교육 원리에 입각한 조기 임상노출(Maastricht)

Early student-patient contacts in general practice: An approach based on educational principles

RAMON P. G. OTTENHEIJM, PAUL J. ZWIETERING, ALBERT J. J. A. SCHERPBIER, & JOB F. M. METSEMAKERS

Maastricht University, Maastricht, The Netherlands

Abstract

Background: Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students’ learning processes.

Aims: To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility.

Method: Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme.

Results: Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients, transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible.

Conclusion: In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in general practice based on educational principles.

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Introduction

임상교육은 학부 의학교육의 중요한 요소이다. 조기 임상노출에 대한 언급은 1970년대로 거슬러 올라간다. 또한 최근의 많은 교육과정 개선이 학생들을 조기에 임상경험을 시키는 것을 목표로 하고 있다. 일반적으로 조기 임상 경험은 affective and cognitive 측면에서 긍정적인 효과가 있다. 또한 본격적인 임상실습에 잘 준비할 수 있도록 하며, 배우는 내용을 실제 환경에서 적용할 수 있게 되는 등 여러 장점이 있다. 그러나 이러한 중요성에도 불구하고 최선의 설계가 무엇인지에 대해서는 알려져 있지 않다.

Clinical education is a core component of undergraduate medical education, comprising early clinical experiences and clinical clerkships. Programme descriptions of early clinical experiences go back to the 1970s (Pittman & Barr 1977; Smith et al. 1977; Benor 1987). Many recent curriculum revisions have been aimed at promoting students’ early clinical experiences (Howe 2001; Whipple et al. 2006; Howe et al, 2007; Diemers et al. 2007; Hook & Pfeiffer 2007). Generally, early clinical experiences have positive effects on affective and cognitive outcomes and on knowledge and skill development. Further, they offer good preparation for clerkships. More specifically, they provide an authentic context for learning, help students develop clinical ways of thinking, support students’ learning of biomedical and behavioural/social sciences and offer knowledge that cannot be learned from books (Dornan & Bundy 2004; Dornan et al. 2005). However, despite the fact that the importance of early clinical experiences is underpinned by an evidence-based set of learning outcomes, little is known about the best way to construct such experiences

임상실습에 대한 연구문헌을 살펴보면 임상환경이 항상 최선의 학습환경은 아님이 드러난다. 지나친 다양성과 예측불가능성, 불연속성 등의 특징이 있기 때문에 일차의료진료환경에서 일대일로 가르치는 것이 효과적인 임상교육을 위해서 더 좋을 수도 있다.

Research on clerkships has shown that the clinical environment is not always the best setting to enhance students’ learning processes. Students’ learning experiences are characterized by variability, unpredictability, and lack of continuity (Remmen et al. 2000; Murray et al. 2001; Irby & Bowen 2004). Primary care settings and teaching based on one-to-one contacts may be environments most likely to fulfil criteria for effective clinical teaching (van Leeuwen 1995; Gordon et al. 2000).

2001년 Maastricht의과대학의 6년 교육과정의 revision이 있었고, 그 목적 중 하나는 초기 임상경험을 강화하는 것이었다. 

In September 2001, a revision of the six-year undergraduate medical curriculum of Maastricht University was launched. One of the aims was to intensify early clinical experiences in different practice settings. Until 2001, the Department of General Practice delivered two undergraduate courses based on student-patient contacts: the early clinical Adoption Programme and a clerkship in Year 6 (Martens & op ‘t Root 1992; Crebolder & Metsemakers 1994; van Bokhoven et al. 1998).

Method

우리는 조기임상경험을 '임상실습 전에 실제 환자와 실제 임상 상황에서 접촉함으로서 학습과정을 촉진하는 경험'이라고 정의했다.

We defined early clinical experience as pre-clerkship experiences with authentic patient contact in a clinical context that enhances the process of learning (Dornan et al. 2005)

1단계 : 배경정보 - 문헌 검색

Step 1 Background information

We searched Medline and Psycinfo for articles published after 1970, using the keywords: medical education, undergraduate, programmes, family practice or general practice, and supervision.

