The students said they had encountered all of the six teaching methods during clinical training and cited both positive and negative examples. Differences between students’ experiences are mostly related to individual teachers, hospitals, disciplines and students (pro-active or not, amount of experience).
We present the results for each of the six teaching methods and for learning climate separately. Starting with the vignette in question we present descriptive summaries of students’ experiences with the method, their descriptions of the method in action, problems with the method and suggestions for improvement. We illustrate these by quotations from the interviews. A letter number combination identifies the quotations by focus group and student.
Students said that looking back on their clinical training they could think of several instances of modelling, especially when new topics or technical skills were introduced. They noted that they could still remember why and how a certain procedure was performed when a teacher had explained it to them very clearly. The main perception of students about role modelling was that they continuously observed clinicians and considered whether they wanted to be like them or not. Students expressed a high regard for teachers who explained and demonstrated things repeatedly and actively involved students in modelling by thinking aloud and by explaining why they performed certain actions.
Yes, well with neurology in Heerlen, I did not particularly like that rotation, but what I did like very much was that the first few days, I think it was the second day when I was shadowing the house officer and she extensively demonstrated the full neurological examination from head to toe. And after that it was like just do it yourself, but that one time, demonstrating it. For of course it is an extensive examination, like what was it like in reality, I really like that. It was only once, but it was really good that they did it just to see how to do it systematically. (B8)
Modelling was not a regular occurrence, however, and students were not always actively engaged in the process. Often clinicians did not take enough time to model activities in a sufficiently explicit manner. Teachers frequently left it largely unexplained why certain actions were performed and certain questions asked. As a result students sometimes felt they were just imitating what they had seen a doctor do during physical examination but did not have a clue as to what they were doing or why they were doing it.
That you just do what you have seen them doing, and that is often just a poor example of how it is supposed to be done. And that you, just because they do it that way, that you do it that way too … But actually that is not how it is supposed to be done. (C5)
Students suggested that modelling would be greatly enhanced when teachers would explain the rationale and method of their actions. Most of the time the students just watched procedures being performed without any active involvement on their part.
For the students, coaching was mainly associated with being observed during assessments, especially when presenting a patient history. Although the students indicated that they did not always like being observed, there was general appreciation of observation when it was followed by suggestions as to what and how they could do better. Students with more experience in clinical practice were more confident and found it easier to ask for observation and feedback.
Yes, you really learn from it [being observed], I don’t really like it, but you do learn a lot when a person gives you decent feedback afterwards, like hey look, in that part it would have been better if you had done it that way. (B3)
Time constraints played a part and, despite their lack of enthusiasm for being observed, students felt more observation was possible. Students also reported that observation was mostly limited to parts of activities, such as reporting after performing a history and physical examination.
Students said they wanted a stronger emphasis on feedback rather than assessment because the latter offered few concrete directions for improvement. According to the students, the assessment checklists were not helpful in providing specific feedback, because the clinicians were only required to check boxes before giving a final judgement.
The students expected that matters would improve when they were assigned to one personal supervisor who could observe them more frequently. Feedback training for clinical teachers was also expected to be helpful. The students asked for more specific feedback in addition to global ratings.
Scaffolding was mainly experienced by the students during longer rotations—for example the 10-week family medicine clerkship—where they had repeated one-on-one contact with one supervisor. Some students said they had experienced it during shorter rotations too but this depended on individual supervisors and hospitals’ specific approach to students.
Scaffolding motivated students and they appreciated it when supervisors showed an interest in and took account of their level of skills and knowledge.
I think it mostly occurs during the longer rotations. That at first you are told ‘come along and observe in the outpatient clinic, in the operating theatre or an emergency patient or whatever’ and after the first two weeks, you were told like ‘well, now you have some idea of what to do, come on.’ (B6)
The shorter the rotation, the less likely they were to experience scaffolding according to the students. Because they were always shadowing different people, the students felt that none of the supervisors had a good idea of their knowledge and skills. One student argued that it would be unrealistic for them to expect the teachers to really know their level of knowledge and skill because a teacher would have to be virtually omniscient and omnipresent to manage that.
It sort of suggests that teachers are like Father Christmas or God, who knows all along whether you can do something or not and who is not just watching you all of the time, but also helps you when things are difficult and otherwise allows you to manage on your own. And well, I think that is very difficult to achieve. (C4)
Students say they would like to feel that it was safe for them to inform their supervisors of their level of competence so that supervisors can act accordingly. They suggested that things could improve greatly, if teachers would ask them in which year they were and which rotations they had completed. Students also said they liked the concept of ‘constructive friction’. In other words they liked to be challenged to make an effort to move to the next level.
It would actually be quite good if in a manner of speaking you were literally asked at the start “just tell me honestly what you know and don’t know, it won’t be held against you” but that someone just knows the gaps in your knowledge so that you can do something about it. (A5)
The students said they had experienced aspects of articulation throughout the clinical years. Whenever it occurred it deepened their knowledge and experience and enhanced their memory. Articulation did not depend on the amount of time spent with supervisors and occurred right from the start of clerkships.
