Empirical evidence for symbiotic medical education: A comparative analysis of community and tertiary-based programs

Flinders University Rural Clinical School, Flinders University, Adelaide, South Australia, Australia.
Medical Education (Impact Factor: 3.2). 03/2006; 40(2):109-16. DOI: 10.1111/j.1365-2929.2005.02366.x
Source: PubMed


Flinders University has developed the Parallel Rural Community Curriculum (PRCC), a full year clinical curriculum based in rural general practice in South Australia. The examination performance of students on this course has been shown to be higher than that of their tertiary hospital-based peers.
To compare the learning experiences of students in the community-based programme with those of students in the tertiary hospital in order to explain these improved academic outcomes.
A case study was undertaken, using an interpretivist perspective, with 3 structured interviews carried out over 2 academic years with each of 6 students from the community-based programme and 16 students from the tertiary hospital. The taped interviews were transcribed and analysed thematically using NUD*IST software.
The community-based programme was successful in immersing the students in the clinical environment in a meaningful way. Four key themes were found in the data. These represented clear differences between the experiences of the community-based and hospital-based students. These differences involved: the value that students perceived they were given by supervising doctors and their patients; the extent to which the student's presence realised a synergy between the work of the university and the health service; opportunities for students to meet the aspirations of both the community and government policy, and opportunities for students to learn how professional expectations can mesh with their own personal values.
This study has provided empirical evidence for the importance of the concept of symbiosis in understanding quality in medical education.

