How and what do medical students learn in clerkships? Experience based learning (ExBL)

Clerkship education has been called a ‘black box’ because so little is known about what, how, and under which conditions students learn. Our aim was to develop a blueprint for education in ambulatory and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. We identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers published over 7 years and synthesised a theory of how students learn. They do so when they are given affective, pedagogic, and organisational support. Affective support comes from doctors’ and many other health workers’ interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors’ teaching, supervision, and precepting. Organisational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase ‘supported participation in practice’ best describes the educational process. Much of the learning that results is too tacit, complex, contextualised, and individual to be defined as a set of competencies. We conclude that clerkship education takes place within relationships between students, patients, and doctors, supported by informal, individual, contextualised, and affective elements of the learned curriculum, alongside formal, standardised elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula as well as helping patients, students, and practitioners collaborate in educating tomorrow’s doctors.

[1]  L. Mauksch,et al.  Integrating Communication Training into a Required Family Medicine Clerkship , 2004, Academic medicine : journal of the Association of American Medical Colleges.

[2]  T. Dornan,et al.  Supporting medical students’ workplace learning: experience‐based learning (ExBL) , 2009 .

[3]  E. Wenger-Trayner,et al.  Learning in a landscape of practice : A framework , 2014 .

[4]  E. Wenger.  Communities of Practice: Learning, Meaning, and Identity , 1998 .

[5]  K. Hauer,et al.  The role of role: learning in longitudinal integrated and traditional block clerkships , 2012, Medical education.

[6]  S. Billett.  Relational Interdependence Between Social and Individual Agency in Work and Working Life , 2006 .

[7]  T. Dornan,et al.  Power in clinical teachers’ discourses of a curriculum-in-action. Critical discourse analysis , 2013, Advances in Health Sciences Education.

[8]  K. McCarten,et al.  Importance of radiology clerkships in teaching medical students life-threatening abnormalities on conventional chest radiographs. , 2002, Academic radiology.

[9]  J. Bates,et al.  Longitudinal integrated clinical placements: where are we going? , 2012, Medical education.

[10]  E. Wenger,et al.  How Clerkship Students Learn From Real Patients in Practice Settings , 2014, Academic medicine : journal of the Association of American Medical Colleges.

[11]  Elaine H. J. Yew,et al.  The process of problem‐based learning: what works and why , 2011, Medical education.

[12]  Debra F. Weinstein,et al.  2014 question of the year. , 2014, Academic medicine : journal of the Association of American Medical Colleges.

[13]  A. McCaw-Binns,et al.  More questions than answers? Expanding students' reflections from a community health experience. , 2006, Education for health.

[14]  E. Holmboe,et al.  The rotational approach to medical education: time to confront our assumptions? , 2011, Medical education.

[15]  H. Kirsch,et al.  Development of a longitudinal integrated clerkship at an academic medical center , 2011, Medical education online.

[16]  Tim Dornan,et al.  Outcome (competency) based education: an exploration of its origins, theoretical basis, and empirical evidence , 2012, Advances in Health Sciences Education.

[17]  T. Dornan,et al.  Kirkpatrick’s levels and education ‘evidence’ , 2012, Medical education.

[18]  B. Hodges.  A tea-steeping or i-Doc model for medical education? , 2010, Academic medicine : journal of the Association of American Medical Colleges.

[19]  P. Carney,et al.  Preclinical Preceptorships in Medical School: Can Curricular Objectives Be Met in Diverse Teaching Settings? , 2006, Teaching and learning in medicine.

[20]  T. Dornan,et al.  Student evaluation of the clinical ‘curriculum in action’ , 2006, Medical education.

[21]  E. Henley,et al.  Medical student evaluation of family nurse practitioners as teachers. , 2000, Family medicine.

[22]  Caragh Brosnan,et al.  The consequences of authentic early experience for medical students: creation of mētis , 2013, Medical education.

[23]  T. Dornan,et al.  Conducting a best evidence systematic review. Part 1: From idea to data coding. BEME Guide No. 13 , 2010, Medical teacher.

[24]  E. Krupat,et al.  Students’ workplace learning in two clerkship models: a multi‐site observational study , 2012, Medical education.

[25]  H. Loeser,et al.  Outcomes of Different Clerkship Models: Longitudinal Integrated, Hybrid, and Block , 2013, Academic medicine : journal of the Association of American Medical Colleges.

[26]  T. Dornan,et al.  Identification of best evidence in medical education. Case study , 2007, Medical teacher.

[27]  Tim Dornan,et al.  How can medical students learn in a self‐directed way in the clinical environment? Design‐based research , 2005, Medical education.

[28]  David M. Irby,et al.  Educating Physicians: A Call for Reform of Medical School and Residency , 2010 .

[29]  T. Dornan,et al.  What has changed in the evidence for early experience? Update of a BEME systematic review , 2010, Medical teacher.

[30]  T. Dornan,et al.  Learning in practice Early practical experience and the social responsiveness of clinical education: systematic review , 2005 .

[31]  Etienne Wenger,et al.  Situated Learning: Legitimate Peripheral Participation , 1991 .

[32]  G. Thibault,et al.  "Continuity" as an organizing principle for clinical education reform. , 2007, The New England journal of medicine.

[33]  T. Dornan,et al.  ‘They’ve all got to learn’. Medical students’ learning from patients in ambulatory (outpatient and general practice) consultations , 2009, Medical teacher.

