Patient-centred learning in practice. A mixed methods study of supervision and learning in student clinics.

OBJECTIVE: Patient-centred learning (PCL) allows medical students to practice a patient-centred approach; however, didactic characteristics of PCL have yet to be fully elucidated. Clinical placements structured as a student clinic (SC) enable authentic student-patient learning relations through enhanced student responsibility and can serve as examples of PCL. We explored the didactic characteristics of supervision and learning in SCs to provide recommendations for PCL-oriented medical education. METHODS: Triangulation mixed methods study based on qualitative data collected from in-depth interviews with clinical teachers and quantitative data collected from student evaluations of supervision and learning in the SCs. RESULTS: Supervision and learning in SCs were characterized by 1) a focus on student-patient compatibility and patient needs and resources, which indicated PCL, 2) person-centred explorative supervision to adjust challenges to students' needs and resources, and 3) support of student autonomy to take responsibility for patient treatment. CONCLUSION: PCL was facilitated by clinical teachers through a dual person-centred didactic approach combined with autonomy-supportive didactic practice. This enabled the integration of patients' and students' needs and resources in clinical teaching. PRACTICE IMPLICATIONS: Clinical teachers can stimulate student-patient learning relations by selecting patients, exploring students' needs and resources, and supporting student autonomy through reflective practice and backup.

Ticket to perform: an explorative study of trainees' engagement in and transfer of surgical training.

BACKGROUND: Research suggests that simulation-based surgical skills training translates into improved operating room performance. Previous studies have predominantly focused on training methods and design and subsequent assessable performances and outcomes in the operating room, which only covers some aspects of training engagement and transfer of training. The purpose of this qualitative study was to contribute to the existing body of literature by exploring characteristics of first-year trainees' engagement in and perceptions of transfer of surgical skills training. METHODS: We conducted an explorative study based on individual interviews with first-year trainees in General Surgery, Urology, and Gynaecology and Obstetrics who participated in a laparoscopic skills training program. Informants were interviewed during and two months after the training program. A thematic cross-case analysis was conducted using systematic text condensation. RESULTS: We interviewed 12 informants, which produced 24 transcripts for analysis. We identified four main themes: (1) sportification of training, (2) modes of orientation, (3) transferrable skills, and (4) transfer opportunities. Informants described their surgical training using sports analogies of competition, timing, and step-by-step approaches. Visual orientations, kinaesthetic experiences, and elicited dialogues characterised training processes and engagement. These characteristics were identified in both the simulated and the clinical environment. Experiences of specific skills transfer included ambidexterity, coordination, instrument handling, and visuospatial ability. General transfer experiences were salient in informants' altered training approaches. Informants considered the simulation-based training an entry ticket to perform in the operating room and mentioned supervisor-trainee relationships and opportunities in the workplace as critical conditions of transfer. CONCLUSIONS: Our findings elucidate characteristics of surgical training engagement that can be interpreted as self-regulated learning processes that transcend surgical training environments. Despite appreciating the immediate skills improvements resulting from training, trainees' narratives reflected a struggle to transfer their training to the clinical setting. Tensions existed between perceptions of transferable skills and experiences of transfer within the clinical work environments. These results resonate with research emphasising the importance of the work environment in the transfer process. Our findings provide insights that may inform the development of training programs that support self-regulated learning and transfer of training from the simulated to the clinical environment.

'Making room for student autonomy' - an ethnographic study of student participation in clinical work.

Participation in clinical work is important for medical students' professional development. However, students often report that they experience a passive observer role, and further research on contextual factors that influence student participation is needed. The theory of practice architectures contributes a new perspective to this challenge by elucidating how cultural-discursive, material-economic, and social-political arrangements enable and constrain student participation in clinical work. The aim of this study was to explore how practice architectures in clinical learning environments enable and constrain medical students' participation. The study was designed as an ethnographic field study in three student clinics: 106 h of observation. Analysis comprised ethnographic analysis followed by application of the theory of practice architectures. The ethnographic analysis resulted in six themes: setting the scene, when to call for help, my room - my patient, getting in a routine, I know something you don't, and my work is needed. Applying the theory of practice architectures showed that material-economic arrangements, such as control of the consultation room and essential artefacts, were crucial to student participation and position in the clinical workplace. Furthermore, co-production of a student mandate to independently perform certain parts of a consultation enabled a co-productive student position in the hierarchy of care-producers. The findings offer a conceptually generalisable model for the study of material and social dimensions of clinical learning environments. Although not all clinical learning environments may wish to or have the resources to implement a student clinic, the findings offer insights into general issues about the arrangements of student participation relevant to most clinical teaching contexts.

