Journal of the New Zealand Medical Association, 09-October-2009, Vol 122 No 1304
At the outset we wish to acknowledge the dedication and commitment to teaching in the clinical setting. The ward is an environment that is potentially rich in teaching and learning opportunities, both formal and informal. It is an authentic clinical context for medical education and a place where students can test skills and knowledge in a practical way.
Clinical settings are also the context of professional socialisation. However, they vary in the scope of learning opportunities available and students do not always make the most of these opportunities.1 Long rounds, large teams, or too detailed discussions between clinicians limit the opportunities for student learning.2,3
Inevitably there are many tensions within the working environment of the teaching hospital. As others have pointed out, its primary function is in healthcare provision, and secondarily it functions as a learning environment.1,4-6 However, Wenger argues, working environments are learning environments.7
One consequence of clinical contexts as learning environments is that all clinicians are implicated in teaching even though they may not be employed to teach or see themselves as teachers. The modelling of clinical practice and professionalism are obvious examples of the way in which their roles become educational.
Wenger’s model of social learning within communities of practice has recently caught the attention of medical educators because of its usefulness in detailing how medical students learn in clinical contexts. In particular, his concept of legitimate peripheral participation is highly applicable to clinical education settings.4,8–12
In this article we report an observational study of 4th-year medical students’ surgical attachment during which students are required to expand and apply their medical knowledge, learn clinical skills, and to think of themselves as emergent medical professionals. However, our data showed several key tensions. The foremost of these, and the one we ‘trouble’ in this paper, was the issue of whether space is made available for students to participate in the clinical setting, and what students can do to claim that space.
It should be noted that the surgery attachment is popular with medical students. Contributors to a 4th-year student website in 2005 gave the surgery run a 4-star rating (out of 5) and advised students yet to experience this attachment that it is a tough environment but not to take this personally
Setting—At the time this research was conducted (2004), students in our medical school began the clinical component of their medical education in their 4th year of study. Typically, they spent 8 weeks on attachment in the Department of Surgery.
Students participate in a wide variety of clinical activities during attachments. One component of this is the formal full team ward round that occurs once a week. These ward rounds are the primary focus of this study. The observer (KSH) followed the team ward round and also observed some small group tutorials. Other components include outpatients and pre-admissions clinics, operating theatres, small group tutorials, bedside teaching, and discretionary activities. These were not observed.
Participants—Four groups of 4th-year medical students were recruited along with the two surgical teams to which they were attached (16 students in total; 5 consultant surgeons). Attachments are of 8 weeks duration; comprising two attachments of 4 weeks each with different teams.
Author KSH observed ward rounds for half of the first 4-week attachment, and a full remaining 4 weeks of the second attachment (a total of 6 weeks). Patients were given information about the study when they were admitted to the ward and were able to opt out of the study. In these cases, the observer (KSH) waited outside the patient’s room and rejoined the team when they moved on from the non-consenting patient.
Data collection—A multi-method strategy similar to that described by Lyon13 incorporating observations and interviews was used. Group interviews were conducted with the student groups following the ward round.
One-to-one interviews were conducted with each of the consultant surgeons. Each student group interview began with the prompt “how did you find today’s ward round?” The interviewer (KSH) then encouraged open discussion about students’ experiences and perspectives on what they felt they were learning and being taught, both directly and indirectly.
Similarly, the interviews with consultant surgeons were structured around the questions of what they were trying to teach students, and what did they consider that students were learning in ward rounds. Ethical approval was granted by the Otago Ethics Committee (ref. 03/10/114).
Table 1. Summary of data collected
Analysis—The interview and observation data (see Table 1) were initially read by authors CJ, TE and KSH, and entered into the computer assisted qualitative data analysis software program, Atlas.ti.
Initially, the data were coded using an editing analytical style so that segments of data, both observational and interview, were grouped into categories of activities and meanings.14 Subsequently, a crystallisation/immersion analysis was conducted in order to gain greater depth and insight into the data, specifically to explore covert meanings, subtleties, and nuance.15
Continuing discussion between authors during the analytical process established interpretive concordance.
Limitations—The primary critique of all research of this design is the question of whether there were enough participants and the study period of sufficient duration for meaningful conclusions to be drawn. Ideally, data collection should proceed until no new data are emerging.16
KSH observed for 6 of the 8 weeks that medical students are rostered on their surgical attachment although his participation was limited in that his observations did not encompass all student teaching and learning nor clinical activities.
We can make no claim as to the representativeness of our participants of the larger population of medical students, and therefore do not claim generalisability of our findings to other clinical schools. However, as an indicator of internal validity, there was general concordance between each of the four student groups in terms of their experiences, and recognition by consultant surgeons of these common experiences.