(…) That doctor had really made it an art to start with a simple question making you feel like o.k. I know a lot of basic knowledge and then at a certain point start firing challenging questions at you about things you didn’t know yet, first brainstorm about that with you and then ask you to take the remaining issues home with you and follow up on them the next day. Yes, well, er that is really an art you would want to cultivate. (C2)
Articulation was not always effective and students noted that occasionally it focused on highly specialised knowledge on a supervisor’s pet topic. An experience shared by all students was that supervisors after telling them to ‘look it up’ rarely followed up on that. This was qualified as frustrating. Students sometimes felt that telling them to ‘look it up’ was a good way for teachers to be rid of them. Nevertheless, it was also clear that some supervisors were very good at asking probing questions to stimulate students to learn whereas other teachers tended to use articulation primarily to expose gaps in students’ knowledge.
Another point made by the students was that they gradually developed a pro-active attitude towards articulation as their confidence and knowledge grew or they felt safer with a supervisor or in a specific learning environment. Nevertheless, it was sometimes difficult for them to ask the ‘right’ questions because of lack of knowledge in a specific domain.
Also what they ask you to look up. Of course it is easy for a doctor to find lots of gaps in students’ knowledge. And then they ask about very specific details, but what is the point for a student to look that up only to find that you will never use it anyway. (A5)
Yes, but sometimes you just don’t know what to ask. For then, for instance when you do not recognise things, you just don’t [ask about them]. (C5)
It was the students’ final conclusion that articulation should be applied more often because it stimulated learning and that teachers who told them to ‘go and look it up’ should follow up on this and discuss it with them afterwards.
For the students, reflection was mainly associated with the reflective portfolio and their portfolio mentor rather than with their clinical training. During clerkships reflection was generally limited to a few scattered incidents on longer rotations, to one-on-one contacts with supervisors and to contacts with a few supervisors who were interested in reflection. Some of the supervisors who tried to encourage reflection focused exclusively on strengths and weaknesses but failed to give directions for improvement.
The supervisors who engaged in reflective activities were typically those with whom the students had contact for a longer time or who could be characterised as having a proactive approach to education.
Students recognised the value of (self-)reflection, which in their opinion was stimulated by multi-source feedback, by video-tapes of their performance as a starting point of discussions, and by a favourable climate in the department. According to the students what they appreciated most in reflection was supervisors suggesting ways in which they could address their strengths and weaknesses.
Exploration was experienced infrequently by students and only during longer rotations and only with some supervisors. Students were told to ‘go and look things up’ more often than they were asked to formulate personal learning goals. Moreover, the students felt they did not have time for personal learning goals because they were too busy with other assignments. There were supervisors who thought learning objectives should be the same for all students, leaving no room for personal learning goals. Other supervisors said they ‘did not believe in learning goals’. On the whole, most students perceived exploration as a component of their portfolio or associated it with a particular form for analysing patient cases.
In the few instances where attention was paid to learning goals, the students experienced it as highly simulating and said it helped them focus their learning process. The students also said that documented personal learning goals could be useful in impelling supervisors to provide more meaningful learning experiences.
Well, in the outpatient clinic it was o.k. when you were sitting there or had actually done things, that was much better of course. But that when you were finished you would talk about the patients who had been seen and why not this and why not that. And that afterwards you would say, hey I don’t know this, I’ll look it up. Or that she sometimes said like “that is a really good question, but look it up for yourself first and then we will talk about it tomorrow for that way you will learn more than when I just give you the answer right now.” (B6)
As a way of promoting exploration, students suggested teachers should pay more attention to and help them formulate individual learning objectives and opportunities to pursue them.
General learning climate
The general learning climate was recognised as an aspect that was always present either in a positive or in a negative way. Students said the general learning climate largely determined to what extent they felt free, for example to ask questions. According to the students, supervisors who created a good learning climate made them feel that they were treated as equals and that the supervisor was genuinely interested in their learning. Feeling respected by their teachers was considered of crucial importance by the students. Additionally, several students said that students could also influence the learning climate by being positive and enthusiastic.
I mean in my experience there were occasions when I felt more like an equal … That house officers come up to you like ‘hey a new student’ and shake hands ‘I am …’ That makes you feel much better (…) then I immediately feel that it is safe to ask questions … that is much easier than when everybody just waits until you approach them. (B3)
It is also good … when there is someone, er someone whose task it is to guide you who says ‘when there is a problem, if things aren’t going smoothly, just come and see me, it can be quite anonymous (C1); A safety net (C4); Yes, some sort of safety net, That you can be sure in any case that when you have a confrontation with one of your bosses, that in any case there is someone to whom you can go and talk about it. (C1)
Whenever students felt the learning climate was negative, they did not feel free to ask questions and it hindered their learning. Students also described the learning climate as a delicate balance which was easily disturbed. For instance, when you did something wrong in the eyes of a supervisor, a good learning climate could easily turn into an unpleasant one. Frequently, supervisors showed no interest in students at all, which made students systematically avoid those supervisors.
As for respect it has happened that I politely asked the ward doctor in the morning ‘can I come with you today?’ ‘Well, is that really necessary? Oh well all right then.’ Well then you are following them the whole day with a look on your face like he does not want me along … Then you don’t feel comfortable and you do not feel that you are treated with respect. (B8)
Supervisors being more respectful to students and showing a genuine interest in their presence and learning activities would go a long way towards optimising the general learning climate.