Embodied teacher identity: a qualitative study on 'practical sense' as a basic pedagogical condition in times of Covid-19.

Worldwide, the Covid-19 pandemic has transformed teaching contexts rapidly. Studies on the effects of the Covid-19 pandemic have largely focused on students' learning and well-being. In contrast, little is known about how emergency online teaching affects teachers. The aim of this study was to examine how disrupted teaching contexts during the Covid-19 pandemic affected academic teacher identities in health science education. Interviews were conducted with 19 experienced lecturers in health science education from two universities. Interview data were analysed using systematic text condensation. The established codes were compared across interviews to identify common themes and subsequently synthesized into descriptions of the emerging phenomena. Findings indicated that a form of embodied teacher identity, i.e. internalized teaching practices turned into dispositions, constituted a basic pedagogical condition and a resource for the teachers, and that the sudden change in the teaching context caused a loss of teacher identity. This identity loss was related to an incorporated understanding and use of the teacher's sense of the classroom (subtheme 1), non-verbal feedback from students (subtheme 2) and reciprocal visual contact (subtheme 3). Data also indicated that teachers' ability to adapt their teaching to students' needs while teaching and teachers' motivation and job satisfaction may have suffered. Universities should carefully consider how to cultivate sustainable and adaptive teacher identities compatible with the increasing digitalization of learning environments. Teaching is an embodied affair, and teacher identities are sensitive to structural changes in teaching contexts.

Remote training in laparoscopy: a randomized trial comparing home-based self-regulated training to centralized instructor-regulated training.

BACKGROUND: Simulation-based surgical training (SBST) is key to securing future surgical expertise. Proficiency-based training (PBT) in laparoscopy has shown promising results on skills transfer. However, time constraints and limited possibilities for distributed training constitute barriers to effective PBT. Home-based training may provide a solution to these barriers and may be a feasible alternative to centralized training in times of assembly constraints. METHODS: We randomly assigned first-year trainees in abdominal surgery, gynecology, and urology to either centralized instructor-regulated training (CIRT) or home-based self-regulated training (HSRT) in laparoscopy. All participants trained on portable box trainers providing feedback on metrics and possibility for video reviewing. Training in both groups was structured as PBT with graded proficiency exercises adopted from the Fundamentals of Laparoscopic Surgery (FLS). The HSRT group trained at home guided by online learning materials, while the CIRT group attended two training sessions in the simulation center with feedback from experienced instructors. Performance tests consisted of hand-eye and bimanual coordination, suture and knot-tying, and FLS exercises. We analyzed passing rates, training time and distribution, and test performances. RESULTS: Passing rates were 87% and 96% in the CIRT and HSRT group, respectively. HSRT facilitated distributed training and resulted in greater variation in training times. Task times for hand-eye and bimanual coordination were significantly reduced between pretest and posttest in both groups. Trainees maintained their posttest performances at the 6-month retention test. Our analyses revealed no significant inter-group differences in performances at pretest, posttest, or retention test. Performance improvements in the two groups followed similar patterns. CONCLUSION: CIRT and HSRT in laparoscopy result in comparable performance improvements. HSRT in laparoscopy is a feasible and effective alternative to CIRT when offered inside a supportive instructional design. Further research is needed to clarify trainees' preferences and explore facilitators and barriers to HSRT.

Exploring patient experiences in the student outpatient clinic - A contribution to learning.

OBJECTIVE: To understand how patients experience participation in student encounters. METHODS: Qualitative semi-structured telephone interviews with ten cardiac surgery patients who had attended voluntary postoperative consultations in a student outpatient clinic. The interview guide included questions about reasons for and experiences of being part of a teaching situation. Interviews were analysed through inductive thematic analysis where pieces of text in each interview were assigned different codes and condensed into themes. RESULTS: The patients expressed a duality in their reasons for participating in student consultations: (1) a personal need for assurance (safety) and (2) a wish to help students (altruism). Students were perceived as professional and sometimes insecure. Being part of an educational situation was meaningful to the patients because they did not feel objectified. Knowing that there was a backup supervisor made the patients feel safe even though the supervisor was not present during all parts of the consultation. CONCLUSIONS: Patients experienced safety, understood their role in all parts of the consultation, and shared a wish to help students learn. PRACTICE IMPLICATIONS: A sequential consultation model alternating between student- and supervisor-driven supervision can balance student autonomy and patient safety. This knowledge could guide future patient-centred medical education in student clinics.