As an indicator of external validity, our findings do support national and international research in medical education (see Discussion).
Here, we present the thematic results of our analysis. These are supported by quotations from our participants. While these lack the subtleties of the spoken word (particularly intonation) they illustrate the tensions, contradictions and anomalies that students found challenging.
Making space and claiming space—Although this is a teaching and learning setting, the primary business of the ward is patient care. Students’ immediate concerns were their own learning needs, and they frequently expressed ambiguity about the value of ward rounds, often critical of the prioritisation of clinical care over their learning needs:
They [the consultants] are conversing with each other because they see it as a collegial conversation, the ones that do include students I think make a conscious effort to do so—people like [consultant], he thinks the ward round is to grill students so he will grill students. These guys think a ward round is where you have a collegial discussion and the students aren’t really involved in that (Student interview, Day 9)
The above quotation shows students feeling excluded from the day-to-day business of patient care. Our field notes also illustrated this. For example, on Day 4, the consultants, registrar, and house surgeon were observed discussing the patient while the students hovered on the peripheries of the group, paying little attention and making no effort to move closer to hear the discussion.
In this case, the house surgeon took time to explain to them that the clinicians were discussing a diagnostic test and the students then began to pay more attention to the discussion.
This suggests that students’ participation is dependent on space being made available to them, and being invited into that space through informal invitations to pay attention to what is being said, in addition to formal presentations, and Socratic questioning. Also, the larger the group, the more students had to muscle in to view examinations, and the more intimidating it became for them to ask questions. In these situations it was easier for students to hang back on the peripheries and not be involved.
The question here is, given that space is reserved for students as legitimate peripheral participants, are there ways in which they can be encouraged to claim this space?
Both students and consultants suggested similar strategies; these included smaller groups so that students get more dedicated attention from medical staff, more bedside tutorials where students have the opportunity to have consultants watching them practice examinations and to ask them questions free of performance anxiety:
The ones I actually found most helpful are the ones where there aren’t any other students, like maybe the ones in the wards in the morning on post op call and stuff like that and they are actually quite helpful because there aren’t many people and you can hear what is going on and stuff and you get to know all the patients (Student interview, Day 9)
The ideal for student learning, I think, would be one to one with the consultant. However the reality is we have four students at a time. Sometimes we have a 6th Year student. Usually we have a house surgeon and one or two registrars and a Pharmacist to check for drug problems. Also the ward charge nurse may be there and the patient’s nurse... Sometimes we have a nephrologist... With this number of staff I think the teaching component for students may be diluted a bit. Some of the discussion may be a bit over their heads. It takes a brave student to ask about something they don’t understand in front of this size of group. We try to keep the students involved by getting them to present the case first and then asking them questions to see what they understand or correct any mistakes they make (Consultant surgeon)
Interestingly, on Day 16 of our observation, the consultant concerned changed the structure of the ward round to resemble a series of bedside tutorials. In this format students learned and practiced taking histories, interviewing patients and conducting examinations. This represented a re-orientation from a focus on performance in presenting patients to a more focused approach to learning and practicing clinical skills.
The students commented that they learned more about the patients they saw and the fewer numbers attending the round made it easier to answer questions:
We sort of got actual teaching rather than just sort of crowding around the patient with everybody else... We didn’t see every patient but we probably learned more about those two cases, three cases that we did...I think it was much easier to just answer the questions without thinking about whether you are going to bore the registrar or bore the TI [Trainee Intern, 6th-year medical student] with the 4th-year level questions (Student interview, Day 16)
Students in all groups discussed the need to take responsibility for recognising and taking advantage of the learning opportunities on the ward – creating your own learning opportunities by insisting on them, even if this meant annoying busy clinicians. However, from their clinical teachers’ perspectives, while students need to be assertive, assertive students can be annoying to patients:
I said, “can I present this patient” and they said, “yes”. I mean you have got to be assertive in this sort of thing (Student interview, Day 6)
There is no doubt that assertive students tend to find [clinical work] easier and accomplish more in that regard but being assertive alone is not necessary. Some assertive students... don’t always show great insight... and they often get offside with patients because although they are assertive, they don’t show terribly good judgement (Consultant surgeon)
However, being able to practice history taking and examination skills as well as procedural skills on patients, was also part of the space reserved for students and they did need to be proactive in order to claim it. On one hand, they were often reticent about approaching patients because they knew they were being a nuisance, but on the other hand, were driven by learning needs and directives from consultants to spend as much time with patients as possible.
