagement and learning occurred in transient learners in the absence of prolonged participation, belonging or a clear trajectory of learning. The study offers evidence from multiple learner perspectives as to how the learning environment might be enhanced in all educational settings.

When only the real thing will do: junior medical students' learning from real patients

OBJECTIVES

This study aimed to explore how medical students experience contacts with real patients and what they learn from them.

METHODS

We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers.

RESULTS

Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent.

CONCLUSIONS

Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical 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.

Evaluating Student Performance in Undergraduate Preceptorships

This article explores the challenges in evaluating student performance in preceptorships based on data collected during academic years 1999-2002, which revealed an unusually large number of high grades and relatively few average grades. Multiple perspectives are explored, including preceptor issues of selection, orientation, recognition, role conflict, and experience with giving grades; faculty issues of role confusion and unclear expectations for student performance; and environmental issues of lack of control of the learning environment and differences in the values of education and workplace. Solutions are proposed, including an orientation for preceptors and faculty, ongoing faculty mentoring of preceptors, official preceptor recognition, clear articulation of expectations for student performance and faculty site visits, and creation of grading rubrics for various aspects of the course to be used by preceptors, faculty, and students.

How can experience in clinical and community settings contribute to early medical education? A BEME systematic review

REVIEW DATE

Review period January 1992-December 2001. Final analysis July 2004-January 2005. BACKGROUND AND REVIEW CONTEXT: There has been no rigorous systematic review of the outcomes of early exposure to clinical and community settings in medical education. OBJECTIVES OF REVIEW: Identify published empirical evidence of the effects of early experience in medical education, analyse it, and synthesize conclusions from it. Identify the strengths and limitations of the research effort to date, and identify objectives for future research.

SEARCH STRATEGY

Ovid search of: BEI, ERIC, Medline, CINAHL and EMBASE Additional electronic searches of: Psychinfo, Timelit, EBM reviews, SIGLE, and the Cochrane databases. Hand-searches of:Medical Education, Medical Teacher, Academic Medicine, Teaching and Learning in Medicine, Advances in Health Sciences Education, Journal of Educational Psychology.

CRITERIA

DEFINITIONS

EXPERIENCE

Authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional. Early: What would traditionally have been regarded as the preclinical phase, usually the first 2 years. Inclusions: All empirical studies (verifiable, observational data) of early experience in the basic education of health professionals, whatever their design or methodology, including papers not in English. Evidence from other health care professions that could be applied to medicine was included.

EXCLUSIONS

Not empirical; not early; post-basic; simulated rather than 'authentic' experience.

DATA COLLECTION

Careful validation of selection processes. Coding by two reviewers onto an extensively modified version of the standard BEME coding sheet. Accumulation into an Access database. Secondary coding and synthesis of an interpretation.

HEADLINE RESULTS

A total of 73 studies met the selection criteria and yielded 277 educational outcomes; 116 of those outcomes (from 38 studies) were rated strong and important enough to include in a narrative synthesis of results; 76% of those outcomes were from descriptive studies and 24% from comparative studies. Early experience motivated and satisfied students of the health professions and helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills. There were outcomes for beneficiaries other than students, including teachers, patients, populations, organizations and specialties. Early experience increased recruitment to primary care/rural medical practice, though mainly in US studies which introduced it for that specific purpose as part of a complex intervention.

CONCLUSIONS

Early experience helps medical students socialize to their chosen profession. It helps them acquire a range of subject matter and makes their learning more real and relevant. It has potential benefits for other stakeholders, notably teachers and patients. It can influence career choices.

Instrumental strategy: A stage in students' consultation skills training? Observations and reflections on students' communication in general practice consultations

OBJECTIVES

To explore and examine students' abilities to communicate with patients during a general practice course in the final year of the curriculum and to analyse and consider this experience in relation to earlier consultation training.

SETTING

General practice courses in the undergraduate curriculum.

DESIGN

Qualitative data analysis was used. A special focus-group interview of experienced supervisors was performed and analysed (editing analysis). Credibility of data was tested at local seminars and conferences. Authors' experiences of observing student consultations over many years were also used.

RESULTS

A main theme, 'open invitation', emerged based on categories 'initially attentive' and 'listening attitude'. In contrast, the second main theme was 'instrumental strategy', based on the following categories: 'one-sided collection of medical facts' and 'relationship-building lost'. The students also had difficulties in devoting attention to patients' life experiences. An hourglass metaphor of students' and young physicians' progression of communication strategies is presented. The narrow part of the hourglass corresponds to an instrumental strategy at the end of undergraduate clinical education.

CONCLUSIONS

An instrumental strategy may be a stage in student's consultation learning progression that interferes with communication training. A question is raised: is training of a patient-centred approach throughout the clinical curriculum needed for optimal development of consultation skills? Further research is needed to test this hypothesis.

Early practical experience and the social responsiveness of clinical education: systematic review

OBJECTIVES

To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence.

DESIGN

A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001.

DATA SOURCES

Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration.

SELECTION OF STUDIES

All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication.

RESULTS

Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations.

CONCLUSION

Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Medical Students’ Perceptions of Feedback in a Busy Ambulatory Setting: A Descriptive Study Using a Clinical Encounter Card

BACKGROUND

Residents and medical students have expressed repeated concerns over the years about the inadequate amounts and quality of feedback in the clinical setting. Despite innovative ways to teach the skill of giving feedback, the problem has not been fixed.

METHODS

In this study, the author introduced the clinical encounter card to the ambulatory setting for faculty to use as a cue to provide feedback to students. At the end of the 4-week rotation, students anonymously reported on the amount, frequency, and quality of feedback they received.

RESULTS

Students reported that the learning climate for giving/receiving feedback was very good to excellent. They rated the quality and amount of feedback they received from faculty as high on the Likert scale and the frequency just above the mean. Most of the feedback was directed toward knowledge and skills, and there were few reports of demeaning behavior. Feedback was timely, and students reported using the feedback to improve their performance. The clinical encounter card improved feedback to students in a busy ambulatory setting. Whereas the author did not monitor how often the clinical encounter card was used, there were ample cards on each student to provide mid-rotation feedback and summative evaluations. The students rated the process as the best of any clerkship rotation.

CONCLUSIONS

The clinical encounter card is an effective tool to enhance feedback in a busy pediatric ambulatory setting. It is not known if these results are generalizable, but readers are encouraged to repeat the study in other settings.

Contributing to the theory development of preceptorship

The purpose of the study was to clarify and analyze the concept of preceptorship as experienced by the preceptor. Preceptorship is a teaching method commonly used in many professions. The current study assists in the clarification and analysis of the concept of preceptorship as experienced by the preceptor. Regarding methodology, the literature was reviewed to compare the experience of clinical teaching with preceptorship. Literature was reviewed from the following fields/domains: nursing, medicine, education, social work, rehabilitation, dentistry, law, and pharmacy. Through application of the framework outlined by Walker, L.O., Avant, K.C., 1995. Strategies for Theory Construction in Nursing, third ed. Appleton & Lange, Norwalk, attributes, antecedents, consequences, and empirical referents were identified that help define preceptorship. There were three main findings: The nature of the relationship between the preceptor and preceptee is pivotal, evaluation is a challenge, and preceptorship is distinct from mentorship. The consequences of a preceptorship experience are better prepared and more confident preceptors, evolution into a mentorship relationship, and professional development of both the preceptor and the preceptee. This article concludes with numerous topics that could be addressed in future research: (a) screening tools for the preceptor; (b) evaluation of the preceptee; (c) the relationship between preceptee, preceptor, and faculty; (d) preparation of the preceptor, and (e) rewarding the preceptor.