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    • "Students in subspecialty clinics lacked variety and some were unable to follow up patients as often as they would have liked (Walmsley et al. 2009). Having only a single supervisor could be a problem if relationship issues arose (Worley et al. 2006). "
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    ABSTRACT: Background: Traditionally, clinical learning for medical students consists of short-term and opportunistic encounters with primarily acute-care patients, supervised by an array of clinician preceptors. In response to educational concerns, some medical schools have developed longitudinal placements rather than short-term rotations. Many of these longitudinal placements are also integrated across the core clinical disciplines, are commonly termed longitudinal integrated clerkships (LICs) and often situated in rural locations. This review aimed to explore, analyse and synthesise evidence relating to the effectiveness of longitudinal placements, for medical students in particular to determine which aspects are most critical to successful outcomes. Method: Extensive search of the literature resulted in 1679 papers and abstracts being considered, with 53 papers ultimately being included for review. The review group coded these 53 papers according to standard BEME review guidelines. Specific information extracted included: data relating to effectiveness, the location of the study, number of students involved, format, length and description of placement, the learning outcomes, research design, the impact level for evaluation and the main evaluation methods and findings. We applied a realist approach to consider what works well for whom and under what circumstances. Findings: The early LICs were all community-based immersion programs, situated in general practice and predominantly in rural settings. More recent LIC innovations were situated in tertiary-level specialist ambulatory care in urban settings. Not all placements were integrated across medical disciplines but were longitudinal in relation to location, patient base and/or supervision. Twenty-four papers focussed on one of four programs from different viewpoints. Most evaluations were student opinion (survey, interview, focus group) and/or student assessment results. Placements varied from one half day per week for six months through to full time immersion for more than 12 months. The predominant mechanism relating to factors influencing effectiveness was continuity of one or more of: patient care, supervision and mentorship, peer group and location. The success of LICs and participation satisfaction depended on the preparation of both students and clinical supervisors, and the level of support each received from their academic institutions. Conclusion: Longitudinal placements, including longitudinal integrated placements, are gaining in popularity as an alternative to traditional block rotations. Although relatively few established LICs currently exist, medical schools may look for ways to incorporate some of the principles of LICs more generally in their clinical education programmes. Further research is required to ascertain the optimum length of time for placements depending on the defined learning outcomes and timing within the programme, which students are most likely to benefit and the effects of context such as location and type of integration.
    Medical Teacher 07/2013; 35(8). DOI:10.3109/0142159X.2013.806981 · 1.68 Impact Factor
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    • "While longitudinal clerkship students work with several interprofessional hospital and community teams, it is the family practice team in which the student is based that is significant for learner development. Regan-Smith et al. [7] described how to explicitly integrate the learner into an ambulatory care clinic by conceptualising the practice as a ‘microsystem’, and others have shown that extended placement in this teaching microsystem can help students appreciate its importance in the health-care environment [8]. A microsystem has been defined as…a small group of interdependent people in health care delivery who work together on a regular basis, to provide care to a discrete population of patients[9], and importantly includes the patient. "
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    ABSTRACT: Background Medical students at the University of Wollongong experience continuity of patient care and clinical supervision during an innovative year-long integrated (community and hospital) clinical clerkship. In this model of clinical education, students are based in a general practice ‘teaching microsystem’ and participate in patient care as part of this community of practice (CoP). This study evaluates patients’ perceptions of the clerkship initiative, and their perspectives on this approach to training ‘much-needed’ doctors in their community. Methods Semi-structured, face-to-face, interviews with patients provided data on the clerkship model in three contexts: regional, rural and remote health care settings in Australia. Two researchers independently thematically analysed transcribed data and organised emergent categories into themes. Results The twelve categories that emerged from the analysis of transcribed data were clustered into four themes: learning as doing; learning as shared experience; learning as belonging to a community; and learning as ‘becoming’. Patients viewed the clerkship learning environment as patient- and student-centred, emphasising that the patient-student-doctor relationship triad was important in facilitating active participation by patients as well as students. Patients believed that students became central, rather than peripheral, members of the CoP during an extended placement, value-adding and improving access to patient care. Conclusions Regional, rural and remote patients valued the long-term engagement of senior medical students in their health care team(s). A supportive CoP such as the general practice ‘teaching microsystem’ allowed student and patient to experience increasing participation and identity transformation over time. The extended student-patient-doctor relationship was seen as influential in this progression. Patients revealed unique insights into the longitudinal clerkship model, and believed they have an important contribution to make to medical education and new strategies addressing mal-distribution in the medical workforce.
    BMC Family Practice 07/2012; 13(1):72. DOI:10.1186/1471-2296-13-72 · 1.67 Impact Factor
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    • "A recent survey of sixteen medical schools from four countries revealed that the sub-group of 2, 700 students who had completed longitudinal integrated clerkships were very supportive of the program, and performed as well as colleagues from more traditional clerkships in national exams [14]. Other student outcomes reported from national and international long-term placements have included continuity of patient care experiences; continuity of supervision and curriculum; advocacy for the patient and health service; participatory learning; mentoring; team work; and confident and skilled students [4,15,16]. "
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    ABSTRACT: In keeping with its mission to produce doctors for rural and regional Australia, the University of Wollongong, Graduate School of Medicine has established an innovative model of clinical education. This includes a 12-month integrated community-based clerkship in a regional or rural setting, offering senior students longitudinal participation in a 'community of practice' with access to continuity of patient care experiences, continuity of supervision and curriculum, and individualised personal and professional development. This required developing new teaching sites, based on attracting preceptors and providing them with educational and physical infrastructure. A major challenge was severe health workforce shortages. Before the new clerkship started, we interviewed 28 general practitioners to determine why they engaged as clerkship preceptors. Independent researchers conducted semi-structured interviews. Responses were transcribed for inductive qualitative content analysis. The new model motivated preceptors to engage because it enhanced their opportunities to contribute to authentic learning when compared with the perceived limitations of short-term attachments. Preceptors appreciated the significant recognition of the value of general practice teaching and the honour of major involvement in the university. They predicted that the initiative would have positive effects on general practitioner morale and improve the quality of their practice. Other themes included the doctors' commitment to their profession, 'handing on' to the next generation and helping their community to attract doctors in the future. Supervisors perceive that new models of clinical education offer alternative solutions to health care education, delivery and workforce. The longitudinal relationship between preceptor, student and community was seen as offering reciprocal benefits. General practitioners are committed to refining practice and ensuring generation of new members in their profession. They are motivated to engage in novel regional and rural longitudinal clinical clerkships as they perceive that they offer students an authentic learning experience and are a potential strategy to help address workforce shortages and maldistribution.
    BMC Family Practice 09/2011; 12(1):103. DOI:10.1186/1471-2296-12-103 · 1.67 Impact Factor
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