The students in the first excerpt below discuss the difficulties of gaining access to patients, while the student in the second excerpt has resolved these difficulties by prioritising her learning needs over fears of being a nuisance:
Student 1: And they [the consultants] say, “you are part of this team, if the patient’s got visitors, just tell them to have five minutes alone with the patient”. It is like – as if we are going to do that – do you know what I mean?
Student 2: And I mean there is the thing of being at the bottom of the hierarchy which doesn’t bother me that much but sometimes gets a bit annoying though, you go and see a patient and, “the patient has got to be observed”, and it is, “the patient’s going to have a shower now”; “this visitor is coming to visit the patient now”. It is just a bit annoying when you have waited a whole day to see a patient, there are other things, other more important people coming to see the patient.
Student 1: ...and then when you show up to ward round, “why don’t you know this patient?” ... so what were you meant to do? (a) get up at 6.30, be in here by 7 and wake up the patient; (b) stay here until you see the patient which could be as late as 10 o’clock as night? (Student interview, Day 8)
Well initially I thought it would just be really uncomfortable for the patient to have all these people around but you kind of like— you just have to get over that because there is no other way for those people to learn. You just have to remember that it is a teaching hospital so we all have to be there so that we can learn (Student interview, Day 2)
Students were constantly reminded that they are part of the team during ward rounds, and consultants commented on how important it was that students consider themselves team members. From consultants’ perspectives, team membership confers legitimacy, albeit peripheral, on student’s presence in the ward. However, students expressed varying degrees of belonging as the following excerpt illustrates:
Student 1: You have to try hard to be part of the team.
Student 2: You have to be proactive to actually be part of the team...
Student 1: But even when you – like even when I am there like taking a history and examining, it is like I am there to learn, it is not like I am part of the team - like helping the patients. It’s distant, like I think you are part of the team when you are actually more actively involved in their treatment than just learning.
Student 3: I always feel I am part of the team... I mean I am not an important part, I am not integral. They won’t miss me when I am gone but I try to be helpful (Student interview, Day 7)
This excerpt also illustrates that students are more likely to consider themselves part of the team when they feel useful. Students frequently talked about how much you could learn if you were prepared to help the house surgeon. This also illustrates the role of informal teaching from clinical staff who are not specifically employed as teachers (although an obligation to teach is explicit within the Hippocratic Oath):
If you were just randomly annoying them (house surgeons and TIs) about stuff, they wouldn’t be so happy, you have got to sort of do your bit as well. .. like between us we all sort of take bloods for them or chase stuff or take notes or take someone else down to radiology..., just try to be as helpful as possible... a bit of barter goes on (Student interview, Day 7)
We didn’t have to hang around the ward and help the TI but I mean it is understood and ... sort of helps you learn some of that ward stuff that goes on... the informal teaching you just don’t otherwise would take in - like why are they charting that number of fluids and why they are giving that drug for something? And just learning how to write discharge summaries and all that... (Student interview, Day 16)
One inescapable duty that team membership confers on students during formal team ward rounds is patient presentation. Students are being tested on their ability to take histories, conduct examinations, and how well they know their patients. But students found patient presentation and the Socratic questioning that traditionally accompanies it highly stressful:
And I have got this lady that has got truckloads going wrong with her... and really you just live in fear because they can basically ask you anything about that patient randomly which is what happened to (another student). So it’s not fair (Student interview, Day 3)
Teachers did not mean to distress students. However, it is clear that students perceive that the price for claiming the space provided for them in the clinical team may be the risk of being “grilled” and “slaughtered”. One consultant surgeon acknowledged that students are in a “state of high anxiety” during the ward round because they are frightened of being questioned. He noted that this fear can result in students focusing only on their own patients and ‘zoning out’ during other presentations while they mentally rehearse their own presentation.
The above findings have implications which, in all likelihood, apply to all clinical teaching settings.
The space made available to students as transient team members legitimates their participation in clinical activities. These activities include formal activities such as participation in ward rounds, and practising clinical skills on real patients, and informal activities such as helping out with the daily business of patient care on the ward. However, in a busy clinical setting, there are many factors which influence ability and willingness to make space and it is not always easy for staff to remember to make space for students.
While handbooks and manuals and formal introductions to attachments assist by providing information about what is expected of students during their attachment, even assertive students can find it difficult to claim space when patient care takes priority over teaching and learning. For example, Lyon noted that while surgeons recognised that students have legitimate space in the operating theatre, students may not experience this.11
It is known that patient case mix determines what is available for clinical teaching to students, and that high patient volume and throughput can result in decreased learning activities although, ironically, there may well be increased learning opportunities.4 If students feel they are in the way or a nuisance, opportunities to practice clinical skills and professionalism will not be taken up. The challenge for clinicians is to find ways in which students can avail themselves of these opportunities without compromising patient care or further stressing clinicians.
