Improving student learning

Medical students learn in a wide range of settings: at the bedside, on the wards, in the community, in outpatient clinics and in the classroom. Sometimes this is done alone or in pairs, but mostly in small groups (and often, in much larger groups). Students use books, journals, computers, videos, television, laboratories, microscopes and dissection as resources to help their learning. In many settings, they mostly watch doctors carrying out the tasks they will themselves undertake when qualified. During electives many students gain practical clinical experience to help them apply some of the theory they have learned at medical school. Once students have qualified, learning continues alongside clinical experience and has two main components. Much of this learning is based on the work newly qualified doctors are doing, but is often unstructured, hurried and with poor access to the learning resources they have relied on at medical school. At the same time, for most specialties, learning for professional examinations is based on reading and classroom-based teaching. Medicine inevitably is a complex discipline and learning to become a doctor is a complex task. One of the most intriguing questions in medical education is: how do students learn? Whilst we can describe the settings in which students learn, and discover those that students like the most, and the least, we are struggling to find answers about the how of learning. Authors of papers in this issue of Medical Education approach this question by asking: What conditions can be created by teachers to ensure that students learn in the most effective way? A team from Maastricht led by two educational psychologists, Dolmans and Wolfhagen, has examined aspects of outpatient teaching from the students’ perspective. They used path analysis to test relationships and interactions between six common variables obtained from a questionnaire completed by students. They characterize the outpatient clinic as an educational paradox. On the one hand, it is ideal as an authentic setting for clinical teaching about a specialty, but on the other, it is one of the most difficult settings students encounter, because much of the teaching is passive and involves little feedback, it is based on a narrow range of cases and is often dependent on available time between consultations. A process evaluation approach was used in the study because the authors wanted to find out more about how students learned rather than what they learned. The variables investigated in the study included space for examining patients, the number of students involved, organizational quality, patient mix and supervision provided. The results of the study showed that each of the variables was important and influenced the quality of the experience. However, it was the influence of supervision that emerged as the most important factor, suggesting that sitting and watching in the outpatient department is a lot less useful than doing and receiving feedback on performance. Nendaz and Bordage from Chicago examine clinical reasoning skills amongst medical students from the starting point that traditional clinical teaching about history taking overemphasizes depth of data collection at the expense of focused, more structured enquiry. They argue that encouraging students to think about the data they are collecting during history taking and to relate it to understanding the patient’s problem, will lead to a more selective approach – one that more closely matches the way in which experienced clinicians work. A semantic qualifier is the expression used to describe the result of converting patient history data into abstract terms that clinicians use to depict a clinical problem. Although the use of semantic qualifiers has been shown to improve diagnostic accuracy, little work has been done on how students learn to use them. In their study, the authors found that effective use of semantic qualifiers was related, amongst other things, to the amount of content knowledge students possess and to the degree to which students are able to integrate their use into a real patient encounter. Whilst further work is needed, it is clear that structured and organized learning about history taking and identifying clinical problems should take place early and be integrated with learning about disease and illness.