Medical students’ reactions to an experience-based learning model of clinical education

The answer to the question ‘How does an ExBL model align with students’ experiences of clinical learning?’ is that respondents were able to give many examples of how their workplace learning experiences fitted the model. The fidelity of the model to respondents’ experiences was further supported by statements like ‘the conditions of learning really affect the processes of it because if you don’t have a consultant who will let you be part of the clinic and let you take histories then you don’t have a chance to move from the observing role to the contributing role’ (FG2e-1). Whilst the study design made it likely respondents would identify elements of ExBL in their experiences, replicate them in their written accounts, and write positively about the model, some comments were analytical enough to suggest respondents had truly reflected on ExBL. For example, the comments ‘although you’re made to feel welcome it doesn’t necessarily mean the teaching you’ll have will be that great’ (FG2e-2) and ‘if you have someone who is really nice but doesn’t know anything then that’s a bit pointless as well’ (FG1e-1) show how respondents recognized the distinction between affective and pedagogic support in their own experiences. There was other evidence that students did more than replicate ExBL in an affirmative way to earn points for portfolio learning. Nearly a third of comments were negative ones, describing how the model (which was presented in positive terms) could work in reverse. Also, respondents picked up strongly on the theme of affects, both as conditions for and as outcomes of workplace learning, as captured in the phrase: ‘for me, positive affective support offered by my teachers does seem to be a key to success’ (W2e-1). The finding that learning episodes almost always had their origins in the learning environment has to be interpreted cautiously because that is what ExBL predicted. It is striking, however, that ‘self-directedness’, even when it was described, tended to take the form of eliciting support rather than functioning independently of support.

The preceding paragraph has highlighted the main threat to the validity of our findings. There is potential, inherent in the study design, for the conditions of the research to predetermine its outcome. That would be a fatal flaw if this were theory-testing research, but that was not its purpose. Rather, the purpose of the research was to find if a working theory resonated well enough with the situations it applied to for further research to be justified. We do not claim the findings to be generalizable, but we do suggest they give sufficient support to justify further testing of the utility of the theory. There are other limitations: The recruitment of self-selected, enthusiastic volunteers; failure of two respondents to complete the study; the relatively short interval between attending the presentation and writing the reflective piece. The methodology has strengths as well as limitations. It has similarities with constructivist grounded theory [22], which is gaining popularity as a way of using prior theory to interpret new empirical findings. By doing so, it is possible to refine theory over time, rather than generate a new grounded theory with each new piece of qualitative research. One final caution is that the numbers of statements in the various categories (for example, the proportion of positive and negative responses) are not intended to be representative of an absolute truth but are offered to give readers a sense of the relative strength of reaction to different elements of ExBL.

In addition to the theories quoted earlier, our findings are consistent with the work of Illeris [23]. He stressed the importance of ‘interaction processes’ between learners and their social environments, and the importance of affective as well as cognitive dimensions of learning. Wilkerson and Doyle [24] recently wrote that ‘one of the significant changes in… the new millennium is a commitment to help learners improve their skills and potential in regards to the learning experience’. Whilst Faculty Development is a well-established theme in medical education research [25], learner development (the theme within which our research is located) is an emerging one. Wilkerson and Doyle [24] went on to ask if learner development should be restricted to learners in difficulty or available to all learners. By analogy with elite athletes, they argued that succeeding as well as failing students should be supported in developing learning skills, although efforts to date have been focused primarily on the latter. ExBL is applicable to both succeeding and failing students. Moreover, it differs from interventions that are focused primarily on success in summative assessments. Rather, it addresses the learning skills needed to be effective workplace learners and practitioners. A search of recent accessions to the search engine Google Scholar using the keywords ‘Medical student learner development’ and ‘Medical student study skills’ showed a lack of current research into how best to develop medical students as workplace learners. Teaching (rather than learning) strategies were dominant. Those initiatives that did set out to make students more independent learners were focused on project or non-experiential components of undergraduate medical curricula. An important exception was a review by Murdoch-Eaton and Whittle [26], who wrote of the importance of developing generic learning skills as tools for medical students’ successful lifelong learning. They highlighted the importance of contextualizing learner development to clinical workplace learning, but the means of doing so was beyond the scope of their review.

We have systematically reviewed 168 research publications in the years 2000–2006 inclusive concerning medical students’ ExBL [27]. There were many reports of curriculum innovations, which increased medical students’ immersion in learning environments, clinical teaching, and acquisition of clinical skills. Particularly relevant to this paper were a number of interventions that used education technology [28, 29], learning logs or encounter cards [30, 31], proformas to structure patient assessments [32, 33], and the establishment of clinical teaching wards [34] to foster favourable interactions between learners and learning environments. A limitation of many interventions was that they were contextually bound or addressed only very limited learning skills. What the present research adds to them is a generic and comprehensive model of workplace learning that could help make such interventions broader in their scope and provide a framework for evaluating them.

This research indicates that ExBL has face validity in the eyes of students and provides a rich set of instances of various components of the model. What it does not do is move beyond opening the black box of clerkship learning to show how to train faculty and students, or show how ExBL can contribute to curriculum design. It can, however, help researchers develop testable hypotheses. It might be hypothesized, for example, that strengthening pedagogic, organizational, and affective support would strengthen students’ learning. It might be hypothesized, also, that making students and teachers aware of the affective outcomes of clerkship learning might help them, as members of communities of educational practice, work together to develop students’ identities. ExBL is a complex model, according to which learning outcomes are caused by multiple interacting factors. Randomized controlled trials are of limited value in education research because they test simple rather than complex interventions so we favour using design-based (or action) research methodology to explore the application of ExBL. The main goal of such research, we suggest, would be to find how best to support teachers’ teaching and students’ learning.