• Abstract
    • 결론 : 습이 끝날 시점에서 LIC학생들이 patient care 독립적으로 engage 하며, clinic pt 기회가 많았다. 대부분 ambulatory setting에서 이뤄지는 LIC 교육모델은 학생들이 많은 기회를 제공한다는 점에서 Workplace learning principle 일치한다.
      • By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.
  • Introduction
    • 학교마다 거의 동일했던 Core clinical year 이제는 모델이 다양해지고 외래/입원환자 경험이 다양해지고, 환자에 대한 연속성과 감독의사, 세팅 등이 다양해지고 있다. LIC 모델은 하나의 학생이 전문직으로서 배우고 성장하는 과정은 실제 의사가 환자를 care하는 과정에 meaningful, supported participation 함으로서 가능하다는 전제에서 출발한다. 이러한 전제를 지키기 위해서 LIC 주로 외래환자 중심이며, block보다는 longitudinal 경험을 중시하여 환자, 그리고 supervising doctor와의 관계를 쌓는 것을 가능케 한다.
    • 다양한 clerkship model 존재함에 따라 그들 사이에 상대적인 효과성의 문제가 항상 있어왔고, 일부 연구는 LIC 학생들이 BC 비해서 환자중심의 태도를 갖는다는 것을 보여주기도 했다. 또한 LIC학생은 시험에서는 거의 비슷한 수준의 능력을 보여줬고, 환자가 가진 질병의 전체 코스를 배울 있는 특징이 있다. 이론적으로 이러한 결과는 LIC 모델을 뒷받침하는 learning science 연관이 되어있으나, 아직 이러한 결과를 뒷받침하는 기전에 대한 근거는 없다. 어떻게 LIC BC 학습 경험이 다를까? 예를 들면 환자와 보내는 시간이나 감독의사와 보내는 시간이 얼마나 차이가 날까? LIC모델은 BC보다 환자에 대해 책임의식을 갖게 하고, 독립적으로 환자 care 있게 해주는가?
  • Sample
    •  University of California San Francisco (UCSF), the University of South Dakota Sanford School of Medicine (USD) and Harvard Medical School (HMS)
  • Conclusion
    • Clerkships 학생들이 임상현장에 처음으로 full-time으로 접하는 중요한 기간이다. 여기서는 종료 시점에서 차이가 발견되었으며 LIC학생이 환자와 독립적으로 직접 일하는 시간이 많았고, 환자를 관찰하는 시간은 적었고, BC학생보다 return visit환자를 많이 보았다. 이러한 결과로부터 workplace learning 핵심이라고 있는 independent practice 향상은 LIC모델이 가장 중요하게 강조하는 점이라는 사실과, rotation-based 기존 방법에서는 이루어지지 않는다는 사실을 있다.


Students' workplace learning in two clerkship models: a multi-site observational study.

Source

Department of Medicine, University of California San Francisco (UCSF), San Francisco, CA, USA. bridget.obrien@ucsf.edu

Abstract

CONTEXT:

Longitudinal integrated clerkships (LICs) are established, rapidly growing models of education designed to improve the core clinical year of medical school using guiding principles about workplace learning and continuity. This study is the first to report data from direct observations ofworkplace learning experiences of students on LICs and traditional block clerkships (BCs), respectively.

METHODS:

This multi-institution study used an observational, work-sampling methodology to compare LIC and BC students early and late in the core clinical year. Trained research assistants documented students' activities, participation (observing, with assistance, alone), and interactions every 10 minutes over 4-hour periods. Each student was observed one to three times early and/or late in the year. Data were aggregated at the student level and by in-patient or out-patient setting for BC students. One-way analysis of variance (anova) was used to compare two groups early in the year (LIC and BC students) and three groups late in the year (LIC, out-patient BC and in-patient BC students).

RESULTS:

Early-year observations included 26 students (16 LIC and 10 BC students); late-year observations included 44 students (28 LIC, eight out-patient BC and eight in-patient BC students). Out-patient activities and interactions of LIC and BC students were similar early in the year, but in the later period LIC students spent significantly more time performing direct patient care activities alone (25%) compared with out-patient (12%) and in-patient (7%) BC students. Students on LICs were significantly more likely to experience continuity with patients as 34% of their patients returned to them, whereas only 5% of patients did so for out-patient BC students late in the year.

CONCLUSIONS:

By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.



  • LIC BC 학생 모두 환자를 support하고 care 대한 정보를 공유하는데 있어서 중요한 역할을 하고 있다고 응답한 데에 반해, LIC학생만이 "doctor role with patients"로서 성장(grow)하는 것에 대한 지속적인 기회가 있었다고 응답했다. LIC학생들은 care system 높은 수준으로 통합(integration)되고, 교수자 또는 환자와 깊은 관계를 형성함으로써 환자중심care 역량이 향상되고 동기화됨을 느낀다고 하였다.
  • 전통적인 BC방식의 임상 교육은 in-patient service team 일원으로서 학생을 투입하지만, 임상 참여를 encourage하는 측면에서 부족한 점이 많다. 이러한 모델에서는 초보 학습자는 가장자리로 밀려나고(marginalize), 감독하는 staff 자주 바뀌게 된다. Clerkship 구조와 학생이 얼마나 integration되었느냐는 clerkship 만족도와 직결된다. 그러나 학생들은 학습 니즈에 맞지도 않고, 적절한 학습기회도 제공하지 못하는, 그러나 자주 변화하는 service 대해서 연속적으로 적응해야 한다. 학생들에게 과의 문화에 동화되는 것은 어려운 일이고, 바뀌는 세팅에 따라서 배운 것을 적용시키느라(transfer) 애를 먹는다. 심지어 core clerkship 마지막까지도 학생들은 novice처럼 새롭게 시작하게 된다.
  • 이러한 상황은 "supported or guided participation"으로 대변되는 successful workplace learning 대비된다. (health care provider 활발하게 상호작용하며, 환자 care 적극적으로 참여시킴으로써 학습의 기회를 주고, 의도적으로 도전적인 과제를 주는 방식)
  • Sample
    • We selected participants from the University of California San Francisco (UCSF), the University of South Dakota Sanford School of Medicine (USD) and Harvard Medical School (HMS).
    • All three schools have concurrent LICs (at a tertiary hospital for UCSF, and at community sites for USD and HMS) and BCs (at tertiary hospitals and affiliated clinics). Students rank their clerkship preferences; most receive their first choice. Each LIC included 2–6 weeks in an in-patient context during an otherwise predominantly out-patient core clerkship experience.
    • Block clerkship students had predominantly in-patient experiences with varying amounts of ambulatory time in discipline-based clerkships, and a single longitudinal clinical experience

 

  • Discussion
    • BC 학생들은 스스로를 감독 의사의 바쁜 스케줄로 인해 비는 시간을 채우는 역할로 인지하고 있었고, LIC 학생들은 환자를 위하여 의사와 같은 역할을 한다고 느꼈으며, 그들의 감독의사와 collaborate with 했다고 생각했다. 반면 BC학생들은 스스로를 연말이 되어서는 학생과 같은 역할로 묘사했다.


 2012 Jul;46(7):698-710. doi: 10.1111/j.1365-2923.2012.04285.x.

The role of rolelearning in longitudinal integrated and traditional block clerkships.

Source

Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA. karen.hauer@ucsf.edu

Abstract

CONTEXT:

Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinalintegrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design.

METHODS:

This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data.

RESULTS:

Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care.

CONCLUSIONS:

Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.



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