Gender differences in dentistry: A qualitative study on students' intrinsic and extrinsic motivations for entering dentistry at higher education.

INTRODUCTION: Having a balanced gender distribution is thought to ensure the diversity of knowledge and know-how and take better into account the different needs in society. The aim of the study is to explore and understand possible gender differences in (a) the students' motivational spectrum to choose a dental education and (b) their prospect of a professional career in dentistry. METHODS: We conducted in-depth interviews with male and female dental students (n = 14) followed by a theoretical reading based on Self-Determination Theory to explore the students' intrinsic and extrinsic motivations for entering dentistry in Denmark. RESULTS: Regardless gender, the dental students are motivated by role models, people orientation and strong interest in health sciences, but prefer dentistry to medicine, because of the responsibilities and working conditions. They were also motivated by the dental school's combination of theory and practice in students' learning of craftsmanship. Moreover, students valued the prospect of job security and a good work-life balance. However, there were markedly gender differences in motivation in relation to financial incentives as well as working life and career as a dentist, as it seemed that dental students needed gendered relatedness in relation to specialisation and employment in public versus private sector. CONCLUSION: The motivational spectrum varies widely, regardless of gender. In line with the standpoint feminist theory, a balanced gender distribution in dental education helps to meet the different needs in society and labour market. Consequently, a gender-sensitive recruitment strategy reflecting the gender differences in identities, knowledge and interests will be needed.

Trainees' surgical activity and opportunity to transfer after simulation-based training.

INTRODUCTION: Simulation-based surgical training (SBST) is predicated on the assumption that trainees transfer their acquired skills and competencies into the operating room. Research on transfer of surgical training has focused on trainees' performance improvements and not on their actual opportunity to transfer their trained skills. METHODS: This was a retrospective study conducted using data on surgical procedures performed by first-year trainees in abdominal surgery, gynaecology and urology in the Central Denmark Region. We included data on trainees who participated in two different SBST courses; open surgery and laparoscopic surgery from 2014 to 2018. RESULTS: Data on a total of 127 first-year trainees were included. Our results revealed considerable variation in the number of procedures performed by first-year trainees in the three specialities. Comparing surgical activity after and before the SBST courses, we found median differences between 0 and 3, indicating no consistent increases in trainees' surgical activity in the post-course periods (five out of six comparisons were insignificant (p > 0.05)). CONCLUSIONS: Trainees' surgical exposure varies within specialities and this may have consequences for achieving uniform levels of competence among trained specialists. Our results suggest that trainees do not have timely opportunities to intensify their clinical surgical activities after participating in SBST courses. A delay in opportunities to perform may inhibit the trainee's use of acquired skills and competencies and hamper transfer of training. FUNDING: none. TRIAL REGISTRATION: not relevant.

Being a surgeon or doing surgery? A qualitative study of learning in the operating room.

CONTEXT: A key concern for surgical educators is to prepare students to perform in the operating room while ensuring patient safety. Recent years have seen a renewed discussion of medical education through practice theoretical and sociomaterial lenses. These lenses are introduced to understand and prepare the learner to perform in the given context. This paper takes its point of departure from practice theory by introducing a lens through which to understand learning environments in surgery. METHODS: Using a multi-site ethnographic and practice-based design, this study investigates how aspiring surgical students are stirred into surgical practices and learn to engage as surgeons. During 70 hours of observations of medical students' participation in the operating room, we analysed how the phenomenon of surgical learning can be perceived as instances of transformation in and among social practices. RESULTS: By applying an analytical perspective, this article highlights the use of practice theory in surgical education, which can help to establish a firmer understanding of the learning environment and thereby help educators to improve curricula and prepare students more effectively to enter surgical training. CONCLUSIONS: The use of a practice theory adds the perspective that the education of surgeons needs to take the sayings, doings and relatings that constitute a surgical practice into account when preparing students to perform in their future workplace. In this way, surgical training can be perceived as a process of being stirred into practice. This means that one learns by participating in the practice of providing high-quality care, where the aim is to teach students to be surgeons instead of teaching them to perform surgery.

Science in the clinic: a qualitative study of the positioning of MD-PhDs in the everyday clinical setting.

