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Introduction
There is a long tradition of medical student teaching taking place on hospital wards. Increasingly, however, neurological inpatients have rare and complex diseases. In contrast, 40% of patients referred to neurology outpatient clinics have headache or loss of consciousness,1 which are typical of the presentations graduates will encounter in their generalist careers. Another advantage of outpatient settings is that students can participate in authentic clinical care rather than be passive recipients of teaching. So, neurology teaching has to take place in outpatient clinics, whether it fits a traditional teaching style or not. But numbers of referrals are on the increase and neurologists faced with waiting list targets might not know how to accommodate students’ learning in their busy clinics. How is time to be found to teach students and how should that time best be used?
The impact of teaching encounters on clinic throughput has been thoroughly researched in the USA, where time is money. The results are clear.2 Skilled outpatient teachers do not strictly ‘teach’, they help students learn from their practice. Moreover, they allow students to give as well as take. A friendly and skilled clinician makes chores like ushering patients in and out, completing blood forms, looking up information in the British National Formulary, making telephone calls and explaining things to patients very positive experiences for medical students. If time permits, they may put a student in the driving seat so the teacher can take notes while the student interviews. Research showed students’ presence slowed consultations down a little but increased doctors’ satisfaction.3 ,4 There is also clear evidence that most patients do not mind students’ presence, even in private medical settings, unless they have something very confidential to discuss.5 Learning in outpatient clinics, then, is a virtue waiting to happen!
The snag is that doctors are too often unskilled. A study of outpatient teaching in Manchester, UK showed that many consultants treated medical students as passive observers, while they threw junior doctors in at the deep end and gave them insufficient support.6 Neurology clinics are brimming with learning opportunities. The aim of this article is to help readers find a happy medium, where students are actively involved in busy clinics and learn the elements of effective outpatient practice as well as the ways neurological diseases present.
Experience-based learning
When problem-based learning was introduced to our medical school, we complemented it with a theory of how medical students learn from real practice called experience-based learning (eXBL), which we have thoroughly researched.7 eXBL is specific to clinical learning environments. It starts from a number of assumptions: students should learn to practise from practice; ‘experience’ means authentic experience of real patients in real workplace settings; and learning happens at the point of contact between clinicians, students and patients. eXBL emphasises the conditions for, mechanisms of, and outcomes of experience.
Conditions: support
The term ‘teaching’ conjures up images of experts imparting knowledge. Learning in busy clinics is not like that because patients and their needs come first. Doctors do not so much ‘teach’ as support students’ learning by participation. They think out how to run their clinical activities in ways that help students interact with patients. They task students to perform clinical tasks, debrief them, give feedback, and share their thoughts with students. They do not just facilitate humane interactions between students and patients but role model them. It is well described that practitioners can become so skilled at delegating tasks to students that they find it hard to do clinics without them.⇓
Mechanisms: learning by participating
The core condition for learning is participation; experience with a neurological outpatient in the presence of a neurologist. There are three levels of participation: observing, rehearsing and contributing. Rehearsing means clerking a patient as a pure educational exercise, but not in the course of patient care. Contributing means that the student's learning activity is part of the process of care. Whether a student observes, rehearses or contributes depends on their expertise and the complexity of the patient's illness. As a general rule, the closer students come to contributing, the more they learn. Delegating some routine but necessary parts of taking the history of a patient with headache, for example, turns clerking into a contribution towards patient care that may be time neutral or even helpful to a neurologist in a busy clinic.
Mechanism and outcome: real patient learning
Participation in neurological practice under the supportive eye of a neurologist results in ‘real patient learning’. Students learn about headache, TIAs, or epilepsy and how to care for them by gaining first-hand experience. They bridge theory and reality, developing situated understanding of what it is to have epilepsy and to be an epileptologist. Real patient learning is highly valued by students, clinical teachers and patients, who are mostly very willing to contribute to students’ learning.
Outcomes: proficiency and affects
Moving towards an emphasis on learning rather than teaching in clinical workplaces draws attention to individual students’ development of the identity of a doctor, which can be described in terms of proficiency (knowledge and skills) and affects (confidence, sense of belonging and motivation).
Teaching and learning in practice
So far, this article has outlined a theoretical approach, which reframes clinical teaching as supporting medical students’ participation in neurological practice. But can that really lead to the desired learning outcomes and, if so, how? Traditional views of teaching and learning were based on what has been described as ‘the acquisition metaphor’, within which ‘language of knowledge acquisition … makes us think of the human mind as a container to be filled with certain materials and a learner as owner of those materials’. The alternative ‘participation metaphor’, views learners as ‘interested in participating in certain types of activities rather than in accumulating private possessions’.8
Before you even start your clinic, you need to think how many students should attend a single consultation. We thought we were compromising educational quality by having two students rather than one in a consultation but were pleasantly surprised that students often preferred it that way because one could ‘come up for air’ while the other was ‘in the hot seat’.9 Having made that observation, we had one student interview the next patient in a separate room while debriefing the other student on the present patient in his own consulting room and found we could get into an efficient rhythm that way.
