Early Learner Engagement in the Clinical Workplace

Abstract

Introduction

Recent calls for medical education reform advocate for the integration of knowledge with clinical experience through early clinical immersion. Yet, early learners rarely are invited to participate in workplace activities and early clinical experiences remain largely observational. We conducted a series of studies to identify legitimate workplace roles and activities for pre-clerkship students and the environmental, teacher, and learner factors that facilitate their workplace participation and learning.

Methods

We conducted semi-structured interviews with pre-clerkship student and faculty volunteers at student-run clinics, asking them to describe student roles in these clinics. We performed open and axial coding of the transcripts using the sensitizing concepts of workplace learning and communities of practice. Using data from the student-run clinics, additional student focus groups, and faculty interviews, we defined entrustable professional activities (EPAs) appropriate for pre-clerkship students. We identified activity domains and mapped them to pre-clerkship objectives, graduation competencies, and resident-level EPAs. We developed elaborated EPA descriptions for each domain and conducted local, national, and international workshops to verify appropriateness of EPA content and supervision level. We then conducted semi-structured interviews with excellent clinical teachers, exploring their approach to teaching different-level learners and the development of their approach. We performed thematic analysis of the transcripts using open and axial coding. Lastly, we surveyed pre-clerkship students at four institutions about their personal goal orientation and perceptions of their early clinical experiences, and collected performance evaluation and standardized-patient exam scores. Data analyses included descriptive statistics and mediation analysis.

Results

We interviewed 22 students and 4 faculty from the student-run clinics. Students had legitimate roles in direct patient care and clinic management. Clinic features supporting this included defined scopes of practice and limited presenting illnesses. Five EPAs of narrow scope were developed for early learners: 1) information gathering, 2) differential diagnosis and management plan development, 3) healthcare team communication, 4) information sharing with patients, and 5) resource identification. Interviews with 19 clinical teachers revealed teachers used sequencing as a teaching strategy by varying content, complexity, and expectations by learner level. They initially selected learning activities based on learner level, adjusting for individual competencies over time. They used sequencing to promote both learner education and patient safety. Teachers were proactive in using on-the-job experiences to develop their teaching practices, which followed a developmental trajectory towards learner-centeredness and was associated with the development of clinical skills and confidence. 296 of 517 (57.3%) students completed the survey and 253 (85.5%) had linked performance data. Students held a predominantly mastery goal orientation towards their early clinical experiences. Mastery-oriented students perceived the curriculum as mastery-oriented with positive workplace affordances, and those perceiving a mastery-structured or inviting workplace, performed better.

Conclusion

Pre-clerkship students are capable of participating in patient care activities of narrow scope, characterized by five EPAs. Their participation and learning require teachers who employ sequencing to ensure developmentally appropriate patient-safe activities and attention to the workplace environment. By expanding EPAs to early learners and employing strategies for their workplace engagement, we can realize the intended goals of early clinical experiences.