Interns' participation and learning in clinical environments in a New Zealand hospital

Junior doctor skill in the art of physical examination: a retrospective study of the medical admission note over four decades

OBJECTIVES

To investigate the hypothesis that junior doctors' examination skills are deteriorating by assessing the medical admission note examination record.

DESIGN

Retrospective study of the admission record.

SETTING

Tertiary care hospital.

METHODS

The admission records of 266 patients admitted to Wellington hospital between 1975 and 2011 were analysed, according to the total number of physical examination observations (PEOtot), examination of the relevant system pertaining to the presenting complaint (RelSystem) and the number of body systems examined (Nsystems). Subgroup analysis proceeded according to admission year, level of experience of the admitting doctor (registrar, house surgeon (HS) and trainee intern (TI)) and medical versus surgical admission notes. Further analysis investigated the trend over time in documentation with respect to cardiac murmurs, palpable liver, palpable spleen, carotid bruit, heart rate, funduscopy and apex beat location and character.

RESULTS

PEOtot declined by 34% from 1975 to 2011. Surgical admission notes had 21% fewer observations than medical notes. RelSystem occurred in 94% of admissions, with no decline over time. Medical notes documented this more frequently than surgical notes (98% and 86%, respectively). There were no differences between registrars and HS, except for the 2010s subgroup (97% and 65%, respectively). Nsystems declined over the study period. Medical admission notes documented more body systems than surgical notes. There were no differences between registrars, HSs and TIs. Fewer examinations were performed for palpable liver, palpable spleen, cardiac murmur and apex beat location and character over the study period. There was no temporal change in the positive findings of these observations or heart rate rounding.

CONCLUSIONS

There has been a decline in the admission record at Wellington hospital between 1975 and 2011, implying a deterioration in local doctors' physical examination skills. Measures to counter this trend are discussed.

Workplace learning in veterinary education: a sociocultural perspective

Veterinary practice is a broad sphere of professional activity encompassing clinical activity and other vocational opportunities conducted in rapidly changing contemporary social conditions. Workplace learning is an important but resource-intensive component of educating students for practice. This conceptual article argues that literature on workplace learning in the veterinary context is dominated by descriptive accounts and that there is a dearth of theoretically informed research on this topic. Framing veterinary practice as a social, relational, and discursive practice supports the use of workplace learning theories developed from a sociocultural perspective. Situated learning theory, with its associated concepts of communities of practice and legitimate peripheral participation, and workplace learning theory focused on workplace affordances and learner agency are discussed. Two composite examples of student feedback from veterinary clinical learning illustrate the concepts, drawing out such themes as the roles of teachers and learners and the assessment of integrated practice. The theoretical perspective described in this article can be used to inform development of models of workplace learning in veterinary clinical settings; relevant examples from medical education are presented.

The role of role: learning in longitudinal integrated and traditional block clerkships

CONTEXT

Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design.

METHODS

This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data.

RESULTS

Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care.

CONCLUSIONS

Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.

Impact of a Resident-as-Teacher Workshop on Teaching Behavior of Interns and Learning Outcomes of Medical Students

BACKGROUND

Residents and interns are recognized as important clinical teachers and mentors. Resident-as-teacher training programs are known to improve resident attitudes and perceptions toward teaching, as well as their theoretical knowledge, skills, and teaching behavior. The effect of resident-as-teacher programs on learning outcomes of medical students, however, remains unknown. An intervention cohort study was conducted to prospectively investigate the effects of a teacher-training workshop on teaching behavior of participating interns and on the clerkship learning outcomes of instructed fourth-year medical students.

METHODS

The House Officer-as-Teacher Training Workshop was implemented in November 2009 over 1.5 days and attended by all 34 interns from one teaching hospital. Subsequently, between February and August 2010, 124 fourth-year medical students rated the observable teaching behavior of interns during 6-week general surgery clerkships at this intervention hospital as well as at 2 comparable hospitals serving as control sites. Ratings were collected using an anonymous 15-item Intern Clinical Teaching Effectiveness Instrument. Student achievement of clerkship learning outcomes during this period was evaluated using a validated and centralized objective structured clinical examination.

RESULTS

Medical students completed 101 intern clinical teaching effectiveness instruments. Intern teaching behavior at the intervention hospital was found to be significantly more positive, compared with observed behavior at the control hospitals. Objective structured clinical examination results, however, did not demonstrate any significant intersite differences in student achievement of general surgery clerkship learning outcomes.

