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

A model for improving the learning environment in high-stress and emotion-bound clinical settings

INTRODUCTION

In clinical settings, it is necessary to create a clinical learning environment that provides the ground for the learners to acquire competencies especially in high-stress and emotion-bound clinical settings.

METHODS

In the present study, a model for improving the learning environment in high-stress and emotion-bound clinical settings was designed by conducting a multi-method study in the form of three sub-studies.

RESULTS

This model was designed with 3 pivotal concepts; organizing learning opportunities around safe care, fair participation in learning opportunities and creating a positive emotional climate and 6 peripheral concepts; designing physical space and appropriate equipment for education and care, preparing learners to attend the clinical setting, preparing learners to participate in learning opportunities, balancing the learner role and the care provided by the learners, the presence of a competent educator and providing education to all learners, and acquiring the ability to manage emotions by learners, faculty and staff.

CONCLUSIONS

The implementation of the model obtained from this study provides the basis for solving the challenges of clinical learning environments, especially in high-stress and emotion-bound clinical settings, and improves clinical education and the realization of educational and care outcomes.

Shared understanding and task-interdependence in nursing interns' collaborative relations: A social network study of vocational health care internships in the Netherlands

Shared understanding among collaborators is a key element of delivering successful interprofessional care and a main challenge for professional education concerns nurturing such understanding among students. We assessed how nursing students perceived different levels of shared understanding in their collaborations with others in clinical internships. We analyse the collaborative networks of interns to examine whether individual factors (attitudes, perceptions of collaborative cultures, and motivation) or relational factors among collaborators (task-interdependence, cooperation frequency, and interprofessional and hierarchical roles) affect shared understanding among 150 Dutch nursing interns and their collaborators (n = 865). Theoretically, we stress the importance of focusing on collaborative relations in interprofessional care settings. Multilevel models distinguish two levels in explaining the variation in shared understanding, nesting collaborative relationships within individuals. Results indicate merely 37.4% of found variation of shared understanding could be attributed to individual-level factors (variation between interns), while 62.6% of variation is found within interns, showing that shared understanding differs substantially between the collaborations one intern engages in. Multilevel models reveal that task-interdependence strongly predicts shared understanding in inter- and intraprofessional collaborations. We conclude that focusing on collaborative relations is essential to foster shared understanding in vocational internship programmes, and that health care organisations should pay explicit attention to task-interdependence in interns' collaborations.

The Case for Feedback-in-Practice as a Topic of Educational Scholarship

The importance of clinical performance feedback is well established and the factors relevant to its effectiveness widely recognized, yet feedback continues to play out in problematic ways. For example, learning culture modifications shown to facilitate feedback have not seen widespread adoption, and the learner-educator interactions prescribed by research rarely occur organically. Nevertheless, medical learners achieve clinical competence, suggesting a need to expand educational scholarship on this topic to better account for learner growth. This Scholarly Perspective argues for a more extensive exploration of feedback as an educational activity embedded in clinical practice , where joint clinical work that involves an educator and learner provides a locus for feedback in the midst of performance. In these clinically embedded feedback episodes, learning and performance goals are constrained by the task at hand, and the educator guides the learner in collaboratively identifying problematic elements, naming and reframing the source of challenge, and extrapolating implications for further action. In jointly conducting clinical tasks, educators and learners may frequently engage in feedback interactions that are both aligned with workplace realities and consistent with current theoretical understanding of what feedback is. However, feedback embedded in practice may be challenged by personal, social, and organizational factors that affect learners' participation in workplace activity. This Scholarly Perspective aims to provide a conceptual framework that helps educators and learners be more intentional about and fully participatory in this important educational activity. By topicalizing this feedback-in-practice and exploring its integration with the more commonly foregrounded feedback-on-practice , future educational scholarship may achieve optimal benefit to learners, educators, and clinical practice.

The Perceptions of Non-native Medical Students Towards Language Barrier on Clinical Teaching and Learning: a Qualitative Study from Saudi Arabia

BACKGROUND

Patient-doctor communication is essential for achieving the best healthcare quality for the patients. Saudi Arabia hosts a variety of healthcare providers from diverse cultures and languages, making language barriers distinctive towards effective communication for a predominantly Arab population. There is limited research on the challenges associated with language barriers among non-native medical students. The current qualitative study aims to explore the perceptions and experiences of non-native medical students during clinical encounters with Arabic speaking patient population at a private university in Riyadh, Saudi Arabia.

METHODS

This is a qualitative case study employing non-native medical students in clinical years to explore their perceptions and experiences towards language barriers. Participants attended four focus group discussions, following a brief regarding the concept of the challenges that language barriers pose. All interviews were recorded and transcribed verbatim. A thematic framework analysis was employed to analyze the data.

RESULTS

Twenty-two non-native medical students participated in the study. We identified four broad themes constituting problems in patient interaction, development of clinical skills, managing and overcoming language barriers, and student recommendations to overcome language barrier. Participants suggested improvements in available Arabic language courses and the introduction of a professional skills course in Arabic for non-native students.

CONCLUSION

Non-Native medical students perceived language barriers as an obstacle to a meaningful clinical experience. They identified implications for clinical learning environment, professionalism, empathy, and patient care. Recommendations for advanced occupation-related Arabic language courses to facilitate doctor-patient interactions were made to improve patient-student interactions between native patients and non-native medical students.

Widening how we see the impact of culture on learning, practice and identity development in clinical environments

As part of this State of the Science series on Self, Society and Situation, we focus on how we might see the situation of the workplace as a learning environment in the future. Research to date into how health professionals learn while working in clinical workplace environments has mostly focused on the supervisor-trainee relationship or on the interaction between the affordances of a workplace and the receptiveness of trainees. However, the wider environment has not received as much focus-though frequently mentioned, it is seldom investigated. We suggest there is a need to embrace the wider institution factors, recognise and acknowledge an organisation's values and culture as they impact on clinical learning in order to work with these, not around them or ignore them, to make what may be tacit visible through reflection and observation and to embrace a range of perspectives on culture.

