Influence of clerkship experiences on clinical competence

Erasmus Universiteit Rotterdam, Rotterdam, South Holland, Netherlands
Medical Education (Impact Factor: 3.62). 06/2006; 40(5):450-8. DOI: 10.1111/j.1365-2929.2006.02447.x
Source: PubMed

ABSTRACT Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear.
This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence.
Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software.
Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters.
Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.

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    • "Eight studies compared the patient mix of training sites and their contribution to learning. In three of these studies, similar sites were compared (Chatenay et al. 1996; Wimmers et al. 2006a; Yu et al. 2011), three others compared academic vs. nonacademic sites (Schwiebert et al. 1993; McLeod et al. 1997; Nomura et al. 2008) and two compared inpatients and outpatients (Jacobson et al. 1998; Duke et al. 2011). Four studies evaluated the learning effects of an intervention: the introduction of a rotation (Gruppen et al. 1993), a skill-training programme (Boots et al. 2008), identification of 10 preselected complaints (Lampe et al. 2008) and a new internship (Nomura et al. 2008). "
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    ABSTRACT: Background: Clinical workplace-based learning has been the means to becoming a medical professional for many years. The importance of an adequate patient mix, as defined by the number of patients and the types of medical problems, for an optimal learning process is based on educational theory and recognised by national and international accreditation standards. The relationship between patient mix and learning in work-based curricula as yet remains unclear. Aim: To review research addressing the relationship between patient mix and learning in work-based clinical settings. Method: The search was conducted across Medline, Embase, Web of Science, ERIC and the Cochrane Library from the start date of the database to July 2011. Original quantitative studies on the relationship between patient mix and learning for learners at any level of the formal medical training/career were included. Methodological quality was assessed and two reviewers using pre-specified forms extracted results. Results: A total of 10,420 studies were screened on title and abstract. Of these, 298 articles were included for full-text analysis, which resulted in the inclusion of 22 papers. The quality of the included studies, scored with the Medical Education Research Study Quality Instrument (MERSQI), ranged from 8.0 to 14.5 (of 18 points). A positive relationship was found between patient mix and self-reported outcomes evaluating the progress in competence as experienced by the trainee, such as self-confidence and comfort level. Patient mix was also found to correlate positively with self-reported outcomes evaluating the quality of the learning period, such as self-reported learning benefit, experienced effectiveness of the rotation, or the instructional quality. Variables, such as supervision and learning style, might mediate this relationship. A relationship between patient mix and formal assessment has never been demonstrated. Conclusion: Patient mix is positively related to self-reported learning outcome, most evidently the experienced quality of the learning programme.
    Medical Teacher 06/2013; 35(6):e1181-e1196. DOI:10.3109/0142159X.2013.797570 · 2.05 Impact Factor
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    • "However, the assessment of its impact on their performance and their ability to manage the patient yielded contradictory results and needs further research. Other studies suggested that the number of real patient cases encountered is not necessarily a predictor of acquired clinical competence, if this experience is not associated with highquality supervision and feedback (Ericsson 2004; Wimmers et al. 2006; Fung et al. 2007). Although the clerkship tradition is well established, some concerns are raised because of the reduced availability of "
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    ABSTRACT: Background: Medical students' limited access to patients induces a shift of learning activities from clinical wards to classrooms. Aim: Identify clinical competencies specifically acquired during real-life contextual clerkship added to case-based tutorials, by a prospective, controlled study. Methods: Students entering our eight-week internal medicine (IM) clerkship attended paper case-based tutorials about 10 common presenting complaints and were assigned to an IM specialty ward. For each tutorial case, two groups of students were created: those assigned to a ward, the specialty of which was unrelated to the case (case-unrelated ward, CUW) and those assigned to a ward, the specialty of which was related to the case (case-related ward, CRW). Results: Forty-one students (30 CUW and 11 CRW) volunteered for the study. Both groups had similar previous experiences and pre-clerkship exam scores. The CRW students collected more relevant clinical information from the patient (69% vs. 55% of expected items, p = 0.001) and elaborated charts of better quality (47% vs. 39% of expected items, p = 0.05). Clinical-knowledge mean score was similar (70%) in both groups (p = 0.92). Conclusions: While paper-case tutorials did provide students with clinical knowledge, real contextual experience brought additional, specific competencies. This supports the preservation of clinical exposure with supervision and feedback.
    Medical Teacher 09/2012; 35(2). DOI:10.3109/0142159X.2012.714887 · 2.05 Impact Factor
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    • "Nevertheless, we recognize that clerkship grades are influenced by a multitude of factors and may not be the most sensitive metrics for the impact of clinical experience. As shown in an elegant analysis, Wimmers et al. (2006) demonstrated that while the number of patient encounters had a statistically significant (albeit modest) correlation with clinical evaluations, quality of supervision had a more direct effect on end-of-year exam scores. "
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    ABSTRACT: Logbooks are used by US medical schools to evaluate curricular objectives and meet accreditation requirements, but research supporting their utility is conflicting. The goal of our study was to examine the relationship between volume of clinical rotation experiences as reported in a logbook and clerkship grades within a longitudinal integrated clerkship. We conducted a retrospective cohort study of third-year (clinical) medical students during academic year 2008-2009. We tracked student entries in a pocket-sized logbook (number of clinical encounters per clerkship, total number of exams, and procedures over the academic year). We performed correlation analyses between logbook entries and clerkship grades. We enrolled 36 students, who reported a total of 2992 encounters, 2262 exams, and 2342 procedures. Correlation coefficients between volume of clinical experience and clerkship grades were less than 0.4, indicating low correlation. We found borderline statistical significance for the Neurology, OB/Gyn, and Surgery clerkships. Sensitivity analyses showed little correlation between low-reporting activity and clerkship grades. Even within an integrated longitudinal clerkship framework, our findings are consistent with previous studies showing a negligible relationship between logbooks as an educational process measure and how they relate to educational outcomes.
    Medical Teacher 03/2012; 34(3):e185-8. DOI:10.3109/0142159X.2012.642826 · 2.05 Impact Factor
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