Hauer, Karen E. MD; O’Brien, Bridget C. PhD; Hansen, Lori A. MD; Hirsh, David MD; Ma, Iris H. MD; Ogur, Barbara MD; Poncelet, Ann N. MD; Alexander, Erik K. MD; Teherani, Arianne PhD
Dr. Hauer is professor of medicine, director of internal medicine clerkships, and Gold Headed Cane Endowed Chair in Medical Education, Department of Medicine, School of Medicine, University of California, San Francisco, California.
Dr. O’Brien is assistant adjunct professor, Teaching Scholars Program, School of Medicine, University of California, San Francisco, California.
Dr. Hansen is pulmonologist and dean, Yankton Campus, Sanford School of Medicine, University of South Dakota, Yankton, South Dakota.
Dr. Hirsh is assistant professor of medicine, Harvard Medical School, Cambridge Health Alliance, Boston, Massachusetts.
Dr. Ma is a resident, Department of Medicine, Stanford School of Medicine, Palo Alto, California.
Dr. Ogur is associate professor of medicine, Harvard Medical School, Cambridge Health Alliance, Boston, Massachusetts.
Dr. Poncelet is professor of clinical medicine, Department of Neurology, University of California, San Francisco, California.
Dr. Alexander is director of medical student education, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
Dr. Teherani is associate adjunct professor and director, Program Evaluation, School of Medicine, Department of Medicine, University of California, San Francisco, California
Correspondence should be addressed to Dr. Hauer, University of California at San Francisco, Department of Medicine, 505 Parnassus Ave., M1078, Box 0120, San Francisco, CA 94143-0120; telephone: (415) 476-1964; fax: (415) 502-7544; e-mail: firstname.lastname@example.org.
Continuity between learners and teachers is a proposed strategy to enhance clinical teaching and learning.1,2 In contrast to the traditional block core clerkship model, in which students move among disciplines, settings, and supervisors, longitudinal attachments structure continuity between students and teachers over months to a year. Continuity allows student and teacher to establish a relationship in which they can appreciate each other’s skills and interpersonal style, with time for the student to mature with the teacher’s guidance.2,3 Longitudinal integrated clerkship (LIC) preceptors feel more able to adjust their teaching to students’ learning needs and know them better than block clerkship students.4
Relationships with teachers constitute important student learning experiences. A literature review highlighted five features of good clinical teachers: medical knowledge, clinical skills/clinical reasoning competence, relationships with learners in a supportive learning environment, communication skills, and enthusiasm.5 Good clinical teachers share wisdom using a range of teaching strategies, engage learners in discussion, encourage participation, exude enthusiasm, and inspire confidence in students’ own skills.6–8 Although the clinical teaching literature provides insight into these qualities and characteristics of good teachers in traditional inpatient or ambulatory block clerkship settings, less is known about teachers’ longitudinal relationships with learners.
A longitudinal student–teacher relationship should facilitate students’ learning, participation, and professional development beyond that in briefer interactions.9–11 Relationship-centered medical education emphasizes the central role of relationships in determining how students incorporate new knowledge and acquire professional values within trusting interactions with teachers.9 Whereas many characteristics of good clinical teachers likely occur across teaching venues, the modern clinical environment often hinders student–teacher relationship formation in block clerkships.12 Shortened inpatient attending rotations on service minimize learner–teacher contact.13 Ambulatory teaching often focuses on immediate patient care demands and also suffers from a lack of robust student–teacher relationships.14,15
Students’ perspectives on their relationships and learning with clinical teachers with different amounts of continuity have not been explored. We sought to expand on what is known about elements of successful teaching5 by comparing those facets in brief and longitudinal relationships, with a focus on relationship formation as the facet most likely to differ. We solicited students’ characterization of successful and unsuccessful relationships with clinical teachers to explore their range of experiences. These findings about students’ learning and professional development in teaching relationships of different lengths would inform recommendations for clinical teachers, faculty development, and design of educational experiences.
Study design and sample
We performed a qualitative study based on semistructured interviews with third-year medical students in 2009–2010 at three institutions: the University of California, San Francisco, School of Medicine (UCSF); University of South Dakota Sanford School of Medicine (USD); and Harvard Medical School (HMS). All three have concurrent LICs (at a UCSF tertiary center and at community sites for USD and HMS) and traditional block clerkships (at tertiary hospitals and affiliated clinics). At each institution, students choose their clerkship track. All block students have one longitudinal preceptor in addition to their block clerkship supervisors.
Each student participated in two interviews: one in the first half and one at the end of the third year. We aimed to recruit 10 LIC students and 10 block students at each institution. Recruitment of LIC students occurred via e-mails to all LIC students at each school (10–16 per school). Recruitment of block clerkship students was via e-mail, using purposeful sampling of students assigned to the same or similar hospitals.16
Each participating institution’s institutional review board approved the study.