Chinese doctors' views on workplace-based assessment: trainee and supervisor perspectives of the mini-CEX

Purpose: This study investigated whether the mini-clinical evaluation exercise (mini-CEX) has been successfully integrated into the Chinese context, following its introduction as part of the national general training programme. Materials and methods: Online questionnaires (N = 91) and interviews (N = 22) were conducted with Year 1 trainee doctors and clinical supervisors at a cancer hospital in China to explore users' experiences, attitudes and opinions of the mini-CEX. Results" Trainees were more likely than supervisors to report understanding the purpose of the mini-CEX and agree that it encouraged reflection and helped improve overall performance. Both trainees and supervisors felt that it provided a framework for learning, that it was useful in identifying underperformance, and that it informed learning progression. Groups were equally positive about the commitment of their counterpart in the process and valued the focus on detailed feedback. It was perceived as cultivating the learner-teacher relationship. Overall, both groups felt they 'bought in' to using the mini-CEX. However, concerns were raised about subjectivity of ratings and lack of benchmarking with expected standards of care. Conclusions: Chinese trainees and supervisors generally perceived the mini-CEX as an acceptable and valuable medical training tool, although both groups suggested enhancements to improve its efficacy.

Medical interns; the neglected learners of the maternity ward learning environment

BACKGROUND

Clinical training during internship is an important part of medical education. The maternity ward is a clinical environment in which medical students pass their obstetrics and gynecology internship to obtain competencies in this field. The present study was conducted to explain medical interns' manner of learning in the maternity ward.

MATERIAL AND METHODS

The present study was conducted using a qualitative approach with the inductive content analysis method. This study observed the maternity wards of teaching hospitals affiliated to medical sciences universities of Isfahan and Shahrekord. Data were collected through observation and semi-structured individual interviews.

RESULTS

Two main categories and seven subcategories emerged from the analysis of the data. Inadequate participation in learning opportunities included the following three subcategories: the incongruousness of the learning opportunities with the educational goals, inadequate readiness for participation in learning opportunities, and the overlap between learning opportunities and diminished autonomous practice. Inadequate formal and structured education included the following four subcategories: inadequate learning support and direction, subordinate roles and aimless presence, the pale educational role played by the attendants and senior residents, and learning through the support of midwifery educators.

CONCLUSION

Participation in and access to learning opportunities in the maternity ward are very difficult for interns. Interns, therefore, need to attend the maternity ward by a structured program and in the company of training supervisors or competent educators to obtain the required competencies in pregnancy and childbirth.

Medical Students' Perspectives on Entrustment Decision Making in an Entrustable Professional Activity Assessment Framework: A Secondary Data Analysis

PURPOSE

Research on how entrustment decisions are made identifies 5 influential factors (supervisor, trainee, supervisor-trainee relationship, context, task). However, this literature primarily represents the perspective of supervisors in graduate medical education and is conducted outside of an assessment framework where entrustment decisions have consequences for trainees and for patients. To complement the literature, the authors explored how medical students in a pilot program that used an entrustable professional activity (EPA) assessment framework perceived factors influencing entrustment decisions.

METHOD

The authors conducted a secondary analysis of qualitative data from program evaluation of a pilot project using an EPA assessment framework to advance students through their curriculum and into residency. Data were derived from 8 focus groups conducted over 4 years (2015-2018) with 27 students who shared their experience of learning and supervision in the project. Sensitized by the entrustment literature, the authors coded and analyzed focus group transcripts according to principles of thematic analysis.

RESULTS

Components of the trainee and supervisor-trainee relationship factors predominated students' perceptions of entrustment decisions. Students directed their own learning by asking for feedback, seeking opportunities to engage in learning, sharing limitations of their knowledge with supervisors, and pushing supervisors to recalibrate assessments when appropriate. Students' agentic actions were facilitated by longitudinal supervisor-trainee relationships wherein they felt comfortable asking for help and built confidence in patient care. Students mentioned components of other factors that influenced entrustment decisions (supervisor, clinical task, clinical context), but did so less frequently and from a nonagentic vantage point.

CONCLUSIONS

Students' perspectives on entrustment decisions can be derived from their views on learning and supervision in an EPA assessment framework. Their perspectives complement the literature by highlighting students' agentic actions to influence entrustment decisions and promotion of agentic action through practices incorporating longitudinal supervisor-trainee relationships.

The regulation of learning in clinical environments: A comment on 'Beyond the self'

In this commentary, the authors highlight the importance of analyzing real time social interactions to discover strategies clinical students and residents use to self‐ and co‐regulate their learning.

Finding your feet: student participation during initiation of international clinical placements : Student participation during initiation

INTRODUCTION

International placements challenge students to find the right level of participation, as local practices, language and time pressure may affect their engagement in patient-related tasks or team activities. This study sought to unpack the initiation process during international clinical placements with the ultimate aim to achieve active student participation.

METHODS

Following a constructivist grounded theory approach, we conducted two individual interviews with 15 undergraduate healthcare students (before departure and whilst on placement). To identify emerging themes, we applied an iterative process of data collection and constant comparative analysis. Several team discussions informed further analysis, allowing us to reach a more conceptual level of theory.

RESULTS

From our findings we constructed a four-phase model of healthcare students' initiation of international clinical placements, which brings into focus how the phases of 'orientation', 'adjustment' and 'contribution to patient care' build up towards a 'sense of belonging'. We identified several factors that induced active student participation in practice, such as a favourable workplace setting, opportunities for learning and a local support network.

DISCUSSION

Active student participation is aimed at different goals, depending on the four phases of initiation that eventually lead to a sense of belonging and support workplace learning.

Learning to interact and interacting to learn: a substantive theory of clinical workplace learning for diverse cohorts

Social interactions are integral to clinical workplace functioning and are recognised to play an important role in clinical workplace learning. How, why and to what end students, in the context of today's culturally and linguistically diverse cohorts, interact with members of clinical workplace communities during clinical workplace learning is not well understood. The aim of this research was to generate a theoretical understanding of students' interactive processes in clinical workplace learning that accounted for high levels of cultural/linguistic diversity. In accordance with constructivist grounded theory methods, data collection and analysis were premised on theoretical sampling and constant comparative analysis, and undertaken from an informed and reflexive stance. This involved iterations of survey, interview and diary data from two diverse cohorts of final year veterinary students who had undergone 11 months of clinical workplace learning. Clinical preceptors were also interviewed. As an aid to theory building, testing and refinement, and in order to test the theory's relevance, usefulness and transferability beyond veterinary clinical education, critical feedback was sought from medical and allied health educators. Our substantive level theory demonstrates that upon entering the clinical workplace community, students learn how to 'harness dialogue' in order to effectively coordinate three, inter-related interactive processes: (i) functioning in the workplace, (ii) impression management and (iii) learning-in-the-moment. We found both positive and negative consequences ensued, depending on how students harnessed dialogue. The theory responds to a perceived need in international student education to move away from a deficit discourse by developing educational theory which focuses on the nature of participation, rather than the nature of the student.