BACKGROUND: MD-PhDs have been hailed as significant to the advancement of medicine and health care. Yet when it comes to which positions MD-PhDs should be holding in the clinic and the academic world, there seems to be no real consensus. This article examines the ways in which a PhD-degree may contribute to medical doctors' professional practice in the clinic and discusses the positioning of MD-PhDs in the clinic. METHODS: The study is explorative and qualitative, based on interviews with MD-PhDs, their physician colleagues without a PhD-degree, and their leaders. Positioning theory was applied as the analytical framework for data analysis. RESULTS: We found two opposing positions cutting across the groups of informants with one side critiquing the MD-PhDs for not doing enough research and for using the PhD-degree to climb the career ladder, while the other side emphasized the ways in which MD-PhDs increase the clinical focus on evidence-based medicine and integrate it with clinical decision making, thereby enhancing patient care. CONCLUSIONS: A debate is needed to establish more clearly how we wish to position MD-PhDs in the clinic, which in turn will give us a better idea of how many to educate and how to make better use of their competencies.

"We're at a watershed": The positioning of PhD nurses in clinical practice.

AIM: The aim of this study was to explore different perspectives on the positioning (i.e. the perceived rights and duties) of PhD nurses and how they contribute to clinical nursing practice. BACKGROUND: The number of PhD nurses is growing worldwide, but we only have little knowledge of what is expected of PhD nurses and what their actual impact is in the clinic. DESIGN: The findings of this article stem from a qualitative, explorative interview study. METHODS: Semi-structured interviews were carried out with six PhD nurses, nine nurse colleagues and six clinical nurse leaders. Data collection took place from April - June 2016 in Central Denmark Region. Data were analysed using positioning theory. FINDINGS: The PhD nurses were positioned as responsible for implementing evidence-based practice in the clinic and in nursing culture as such. Emphasis was put on the importance of PhD nurses staying close to the clinic to do practice-based research of immediate effect for patient care. CONCLUSION: The study reveals several positive effects of PhD nurses in the clinic but also problematizes the many and diverse duties they are expected to carry out.

How Surgeons Conceptualize Talent: A Qualitative Study Using Sport Science as a Lens.

OBJECTIVES: Debates prevail regarding the definition of surgical talent, and how individuals with the potential to become talented surgeons can be identified and developed. However, over the past 30 years, talent has been studied extensively in other domains. The objectives of this study is to explore notions of talent in surgery and sport in order to investigate if the field of surgical education can benefit from expanding its view on talented performances. Therefore, this study aims to use the sport literature as a lens when exploring how surgeons conceptualize and define talent. DESIGN: Semi-structured interviews were conducted with a sample of 11 consultant surgeons from multiple specialties. We used constructivist grounded theory principles to explore talent in surgery. Ongoing data analysis refined the theoretical framework and iteratively informed data collection. Themes were identified iteratively using constant comparison. SETTING: The setting included 8 separate hospitals across Canada and Denmark. PARTICIPANTS: A total of 11 consultant surgeons from 6 different surgical subspecialties (urology, orthopedic surgery, colorectal surgery, general surgery, vascular surgery, head & neck surgery) were included. RESULTS: We identified three key elements for conceptualizing surgical talent: (1) Individual skills makes the surgical prospect "good", (2) a mixture of skills gives the surgical prospect the potential to become talented, and (3) becoming talented may rely on the fit between person and environment. CONCLUSION: We embarked on a study aimed at understanding talent in surgery. Talent is a difficult construct to agree on. Whether in medicine or sports, debates about talent will continue to persist, as we all perceive talent differently. While we heard different opinions, three key ideas summarize our participants' discussions regarding surgical talent. These findings resonate with the holistic ecological approach from sport science and hence highlight the limits of a reductionist approach while favoring the individual-environment system as the minimal ontology for describing talented performances.

The employers' perspective on how PhD training affects physicians' performance in the clinic.