CONCLUSIONS

The House Officer-as-Teacher Training Workshop noticeably improved teaching behavior of surgical interns during general surgery clerkships. This improvement did not, however, translate into improved achievement of clerkship learning outcomes by medical students during the study period.

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.

Simple truths from medical students: perspectives on the quality of clinical learning environments

BACKGROUND

The opportunity for students to learn whilst in a clinical placement is a central component of undergraduate medical education and an educationally conducive clinical environment is essential if the student is to optimise learning opportunities.

AIM

This study, which was conducted by medical students, and amongst medical students aims to investigate the key conditions that students most value when placed in clinical settings.

METHODS

A qualitative approach was adopted in which a series of focus group discussions were conducted by senior medical students trained in the facilitation of focus group moderation. In total, 30 students contributed to four separate focus groups.

RESULTS

Whilst students identified some factors which were similar to previous studies, other factors considered important to learning in the clinical setting surfaced. Namely, the need for students to be self-motivated and the valuable contribution that other medical students can make to the learning of their peers.

CONCLUSIONS

Our findings concur with other similar studies. However, our findings were generated by medical students and not subject to influence by university teachers during the data collection and analysis. This not only serves to reinforce previous studies but also supports the use of peer data collection from medical students.

Becoming a practitioner: workplace learning during the junior doctor's first year

BACKGROUND

Newly qualified doctors (interns) report that they learn a great deal in the first year of practice, but exactly what is learnt is not well understood.

AIMS

To document the reflections and perceptions of first year junior doctors in order to reveal and chronicle their informal and often tacit learning in the workplace within a practice methodology framework.

METHODS

New Zealand interns, from three sites, participated in group interviews modelled on a conversation and joint enquiry style.

RESULTS

We found that learning in the first year after graduation falls into three broad themes: (1) concrete tasks, (2) project management and (3) identity formation. Identity formation appeared the most challenging and included getting used to being seen by others as a doctor.

CONCLUSION

All themes have implications for curriculum development and clinical supervision in both undergraduate programmes and during internship. The third theme (identify formation) is the most complex. We draw on a model from management literature, to describe intern education as a process of becoming: as an unfolding and as a transformation of the self over time. We argue that reconfiguring internship as a period of identity formation, and as a self-determined, active process of 'becoming a doctor' provides a wider perspective than enculturation or socialisation theories to understand this significant transition.

Experiential learning: AMEE Guide No. 63

This Guide provides an overview of educational theory relevant to learning from experience. It considers experience gained in clinical workplaces from early medical student days through qualification to continuing professional development. Three key assumptions underpin the Guide: learning is 'situated'; it can be viewed either as an individual or a collective process; and the learning relevant to this Guide is triggered by authentic practice-based experiences. We first provide an overview of the guiding principles of experiential learning and significant historical contributions to its development as a theoretical perspective. We then discuss socio-cultural perspectives on experiential learning, highlighting their key tenets and drawing together common threads between theories. The second part of the Guide provides examples of learning from experience in practice to show how theoretical stances apply to clinical workplaces. Early experience, student clerkships and residency training are discussed in turn. We end with a summary of the current state of understanding.

Participation and progression: new medical graduates entering professional practice

The first year of practice after medical school is considered to be an essential part of becoming a medical practitioner in Australia. Previous qualitative investigations have investigated a number of significant aspects of this early stage of professional development. This qualitative study explores experiences and developing professional identities during internship. Thirty interns and six intern supervisors were interviewed from three different Australian states. Grounded theory techniques were used to develop three key themes: internship-as-participation, internship-as-progression, and conflicts, parallels, disturbances and outliers. Key findings were: the important balance between support from colleagues and development through taking independent responsibility; and the strength of the view of internship as part of a 'natural progression', an inevitable evolution through the stages of medical training.

Early clinical experience: do students learn what we expect?

CONTEXT

Early clinical experience is thought to contribute to the professional development of medical students, but little is known about the kind of learning processes that actually take place. Learning in practice is highly informal and may be difficult to direct by predefined learning outcomes. Learning in medical practice includes a socialisation process in which some learning outcomes may be valued, but others neglected or discouraged.

OBJECTIVES

This study describes students' learning goals (prior to a Year 1 nursing attachment) and learning outcomes (after the attachment) in relation to institutional educational goals, and evaluates associations between learning outcomes, student characteristics and place of attachment.

METHODS

A questionnaire containing open-ended questions about learning goals and learning outcomes was administered to all Year 1 medical students (n = 347) before and directly after a 4-week nursing attachment in either a hospital or a nursing home. Two confirmatory focus group interviews were conducted and data were analysed using qualitative and quantitative content analyses.