Simulation Training to Improve the Ability of First-Year Doctors to Assess and Manage Deteriorating Patients: a Systematic Review and Meta-analysis

Many simulation courses now exist which aim to prepare first-year doctors for the task of assessing and managing potentially deteriorating patients. Despite the substantial resources required, the degree to which participants benefit from such courses, and which aspects of the simulation training are optimal for learning, remains unclear. A systematic literature search was undertaken across seven electronic databases. Inclusion criteria were that the intervention must be a simulation of a deteriorating patient scenario that would likely be experienced by first-year doctors, and that participants being first-year doctors or in their final year of medical school. Studies reporting quantitative benefits of simulation on participants' knowledge and simulator performance underwent meta-analyses. The search returned 1444 articles, of which 48 met inclusion criteria. All studies showed a benefit of simulation training, but outcomes were largely limited to self-rated or objective tests of knowledge, or simulator performance. The meta-analysis demonstrated that simulation improved participant performance by 16% as assessed by structured observation of a simulated scenario, and participant knowledge by 7% as assessed by written assessments. A mixed-methods analysis found conflicting evidence about which aspects of simulation were optimal for learning. The results of the review indicate that simulation is an important tool to improve first-year doctors' confidence, knowledge and simulator performance with regard to assessment and management of a potentially deteriorating patient. Future research should now seek to clarify the extent to which these improvements translate into clinical practice, and which aspects of simulation are best suited to achieve this.

The challenge of planning learning opportunities for clinical medicine: a triangulation study in Iran

BACKGROUND

An essential characteristics of clinical education is the need to learn a large number of practical and communication skills along with theoretical knowledge. It is challenging to design learning opportunities (LOs) for clinical setting. We aimed to determine optimal learning opportunities from the viewpoint of Medical curriculum planners, to determine the gap between the current condition and the optimal condition in medical schools, and to present feasible tactic for clinical learning opportunities.

METHODS

This study comprised of three sub-studies and was conducted using triangulation. The first sub-study was performed using the Modified Delphi method with a view to identifying optimal learning opportunities. Data was collected by online focus group discussion and a questionnaire. The second sub-study was conducted with the aim of comparing the current condition and the optimal condition. Data was collected from nine medical schools across Iran using a checklist, available documents, observation, and interview. The third sub-study was conducted using an expert panel comprising of seven curriculum planners of the M.D.

PROGRAM

The goal of this phase was to provide feasible tactic to improve clinical education in medical schools.

RESULTS

In the first sub-study, the participants determined all items, including student-centered learning, non-threatening learning environment, and record and management system of clinical learning opportunities as implementable learning opportunities with over 70% consensus. However, in the second sub-study, student-centered teaching methods were practiced in 33% of medical schools and the non-threatening learning environment in 67% of the schools, while the record and management system of learning opportunities was not launched in any of the schools. From the viewpoint of the expert panel members, learning opportunities adapted to clinical contents, specification of content-based learning opportunities, and continuous supervision on learners to achieve the expected learning outcomes were among clinical learning opportunities with over 70% consensus.

CONCLUSIONS

Student-centered clinical learning practices, together with virtual learning methods, can lead to clinical enhancement. Opportunities such as interactive and participatory practices should gain further consideration. Also assigning responsibility to learners and monitoring them are strategies for enhancement.

"They cared about us students:" learning from exemplar clinical teaching environments

PURPOSE

In order to foster positive student experiences in the clinical learning environment, we wanted to better understand which teaching practices they regard highly.

METHODS

In 2016, the authors undertook a paper 'exemplar' survey (ES) of all fifth year medical students at one tertiary teaching site. Students had experienced all assigned clinical rotations over a two year period. Following a 66% response rate, we identified two clear exemplar clinical areas (ECAs). Over 2016-7, six focus groups with multidisciplinary staff members from these clinical areas were held, with the aim to identify, discuss and understand their specific teaching practices in more detail.

RESULTS

The authors present descriptions of positive student experiences and related staff practices, in five themes. Themes emerged around foundational logistic and personal factors: central to student and staff data is that 'welcome' on a daily, and ongoing basis, can be foundational to learning. Central to ECA staff data are universal practices by which all staff purposefully work to develop a functional staff-student relationship and play a part in organising/teaching students. Students and ECA staff groups both understood teacher values to be central to student learning and that cultivating a student's values is one of their major educational tasks.

CONCLUSIONS

The framework formed by this thematic analysis is useful, clear and transferrable to other clinical teaching contexts. It also aligns with current thinking about best supporting student learning and cultivating student values as part of developing professionalism. Instigating such practices might help to optimise clinical teaching. We also tentatively suggest that such practices might help where resources are scarce, and perhaps also help ameliorate student bullying.

A qualitative exploration of factors influencing medical staffs' decision-making around nutrition prescription after colorectal surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines recommend early oral feeding with nutritionally adequate diets after surgery. However, studies have demonstrated variations in practice and poor adherence to these recommendations among patients who have undergone colorectal surgery. Given doctors are responsible for prescribing patients' diets after surgery, this study explored factors which influenced medical staffs' decision-making regarding postoperative nutrition prescription to identify potential behaviour change interventions.

METHODS

This qualitative study involved one-on-one, semi-structured interviews with medical staff involved in prescribing nutrition for patients following colorectal surgery across two tertiary teaching hospitals. Purposive sampling was used to recruit participants with varying years of clinical experience. The Theoretical Domains Framework (TDF) underpinned the development of a semi-structured interview guide. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and sub-themes were discussed by all investigators to ensure consensus of interpretation.

