Exploring patient experiences in the student outpatient clinic - A contribution to learning

Clinical Clerkship With or Without Scheduled Patient Consultations: Does It Make a Difference to Medical Students' Experiences of Learning?

Background

Becoming a medical expert involves leadership and professionalism, which are critical skills to learn in medical education. However, a gap exists in understanding how didactic variations in the organisation of clinical clerkships impact medical students' opportunities to develop these skills. This study explored how clinical clerkships with or without scheduled patient consultations affect medical students' experiences of learning leadership and professional behaviour.

Materials and Methods

We conducted a qualitative, quasi-experimental study. Data were gathered through 11 end-of-clerkship focus group interviews with 87 fifth-year medical students who participated in one of two 8-week clerkships at a surgical department: a clerkship with a mentor physician or a clerkship with scheduled patient consultations in combination with a mentor physician. Using a constructivist lens, we analysed the focus group interview transcripts and applied grounded theory principles to the iterative coding process.

Results

The analyses resulted in a descriptive framework displaying nine themes. Each theme was described as a spectrum of meanings that offers a nuanced understanding of how didactic variations in the organisation of clerkship impact how students ascribed meaning to the learning experiences in undergraduate medical education, focusing on learning leadership and professional behaviour.

Discussion

This study investigates differences in student learning experiences when participating in a clerkship with or without scheduled patient consultation and, therefore, adds new insight into the need for a balanced, thoughtful, and didactic approach to medical education that considers both clinical exposure and co-regulated learning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-024-02160-3.

From shadowing to active learning: exploring the impact of supervised teaching clinics on gynecology education

Background

Supervised Teaching Clinics (STCs) have emerged as an innovative approach to medical education, particularly in specialties like gynecology, where hands-on experience is crucial. Traditional clinical rotations often leave students in passive roles, limiting their active participation and the development of essential clinical skills.

Aim

This study aimed to evaluate the impact of STCs on the clinical competencies and professional development of medical students within a gynecological clinic, comparing the outcomes with those of traditional clinic shadowing.

Methods

A total of 144 fifth-year medical students were randomly assigned to either a control group, which participated in traditional clinic shadowing, or an STC group, which engaged in both shadowing and supervised teaching activities. The study utilized the Generalized Self-Efficacy Scale (GSES) and the mini-Clinical Evaluation Exercise (mini-CEX) to assess clinical performance. Feedback was also collected from students, tutors, and patients to gage satisfaction and perceived effectiveness.

Results

Students in the STC group demonstrated significantly higher improvements in clinical skills, particularly in medical interviewing, counseling, and overall clinical competence, compared to the control group. The STC group also reported greater satisfaction with their learning experience, citing enhanced confidence and a deeper understanding of gynecological practice. Tutors and patients provided positive feedback, noting the STC's role in fostering effective student-patient interactions and comprehensive learning.

Conclusion

The structured design of the STC, with a focus on goal direction, relationships, and supporting services, significantly improved educational outcomes in gynecology. By fostering active learning and delivering constructive feedback, STCs effectively enhance students' clinical competencies and professional development. The study suggests that integrating STCs into traditional clinical education models could substantially optimize medical training.

When the Patient is Absent in Patient-Centered Communication Training: A Discursive Analysis of How Medical Students Learn to Interact with Patients

Phenomenon: Patient-centered communication is an ideal for undergraduate medical education and has been for decades. However, medical students often find the patient-centered approach challenging. The present study finds a possible discordance between formal intentions of a medical curriculum and the corresponding learning environment. The objective of our study was to explore how medical curriculum resonates with the purpose of patient-centered medicine, including how a possible dynamic may have helped maintain this discordance in undergraduate medical education. Approach: The study took a qualitative approach exploring the medical curriculum via a structured communication course. The educational context for the course was considered a discursive environment, partially constructed through documents. The concept of textual agency was used to analyze curriculum and course documents. This was to explore how competencies were presented in the medical curriculum and course descriptions and how they were translated through the practices of the communication course. Inductive thematic analysis was used to analyze observations made during the course. Findings: Our analysis suggested that the medical curriculum content and structure still emphasize bio-medical disciplines and knowledge domains in students learning. This connected well with the socialization of medical students toward the role as medical experts whose primary task is to provide information, while patients are defined as passive subjects, who received information. The course description also operationalized complexities of patient-centered communication to a measurable, instrumental structure of skills. This focus on one-directional communication frames the students' understanding of the courses and their performance in it. They learn that: (1) meeting a real patient is a rare opportunity, (2) engaging patients' thoughts and feelings in the conversation is challenging, and (3) the biomedical aspect should be prioritized in the conversation. Insights: These findings suggested that the medical curriculum we studied gave limited room for patient-centered medicine, even in communication training. The power of macro-level documents framed and focused micro-level learning activities and could help explain observed disharmonies in patient-medical student encounters. We see how patient-centered medicine - in both texts and practice - is represented and enacted as a peripheral activity and patients are given a marginal position in encounters with students. The findings suggested that there are challenges for progress and change toward a more patient-centered communication training and curriculum. However, empirical findings also offered points of departure for course leaders and curriculum planners wishing to take steps toward a stronger and more reflective patient-centered approach in medical education, supported through the document structure and the translation of the curriculum through relevant learning activities.