[34]  M. Eraut,et al.  Informal learning in the workplace , 2004 .

[35]  Ronald M. Harden,et al.  AMEE Guide No. 14: Outcome-based education: Part 1-An introduction to outcome-based education , 1999 .

[36]  G. Bordage.  Moving the field forward: going beyond quantitative-qualitative. , 2007, Academic medicine : journal of the Association of American Medical Colleges.

[37]  Anthony E. Kelly,et al.  Theme Issue: The Role of Design in Educational Research , 2003 .

[38]  Douglas H. Fernald,et al.  Student Perspectives on Primary Care Preceptorships: Enhancing the Medical Student Preceptorship Learning Environment , 2001, Teaching and learning in medicine.

[39]  Sigall K. Bell,et al.  Longitudinal Pedagogy: A Successful Response to the Fragmentation of the Third-Year Medical Student Clerkship Experience , 2008, Academic medicine : journal of the Association of American Medical Colleges.

[40]  B. Hodges,et al.  Theory and practice in the design and conduct of graduate medical education. , 2012, Academic medicine : journal of the Association of American Medical Colleges.

[41]  II ON SOCIOLOGICAL THEORIES OF THE MIDDLE RANGE , 2022 .

[42]  W. DeWolf,et al.  Does the outpatient setting provide the best environment for medical student learning of urology? , 2002, The Journal of urology.

[43]  L. Walters,et al.  Outcomes of longitudinal integrated clinical placements for students, clinicians and society , 2012, Medical education.

[44]  H. Schmidt,et al.  Description, justification and clarification: a framework for classifying the purposes of research in medical education , 2008, Medical education.

[45]  Etienne Wenger,et al.  Communities of Practice: Learning, Meaning, and Identity , 1998 .

[46]  K. Mann,et al.  Motivation in medical education: how theory can inform our practice. , 1999, Academic medicine : journal of the Association of American Medical Colleges.

[47]  J Spencer,et al.  Patient‐oriented learning: a review of the role of the patient in the education of medical students , 2000, Medical education.

[48]  Andrew Stapleton,et al.  Research as Design-Design as Research , 2005, DiGRA Conference.

[49]  Susan Michie,et al.  Developing and Evaluating Complex Interventions , 2015 .

[50]  J. Kirby,et al.  Assessing the Relationship of Learning Approaches to Workplace Climate in Clerkship and Residency , 2004, Academic medicine : journal of the Association of American Medical Colleges.

[51]  J Spencer,et al.  How can experience in clinical and community settings contribute to early medical education? A BEME systematic review , 2006, Medical teacher.

[52]  D. Schaad,et al.  Longitudinal Integrated Clerkships for Medical Students: An Innovation Adopted by Medical Schools in Australia, Canada, South Africa, and the United States , 2009, Academic medicine : journal of the Association of American Medical Colleges.

[53]  E. Krupat,et al.  Educational Outcomes of the Harvard Medical School–Cambridge Integrated Clerkship: A Way Forward for Medical Education , 2012, Academic medicine : journal of the Association of American Medical Colleges.

[54]  M. Monga,et al.  Third year medical student attitudes toward learning urology. , 2001, The Journal of urology.

[55]  T. Dornan,et al.  When only the real thing will do: junior medical students' learning from real patients , 2009, Medical education.

[56]  D. Cook,et al.  What is the validity evidence for assessments of clinical teaching? , 2005, Journal of General Internal Medicine.

[57]  E. Wenger,et al.  Legitimate Peripheral Participation , 1991 .

[58]  Tim Dornan,et al.  Medical students’ reactions to an experience-based learning model of clinical education , 2013, Perspectives on Medical Education.

[59]  P. James,et al.  Measuring instructional quality in community‐orientated medical education: looking into the black box , 1999, Medical education.

[60]  C. Silagy,et al.  The Parallel Rural Community Curriculum: an integrated clinical curriculum based in rural general practice , 2000, Medical education.

[61]  J. Singer,et al.  Variation in predictors of primary care career choice by year and stage of training , 2003, Journal of General Internal Medicine.

[62]  M. Delva,et al.  Ambulatory teaching: Do approaches to learning predict the site and preceptor characteristics valued by clerks and residents in the ambulatory setting? , 2005, BMC medical education.

[63]  R. Wodak.  Critical Discourse Analysis , 2003 .

[64]  D. Pratt,et al.  Student perceptions of assessment and feedback in longitudinal integrated clerkships , 2013, Medical education.

[65]  C. Kruger,et al.  Medical students on the value of role models for developing ‘soft skills’ - “That’s the way you do it” , 2006 .

[66]  J. van Dalen,et al.  Teaching and assessing communication skills in Maastricht: the first twenty years , 2001, Medical teacher.

[67]  Harden,et al.  Task‐based learning: the answer to integration and problem‐based learning in the clinical years , 2000, Medical education.

[68]  Tim Dornan,et al.  Clinical teachers and problem‐based learning: a phenomenological study , 2005, Medical education.

[69]  E. Wenger,et al.  Phenomenological analysis of patient experiences of medical student teaching encounters , 2012, Medical education.

[70]  G. Regehr,et al.  A Comparison of Performance Evaluations of Students on Longitudinal Integrated Clerkships and Rotation-Based Clerkships , 2011, Academic medicine : journal of the Association of American Medical Colleges.