RESULTS

Twenty-one medical staff were interviewed, including nine consultants, three fellows, four surgical trainees and five junior medical doctors. Three overarching themes emerged from the data: (i) Prescription preferences are influenced by perceptions, experience and training; (ii) Modifying prescription practices to align with patient-related factors; and (iii) Peers influence prescription behaviours and attitudes towards nutrition.

CONCLUSIONS

Individual beliefs, patient-related factors and the social influence of peers (particularly seniors) appeared to strongly influence medical staffs' decision-making regarding postoperative nutrition prescription. As such, a multi-faceted approach to behaviour change is required to target individual and organisational barriers to enacting evidence-based feeding recommendations.

EDUCATION AND TRAINING: Perceived educational impact, -challenges and opportunities of hospice placements for foundation year doctors: a qualitative study

Foundation year one doctors (F1s) are expected to recognise and care for dying patients, but previous studies have found they can feel unprepared, stressed and unsupported when faced with such situations. Although hospice placements can provide good experiential learning for junior doctors, no studies to date have included F1s. This study used an interpretivist approach to explore educational opportunities and challenges in hospice placements from an F1's perspective. Six F1s who had recently completed hospice placements were interviewed individually. Data analysed qualitatively showed that F1s valued informal experiential learning and felt well supported by senior doctors. The most important learning outcome was the acquisition of enhanced communication skills and challenges included the risk of becoming medically deskilled. F1s felt their medical practice had changed as a result of hospice placement, most commonly in communication skills and recognition of the dying phase. The author recommends increased utilisation of hospice placements in foundation training programmes.

Predicting performance of junior doctors: Association of workplace based assessment with demographic characteristics, emotional intelligence, selection scores, and undergraduate academic performance

INTRODUCTION

Predicting workplace performance of junior doctors from before entry or during medical school is difficult and has limited available evidence. This study explored the association between selected predictor variables and workplace based performance in junior doctors during their first postgraduate year.

METHODS

Two cohorts of medical students (n = 200) from one university in Western Australia participated in the longitudinal study. Pearson correlation coefficients and multivariate analyses utilizing linear regression were used to assess the relationships between performance on the Junior Doctor Assessment Tool (JDAT) and its sub-components with demographic characteristics, selection scores for medical school entry, emotional intelligence, and undergraduate academic performance.

RESULTS

Grade Point Average (GPA) at the completion of undergraduate studies had the most significant association with better performance on the overall JDAT and each subscale. Increased age was a negative predictor for junior doctor performance on the Clinical management subscale and understanding emotion was a predictor for the JDAT Communication subscale. Secondary school performance measured by Tertiary Entry Rank on entry to medical school score predicted GPA but not junior doctor performance.

DISCUSSION

The GPA as a composite measure of ability and performance in medical school is associated with junior doctor assessment scores. Using this variable to identify students at risk of difficulty could assist planning for appropriate supervision, support, and training for medical graduates transitioning to the workplace.

Supervised workplace learning in postgraduate training: a realist synthesis

Context

This paper presents a realist synthesis of the literature that began with the objective of developing a theory of workplace learning specific to postgraduate medical education (PME). As the review progressed, we focused on informal learning between trainee and senior doctor or supervisor, asking what mechanisms occur between trainee and senior doctor that lead to the outcomes of PME, and what contexts shape the operation of these mechanisms and the outcomes they produce?

Methods

We followed the procedures outlined in the RAMESES Publication Standards for Realist Synthesis. We searched the English‐language literature published between 1995 and 2017 for empirical papers related to informal workplace learning between supervisor and trainee, excluding formal interventions such as workplace‐based assessment. We made a pragmatic decision to exclude general practice training to keep the review within manageable limits.

Results

We reviewed 5197 papers and selected 90. Synthesis revealed three workplace learning processes occurring between supervisors and trainees, each underpinned by a pair of mechanisms: supervised participation in practice (entrustment and support seeking); mutual observation of practice (monitoring and modelling), and dialogue during practice (meaning making and feedback). These mechanisms result in outcomes of PME, including safe participation in practice, learning skills, attitudes and behaviours and professional identity development. Contexts shaping the outcomes of these mechanisms were identified at individual, interpersonal, local and systems levels.

Conclusions

Our realist theory of workplace learning between supervisors and trainees is informed by theory and empirical research. It highlights the two‐way nature of supervision, the importance of trainees’ agency in their own learning and the deleterious effect of fragmented working patterns on supervisor–trainee learning mechanisms. Further empirical research is required to test and refine this theory. In the meantime, it provides a useful framework for the design of supportive learning environments and for the preparation of supervisors and trainees for their roles in workplace learning.

The authors describe a realist theory of learning between supervisor and postgraduate trainee in the workplace, emphasising the role of individual, interpersonal, local and systems contexts in shaping key mechanisms and their outcomes.

Getting the picture: visual interpretation in ophthalmology residency training

OBJECTIVES

Visual interpretation is essential in many fields of health care. Although diagnostic competency can be measured as an educational outcome, few accounts have addressed tacit aspects of visual interpretation in clinical training; these include the disciplining of the trainee's attentions and the trainee's acculturation into expected styles of communicating visual interpretations to others. This paper describes values and dispositions that are taught to ophthalmology trainees as they learn to reason through visual information, and explores how these qualities are evaluated during residency training.

METHODS

The project was based on 6 months of ethnographic participant observation and interviews in an ophthalmology residency programme. Observational notes and interview transcripts pertaining to visual interpretation were isolated for qualitative analysis in the tradition of sociocultural anthropology, guided by literature on communication in medical education and the socialisation of health professionals.

RESULTS

Residents and faculty members identified visual interpretation as one of the most challenging skills expected of ophthalmology trainees. They expressed a belief that 'systematic' approaches, where visual information is parsed in a stepwise fashion, reduce the chance of trainees overlooking or misinterpreting key diagnostic features. This sensory discipline was represented in narrative form when faculty members asked residents to interpret images aloud, as residents were expected to follow prescribed sequences for describing the content of images before commenting on possible diagnoses.

CONCLUSIONS

Sensory processing is ordinarily opaque to outside observers, but the ritual of describing images in highly regimented narratives allows residents to demonstrate how they gather and reason through visual information. The form of these narratives reflects values that residents are expected to embody during their training, such as being thorough and methodical; it may also serve a pedagogical function by entrenching those values. Further research is needed to characterise how the performance of speech genres shapes the interpretive skills of medical trainees.