RESULTS

Students' learning goals corresponded with educational goals with a main emphasis on communication and empathy. Other learning goals included gaining insight into the organisation of health care and learning to deal with emotions. Self-reported learning outcomes were the same, but students additionally mentioned reflection on professional behaviour and their own future development. Women and younger students mentioned communication and empathy more often than men and older students. Individual learning goals, with the exception of communicating and empathising with patients, did not predict learning outcomes.

CONCLUSIONS

Students' learning goals closely match educational goals, which are adequately met in early nursing attachments in both hospitals and nursing homes. Learning to deal with emotions was under-represented as a learning goal and learning outcome, which may indicate that emotional aspects of medical students' professional development are neglected in the first year of medical education.

Exploring deliberate practice in medicine: how do physicians learn in the workplace?

Medical professionals need to keep on learning as part of their everyday work to deliver high-quality health care. Although the importance of physicians' learning is widely recognized, few studies have investigated how they learn in the workplace. Based on insights from deliberate practice research, this study examined the activities physicians engage in during their work that might further their professional development. As deliberate practice requires a focused effort to improve performance, the study also examined the goals underlying this behaviour. Semi-structured interviews were conducted with 50 internal medicine physicians: 19 residents, 18 internists working at a university hospital, and 13 working at a non-university hospital. The results showed that learning in medical practice was very much embedded in clinical work. Most relevant learning activities were directly related to patient care rather than motivated by competence improvement goals. Advice and feedback were sought when necessary to provide this care. Performance standards were tied to patients' conditions. The patients encountered and the discussions with colleagues about patients were valued most for professional development, while teaching and updating activities were also valued in this respect. In conclusion, physicians' learning is largely guided by practical experience rather than deliberately sought. When professionals interact in diagnosing and treating patients to achieve high-quality care, their experiences contribute to expertise development. However, much could be gained from managing learning opportunities more explicitly. We offer suggestions for increasing the focus on learning in medical practice and further research.

Informal learning in the workplace: what are the environmental barriers for junior hospital pharmacists?

Objective

To determine the environmental barriers to informal learning in the workplace of junior hospital pharmacists.

Setting

A pharmacy department within a large teaching hospital in the north west of England.

Method

Twelve semi-structured interviews were conducted with the entire population of junior hospital pharmacists (n = 12). Interviewees were asked about their responsibilities and their learning in the workplace. Questions were also asked about how various aspects of the workplace environment influenced their learning and ability to develop as a pharmacist.

Key findings

Three key environmental barriers to informal learning in the workplace were identified. Firstly, the allocation and structuring of work inhibited the junior hospital pharmacists' informal learning by causing them to work under pressure and in isolation; in addition, the rotational nature of the job created barriers to informal learning. Secondly, lack of feedback and goals inhibited their learning. They also felt that the managers were not fostering an environment conducive to learning. Finally, structural inhibitors such as location of departments, and lack of desk space and computers were perceived to limit their ability to learn.

Conclusion

This study highlights the presence of environmental barriers to informal learning for junior hospital pharmacists. While these barriers are contextual and closely related to the workplace setting, their identification will enable those responsible for the development of junior pharmacists in the workplace to take these into consideration when promoting informal learning.

The learning environment of paediatric trainees in New Zealand

AIMS

To assess the learning environment of New Zealand paediatric trainees, examine the factors influencing the trainee's perceptions of their learning environment and to assess the suitability of using the Postgraduate Hospital Education Environment Measure (PHEEM) in New Zealand.

METHODS

Paediatric trainees completed the PHEEM questionnaire and returned this anonymously by email.

RESULTS

Both basic and advanced trainees' perceptions of the environment were generally positive but significant concerns were identified. There were differences in perceptions of the learning environment between the basic and advanced trainees and between sites with more than six trainees compared with those with six or fewer trainees. The PHEEM is practical to use, showed good internal consistency and was acceptable to trainees.

CONCLUSIONS

Both basic and advanced trainees perceived the learning environment positively but significant concerns must be addressed. The advanced trainees perceived the overall learning environment and the teaching they receive more positively than basic trainees. Trainees at smaller hospitals perceived that their social supports were better than at larger hospitals. The PHEEM can be used to assess the paediatric training environment in New Zealand.

