How medical students learn in primary care

Medical students' perception of learning from patient encounters in primary health care; a qualitative interview study

BACKGROUND

Clinical practice gives medical students opportunities to develop clinical skills and to gain insight into their future profession as a physician. Students in the medical programme at Karolinska Institutet in Sweden had clinical practice in primary health care in nine of their 11 semesters. The aim of this study was to explore medical students' perceptions of learning from patient encounters in a primary health care context.

METHODS

The study was a qualitative inductive interview study. The 21 participating medical students were from their 3rd, 4th and 5th (final year) year of the study programme. A semi-structured interview guide was used. The data analysis was performed with qualitative content analysis.

RESULTS

The overarching theme of the study was: The individual patient encounters are the key to learning in primary health care. The patient encounters presented both useful opportunities and challenges that could contribute to the students' professional development. The following four categories were found: 1. Patient encounters in are instructive, rewarding and challenging. Practising in primary health care provided experience in meeting and communicating with a wide variety of patients. Students described it being challenging to trust in their own clinical competence and feeling a responsibility towards the patients. 2. Encounters with patients in primary health care provide opportunities for gradual professional development. Students had the opportunity of increasing independence based on their level of clinical competence. They experienced a progression in their professional development after each period in primary health care. 3. A committed supervisor plays a significant role in learning. Committed supervisors who set aside time for supervision, offered support, and encouraged the student, played an important role in the student's learning. 4. Learning in primary health care and learning in hospitals complement one another. It could be difficult for the students to sort out exactly where they learnt different things as they perceived that learning in primary health care and in hospitals complemented one another.

CONCLUSIONS

The students' encounters with authentic patients in primary health care gave them recurring opportunities to develop communication skills and to be trusted to work on their own under supervision, giving them guidance on their way to becoming future physicians.

A concept analysis on the transfer climate in health sciences education

The transfer of learning is complex, with factors such as transfer climate influencing students' transfer of learning. This transfer climate will shape a student's experiences during work-integrated learning and can be modified to enhance the transfer of learning. However, studies on transfer climate are mainly reported from a human resource development context and the outcomes may not be transferable to health sciences education. Furthermore, there is no uniformity in defining and measuring transfer climate. Rodgers' evolutionary concept analysis approach was used to describe the antecedents, attributes, and consequences of a positive transfer climate. An information specialist assisted in developing a Boolean search string and searched 15 databases to identify relevant sources. In total, 156 relevant articles were selected from 1448 sources. Data were charted and thematically analyzed. Antecedents comprise interpersonal relationships and theory-practice correlation. The presence of student support, training programs, student characteristics, clinical facilitator characteristics and a well-resourced clinical environment are the attributes of a positive transfer climate and act as learning transfer mediators. Transfer climate consequently influences student, educational, and organizational performance. A conceptual definition for transfer climate was then proposed. It was subsequently concluded that developing competent healthcare professionals and providing support to students depend on the synergy and good working relationship between health services and educational institutions. The insights into modifiable elements to enhance transfer climate could benefit health sciences educators in reconsidering their clinical training models to ensure sufficient support during students' clinical placements to meet the demands for a better-qualified healthcare workforce.

Medical students' learning experience and participation in communities of practice at municipal emergency care units in the primary health care system: a qualitative study

BACKGROUND

Medical education has been criticised for not adapting to changes in society, health care and technology. Internationally, it is necessary to strengthen primary health care services to accommodate the growing number of patients. In Norway, emergency care patients are increasingly treated in municipal emergency care units in the primary health care system. This study explores medical students' learning experience and how they participated in communities of practice at two municipal emergency care units in the primary health care system.

METHODS

In this qualitative study, we collected data from March to May 2019 using semi-structured individual interviews and systematic observations of six ninth-semester medical students undergoing two-week clerkships at municipal emergency care units. The interview transcripts were thematically analysed with a social constructivist approach. A total of 102 systematic observations were used to triangulate the findings from the thematic analysis.

RESULTS

Three themes illuminated what the medical students learned and how they participated in communities of practice: (i) They took responsibility for emergency care patients while participating in the physicians' community of practice and thus received intensive training in the role of a physician. (ii) They learned the physician's role in interprofessional collaboration. Collaborating with nursing students and nurses led to training in clinical procedures and insight into the nurses' role, work tasks, and community of practice. (iii) They gained in-depth knowledge through shared reflections when time was allocated for that purpose. Ethical and medical topics were elucidated from an interprofessional perspective when nursing students, nurses, and physicians participated.

CONCLUSIONS

Our findings suggest that this was a form of clerkship in which medical students learned the physician's role by taking responsibility for emergency care patients and participating in multiple work tasks and clinical procedures associated with physicians' and nurses' communities of practice. Participating in an interprofessional community of practice for professional reflections contributed to in-depth knowledge of ethical and medical topics from the medical and nursing perspectives.

From Passive Gatekeeper to Quarterback: Evolving Perceptions of Primary Care Among Medical Students in Longitudinal Outpatient Clerkships

BACKGROUND

Longitudinal clerkships provide students with meaningful clinical care roles that promote learning and professional development. It remains unclear how longitudinal primary care clerkships inform students' perceptions of primary care.

OBJECTIVE

To explore perceptions of primary care among medical students enrolled in longitudinal primary care clerkships.

DESIGN

Qualitative, semi-structured interviews with medical students over 4 years.

PARTICIPANTS

Thirty-eight medical students participated at baseline; 35 participated in a 2-year follow-up interview; 24 participated at 4 years. Each student was enrolled in one of two longitudinal primary care clerkships: a team-based Education-Centered Medical Home (ECMH) or a one-on-one individual preceptorship (IP).

APPROACH

De-identified interview transcripts were analyzed using a process of open and axial coding, followed by elaborative coding for longitudinal analysis. Codes were compiled into a set of themes and compared across time periods and between clerkships.

KEY RESULTS

Students reported that primary care serves as a first point of contact, emphasizing longitudinal care with a wide scope of practice and approaching patient care with a biopsychosocial perspective. Student perceptions of primary care greatly expanded over the course of 4 years: for instance, initial perceptions of primary care physicians evolved from "passive gatekeeper" to a more nuanced "quarterback." Students in ECMH, whose clerkship provided more opportunity for patient continuity, further reflected on the relationships they themselves developed with patients.

CONCLUSIONS

Regardless of their eventual specialty choice, longitudinal experiences may aid all students in fostering a sense of the broad scope and importance of primary care. However, without numerous opportunities to witness continuity of care, students may perceive primary care as having limited scope and importance. Longitudinal clerkships, emphasizing continuity with patients and preceptors, may foster in students a broad and nuanced perspective of the scope of primary care as a field.