Medical Student Perceptions of Factors That Inhibit Development of Clinical Skills in the Clinical Setting
Matthew DiBartolomeo1, Matthew Smith1, Danielle James1 and Clare Whelan2
1Fifth year Medicine, School of Medicine, Trinity College Dublin
2School of Clinical Medicine, Trinity College Dublin
Background: In the clinical environment students are given the opportunity to actively engage in real cases, observe professional behavior and attitudes displayed by qualified physicians serving as role models, be a part of a health care team and develop their clinical skills. By understanding the factors that students perceive to hinder their learning in the clinical setting, we hope to improve the clinical learning environment and maximize student learning.
Objectives: To determine what factors medical students perceive to inhibit their clinical skills development in the clinical setting.
Methods: A quantitative survey using a 6-point Likert scale was administered to third and fifth year medical students of an Irish University.
Results: The students (n= 45) were positive overall about the clinical teaching (means 3.67 medical, 3.53 surgical), patient census (means 4.14 medical,4.14 surgical), environment (means 3.51 medical, 3.59 surgical) and the organization of the clinical learning environment (mean 3.44 medical, 3.42 surgical). The medical students rated supervision on clinical rotation poorly (mean 2.67 medical, 2.51 surgical).
Conclusion: The medical students viewed their clinical setting placements positively overall but perceived that they received a lack of supervision and insufficient feedback.
Teaching in a clinical setting involves direct patient interaction and lies at the core of medical education, allowing students to develop skills and competencies in an authentic learning environment and professionally relevant context (Daelmans et al., 2004). Students are given the opportunity to actively engage in real cases, observe professional behaviour, and be a part of a healthcare team while developing their clinical skills through an integrated approach (Conn et al., 2012; Spencer, 2003).
The clinical environment’s inherent fast-paced and chaotic environment does not always promote learning. Several studies have looked into the shortfalls of today’s clinical teaching environment from a medical students’ perspective. Students have reported a lack of supervison, rare feedback and having a passive role in the patient’s care as factors that hinder their learning in the clinical area (Daelmans et al., 2004; van der Hem-Stokroos et al., 2003). Hoffman and Donaldson (2004) found patient census to be the major influencing factor of clincial teaching with a high patient volume providing a natural syllabus for learning and a rich learning environment. However, this also results in a decrease in time for elaboration and self directed learning. Conversly, a low number and variety of patients allow more time for reflection and self-direct learning, but less variety in educational opportunities. Dolmans et al. (2008) found that medical students, while completing rotations, felt that they were not given enough opportunities to pactice their skills and that they were inadequately supervised.
The General Medical Council (2009) outline general guidelines to assist medical schools to ensure their clinical placements address aspects of the standards and requirements set out in Tomorrow’s Doctors (2009) relating to clinical placements for medical students. The role of the medical student is to fully integrate themselves within their clinical team through active participation in daily clinical tasks. In addition, prior to starting a clinical rotation, clear learning outcomes should be communicated to the student so that they may be able to work towards achieving them. All students must be supervised by a fully registered doctor with a license to practice. The assigned supervising doctor must determine the degree of supervision required and supervise them directly or should arrange for supervision by or one or more identified fully registered healthcare practitioners. (General Medical Council, 2009).
This study investigates the current factors percieved by medical students from an Irish Medical School to be inhibiting their development of clinical skills in the clinical setting.
The Irish university involved in the study offers a 5-year medical undergraduate program where, in years three and five of the program, students are allocated to a variety of clinical medical and surgical rotations. A quantitative survey (see bottom of page) using a 6-point Likert scale was administered to third and fifth year medical students.
An anonymous online questionnaire was emailed to students with items relating to the following categories identified in the literature as perceived by medical students to be influential in student learning from a student perspective: clinical teachers, patient census (the variety of types of patient conditions they were exposed to), environment, supervision and organization of the clinical learning environment. The survey was author developed with items included based on literature findings. The questionnaire contained 28 items that were each rated on a six-point scale (1- strongly disagree, 2– moderately disagree, 3– slightly disagree, 4– slightly agree, 5– moderately agree, 6– strongly agree).
The population chosen for this study was the entire cohort of third (n = 156) and fifth year (n = 145) medical students at an Irish Medical School. Inclusion criteria for this study required that candidates be either a third or fifth year medical student enrolled at the university and that they must have completed a minimum of 1 medical and 1 surgical rotation at the time of participation.