Transitional clerkship: an experiential course based on workplace learning theory

Starting clerkships is anxiety provoking for medical students. To ease the transition from preclerkship to clerkship curricula, schools offer classroom-based courses which may not be the best model for preparing learners. Drawing from workplace learning theory, the authors developed a seven-day transitional clerkship (TC) in 2007 at the University of California, San Francisco School of Medicine in which students spent half of the course in the hospital, learning routines and logistics of the wards along with their roles and responsibilities as members of ward teams. Twice, they admitted and followed a patient into the next day as part of a shadow team that had no patient-care responsibilities. Dedicated preceptors gave feedback on oral presentations and patient write-ups. Satisfaction with the TC was higher than with the previous year's classroom-based course. TC students felt clearer about their roles and more confident in their abilities as third-year students compared with previous students. TC students continued to rate the transitional course highly after their first clinical rotation. Preceptors were enthusiastic about the course and expressed willingness to commit to future TC preceptorships. The transitional course models an approach to translating workplace learning theory into practice and demonstrates improved satisfaction, better understanding of roles, and increased confidence among new third-year students.

How undergraduate clinical learning climates differ: a multi-method case study

CONTEXT

The clinical learning climate affects undergraduate medical students' behaviour, satisfaction and success. Most studies predominantly describe aspects of the clinical learning climate using quantitative methodologies, such as questionnaires. This study aimed to illuminate medical students' perceptions of the clinical learning climate, and which factors and their interactions explain differences in clinical learning climates.

METHODS

We carried out a multi-method case study. Twelve departments of obstetrics and gynaecology distributed the Postgraduate Hospital Educational Environment Measure (PHEEM), a reliable questionnaire measuring the clinical learning environment, among medical students. After analysis (using anova and post hoc tests), 14 medical students from the highest- and lowest-scoring departments participated in semi-structured interviews. We analysed the transcribed recordings using a content analysis approach. Researchers agreed on coding and an expert group reached consensus on the themes of the analysis.

RESULTS

We found a significant difference between departments in PHEEM scores. The interviews indicated that department and medical student characteristics determine the clinical learning climate. For departments, 'legitimacy', 'clerkship arrangements' and 'focus on personal development' were the main themes. For medical students, 'initial initiatives', 'continuing development' and 'clerkship fatigue' were the principal themes. The amount and nature of participation played a central role in all themes.

CONCLUSIONS

Differences between clinical learning climates appear to be related to differing approaches to participation among departments. Participation depends on characteristics of both departments and students, and the interactions among them. The outcomes give valuable clues to how a favourable clinical learning climate is shaped.

Maximising the clinical learning of junior doctors: applying educational theory to practice

Effective learning in the workplace emphasises the importance of participation in the social context and activities of that workplace. A model has previously been developed that sets out the elements of positive and participatory learning environments. The introduction of an attachment in the Emergency Department for newly graduated doctors provided an opportunity to (1) identify and implement the relevant elements from the theoretical model; (2) develop an evaluation plan in order to guide and monitor the intervention. The lessons learned from converting a theoretical model into practice and the use of quality management processes for implementation, monitoring, and evaluation are discussed.

Postgraduate obstetrics and gynaecology experience: The role for early exposure

BACKGROUND

The early postgraduate years provide the opportunity for junior doctors to gain a range of experience and determine their focused areas of interest. Internship thus requires experience in medicine, surgery and the emergency department. Obstetrics and gynaecology (O & G) is not offered as an internship rotation, despite its suitability as such. A cross-sectional analysis of junior doctors was performed to assess residents' views on the suitability of an O & G rotation for career decision-making and for achieving sufficient clinical experience.

METHODS

Fifty-two resident medical staff in their second postgraduate year were recruited and each was given an anonymous survey for completion. Visual analogue scales (VAS) were used for participant responses.

RESULTS

For whether internship without an O & G rotation provides sufficient experience to include or exclude O & G as a career choice, the average participant response was 2.1 (on a VAS out of 10) (P<0.0001). For whether an O & G internship rotation would provide adequate medical, surgical or emergency department experience, the average response was 7.9 (on the VAS out of 10) (P<0.0001). As to whether participants would have preferred to undergo an O & G rotation during internship, the average response was 7.7 (P<0.0001).

CONCLUSION

The present study demonstrated a perception by residents that an O & G rotation during internship would achieve adequate clinical competencies and assist in career decision-making in O & G, with residents preferring to have undergone an O & G rotation during internship.

Prevocational medical training in Australia: where does it need to go?

The workplace remains the most important learning environment for junior doctors in their postgraduate years. There is no national curriculum to guide the education of prevocational doctors. The apprenticeship model is under threat, and is not sustainable in the future without significant changes to the system. Supervision is crucial for junior doctors' learning and for safe, quality patient care.