Perception and experience of students in the first medical office | BMC Medical Education

Qualitative assessment

Twelve interviews were conducted in the resulting cohort. The cohort consisted of 66% female participants, mean age was 23.25 years (median 22.00 a; SD 3.02 a). Work experience in the health sector (eg voluntary civilian service, nursing) was present in 42% of participants. Regarding the different disciplines, 33% of the participants had completed their recent training in internal medicine, 25% in surgical disciplines, 25% in general practitioners and 17% in other disciplines. More than half of the internships took place in university hospitals (58%). Through qualitative content analysis, four inductive categories could be identified: “coping with uncertainty”, “medical clerkship as a social device”, “medical clerkship as a learning opportunity” and “medical clerkship as a teaching opportunity”. As the interviews were originally conducted in German, the categories, items and leading quotes are provided in the original German version and the corresponding English translation in Supplementary Tables 1 and 2.

Coping with uncertainty

A central motif analyzing students’ perception is ‘dealing with uncertainty’. The triggers for these are different and are described by the following subcategories:

Students often found themselves in clerical situations where they felt unprepared for the specific skills or knowledge required. The reasons in many cases are a lack of training and inconsistencies in the curricula. A typical example is the routine of taking blood samples:

I was a little surprised at first. I told them I had only done it on an anatomical model and it could fail […]. (L2, line 56 – 57)

Students also expected a rigid culture of mistakes, which was described as stigmatizing and humiliating. This can be explicitly shown in linguistic motifs such as “finish” (L2, line 104) or “to be killed” (L3, line 76). In addition, in the clinical environment, students have to cope with their new tasks and responsibilities. Clerkship is also a challenge for medical staff as they must repeatedly adapt to – and integrate – new students. The students themselves, their personality, abilities and skills are unknown to them at the beginning. In addition, unprofessional behavior is a problem among clerks, leading to insecurity and stress. For example, excessive joking was perceived as inappropriate by students:

The team was so disengaged. I got kind of scared. They were joking all the time, but I couldn’t tell the difference between serious work and conscientious work. (L3, line 90-93)

Bureaucracy as a social structure

Getting involved and further integrated into the department team is another important factor that clerical students have to deal with. This was described by the following subcategories:

• Liaison with doctors

• Clerkship in an interprofessional environment

• Disorders of relationships and role expectations

The relationship with physicians as direct supervisors appears to be particularly important at the beginning of the clerkship. For example, the student in an L1 interview described how he was introduced on his first day:

The first day he took us upstairs […]. They introduced us to the other doctors, the head of the department, the residents. It was very nice. (L1, line 70-74)

Also, students reflect on their relationship with other healthcare professionals before and after the clerkship. Additionally, factors such as temporary or personal deficit were identified as causes of disruptions related to team integration and role expectations. For example, one student tolerates being tasked with excessive blood draws rather than participating in the grand rounds because he identifies with his residents:

In the end, I could say no, I’m not doing that. I realized how busy they are and that they work overtime most days […]. (L6, line 52-55)

Clerkship as a learning opportunity

Students view clerkship primarily as a learning opportunity, which is described by the following subcategories:

Factors affecting learning behavior

• Self-assessment and planning of individual learning goals

• Official assessment based on learning objectives

• Factors influencing the selection of a specific position

Learning processes

• Experiencing central procedures and actors

• Getting a broad view

• Soft skills and patient interaction

• Hard skills training

• Learning common procedures

Before choosing a clerical position, students analyzed their competencies and chose “strategic” (L1 line 306) learning objectives. They evaluated the success of their officials based on these questions. For example, the student in interview L10 regretted not being able to do enough practical activities:

I wanted to do more hands-on medicine. So far I’ve only done auscultation, but that’s about the hands-on activities […] (L10 line 50 – 51).

Regarding the choice of a specific clerical position, students applied criteria such as personal interest or a desire to gain insight into a potential future specialization, as reported in interview L6:

I really wanted to do internal medicine because I personally am not interested in surgery right now […] (L6, line 103-104)

Also, experiencing diagnostic and therapeutic procedures was an important learning objective. Students wanted to be trained in practical skills such as drawing blood or performing clinical examinations. Students claimed that these objectives depicted “basic skills” (L2, line 72). In addition, the students wished to become familiar with everyday life, such as large circles. As an example, the student in the L2 interview described wanting to “experience everyday life in the ward” (L2, lines 313–315).