2단계 : 프로그램 기술

Step 2 Description of the programme

This step involved translation of the starting points resulting from step 1 into the new programme.

3단계 : 프로그램 평가

Step 3 Evaluation of the programme

We evaluated the first three years of the new programme by a questionnaire survey among the GPs and students participating in the programme.

Results

전 임상실습 교육과정 중 실제 진료환경에서 학생-환자간 효과적인 학습환경을 만드는 방법

Step 1: How to construct an effective learning environment for pre-clerkship student-patient contacts in real practice

1. 조기 환자 접촉의 중요성 : 환자에 대한 지속적 노출이 중요하다.

1. The importance of early patient contacts

지식의 구조화와 장기기억에 Practical experience의 중요성

학생이 illness script를 쓰는 것이 중요

조기에 폭넓은 문제에 대해 다양한 환자를 만나는 것이 중요

There is evidence that practical experience is a prerequisite for the development of medical expertise, based on cognitive psychological theories regarding clinical reasoning and how knowledge is structured in long-term memory (Bordage & Lemieux 1991; Schmidt & Boshuizen 1993; Custers et al. 1998; van de Wiel et al. 1999). It is important for students to develop illness scripts, which consist of pathophysiological knowledge, information about physical, mental and social consequences of disease and the situation in which illness develops. These structures of expert knowledge result from continuous exposure to patients and thus require extended practice in professionally relevant contexts. This underscores the crucial importance of students seeing, at an early stage, multiple patients with a wide range of problems in a professionally relevant context (Dolmans et al. 2005). Starting point A: Continuing exposure to patients.

2. 효과적인 임상교육과 임상학습

2. Criteria for effective clinical teaching and learning

Whilst we are able to describe the settings in which students learn, we are still struggling to answer the question of ‘how’ learning comes about. 

학습 사이클 : Kolb의 경험학습이론. 다양한 사례로부터 얻은 insight가 지식을 illness script로 변환시킨다.

Learning cycle. Kolb’s experiential learning theory asserts that learning occurs through interactions between persons and their concrete experiences (Kolb 1984; Scho¨n 1990). The essence of learning is transformation of experience into knowledge in a cycle which starts with a concrete experience, such as a patient encounter, followed by reflection on that experience, which in turn leads to conceptualizations and generalizations, which are then tested in new situations at which point the cycle starts again. Experiential learning may be enhanced when learners become aware of the consequences of their actions as a result of feedback and inquiry. Generalisation of insights from many different cases can restructure knowledge in memory into illness scripts (Smith & Irby 1997). Starting point B: Transformation of experience into knowledge

학생의 능동적 역할 : 관찰은 초기 단계에서, 매우 제한된 기간동안만 효과적이다. 더우기 정교한 계획과 촉진적 교수가 필요하다. 환자를 독립적으로 보는 것이 중요하다.

Active role of students. What type of practical experience do students need to develop their illness scripts and basic skills? Several teachers think it is sufficient for students to observe clinical situations to achieve the desired exposure. However, observation is only effective in early stages of training, providing preparation and debriefing take place, and even then only for a limited period of time. Students will inevitably get bored and their enthusiasm will fade. Moreover, it requires careful planning and facilitative teachers (Kachur 2003). Thus, students should not remain passive observers for long. Active approaches are ‘hot seating’, with a student leading (a part of) a consultation, and independent patient encounters, in which a student first sees a patient alone in a separate room before being joined by the teacher. Seeing patients independently is the most valued setting for achieving positive learning outcomes (Lawrence et al. 1999; Spencer 2003; Stark 2003). Starting point C: Active role of students.

감독과 피드백 : 감독은 환자outcome에 긍정적인 효과가 있으며, 감독이 없으면 환자outcome에 악영향을 끼치게 된다. 또한 감독관은 임상적으로 유능하면서 많은 지식을 가지고 있어야 하고, 교수능력과 대인관계 능력이 좋아야 한다. 피드백은 감독하는데 있어서 중요한 요소이나 의학교육에서 피드백은 표준적이지 못하다.