Data collection and instrument
Interviews explored students’ experiences with teachers early in core clerkships and after they had gained clinical experience in order to compare relationships when all students were new to clerkships, and when students had experience interacting with clinical teachers. One or two trained research assistants per site conducted semistructured interviews with consenting respondents. Participation was confidential. Students received $15 for the first interview and $20 for the second.
Interviewers used a semistructured interview guide to elicit each student’s description of a successful relationship with a clinical teacher. Questions addressed the teacher’s approach to teaching and feedback, including specific strategies and examples and ways in which the teacher supported and challenged the student. The same questions were repeated for an unsuccessful teacher. Students were asked to describe whether and how they had tried to improve the unsuccessful teaching relationship they identified. Interviews occurred in private conference rooms or by telephone and were audiotaped and transcribed verbatim by a professional transcription service. Transcription occurred as interviews were completed so that investigators could monitor interviewer technique, conduct analysis concurrent with data collection, and provide feedback to interviewers about consistency.
Coding used thematic analysis.16 Three investigators (K.E.H., I.M., A.T.) independently generated a list of codes based on review of six randomly selected interviews and their knowledge of clinical teaching, based on their own experience and a literature review, to identify sensitizing concepts around relationships between teachers and learners.5,17 These three investigators coded 6 additional transcripts and compared coding to clarify meaning. Two investigators double-coded 18 additional transcripts, resolving discrepancies through discussion and revision of codes as necessary. Using NVivo software (QSR International, Cambridge, Massachusetts), one researcher (I.M.) applied the final codes to the remaining transcripts. Two investigators (K.H., A.T.) independently double-coded 15% of randomly selected transcripts to ensure consistency. We used NVivo to organize and retrieve coded data. Investigators reviewed coded data and, through discussion, identified larger themes relevant to brief and longitudinal experiences early and late in the year. Data collection at two time points in two clerkship models allowed comparison of experiences to inform theme development.18
Of the 35 LIC and 84 block students invited, 54 students participated. The average age was 26 years; 59% were women. Table 1 describes the characteristics of the teachers whom students identified for their successful and unsuccessful teaching relationships. Consistent with the design of each clerkship model, most block students described inpatient teachers, whereas most LIC students described outpatient teachers. Two block clerkship and nine LIC students described the same teacher early and late year.
The analysis compared students in brief and longitudinal relationships. Three themes most distinguished brief and longitudinal relationships: time, purpose, and power, as described below and in Table 2.
Time and the importance of continuity
Students described benefits of continuity as foundational for their brief and longitudinal teaching relationships and the challenges of discontinuity. Subthemes included defining continuity, respect, and the nature of relationship development.
Defining continuity. Students identified continuity as important but defined it differently on the basis of their clerkship model. Many block students identified teaching continuity—namely, two to four sessions over days to a few weeks—as valuable for learning. Ten block students identified their single longitudinal preceptor for their successful teaching relationship. In contrast, LIC students described extended continuity and particularly valued frequent interaction over a whole year. They cited shortcomings when continuity spanned only months or was interrupted for weeks because of scheduling conflicts.
Respect. In brief relationships, students highlighted the value of being known to their supervisors. Students felt respected when supervisors recognized their faces, knew their names, and included them in patient discussions. Students waited to be approached and were mostly reactive to supervisors’ overtures. Early and late year, students in brief relationships shared examples of feeling surprised and satisfied that attendings acknowledged them in the hospital or used their names. They felt discouraged when supervisors seemed not to know them, did not appear to have time or motivation to engage them while also caring for patients, or did not introduce them to patients.
Longitudinal students’ descriptions of their teaching relationships were characterized by collaboration and teamwork. Students inferred from these longitudinal relationships that, as students, they were capable and contributory in patient care. Descriptions of unsuccessful relationships rarely focused on students feeling interpersonally disrespected or neglected. A few reported preceptors’ lack of facility with the longitudinal model or wished that their preceptors would communicate more about expectations or more actively facilitate their autonomous work with patients.
The nature of relationship development. Students characterized successful brief relationships as those in which the supervisor showed personal interest in the student, described as “rapport,” “interested in my personal life,” and caring “about how school was going.” Shared background experiences or outside interests fostered stronger relationships. In these brief interactions, relationships hinged on supervisors’ efforts and behaviors.
Whereas longitudinal students also appreciated their preceptors’ personal interest, they characterized longitudinal relationships as partnerships based on mutual goals. Many noted that relationship development over time particularly motivated and enhanced their learning. They cited preceptors’ investment in their learning. They shared examples of preceptors soliciting their opinions about patients in the way of a peer colleague, and challenging each other to look up information to address a student or preceptor knowledge gap. Many observed how preceptors’ efforts to know them as individuals over time, including their specialty preferences and personal life, also enhanced their relationship. Trust appeared foundational for partnerships in which preceptors allowed students to work independently and students shared uncertainties.
