Sarah Mahoney

A review of longitudinal community and hospital placements in medical education: BEME Guide No. 26

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.

Transformative Learning in Medical Education: Context Matters, a South Australian Longitudinal Study.

This longitudinal study followed the clinical learning journey of 20 medical students over 4 years, from the beginning of their clinical immersion, through one of the three different clinical placement models: block rotation, longitudinal integrated clerkship, or community- and hospital-integrated learning, and then into Year 4 and the intern year postgraduation. This study explored how these different contexts can influence the process of transformative learning. The results identified six well-defined changes to their ways of seeing the world which participants described as insights shaped by their clinical training. These themes were self-awareness, patient centeredness, systems thinking, self-care, clinical skepticism, and understanding diversity. Further analysis explored how changes in worldview can be instrumental, communicative, and emancipatory. This study demonstrates that context matters and that longitudinal models of clinical education may facilitate emancipatory learning.

A longitudinal study of empathy in pre-clinical and clinical medical students and clinical supervisors

BackgroundAlthough appropriate empathy in health professionals is essential, a loss of empathy can occur during medical education. The structure of clinical learning may be one factor that is implicated in a loss of empathy. This study examines student and doctor empathy, and possible associations between empathy and the structure of clinical learning.MethodsThere were three groups of participants: medical students (n = 281), who completed a longitudinal survey consisting of the Jefferson Scale of Empathy and an open question about empathy at the beginning and end of the 2013 academic year; private doctors (medical practitioners) in South Australia (n = 78) who completed a survey consisting of the Jefferson Scale of Empathy and an open question about empathy at the end of the students’ academic year; and doctors (medical practitioners) from public teaching hospitals (n = 72) in southern Adelaide, South Australia who completed a survey consisting of the Jefferson Scale of Empathy at the end of the students’ academic year .ResultsYear one students’ empathy scores at the end of the year (102.8 ± 17.7) were significantly lower than at the start of the year (112.3 ± 9.6) p < .05). There were no other significant differences in students’ empathy scores by year groups or across the two time points. Empathy scores were almost identical for private and hospital clinicians and higher than average scores for students. Free-text comments highlighted the importance students and doctors place on empathy. Students described issues that adversely affected their empathy, including specific incidents, systemic issues, and course structure, but also described some positive role models. Doctors’ comments focused on the importance of empathy but qualified its meaning in the therapeutic setting.ConclusionMedical students and practitioners alike ascribe importance to empathy in clinical practice, yet its developmental course remains poorly understood with possible decrement across the course of medical education. A more sophisticated understanding of empathy in medical students is needed, with attention to issues that might adversely impact on this crucial aspect of their development.Trial registrationThis was not undertaken as the research did not involve a health care intervention on human participants.

How social accountability can be incorporated into an urban community-based medical education program: an Australian initiative.

Background: Medical schools play a role in ensuring that their outcomes ultimately have positive effects on the health status of communities. We describe an initiative that translates this broad intent into meaningful activities that foster positive attitudes to social accountability among medical students in the context of an already full curriculum. Methods: Faculty members from an urban community-based medical education program undertook broad consultation with its community groups. Medical students then undertook activities designed to assist in the well-being of socio-economically disadvantaged adolescents through near-peer counselling and health education. Results: Early evaluation from medical students, secondary students, community organisations and faculty indicates that the activities undertaken to-date have been of value to stakeholders. Discussion: This initiative is intended to develop one model for incorporating social accountability into the medical curriculum with sustainable activities that benefit the community and medical students. Further research and evaluation of the impact of this initiative on both the community group involved and on medical students is essential.

Patient participation in, and attitudes towards, community-based medical education

Improved coordination of care after hospitalizations is essential to decrease readmissions and costs, and most importantly, to prevent undesirable patient outcomes. Changes in care plans may be lost through ineffective communication to the patient or providers, making this transition particularly critical (Kripalani et al. 2007). Thirdyear medical students are frequently involved in discharges though rarely have opportunities to follow patients after the hospitalization and receive little formal training in transitional care. Students’ self-assessed competency in transitional care has been shown to increase after introducing curriculum designed to focus on discharge planning (Bray-Hall 2010). This study aims to assess third-year medical student perceptions of transitional care following an educational exercise. Students identified a patient and completed a semistructured telephone interview within 3–5 days after discharge to assess patients’ adherence with discharge instructions. The survey involved questions about the discharge process guiding the students to: assess the patient’s understanding of perceived need, benefit and disadvantages of the hospitalization, reconcile medications, determine adherence to home services and follow-up appointments, and ascertain if the patient returned to the ED. Students were then asked to comment on their experiences in order to provide an opportunity for reflection. Three independent reviewers analyzed the qualitative data from the students’ reflections for emerging themes. Themes included coordination of care, empathy and patient relationships, in addition to recognition of logistical challenges in patient continuity. Students articulated many components of the discharge process in which difficulties arise and noted that they were more thoughtful in preparing discharge-related documentation when they knew they would be contacting the patient. Several students also highlighted continuity of care and patient relationships as the aspects of this exercise that they found to be most valuable. This exercise serves as an innovative model for incorporating discharge planning into the curriculum of inpatient clerkships and was found to increase insight into the complexities of transitional care. Transitional care is pivotal in decreasing adverse events and readmission, and we recommend that this education be incorporated into undergraduate medical training.

Rural, urban: the real world for medical education.

TO THE EDITOR: The alcohol industry invests in “responsible drinking” advertisements purportedly designed to meet corporate social responsibility objectives. Analysts have proposed that such advertising is used to avoid alcohol control measures and in effect constitutes alcohol promotion.1-4 The Australian alcohol industry organisation DrinkWise recently launched an online video advertisement, “How to drink properly”, which has been seen by tens of thousands of viewers. To investigate young drinkers’ responses, we conducted a qualitative study with 40 Western Australian drinkers aged 18–21 years. A research agency recruited the sample members from among young people listed in its large database, who were sent an invitation email to ascertain whether they drank alcohol. Eligible respondents were then sent an email in March 2014 containing an internet link to the video and an open-ended request to “Let us know your reactions to this video”. The participants responded by reply email. Data were analysed using NVivo 10 (QSR International). The responses were coded according to attitudinal (eg, like/dislike the ad) and behavioural intentions variables. The study was approved by the Curtin University Human Research Ethics Committee. Around two-thirds of respondents reported liking the ad, describing it as “cool”, “classy” and “clever”. It was viewed as specifi cally targeting their age group: “The message was clearly targeting younger drinkers, perhaps in their teens and 20s”; “You can tell it is solely focused on the younger demographic”; and “It seemed as though it was talking to me and my friends, rather than the whole community”. Reasons given for this perception included creative elements (cartoon format, humour, swearing) and recognition of heavy drinking practices: “It accepts that people drink and get ‘shitfaced’, as the ad says”. Some noted that the ad stimulated desire: “It immediately encouraged me to drink”. Overall for this sample, the takeout message was that drinking is a normal part of life with distinct advantages if undertaken at “appropriate” levels. No respondents nominated the number of drinks required to achieve this level. Some commented that they were aware of the need to avoid excessive consumption, but that it is diffi cult to stop once drinking has commenced. There was no demonstrated understanding of the National Health and Medical Research Council guidelines, which note that young people up to the age of 25 “are at particular risk of harm from alcohol consumption”.5 Our study fi ndings suggest that through its “responsible drinking” advertising, DrinkWise instead risks effectively promoting alcohol consumption to 18–21-year-olds. Of considerable concern is that people aged under 18 are also highly likely to be exposed to this advertisement, given its online placement.