Supervision and feedback. Supervision has positive effects on patient outcomes and lack of supervision is harmful to patients. Supervision is key to the success of clerkships (Kilminster & Jolly 2000; Dolmans et al. 2002). Important features of supervision are continuity over time, supervisees’ control of the content of supervision and some reflection by student and supervisor. Effective supervisors give their supervisees responsibility for patient care and offer

opportunities to carry out procedures and review patients, involvement in patient care, guidance, and constructive feedback. They should also be clinically competent and knowledgeable and have good teaching and interpersonal skills (Kilminster & Jolly 2000; Cottrell et al. 2002). Feedback is an essential component of supervision (Rolfe & Sanson Fisher 2002). Unfortunately, the frequency and quality of feedback in medical education are not always up to the mark (Schamroth & Haines 1992; Paul et al. 1998). Feedback should be directed towards behaviour that is amenable to change and be specific rather than general. The needs of the receiver as well as the giver should be considered. Also, feedback should be given timely, i.e. as close as possible to the event, and selectively address one or two key issues rather than too many all at once (Irby 1994; King 1999). Starting point D: Supervision and feedback.

3. 현실적 문제점

3. Practical points

시간과 공간의 제약 : 여러 의사들이 교육과 관련해서 언급하는 문제

Time and space. Most doctors recognize that for clinical teaching the availability of time and space may pose significant problems. Therefore, ample opportunities and acceptable incentives, such as financial reward, are important issues for doctors (Hartley et al. 1999; Haffling et al. 2001; Stark 2003). Given scarcity of time, logistical matters must be dealt with adequately (Hartley et al. 1999). An example of a model of effective and efficient use of time and integration of teaching into day-to-day routine is the ‘one-minute preceptor’ (Spencer 2003). Starting point E: Time and space for teaching. 

교수 훈련 : 학생과 교수가 임상 교육의 내용/스타일/세팅에 대해서 항상 잘 맞는 것은 아니다.

Teacher training. Students and clinical teachers are not always in agreement with regard to content, style and setting of clinical teaching (Stark 2003). Clinical teachers are not fully aware of what to expect and what not to expect from students and may be uncertain about how to give feedback and how to assess. In early patient contacts they are not merely preceptors but they take on the mentor role with a strong focus on supervision and feedback. Therefore, teaching should also include time for preparation and teacher training (Irby 1995; Gordon et al. 2000; Haffling et al. 2001; Stark 2003). Starting point F: Teacher training.

2단계 : 3학년 프로그램의 일반

Step 2: General practice programme in Year 3

The starting points (left column Table 1) resulting from step 1 were used in designing the new GP programme in Year 3 of the new Maastricht curriculum. Within the context of these encounters theory and practice are addressed in an integrated manner. Thus starting points A-D are guaranteed (Figure 1).

After the encounter, they write a structured ‘SOAPEL’ report (subjective, objective, assessment and plan (SOAP) supplemented by elaboration and learning goals)

GP를 대상으로 일 년에 두 차례의 워크숍을 수행함.

Twice a year workshops are offered to inform the GPs about the curriculum and the content of the clinical general practice programme. In the workshop, GPs are instructed about how to fit the programme into their daily practice routine and specific topics are addressed (F) (Table 2).

Step 3: Programme evaluation

The questionnaire items are presented in Table 1. Table 3 shows the response rates and descriptive statistics.

Conclusion and discussion Our findings suggest that early student-patient contacts do indeed enhance learning and integration of theory and practice, and are sustainable (Diemers et al. 2007; Howe et al. 2007).

In designing this programme, we were mindful of Mainhard’s conclusion about the Maastricht Adoption Programme (Mainhard et al. 2004)

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Med Teach. 2008;30(8):802-8. doi: 10.1080/01421590802047265.

Early student-patient contacts in general practice: an approach based on educational principles.

Ottenheijm RP1, Zwietering PJ, Scherpbie AJ, Metsemakers JF.

Author information

Abstract

BACKGROUND:

Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students' learning processes.

AIMS:

To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility.

METHOD:

Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme.

RESULTS:

Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients,transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible.

CONCLUSION:

In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in generalpractice based on educational principles.