Patterns of direct observation and their impact during residency: general practice supervisors' views

CONTEXT

Direct observation (DO) of residents' performance, despite the importance that is ascribed to it, does not readily fit in with the practice of postgraduate medical education (PGME); it is infrequent and the quality of observation may be poor in spite of ongoing efforts towards improvement. In recent literature, DO is mostly portrayed as a means to gather information on the performance of residents for purposes of feedback and assessment. The role of DO in PGME is likely to be more complex and poorly understood in the era of outcome-based education. By exploring the possible complexity of DO in workplace learning, our research aims to contribute to a better use of DO in the practice of PGME.

METHODS

Constructivist grounded theory informed our data collection and analysis. Data collection involved focus group sessions with supervisors in Dutch general practice who were invited to discuss the manifestations, meanings and effects of DO of technical skills. Theoretical sufficiency was achieved after four focus groups, with a total of 28 participants being included.

RESULTS

We found four patterns of DO of technical skills: initial planned DO sessions; resident-initiated ad hoc DO; supervisor-initiated ad hoc DO, and continued planned DO sessions. Different patterns of DO related to varying meanings, such as checking or trusting, and effects, such as learning a new skill or experiencing emotional discomfort, all of them concerning the training relationship, patient safety or residents' learning.

CONCLUSIONS

Direct observation, to supervisors, means much more than gathering information for purposes of feedback and assessment. Planned DO sessions are an important routine during the initiation phase of a training relationship. Continued planned bidirectional DO sessions, although infrequently practised, potentially combine most benefits with least side-effects of DO. Ad hoc DO, although much relied upon, is often hampered by internal tensions in supervisors, residents or both.

Unravelling residents' and supervisors' workplace interactions: an intersubjectivity study

CONTEXT

Successful engagement between residents and supervisors lies at the core of workplace learning, a process that is not exempt from challenge. Clinical encounters have unique learning potential as they offer opportunities to achieve a shared understanding between the resident and supervisor of how to accomplish a common goal. How residents and supervisors develop such a mutual understanding is an issue that has received limited attention in the literature. We used the 'intersubjectivity' concept as a novel conceptual framework to analyse this issue.

METHODS

We conducted a constructivist grounded theory study in an anaesthesiology department in Bogota, Colombia, using focus groups and field observations. Eleven residents of different training levels and 18 supervisors with varying years of teaching experience participated in the study. Through iterative data analysis, collection and constant comparison, we constructed the final results.

RESULTS

We found that residents and supervisors achieved a shared understanding by adapting to one another in the process of providing patient care. Continuous changes in the composition of resident-supervisor dyads exposed them to many procedural variations, to which they responded by engaging in various adaptation patterns that included compliance by residents with supervisors' directions, negotiation by residents of supervisors' preferences, and the sharing of decision making. In the process, the resident played an increasingly key role as a member of the supervisory dyad. Additionally, experiencing these adaptation patterns repeatedly resulted in the creation of a working repertoire: an attuned working code used by the members of each supervisory dyad to work together as a team.

CONCLUSIONS

The development of shared understanding between residents and supervisors entailed experiencing diverse adaptation patterns which resulted in the creation of working repertoires. Seeing supervisory interactions as adaptation processes has essential theoretical and practical implications regarding workplace learning in postgraduate settings. Our findings call for further exploration to understand learning in postgraduate education as a social process.

Not just trust: factors influencing learners' attempts to perform technical skills on real patients

CONTEXT

As part of their training, physicians are required to learn how to perform technical skills on patients. The previous literature reveals that this learning is complex and that many opportunities to perform these skills are not converted into attempts to do so by learners. This study sought to explore and understand this phenomenon better.

METHODS

A multi-phased qualitative study including ethnographic observations, interviews and focus groups was conducted to explore the factors that influence technical skill learning. In a tertiary paediatric emergency department, staff physician preceptors, residents, nurses and respiratory therapists were observed in the delivery and teaching of technical skills over a 3-month period. A constant comparison methodology was used to analyse the data and to develop a constructivist grounded theory.

RESULTS

We conducted 419 hours of observation, 18 interviews and four focus groups. We observed 287 instances of technical skills, of which 27.5% were attempted by residents. Thematic analysis identified 14 factors, grouped into three categories, which influenced whether residents attempted technical skills on real patients. Learner factors included resident initiative, perceived need for skill acquisition and competing priorities. Teacher factors consisted of competing priorities, interest in teaching, perceived need for residents to acquire skills, attributions about learners, assessments of competency, and trust. Environmental factors were competition from other learners, judgement that the patient was appropriate, buy-in from team members, consent from patient or caregivers, and physical environment constraints.

CONCLUSIONS

Our findings suggest that neither the presence of a learner in a clinical environment nor the trust of the supervisor is sufficient to ensure the learner will attempt a technical skill. We characterise this phenomenon as representing a pool of opportunities to conduct technical skills on live patients that shrinks to a much smaller pool of technical skill attempts. Learners, teachers and educators can use this knowledge to maximise the number of attempts learners make to perform technical skills on real patients.

How physicians teach in the clinical setting: The embedded roles of teaching and clinical care

BACKGROUND

Clinical teaching lies at the heart of medical education. However, few studies have explored the embedded nature of teaching and clinical care. The goal of this study was to examine the process of clinical teaching as it naturally, and spontaneously, unfolds in a broad range of authentic contexts with medical students and residents.

METHODS

This focused ethnographic study consisted of 160 hours of participant observation and field interviews with three internal medicine teams. Thematic analysis guided data organization and interpretation.

FINDINGS

Three overlapping themes emerged: the interconnectedness between clinical work and pedagogy; a multiplicity of teachers; and the influence of space and artifacts on teaching and learning. Clinical teaching, which was deeply embedded in clinical care, was influenced by the acuity of patient problems, learner needs, and the context in which teaching unfolded; it also occurred on a spectrum that included planned, opportunistic, formal, and informal teaching (and learning).