Students in both brief and longitudinal relationships frequently cited teachers’ strategies to teach clinical knowledge. Both expressed the importance of reading independently and showing their knowledge to supervisors. However, they experienced different approaches to teaching, and consequently in the nature of learning, in their brief and longitudinal teacher interactions.
In brief relationships, many students discussed “pimping,” which they defined as questioning about a student’s factual knowledge of diseases or clinical problems. Students analyzed preceptors’ intent with “pimping” as either demeaning or supportive. They often concluded that it showed attention to students, interest in students’ learning level, and effort to teach. Students in brief relationships struggled to find opportunities to share knowledge acquired from reading and only occasionally shared their opinions. They often didn’t know what to read until after they saw patients, but they and their teachers rarely returned to discuss students’ reading. Students concluded that “pimping” was better than no supervisor attention at all and that their knowledge would be “tested” regularly. One student felt satisfied by learning to anticipate questions. However, absence of longitudinal interaction usually precluded anticipating questions because different supervisors taught different material.
Longitudinal students’ descriptions of reading and sharing knowledge with preceptors were iterative and collaborative. Students frequently described preceptors responding to their questions about shared patients by suggesting that the student research an answer for discussion next session. Students appreciated that this strategy addressed individual learning gaps and focused their preparation for upcoming sessions. Rather than feeling judged, students felt partnership as their preceptors added teaching points in discussion or admitted their own knowledge gaps. Multiple preceptors revisited material to ensure comprehension and retention. Students learned how knowledge acquisition occurs in service to patient care and became familiar with applying information from reading and discussions with future patients. Students did not mention “pimping” as a method of assessing or sharing knowledge with longitudinal preceptors.
Power dynamics manifested differently in brief and longitudinal interactions. Whereas brief interactions were hierarchical and prompted students to try to accommodate supervisors’ preferences and expectations, longitudinal relationships were more collaborative. Students’ interventions in response to unsuccessful relationships reflected the degree of empowerment they felt over their own learning in brief and longitudinal interactions.
Hierarchy. In brief relationships, students described hierarchical relationships and attributed relationship success to teachers’ qualities and outreach both early and late year. These students described reacting to their teachers’ behaviors and attitudes. Students valued support and being invited to participate in clinical tasks. They also appreciated supervisors who were patient, willing to teach, and nonjudgmental. They expressed frustration about limited contact time with multiple supervisors who were consequently unable to provide feedback on development over time. Several students described negative feedback from brief supervisors that felt unsubstantiated.
Longitudinal relationships were less hierarchical. Students both reacted to and influenced their preceptors’ expectations, which evolved in response to students’ growing patient care competence. Longitudinal students appreciated preceptors’ high expectations that they progress as clinicians and their clear guidance. Early year, students experienced this clarity of expectations for the year as “goal-directed learning” (student study ID number 3673, early year). Late year, students felt independent and accountable because they experienced a “developmental transfer of responsibility” for patient care (6484, late). Multiple longitudinal students described their preceptors trusting them and, late year, valuing their opinions about patient cases. Most described an iterative cycle of action, feedback, and opportunities to act on feedback. Students felt comfortable expressing uncertainty and inexperience without jeopardizing teachers’ perceptions of them.
Intervening with unsuccessful teaching relationships. Interviewers asked all students to describe strategies they used to improve unsuccessful teaching relationships. Students found brief unsuccessful relationships very stressful, and none reported achieving improvement by communicating directly with preceptors. Some tried without success to improve unsuccessful relationships by better aligning with preceptors’ expectations: “be the way that she wanted” (6488, early) or “doing what he thought was best” (1245, late). Students were uncertain why these efforts failed, and some blamed themselves.
More common strategies to address problematic brief teaching relationships were to do nothing and wait for the rotation’s end, or try harder to perform well and match teachers’ preferences. Others consciously avoided the supervisor by working with others, particularly residents. Some expressed their concerns in written evaluations after the rotation without knowing the impact.
In contrast, students nearly always managed unsuccessful longitudinal interactions directly within that relationship. Students expressed strong commitment to taking responsibility for improving problematic aspects of teaching relationships that interfered with their learning because of the yearlong assignment. Students talked with preceptors to understand problems and brainstorm solutions. Some students used strategies provided by clerkship directors to elicit more case discussion or schedule clinical exposure in complementary settings to address learning gaps. Longitudinal students reflected on their goals to determine which aspects of less successful interactions needed addressing and which they could accept as nonmodifiable differences in personality or style. Examples included a preceptor who showed interest in teaching but not in the student personally, and a preceptor whom the student perceived was generally effective but unfriendly.
