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Purpose: Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT)., Methods: Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students' education in 'the implementation of important clinical guidelines' relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants' transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template., Results: There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant's picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants' experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted., Conclusions: After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students' preparedness for safe practice. Merton's seminal work on the 'unanticipated consequences of purposive social action' suggests that intensive teaching may even have contributed to their unpreparedness.

Competing Interests: Competing interests: None declared.

Purpose: Prescribing is a common task, often performed by junior clinicians, with potential for significant harm. Despite this, it is common for medical students to qualify having only prescribed in simulated scenarios or assessments. We implemented an alternative: students were given pens with purple ink, which permitted them to write prescriptions for real patients. We set out to understand how this intervention, pre-prescribing, created a zone of proximal development (ZPD) for learners., Methods: An anonymous, mixed methods, evaluation questionnaire was distributed to all final-year medical students at one university in the United Kingdom. Analysis was guided by Experience Based Learning theory., Results: Two hundred and eighteen students made 386 free-text comments. Most participants reported that pre- helped them become capable doctors (Strongly Agree n  = 96, 45%; Agree: n  = 110, 50%). Pre-prescribing created a ZPD in which participants could use the tools of practice in authentic contexts under conditions that made it safe to fail., Conclusions: This research shows how a theoretically informed intervention can create conditions to enhance learning. It encourages educators to identify aspects of routine practice that could be delegated, or co-performed, by learners. With appropriate support, educators can create 'safe-fails' which allow learners to participate safely in authentic, risky, and indeterminate situations they will be expected to navigate as newly qualified clinicians.

Prescribing (writing medication orders) is one of residents' commonest tasks. Superficially, all they have to do is complete a form. Below this apparent simplicity, though, lies the complex task of framing patients' needs and navigating relationships with them and other clinicians. Mistakes, which compromise patient safety, commonly result. There is no evidence that competence-based education is preventing harm. We found a profound contradiction between medical students becoming competent, as defined by passing competence assessments, and becoming capable of safely caring for patients. We reinstated patients as the object of learning by allowing students to 'pre-prescribe' (complete, but not authorise prescriptions). This turned a disabling tension into a driver of curriculum improvement. Students 'knotworked' within interprofessional teams to the benefit of patients as well as themselves. Refocusing undergraduate medical education on patient care showed promise as a way of improving patient safety.

Background: Compassion fatigue, unprofessional behavior, and burnout are prompting educators to examine medical students' affective reactions to workplace experiences. Attributes of both students and learning environments are influenced by their socio-cultural backgrounds. To prevent 'educational cultural hegemony', opinion leaders have advocated research in under-represented cultural contexts, of which Asia is a prime example. This study aimed to broaden the discourse of medical education by answering the question: how do students react affectively to workplace experiences in a Chinese cultural context?, Methods: In 2014, the authors recruited five female and seven male Taiwanese clerkship students to make 1-2 audio-diary recordings per week for 12 weeks describing affective experiences, to which they had consciously reacted. The authors analyzed transcripts of these recordings thematically in the original Mandarin and prepared a thick description of their findings, including illustrative extracts. An English-speaking education researcher helped them translate this into English, constantly comparing the interpretation with the original, untranslated data., Results: (Mis) matches between their visions of future professional life and clerkship experiences influenced participants' affective reactions, thoughts, and behaviors. Participants managed these reactions by drawing on a range of personal and social resources, which influenced the valence, strength, and nature of their reactions. This complex set of interrelationships was influenced by culturally determined values and norms, of which this report provides a thick description., Conclusion: To avoid educational cultural hegemony, educators need to understand professional behavior in terms of complex interactions between culturally-specific attributes of individual students and learning environments., Trial Registration: The ethics committee of the National Taiwan University (NTU) Hospital gave research ethics approval ( 20130864RINB ).