CONCLUSIONS

Study findings suggest that clinical teaching, which is marked by an intersection between service and teaching, can be viewed as an example of work-based teaching. They also yield suggestions for the enhancement of clinical teaching in inpatient settings, faculty development, and educational policies that recognize clinical teaching and learning.

Clinical learning environments: place, artefacts and rhythm

CONTEXT

Health care practitioners learn through experience in clinical environments in which supervision is a key component, but how that learning occurs outside the supervision relationship remains largely unknown. This study explores the environmental factors that inform and support workplace learning within a clinical environment.

METHODS

An observational study drawing on ethnographic methods was undertaken in a general medicine ward. Observers paid attention to interactions among staff members that involved potential teaching and learning moments that occurred and were visible in the course of routine work. General purpose thematic analysis of field notes was undertaken.

RESULTS

A total of 376 observations were undertaken and documented. The findings suggest that place (location of interaction), rhythm (regularity of activities occurring in the ward) and artefacts (objects and equipment) were strong influences on the interactions and exchanges that occurred. Each of these themes had inherent tensions that could promote or inhibit engagement and therefore learning opportunities. Although many learning opportunities were available, not all were taken up or recognised by the participants.

CONCLUSIONS

We describe and make explicit how the natural environment of a medical ward and flow of work through patient care contribute to the learning architecture, and how this creates or inhibits opportunities for learning. Awareness of learning opportunities was often tacit and not explicit for either supervisor or learner. We identify strategies through which tensions inherent within space, artefacts and the rhythms of work can be resolved and learning opportunities maximised.

Novice students navigating the clinical environment in an early medical clerkship

CONTEXT

The black box that is student learning in clinical environments is an ongoing research project. Our previous research showed that despite the time that students are given to learn with, about and from patients, some lack confidence for those encounters and see few patients. The study reported here investigated individual and environmental factors affecting medical students' self-directed learning time in hospital.

METHODS

We studied second year students in the four-year postgraduate Melbourne Medical School programme as they undertook the first of their four 9-week hospital placements in medical wards. Each week approximately 10 hours of structured teaching is offered; the remaining time is spent in self-directed learning. Over six weeks, we observed 31 medical students and interviewed 17 of them. The interviews were subjected to content analysis procedures and the observation notes added contextual information to what was said in interviews. We considered the findings through the Experience-based Learning framework.

RESULTS

We found four main themes in the data: finding and contacting patients challenges all students and overwhelms some; the educational design of the placement is a flawed navigational device providing inadequate clarity and security; the physical and social terrain of a large tertiary hospital is replete with obstacles making it easy for some students to stumble and retreat; finally, any positive connection with peers, staff and patients is empowering.

CONCLUSIONS

This study throws light on to the uncertain path of the novice clinical learner illuminating both the intractable aspects of hospital environments and opportunities for pedagogical and affective supports that can compensate. The processes and conditions for self-directed learning time need attention in order to provide for a safe, efficient or successful clerkship experience for all students. Particular effort is needed to sensitively identify those individuals who struggle and suffer on the journey, and provide appropriate support.

Kolb, integration and the messiness of workplace learning

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Becoming a member of the team

Changes in modern medicine, ranging from duty hour limitations to compression of on-service time, have transformed the dynamics of medical teams. In this piece, the author explores the impact that these changes have had on both medical education and physician and trainee well-being.

A multicenter study: how do medical students perceive clinical learning climate?

BACKGROUND

The relationship between students and instructors is of crucial importance for the development of a positive learning climate. Learning climate is a multifaceted concept, and its measurement is a complicated process. The aim of this cross-sectional study was to determine medical students' perceptions about the clinical learning climate and to investigate differences in their perceptions in terms of various variables.

METHODS

Medical students studying at six medical schools in Turkey were recruited for the study. All students who completed clinical rotations, which lasted for 3 or more weeks, were included in the study (n=3,097). Data were collected using the Clinical Learning Climate Scale (CLCS). The CLCS (36 items) includes three subscales: clinical environment, emotion, and motivation. Each item is scored using a 5-point Likert scale (1: strongly disagree to 5: strongly agree).

RESULTS

The response rate for the trainees was 69.67% (n=1,519), and for the interns it was 51.47% (n=917). The mean total CLCS score was 117.20±17.19. The rotation during which the clinical learning climate was perceived most favorably was the Physical Therapy and Rehabilitation rotation (mean score: 137.77). The most negatively perceived rotation was the General Internal Medicine rotation (mean score: 104.31). There were significant differences between mean total scores in terms of trainee/intern characteristics, internal medicine/surgical medicine rotations, and perception of success.

CONCLUSION

The results of this study drew attention to certain aspects of the clinical learning climate in medical schools. Clinical teacher/instructor/supervisor, clinical training programs, students' interactions in clinical settings, self-realization, mood, students' intrinsic motivation, and institutional commitment are important components of the clinical learning climate. For this reason, the aforementioned components should be taken into consideration in studies aiming to improve clinical learning climate.

Improving management of student clinical placements: insights from activity theory

BACKGROUND

An approach to improve management of student clinical placements, the Building Teams for Quality Learning project, was trialed in three different health services. In a previous paper the authors explored in some detail the factors associated with considerable success of this approach at one of these services. In this paper, the authors extend this work with further analysis to determine if the more limited outcomes observed with participants at the other two services could be explained by application of activity theory and in particular the expansive learning cycle.

METHODS

Staff at three health services participated in the Building Teams for Quality Learning project: a dental clinic, a community aged care facility and a rural hospital. At each site a team of seven multi-disciplinary staff completed the project over 9 to 12 months (total 21 participants). Evaluation data were collected through interviews, focus groups and direct observation of staff and students. Following initial thematic analysis, further analysis was conducted to compare the processes and outcomes at each participating health service drawing on activity theory and the expansive learning cycle.

RESULTS

Fifty-one interview transcripts, 33 h of workplace observation and 31 sets of workshop field notes (from 36 h of workshops) were generated. All participants were individually supportive of, and committed to, high quality student learning experiences. As was observed with staff at the dental clinic, a number of potentially effective strategies were discussed at the aged care facility and the rural hospital workshops. However, participants in these two health services could not develop a successful implementation plan. The expansive learning cycle element of modeling and testing new solutions was not achieved and participants were unable, collectively to reassess and reinterpret the object of their activities.