Discussion and Conclusions
Our findings illustrate features of good teaching perceived by students in brief and longitudinal teaching relationships. Students in both situations valued teachers’ interest in them, clearly articulated expectations, and guidance. However, the many differences in their descriptions of teaching reflected the structure of their interactions with teachers. Block clerkship students focused mostly on inpatient teaching within brief interactions. In contrast, students in longitudinal relationships emphasized partnership and skill development in outpatient settings. This study expands understanding of clinical teaching by describing students’ perceptions of teaching in longitudinal relationships characteristic of the LIC model, and comparing and contrasting these with teaching in brief relationships typical of the traditional block model.
Students appreciated their teachers’ efforts to impart knowledge and advance their knowledge. However, students described different kinds of knowledge being emphasized in brief and longitudinal teaching interactions. In brief relationships, students’ descriptions focused on explicit knowledge that can be easily written, communicated, and tested—disease facts, mechanisms, and treatments that were probed in a quizzing manner. In contrast, in longitudinal relationships, students reported examples of teachers sharing knowledge about working in particular clinical environments and workplace cultures. Longitudinal students’ descriptions show how tacit knowledge is conveyed through collaborative practice, shared experiences, and ongoing feedback.19,20 Longitudinal students did not emphasize the importance of teachers demonstrating factual knowledge but, rather, how they together applied knowledge for patient care, consistent with previous findings about how longitudinal relationships anchor teaching in longitudinal patient care.11 This finding parallels Sutkin and colleagues’5 conclusion that teachers’ cognitive characteristics are less important than noncognitive characteristics such as communication and relationship building.
The teaching behaviors that students highlighted reflected the settings in which they encountered teachers. Brief interactions between students and supervisors prompted teaching and feedback based on medical knowledge and immediate patient care activities. Inpatient block clerkship students valued immediate feedback on bedside interactions and oral presentations.21 However, participants also desired evidence that their teachers understood their learning level and taught accordingly. High-quality teachers skillfully adapt their teaching content and depth to individual learners.6,22 Not surprisingly, longitudinal preceptorships better facilitate supervisors’ incorporation of students’ learning needs into their teaching.4 Our longitudinal students described preceptors taking a more collaborative approach to teaching and learning by eliciting learners’ goals and mutually identifying learning topics. These behaviors, which have been associated with higher-quality teaching and feedback,23 are facilitated by the opportunity to establish dialogue in a longitudinal relationship.24
Our participants frequently described the effects of a hierarchical structure in their brief teaching relationships. A culture founded on hierarchical principles relegates learners to a novice role rather than encouraging their development as in a more participatory, collaborative culture. The workplace-learning framework, which recognizes the importance of learning while participating in work with guidance from supervisors, emphasizes how learner–supervisor relationships are important for learning.25 Whereas participation in a community of practice entails migrating from outside into the core work and community of a group,10 hierarchy keeps individuals more peripheral. The finding that longitudinal students felt recognized and known by their preceptors indicates a basic premise of participation in a practice community—Its members must be acknowledged as developing participants and professionals. Students who did not feel known in their brief relationships with teachers would not be able to fully participate with those individuals.
This study has limitations. Teachers’ actual behaviors or written teaching evaluations were not measured, nor was students’ learning with the teachers they described, to triangulate our findings. It is unknown how many successful or unsuccessful teaching relationships students experienced because they shared one in-depth example of each. Because students (and, potentially, teachers) chose their clerkship model, they may have had preexisting preferences for the type of teaching relationship they experienced. However, this study explored both successful and unsuccessful relationship examples to avoid bias toward only positive experiences. Although the study included a moderate number of students from only three schools, all schools had multiple clerkship models and, together, represent diverse U.S. regions.
In summary, our findings indicate that the structure of teaching relationships has a large influence on core clerkship students’ experiences and learning. Brief interactions with clinical supervisors are associated with teaching focused on medical knowledge acquisition and demonstration, with limited opportunities for individual supervisors to follow up with students to assess and promote learning over time. By design, longitudinal clerkships are different. Within longitudinal interactions, students experience successful clinical teaching as grounded in supportive, collaborative relationships focused on progressive skill attainment. These findings suggest that teaching and learning goals and strategies should be tailored to the relational context and that clinical learners want and need some longitudinal teaching relationships to anchor their professional development.
Acknowledgments: The authors thank the University of California, San Francisco, ESCape works in progress group; David Irby, PhD, Molly Cooke, MD, and Ed Krupat, PhD, for expert advice; and Joanne Batt for data management.
Funding/Support: The authors thank the Josiah Macy, Jr. Foundation for funding the study.
Other disclosures: None.
Ethical approval: This study was approved by the institutional review boards of the University of California, San Francisco; the University of South Dakota; and Harvard Medical School.
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