The medical clerkship as a teaching opportunity

If clerical positions are considered learning opportunities, they may also be considered teaching opportunities. Two main categories of teaching were identified in the material:

Teaching activity

Concepts of clerical training

• Introduction to Clerkship

• Knowledge transfer through key characters

• Interprofessional learning

• Lack of learning concepts

Students learned through a variety of activities, ranging from as simple as “being shown something” to more demanding activities such as “being observed.” Demonstrations were common in many officials, for example in interview L4:

He showed me the coronary arteries in the catheterization lab. If there was a stenosis, he pinpointed it […]. (L6, lines 81-83)

Explanations and clarifications were described in most of the interviews. On a more practical level, students were instructed regularly. When performing invasive tasks, monitoring by physicians was required, requiring additional time resources. Another important learning activity that rarely occurs is the integration of student opinions and ideas into medical decision-making processes. In many cases experienced by the students, they were not asked for their diagnostic and/or therapeutic reasoning to further develop the patient’s case. The material also includes concepts consisting of many of the aforementioned learning activities. In addition, medical education in clerical positions is perceived as an interprofessional task in which students, for example, benefit from the commitment of surgical nurses:

The nurses in the OR really wanted to show us things and tried to guide us […]. (L3, line 294-295)

There were also briefing papers and orientation procedures at the beginning of the clerkship. The L1 students’ interview showed them the facilities and where to find the different work materials:

When we arrived at the clinic on the first day, the ward assistant introduced us. She showed us around. A nurse explained to us how we would get our equipment for our daily activities […] (L1 line 27-30)

Knowledge transfer and skill training is mostly done by key characters. For example, a senior physician first demonstrated a heart defect using an anatomical model and subsequently transferred the case into his daily work. However, if educational learning concepts were neglected, it negatively affected students’ academic success.

Quantitative validation of category items

Based on the qualitative assessment results in the derivation cohort, a 26-item questionnaire using Likert scales for quantitative assessment was developed (Fig. 2, Supplementary Table 3).

We obtained high agreement scores for almost all items in the four categories: Coping with Uncertainty, Clerkship as a Social Device, Clerkship as a Learning Opportunity, and Clerkship as a Teaching Opportunity. Quantitative survey results assessing the relevance of category items to students in the validation cohort using a five-point Likert scale are provided in Figure 2 and Supplementary Table 3.

“Dealing with uncertainty” was the most diverse and least agreed-upon category (Fig. 2), suggesting a more varied experience of officials in this area. Students’ greatest fear was negative reactions from the clinical team to errors or uncertainty (45% strongly agreed or agreed; mean 2.66; SD 1.13). It was followed by worry about segregation from the team (47% strongly agreed or agreed; mean 2.74; SD 1.22). Closely related is the category “bureaucracy as a social device,” which has consistently high levels of agreement. Most important to the students was the good attitude towards all other members of the clinical team (93% strongly agreed or agreed; mean 1.59; SD 0.76). Also, students wished that different team members made time for them (91% strongly agreed or agreed; mean 1.53; SD 0.78). Our results show that students primarily identify with the medical team, but at the same time are interested in interacting with other professional groups.

In the “clerkship as a learning opportunity” category, students rated patient contact as most important to their learning success (92% strongly agreed or agreed; mean 1.46; SD 0.69). It was closely followed by learning about general medical procedures (91% strongly agree or agree; mean 1.47; SD 0.67) and personal interest in the clerkship (93% strongly agree or agree; mean 1.47; SD 0, 70). Soft skills and self-directed learning were rated as less important.

Regarding “clerkship as a teaching opportunity,” students rated explanations and demonstrations (95% strongly agree or agree; mean 1.37; SD 0.59) as well as instruction and supervision (93% strongly agree or agree; mean 1 , 37; SD 0.64) as most important to their learning process. Participation in decision-making is less important for students. They confirmed that key individuals (eg, specific doctors or nurses) were important to their learning experience (89% strongly agreed or agreed; mean 1.55; SD 0.75). Interprofessional learning and having clearly defined learning objectives are considered less important.