CONCLUSION

The application of activity theory and the expansive learning cycle assisted a deeper understanding of the differences in outcomes observed across the three groups of participants. This included identifying specific points in the expansive learning cycle at which the three groups diverged. These findings support some practical recommendations for health services that host student clinical placements.

Students' reflections on the relationships between safe learning environments, learning challenge and positive experiences of learning in a simulated GP clinic

Learning environments are a significant determinant of student behaviour, achievement and satisfaction. In this article we use students' reflective essays to identify key features of the learning environment that contributed to positive and transformative learning experiences. We explore the relationships between these features, the students' sense of safety in the learning environment (LE), the resulting learning challenge with which they could cope and their positive reports of the experience itself. Our students worked in a unique simulation of General Practice, the Safe and Effective Clinical Outcomes clinic, where they consistently reported positive experiences of learning. We analysed 77 essays from 2011 and 2012 using an immersion/crystallisation framework. Half of the students referred to the safety of the learning environment spontaneously. Students described deep learning experiences in their simulated consultations. Students valued features of the LE which contributed to a psychologically safe environment. Together with the provision of constructive support and immediate, individualised feedback this feeling of safety assisted students to find their own way through clinical dilemmas. These factors combine to make students feel relaxed and able to take on challenges that otherwise would have been overwhelming. Errors became learning opportunities and students could practice purposefully. We draw on literature from medical education, educational psychology and sociology to interpret our findings. Our results demonstrate relationships between safe learning environments, learning challenge and powerful learning experiences, justifying close attention to the construction of learning environments to promote student learning, confidence and motivation.

Conceptions of how a learning or teaching curriculum, workplace culture and agency of individuals shape medical student learning and supervisory practices in the clinical workplace

The role of workplace supervisors in the clinical education of medical students is currently under debate. However, few studies have addressed how supervisors conceptualize workplace learning and how conceptions relate to current sociocultural workplace learning theory. We explored physician conceptions of: (a) medical student learning in the clinical workplace and (b) how they contribute to student learning. The methodology included a combination of a qualitative, inductive (conventional) and deductive (directed) content analysis approach. The study triangulated two types of interview data from 4 focus group interviews and 34 individual interviews. A total of 55 physicians participated. Three overarching themes emerged from the data: learning as membership, learning as partnership and learning as ownership. The themes described how physician conceptions of learning and supervision were guided by the notions of learning-as-participation and learning-as-acquisition. The clinical workplace was either conceptualized as a context in which student learning is based on a learning curriculum, continuity of participation and partnerships with supervisors, or as a temporary source of knowledge within a teaching curriculum. The process of learning was shaped through the reciprocity between different factors in the workplace context and the agency of students and supervising physicians. A systems-thinking approach merged with the "co-participation" conceptual framework advocated by Billet proved to be useful for analyzing variations in conceptions. The findings suggest that mapping workplace supervisor conceptions of learning can be a valuable starting point for medical schools and educational developers working with changes in clinical educational and faculty development practices.

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.

The Role of the Teaching Hospital in the Effective Clerkship

A teaching hospital is a place where both patient care and learning occur together. To identify the role of the teaching hospital in an effective clerkship, we first determined the features of workplace learning and the factors that affect learning in the workplace, and then we proposed a role for the teaching hospital in the clinical clerkship. Features of learning in a clerkship include learning in context, and learning from patients, supervising doctors, others in the team, and colleagues. During the clerkship, medical students learn in three-way learner-patient-teacher relationships, and students’ participation in the tasks of patient care is crucial for learning. Factors that influence learning in the workplace are associated with tasks, context, and learner. Tying the three factors together, we proposed a role for the teaching hospital in the three categories: involvement in the tasks of patient care, engagement in the medical team, and engagement in the learning environment and system. Supervising doctors and team members in a teaching hospital support students’ deep participation in patient care, while improving the learning environment through organizational guidelines and systems. Gathering both qualitative and quantitative data for the evaluation of a teaching hospital is important.

The relationship between medical student learning opportunities and preparedness for practice: a questionnaire study

BACKGROUND

Alongside providing a knowledge base and practical skills, undergraduate medical education must prepare graduates to immediately begin practice as qualified doctors. A significant challenge is to provide safe learning opportunities that will optimise students' preparedness to start work. This study examined UK graduates' preparedness for clinical practice, and their exposure to real-life and simulated immediate care scenarios during final year placements.

METHOD

A questionnaire measuring students' perceived preparedness, and their exposure to immediate care scenarios, was distributed to all new Foundation Year 1 doctors (F1s) attending an induction session in one region of the UK.

RESULTS

356 F1s responded to the questionnaire (91% response rate; 89% of cohort) and data from 344 graduates of UK medical schools were analysed. Respondents were generally prepared for practice, but many reported few 'hands-on' experiences of providing immediate care during final year placements (a median of 1-2 experiences).Those who had 1-2 experiences reported no greater preparedness for acute management than those reporting no experience. Several exposures are necessary for a significant increase in perceived preparedness. Real-life experience was a better predictor of preparedness than simulated practice.

CONCLUSIONS

Gaps still remain in medical students' acute care experience, with a direct relationship to their perceived preparedness. The format and facilitation of placements may need to be addressed in order to enhance the quality of experience during final year.

Unfulfilled promise, untapped potential: feedback at the crossroads

Feedback should be a key support for optimizing on-the-job learning in clinical medicine. Often, however, feedback fails to live up to its potential to productively direct and shape learning. In this article, two key influences on how and why feedback becomes meaningful are examined: the individual learner's perception of and response to feedback and the learning culture within which feedback is exchanged. Feedback must compete for learners' attention with a range of other learning cues that are available in clinical settings and must survive a learner's judgment of its credibility in order to become influential. These judgments, in turn, occur within a specific context--a distinct learning culture--that both shapes learners' definitions of credibility and facilitates or constrains the exchange of good feedback. By highlighting these important blind spots in the process by which feedback becomes meaningful, concrete and necessary steps toward a robust feedback culture within medical education are revealed.

Relationships between academic performance of medical students and their workplace performance as junior doctors

BACKGROUND

Little recent published evidence explores the relationship between academic performance in medical school and performance as a junior doctor. Although many forms of assessment are used to demonstrate a medical student's knowledge or competence, these measures may not reliably predict performance in clinical practice following graduation.