INTRODUCTION: An increase in the number of MD-PhDs has sparked debate as to how physicians with PhD research training contribute in the clinic. This study focuses on the development and employment situation of MD-PhDs from Aarhus University, Denmark, and on the impact of MD-PhDs in the clinic as seen from the employers' perspective. METHODS: The study is based on a mixed methods approach using both quantitative and qualitative data. Quantitative data hail from existing statistical data and reports, while the qualitative data stem from semi-structured interviews with six executive consultants and 36 members of appointment committees, mainly from hospitals in the Central Denmark Region. RESULTS: Quantitative data reveal an increase in the number of MD-PhDs concluding their training at Aarhus University. The MD-PhDs are employed in the public sector and, overall, their skills match the employers' demands. Qualitative data show that employers were satisfied with the skills the MD-PhDs brought to the clinic, particularly in terms of their ability to assess and use new and relevant information and to instigate a more scientific approach in the clinic. Informants from remote hospitals expressed a demand for more MD-PhDs, while other informants were concerned about how some MD-PhDs stopped doing medical research in the clinic after completing their PhD. CONCLUSION: Overall, employers seem satisfied with the skills that MD-PhDs bring to the clinic. However, some voice concern that too much importance is attached to the PhD degree and that some MD-PhDs are not active doing research. FUNDING: The study was funded by the Graduate School of Health (Aarhus University) and The Central Denmark Region. TRIAL REGISTRATION: not relevant.

Publication rate and PhD enrolment following a medical pre-graduate research programme.

INTRODUCTION: In the 1990s, the publication and PhD recruitment rates following the Danish pre-graduate research programme (PGRP) in medicine were 54% and 33%, respectively. Updated estimates are unknown. METHODS: All medical students enrolled in the PGRP at the Faculty of Medicine, Aarhus University (Health), Denmark, during 2003-2012 were included (n = 687). The PGRP files were merged with PhD students' files at Health. A systematic literature search was completed for research students who had enrolled during the 2006-2009 period (n = 227). The factors investigated were student age, sex, PGRP completion time and years in medical school at the time of PGRP initiation. Supervisors were described by sex, title, position and affiliation. Calculations were tested by the chi-squared test; p < 0.05 was considered significant. RESULTS: A larger proportion of male medical students conducted a PGRP compared to female medical students (28% versus 19%; p < 0.01). Within three and a half years from PGRP initiation, 13% of the research students had enrolled in a PhD programme at Health, and 52% had published ≥ 1 paper with ≥ 1 supervisor. The research student was the first author on 43% of the overall 224 papers, and 90% were original articles. Publication was positively associated with completion of the PGRP in < 18 months and with embarking on a PhD and with having a male main supervisor. PhD recruitment was related to enrolment in the PGRP after fewer years in medical school. CONCLUSIONS: Fast completion of the PGRP and early enrolment in the programme were associated with scientific publishing and PhD recruitment. The publication rate has remained stable over time.

[Dream Team--a pre-graduate surgical talent development project]. / Gode erfaringer med kirurgisk talentidentifikation blandt medicinstuderende.

In 2009 surgeons from Aarhus University Hospital founded an extracurricular talent development project based on a skill-acquisition training programme for medical students at Aarhus University. The training program, named Dream Team, provides medical students with the opportunity to pursue a career in surgery. This paper presents and discusses the organizational and pedagogical framework of the concept Dream Team, as well as the results from two inquiries: a survey and an exploratory observational study. The inquiries were conducted in summer 2013.

Residents in difficulty--just slower learners? A case-control study.

BACKGROUND: Recent meta-analyses have found small-moderate positive associations between general performance in medical school and postgraduate medical education. In addition, a couple of studies have found an association between poor performance in medical school and disciplinary action against practicing doctors. The aim of this study was to examine if a sample of Danish residents in difficulty tended to struggle already in medical school, and to determine whether administratively observable performance indicators in medical school could predict difficulties in residency. METHODS: The study design was a cumulative incidence matched case-control study. The source population was all active specialist trainees, who were medical school graduates from Aarhus University, in 2010 to June 2013 in two Danish regions. Cases were doctors who decelerated, transferred, or dropped out of residency. Cases and controls were matched for graduation year. Medical school exam failures, grades, completion time, and academic dispensations as predictors of case status were examined with conditional logistic regression. RESULTS: In total 89 cases and 343 controls were identified. The total number of medical school re-examinations and the time it took to complete medical school were significant individual predictors of subsequent difficulties (deceleration, transferral or dropout) in residency whereas average medical school grades were not. CONCLUSIONS: Residents in difficulty eventually reached similar competence levels as controls during medical school; however, they needed more exam attempts and longer time to complete their studies, and so seemed to be slower learners. A change from "fixed-length variable-outcome programmes" to "fixed-outcome variable-length programmes" has been proposed as a way of dealing with the fact that not all learners reach the same level of competence for all activities at exactly the same time. This study seems to support the logic of such an approach to these residents in difficulty.