Similarly, reports of intimidation are a traditional motif in medical education.17 18 19 Perhaps this is inevitable given the performance anxiety associated with patient presentation and Socratic questioning. But are such experiences conducive to effective learning? Are there better ways in which students can learn presentation skills without being frightened of being criticised in front of their peers? On the other hand, it could be argued that the ability to withstand critique is a key professional attribute in clinical practice. The issue here is when does the Socratic method become an interrogation that may be experienced by students as intimidating?
Both students and clinical teachers in our study had broad agreement on the issues around making space available for students and the need for students to claim that space. The question is what can be done to encourage students’ sense of belonging? And to encourage them to claim the space that is available to them in this setting?
Educational innovations such as the dedicated bedside tutorial described here may be a resolution although they are time consuming for teachers with clinical commitments. Simple things like encouraging students to pay attention and explaining team discussions can be effective ways of including students in teamwork and patient care. Similarly, invitations and denials to students can be conveyed by communication subtleties such as tone and gesture.
Table 2. Summary of key points
What can we do to increase staff awareness of their role in medical training and their acceptance of this role? Can ways be found to support and reward clinical staff who are not employed as teachers? (See Table 2) This includes other health professionals in the clinical setting, particularly nursing staff who represent an important resource for medical students and play a major role in facilitating their engagement in the clinical setting.
At a national level, the Medical Council of New Zealand, the Colleges, and the District Health Boards have an important role in supporting health care professionals in workplace education.
The clinical setting is familiar and ordinary to those who work in it and therefore goes largely uninspected. However, to outsiders (such as students, new staff, and researchers) it presents practices and interactions that reveal tensions, contradictions and anomalies. Clinical teachers and practice team leaders (and their host institutions) must recognise that the working environment is also a learning environment and should encourage this awareness in all those who occupy the work space.
Local solutions are required to enable students to enter and participate in this work space legitimately. Being explicit about expectations and what is and is not allowed is essential in granting legitimacy. Arguably clinical placements are more about professional socialisation than the acquisition of clinical knowledge or skills but students generally focus on the latter. In either case, legitimate participation is a prerequisite of the acquisition of a clinical repertoire.
Since the completion of this study the authors have reported back to the larger group of clinicians from whom the clinical teachers referred to in this report were drawn. At that meeting there were expressions of surprise and disappointment at the disparity between some of the expectations and perceptions of the clinical staff and those of the participating students. Since that time the present report was written and has been reviewed by a small number of clinicians who felt that its contents portrayed the staff and their service in a poor light.
The authors want to make it clear that this report is not intended as either a full or a fair representation of all teaching and learning in clinical surgery. Rather it is a snapshot of two student groups on their first journey through surgical practice. As such it has revealed issues commonly raised internationally in the educational literature on clinical learning and points to the widely recognised need to align more closely the provision of clinical services with the provision of clinical education.
Medical students have a legitimate place in teaching hospitals. All clinical staff are teachers whenever students are present, whether or not they have formal teaching roles. Students and clinical teachers know that students need to make the most of learning opportunities by being proactive; spending time on the ward, being useful, asking questions.
Clinical staff can facilitate student learning by consciously including students in the business of patient care. This means inviting students to ask questions and examine wounds, physically guiding hands on examinations, encouraging students to pay attention to discussions among the clinical team, and explaining what is being discussed.
Competing interests: None known.
Author information: Chrystal Jaye, Senior Lecturer, Department of General Practice, University of Otago, Dunedin; Tony Egan, Senior Teaching Fellow, Department of the Dean, Dunedin School of Medicine, University of Otago, Dunedin; Kelby Smith-Han, Teaching Fellow, Faculty of Medicine, University of Otago, Dunedin; Mark Thompson-Fawcett, Senior Lecturer and Colorectal Surgeon, Department of Surgery, University of Otago, Dunedin
Acknowledgements: This research was funded by a University of Otago Research into University Teaching Grant. The authors are grateful to the Department of Surgery at the Dunedin School of Medicine for opening up the teaching ward rounds and clinical tutorials to the critical gaze of the authors in this exploration of the clinical learning environment, and for the department’s engagement with the perspectives that arose out of it. In addition we thank Professor van Rij for his comments on earlier drafts of this manuscript.
Correspondence: Dr Chrystal Jaye, Department of General Practice, University of Otago, PO Box 913, Dunedin, New Zealand. Fax: +64 (0)3 4797431; email email@example.com
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