Patients' perspectives on their motivations for participating in non-clinical medical teaching and what they gain from their experience: a qualitative study informed by critical theory

In 2019-2021, we engaged in a project aimed at developing, implementing, and evaluating an educational intervention actively involving patient-teachers in undergraduate medical education at Université Laval, Quebec, Canada. Patient-teachers were invited to participate in small group discussion workshops during which medical students deliberate on legal, ethical, and moral issues arising from medical practice. Patients were expected to bring other perspectives, based on their experience with illness and the healthcare system. Little is still known about patients' perspectives on their participation experience in such context. Informed by critical theory, our qualitative study aims to document,: (i) the motivating factors for patients' participation in our intervention; and (ii) what patients gained from the experience. Data collection was based on 10 semi-structured interviews with patient-teachers. A thematic analysis was conducted using NVivo software. Motivators for participation arose from: (i) perceived consistency between patients' individual characteristics and those of the project, and (ii) conceiving the project as a means to reach individual and social goals. What patients gained mainly refers to (1) the appreciation of a positive, enriching, motivating yet uncomfortable and destabilizing experience; (2) a deconstruction of biases against the medical field and critical thinking about their own experience; (3) new knowledge, with a potential impact on their future interactions with the healthcare system. Results reveal patients as non-neutral thinking and knowing subjects, engaged in the participation experience as active teachers and learners. They also highlight the empowering and emancipatory nature of the learning gained through patients' participation experience. These conclusions prompt us to promote transformative interventional approaches that question the pervasive power issues in medical teaching and value patients' specific knowledge in teaching and learning the Art of Medicine.

The effect of early follow-up after open cardiac surgery in a student clinic

Objectives. Readmission rates following open cardiac surgery are high, affecting patients and the cost of care. This study aimed to investigate the effect of early additional follow-up after open cardiac surgery when 5th-year medical students conducted follow-ups under the supervision of physicians. The primary endpoint was unplanned cardiac-related readmissions within one year. The secondary outcomes were the detection of impending complications and health-related quality of life (HRQOL). Methods. Patients undergoing open cardiac surgery were prospectively included. For intervention, additional follow-up visits, including point-of-care ultrasound, were conducted by supervised 5th-year medical students on postoperative days 3, 14 and 25. Unplanned cardiac-related readmissions, including emergency department visits, were registered within the first year of surgery. Danish National Health Survey 2010 questionnaire was used for HRQOL. In standard follow-up, all patients were seen 4-6 weeks postoperative. Results. For data analysis, 100 of 124 patients in the intervention group and 319 of 335 patients in the control group were included. The 1-year unplanned readmission rates did not differ; 32% and 30% in the intervention and control groups, respectively (p = 0.71). After discharge, 1% of patients underwent pericardiocentesis. The additional follow-up initiated scheduled drainage, contrary to more unscheduled/acute drainages in the control group. Pleurocentesis was more common in the intervention group (17% (n = 17) vs 8% (n = 25), p = 0.01) and performed earlier. There was no difference between groups on HRQOL. Conclusion. Supervised student-led follow-up of newly cardiac-operated patients did not alter readmission rates or HRQOL but may detect complications earlier and initiate non-emergent treatment of complications.

Patient-centred learning in practice. A mixed methods study of supervision and learning in student clinics

OBJECTIVE

Patient-centred learning (PCL) allows medical students to practice a patient-centred approach; however, didactic characteristics of PCL have yet to be fully elucidated. Clinical placements structured as a student clinic (SC) enable authentic student-patient learning relations through enhanced student responsibility and can serve as examples of PCL. We explored the didactic characteristics of supervision and learning in SCs to provide recommendations for PCL-oriented medical education.

METHODS

Triangulation mixed methods study based on qualitative data collected from in-depth interviews with clinical teachers and quantitative data collected from student evaluations of supervision and learning in the SCs.

RESULTS

Supervision and learning in SCs were characterized by 1) a focus on student-patient compatibility and patient needs and resources, which indicated PCL, 2) person-centred explorative supervision to adjust challenges to students' needs and resources, and 3) support of student autonomy to take responsibility for patient treatment.

CONCLUSION

PCL was facilitated by clinical teachers through a dual person-centred didactic approach combined with autonomy-supportive didactic practice. This enabled the integration of patients' and students' needs and resources in clinical teaching.

PRACTICE IMPLICATIONS

Clinical teachers can stimulate student-patient learning relations by selecting patients, exploring students' needs and resources, and supporting student autonomy through reflective practice and backup.

'Making room for student autonomy' - an ethnographic study of student participation in clinical work

Participation in clinical work is important for medical students' professional development. However, students often report that they experience a passive observer role, and further research on contextual factors that influence student participation is needed. The theory of practice architectures contributes a new perspective to this challenge by elucidating how cultural-discursive, material-economic, and social-political arrangements enable and constrain student participation in clinical work. The aim of this study was to explore how practice architectures in clinical learning environments enable and constrain medical students' participation. The study was designed as an ethnographic field study in three student clinics: 106 h of observation. Analysis comprised ethnographic analysis followed by application of the theory of practice architectures. The ethnographic analysis resulted in six themes: setting the scene, when to call for help, my room - my patient, getting in a routine, I know something you don't, and my work is needed. Applying the theory of practice architectures showed that material-economic arrangements, such as control of the consultation room and essential artefacts, were crucial to student participation and position in the clinical workplace. Furthermore, co-production of a student mandate to independently perform certain parts of a consultation enabled a co-productive student position in the hierarchy of care-producers. The findings offer a conceptually generalisable model for the study of material and social dimensions of clinical learning environments. Although not all clinical learning environments may wish to or have the resources to implement a student clinic, the findings offer insights into general issues about the arrangements of student participation relevant to most clinical teaching contexts.