The response rate was 15% (n=45). Of the 45 respondents, 24 were in third year and 21 were in fifth year. Figure 1 displays the mean responses for each category. The students were positive about the patient census (means 4.14 medical, 4.14 surgical), clinical teaching (means 3.67 medical, 3.53 surgical) , environment (means 3.51 medical, 3.59 surgical) and the organization of the clinical learning environment for learning (mean 3.44 medical, 3.42 surgical). The medical students responses were more negative regarding supervision (mean 2.67 medical, 2.51 surgical).
Analysis of the Data
An independent t test was carried out to look for any differences between the 3rd and 5th year students. Only 4 items were found to have a statistically significant difference in response between the years (Figure 2).
Overall, students viewed their clinical teachers positively as enthusiastic, open to explaining and having good communication and teaching skills. The students perceived some areas of the clinical teaching less positively. Item 11 “My clinical teachers set clear expectations” (mean 2.9), item 18 “I get regular feedback from my seniors on my strengths and weaknesses” (mean 2.9) and item 16 “My clinical teachers offer support during stressful times” (mean 2.6) highlight areas that the medical students feel could perhaps be improved upon.
Moulaert et al. (2004) showed a positive correlation between deliberate practice and student performance. Questionnaire items “I was observed regularly performing clinical skills previously taught in clinical skills laboratory” (item 10) and “I was encouraged to perform practical skills under supervision” (item 23) relate to the views of the medical students regarding the deliberate practice experienced in the clinical areas. The students perceived that their opportunities for deliberate practice under supervision were fairly poor with both of these items achieving means of less than 3. The year 3 students returning a significantly lower response to item 23 (p= 0.01). The year 3 and year 5 students demonstrated slightly different perceptions about their exposure to a variety of practical skills (item 22, year 3 mean 2.52, Year 5 mean 3.64) with the 5th years rating their medical rotations with a significantly more positive score (p= .002).
The students in the present study felt that they were exposed to a wide variety of patients and patient problems and that there were adequate facilities for them to examine patients independently but that not enough time was devoted to supervision, and that they were not observed regularly during patient contacts or performing practical skills. Daelmans et al. (2004) reported that students believed poor supervision and a lack of feedback from senior staff to be major obstacles in their education.
According to van der Hem-Stokroos et al. (2003) students believe observation and constructive feedback to be key features of effective clinical learning. Item 4, which asked students if they received sufficient feedback, received a mean rating of 3.02 while item 18 asked the students if they regularly received feedback on their performance achieved a poor overall mean score of less than 3.
Spencer (2003) suggests that flaws typically associated with clinical education do not arise from the clinical teaching approach itself, but tend to arise from poor planning and implementation. Therefore, poor organization in a clinical setting is a factor that can have an adverse effect on medical students’ learning. Opinions were divided across the different cohorts with regards to their views on organization of the clinical environment in this study.
Responses to Item 14 “My clinical teachers arrived at scheduled meetings promptly and prepared” found differences in opinion between the year 3 and year 5 students regarding medical rotations (p= .043) with the 5th year students displaying a slightly more negative view on this. There was also a statistically significant difference between the year 3 and year 5 students’ responses to item 26, “Too many students were assigned to the team to promote student learning”. The year 5 students agreed somewhat with this statement whereas the year 3 students seem to view it as less of an issue (p= .018). Item 15, which asked students if they felt that they were assigned a clinical mentor received a very poor response, with a mean of less than 2 from all years for both medical and surgical rotations. It may be that the clinical areas in question do not utilize a specific mentoring assignment system or perhaps clinical mentor means different things to different people and requires clarification when referred to in future.
In conclusion, the medical students viewed their clinical teaching positively overall and perceived that they had exposure to a wide and varied patient census. The main factors which medical students identified as not meeting their expectations in the clinical setting were lack of supervision from senior staff, insufficient feedback, and poor organization. These findings are in line with findings from the literature. There are constant tensions for students between wanting lots of clinical exposure but also wanting a perfectly tailored learning environment. Many medical schools try to solve it by removing students from the clinical setting and real patients from the learning environment. Simulation, while it has its place cannot simulate entirely the authenticity of the clinical environment and so we must strive to seek out ways to enhance the potential for learning and development of skills in the fast paced and complex clinical environment in any way we can.
This paper carries a number of limitations. The survey was author developed and unvalidated with items based on previous literature findings. The numbers are too small for meaningful subgroup analysis. The study is based on students’ perceptions, which may be sensitive to the expectations they have entering each rotation.
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