Be sensitive to students’ and patients’ motivations. How much is the student interested in contributing to the patient's care? And how much is the patient interested in helping the student learn? In this way you can develop co-operation between all parties. Negotiate an agenda for the clinic: the student may want to focus on headache for an upcoming exam. It may be a bugbear of yours that referrals rarely involve good headache histories, so you wish to help the student learn this. That's a great educational agenda for the afternoon. Often the patient can add a rich contextual understanding of their condition for the student. If you can support the interaction, it takes the pressure off both the patient and the student.
Students’ intimidation in the face of neurology, so-called neurophobia, has been featured in this journal before.10 ,11 A daunting challenge is the language associated with neurology, which forms a barrier to participation: dyskinesia, dysphasia, dysphagia, dysdiadochokinesia; even talking to a neurologist becomes a minefield. This is something easy you can help your students with. You probably already do it unconsciously. Students can learn to speak like a neurologist via deliberate mimicry of your technique. Tell your student that you are going to be explaining headache treatments to a number of patients. They could pay attention to what you say and make notes, ask any questions afterwards, and then explain treatment themselves to the next patient. If the patient understands the student is learning, they can clarify anything with you afterwards.
Ideally, experience-based learning should become a mutually beneficial enterprise between doctor, patient and student. To achieve co-operation between the three, you need to be adaptable—clinics comprise many different patients, and time spent with individual students is short. You need to support the student's participation in the interaction at the highest level possible.
A final step in the negotiated agenda is to fit it within the clinical environment. How can the student participate in the context of constraints such as a late-running clinic, a patient unwilling to have a student, your needing to make an urgent trip to the ward? Transparency in the negotiation can help here: make sure the student understands the pressures on you. They may be able to help by preparing the next patient's notes, or pulling up blood or imaging results. Transparency in communication has other benefits too. You can get feedback and decide what to do next time: the same again, increased responsibility for student or trying something new.
Conclusion
Learning from real patients in a clinical setting is an important part of medical students’ development. Three-way doctor–patient–student relationships are laden with potential benefit, yet the experiences of all three could be improved. Successful experience-based learning needs deeper engagement from clinicians to support the participation of students in a clinical setting (boxes 1–2).
Quick tips
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Always greet the student, tell them what you expect of them and orient them to individual consultations.
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Clarify what students want to learn.
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Be enthusiastic and flexible.
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Be transparent about time pressure on you.
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Recognise that each student, patient and clinic is different.
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Give students an authentic role in the process of caring for the patient, and promote direct communication between student and patient.
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Invite students to help you with tasks, however simple, such as taking blood pressure, reading the referral letter out or calling in the next patient.
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Invite patients to help teach students about their experiences.
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Debrief the student at the end, and seek feedback.
A fuller discussion surrounding these tips can be found in a Medical Teacher paper by Ashley et al.9
Key principles
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Be flexible: if something is not working (the patient looks uncomfortable, or the student looks bored) then ask why, negotiate a new plan, then change tack and try something new!
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Be enthusiastic: there is nothing more motivating, as a student, than learning with someone interested in you as an individual, and who genuinely wants to help you progress.
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Be transparent: discuss your agenda and constraints openly with both students and patients.
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eg, with the student: ‘The clinic is running behind, so I can't spend lots of time between patients answering questions, but I will try and include you throughout the clinic in talking to the patients, taking histories, and examining the patients as we go through’. or ‘You could help by getting the notes ready for each patient while I dictate the letter, then summarise them for me. That way you can help me speed up, and you can also join in with the discussion in consultations and examine the patients with me’.
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eg, with the patient: ‘We've got a student with us today who is keen to learn about how you experience your headaches. How do you feel about including them in our discussion and them asking some questions too?’
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Further reading
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O'Neill P, Owen A, McArdle P. Views, behaviours and perceived staff development needs of doctors and surgeons regarding learners in outpatient clinics. Med Educ 2006;40:348–54.
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Dornan T, Boshuizen H, King N, et al. Experience-based learning: a model linking the processes and outcomes of medical students’ workplace learning. Med Educ 2007;41:84–91.
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Ashley P, Rhodes N, Sari-Kouzel H, et al. ‘They’ve all got to learn. ‘Medical students’ learning from patients in ambulatory (outpatient and general practice) consultations. Med Teach 2009;31:e24–31.
Footnotes
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Contributors EH, JG and TD wrote this article collaboratively, from inception through writing to approval of the final draft.
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Competing interests None.
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Provenance and peer review Commissioned. Externally peer reviewed. This paper was reviewed by Leone Risdale, London, UK.
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