METHODS

This descriptive cohort study explores the relationship between academic performance of medical students and workplace performance as junior doctors, including the influence of age, gender, ethnicity, clinical attachment, assessment type and summary score measures (grade point average) on performance in the workplace as measured by the Junior Doctor Assessment Tool.

RESULTS

There were two hundred participants. There were significant correlations between performance as a Junior Doctor (combined overall score) and the grade point average (r = 0.229, P = 0.002), the score from the Year 6 Emergency Medicine attachment (r = 0.361, P < 0.001) and the Written Examination in Year 6 (r = 0.178, P = 0.014). There was no significant effect of any individual method of assessment in medical school, gender or ethnicity on the overall combined score of performance of the junior doctor.

CONCLUSION

Performance on integrated assessments from medical school is correlated to performance as a practicing physician as measured by the Junior Doctor Assessment Tool. These findings support the value of combining undergraduate assessment scores to assess competence and predict future performance.

Influence of the workplace on learning physical examination skills

BACKGROUND

Hospital clerkships are considered crucial for acquiring competencies such as diagnostic reasoning and clinical skills. The actual learning process in the hospital remains poorly understood. This study investigates how students learn clinical skills in workplaces and factors affecting this.

METHODS

Six focus group sessions with 32 students in Internal Medicine rotation (4-9 students per group; sessions 80-90 minutes). Verbatim transcripts were analysed by emerging themes and coded independently by three researchers followed by constant comparison and axial coding.

RESULTS

Students report to learn the systematics of the physical examination, gain agility and become able to recognise pathological signs. The learning process combines working alongside others and working independently with increasing responsibility for patient care. Helpful behaviour includes making findings explicit through patient files or during observation, feedback by abnormal findings and taking initiative. Factors affecting the process negatively include lack of supervision, uncertainty about tasks and expectations, and social context such as hierarchy of learners and perceived learning environment.

CONCLUSION

Although individual student experiences vary greatly between different hospitals, it seems that proactivity and participation are central drivers for learning. These results can improve the quality of existing programmes and help design new ways to learn physical examination skills.

The nursing home as a learning environment: dealing with less is learning more

PURPOSE

Despite the imperative to develop adequate competence in caring for the growing demographic of elderly patients with complex health care problems, nursing homes are underused as learning environments for the education of future doctors; thus, the authors aimed to gain more insight into the characteristics of the nursing home as a learning environment.

METHOD

Approaching the nursing home as a learning environment from a predominantly sociocultural perspective, the authors carried out five focus group interviews (December 2011 through February 2012) with 36 family medicine and elderly care medicine residents during their nursing home placements. Data analysis was an iterative process following a grounded theory approach. The software ATLAS.ti supported data analysis.

RESULTS

The authors identified 23 themes in five categories regarding the nursing home as a learning environment: organization, medical opportunities, communication, teamwork, and supervision. Working and learning in a nursing home was characterized by "dealing with less" (i.e., fewer resources), yet the residents reported that dealing with less resulted in "learning more." Family medicine and elderly care residents from different backgrounds differed in their perceptions and specific learning needs.

CONCLUSIONS

To the authors' knowledge, this study is one of the first to identify characteristics of the nursing home as a learning environment. The main challenge in the nursing home is dealing with less, which, according to the residents in the present study, often leads to learning more. To ensure that learning really happens, the authors call for high-quality supervision to support learners in the nursing home environment.

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.

Music lessons: revealing medicine's learning culture through a comparison with that of music

CONTEXT

Research on medical learning has tended to focus on the individual learner, but a sufficient understanding of the learning process requires that attention also be paid to the essential influence of the cultural context within which learning takes place. In this study, we undertook a comparative examination of two learning cultures - those of music and medicine - in order to unearth assumptions about learning that are taken for granted within the medical culture.

METHODS

We used a constructivist grounded theory approach to explore experiences of learning within the two cultures. We conducted nine focus groups (two with medical students, three with residents, four with music students) and four individual interviews (with one clinician-educator, one music educator and two doctor-musicians), for a total of 37 participants. Analysis occurred alongside and informed data collection. Themes were identified iteratively using constant comparisons.

RESULTS

Cultural perspectives diverged in terms of where learning should occur, what learning outcomes are desired, and how learning is best facilitated. Whereas medicine valued learning by doing, music valued learning by lesson. Whereas medical learners aimed for competence, music students aimed instead for ever-better performance. Whereas medical learners valued their teachers for their clinical skills more than for their teaching abilities, the opposite was true in music, in which teachers' instructional skills were paramount. Self-assessment challenged learners in both cultures, but medical learners viewed self-assessment as a skill they could develop, whereas music students recognised that external feedback would always be required.

CONCLUSIONS

This comparative analysis reveals that medicine and music make culturally distinct assumptions about teaching and learning. The contrasts between the two cultures illuminate potential vulnerabilities in the medical learning culture, including the risks inherent in its competence-focused approach and the constraints it places on its own teachers. By highlighting these vulnerabilities, we provide a stimulus for reimagining and renewing medicine's educational practices.

Contextual dynamics in clinical workplaces: learning from doctor-doctor consultations

CONTEXT

Some studies have explored the role of learning context in clerkships and in clinical teams. Very little is known, however, about the relationship between context and competence development in more loosely framed, day-to-day practices such as doctor-doctor consultations, although such interactions are frequent and typical in clinical work.

METHODS

To address this gap in the literature, a study was conducted using semi-structured interviews in four different hospitals and participant observation at one site. Inductive content analysis was used to develop a framework. Special reference was made to the principles of situated cognition.

RESULTS

The framework illustrates how different situational, personal and organisational factors interact in every learning situation. The interplay manifests in three different roles that doctors assume in highly dynamic ways: doctors learn as 'actors' (being responsible), as 'participants' (being involved) and as 'students' (being taught); contextual influences also impact on the quality of learning within these roles.

CONCLUSIONS

The findings add to the current literature on clinical workplace learning and to the conceptualisation of context in the field of education. The practical contribution of the research lies in disentangling the complex dynamics of learning in clinical environments and in helping doctors and medical educators to increase their responsiveness to contextual factors.