Context: An important part of a doctor's identity is the social position he or she adopts relative to patients. Dialogic theory predicts that medical school discourses influence the positions students incorporate into their professional identities. As this may affect how students later exercise power in doctor-patient relationships, we set out to examine how medical teachers position doctors in relation to patients., Methods: Informed by Holland's Figured Worlds theory, which draws important assumptions from Bakhtin, we chose dialogic research methodology to examine how educators' language positions doctors and may influence students' identity formation. We recruited a maximum variation sample of 10 teaching staff and used open prompts in individual semi-structured interviews to elicit discourses of doctors' social position. We used Sullivan's dialogic methodology reflexively to identify informative speech acts (utterances) and to examine how the language used in these constructed doctors' positions., Results: Dominant discourses of Social Superiority, Technical Effectiveness, and Benevolence elevated doctors' positions based on their social status, applied knowledge and trustworthiness, respectively. These positions were defended by predicating medical care on doctors' mastery of treatments and their superior knowledge. A non-dominant discourse of Distributed Power and Responsibility narrowed the positional gap by constructing doctors as empowering patients., Conclusions: Whereas three conservative discourses upheld doctors' elevated social position, a non-dominant, transformative discourse distributed power. We suggest that doctors will form the best relationships with patients when they are aware of these discourses and know how to navigate them. In pursuit of effective and compassionate patient care, we commend critical pedagogy as a means of articulating non-dominant discourses and increasing students', educators' and doctors' awareness of how they learn the positions of doctors., (© 2020 The Authors. Medical Education published by Association for the Study of Medical Education and John Wiley & Sons Ltd.)

Background: Peer-assisted learning (PAL) increasingly features within medical school curricula. While there is evidence of its effectiveness, less is known about how it promotes learning. Cognitive and social congruence between peer-tutor and student have been described as important concepts underpinning teaching and learning in PAL. We employed interpretative phenomenological analysis for an in-depth exploration of how medical students experience PAL sessions., Methods: We conducted the study at The University of Manchester within a near-peer scheme aimed at developing clinical skills within clinical clerkship students. We conducted individual interviews with three peer tutors and five students. We undertook interpretive phenomenological analysis of interview transcripts. We subsequently synthesised an account of the study participants' lived experiences of PAL sessions from individual personal accounts to explore how medical students experience peer-assisted learning. This analysis was then used to complement and critique a priori educational theory regarding the mechanisms underlying PAL., Results: Students experienced PAL sessions as a safe and egalitarian environment, which shaped the type and style of learning that took place. This was facilitated by close relationships with peer-tutors, with whom they shared a strong sense of camaraderie and shared purpose. Peer-tutors felt able to understand their students' wider sociocultural context, which was the most important factor underpinning both the PAL environment and tutor-student relationship. Participants contrasted this relative safety, camaraderie and shared purpose of PAL with teaching led by more senior tutors in clinical settings., Conclusions: This study provides a rich description of the important factors that characterise medical students' experiences of PAL sessions. Participants felt a strong sense of support in PAL sessions that took into account their wider sociocultural context. Multiple factors interplayed to create a learning environment and tutor-student relationship that existed in contrast to teaching led by more senior, clinical tutors. The insight generated via IPA complemented existing theory and raised new lines of enquiry to better understand how the peer relationship fosters learning in PAL at medical school. We make recommendations to use insights from PAL for faculty and curriculum development.

Background: Educational environment is a strong determinant of student satisfaction and achievement. The learning environments of medical students on clinical placements are busy workplaces, composed of many variables. There is no universally accepted method of evaluating the clinical learning environment, nor is there consensus on what concepts or aspects should be measured. The aims of this study were to compare the Dundee ready educational environment measure (DREEM - the current de facto standard) and the more recently developed Manchester clinical placement index (MCPI) for the assessment of the clinical learning environment in a graduate entry medical student cohort by correlating the scores of each and analysing free text comments. This study also explored student perceptionof how the clinical educational environment is assessed., Methods: An online, anonymous survey comprising of both the DREEM and MCPI instruments was delivered to students on clinical placement in a graduate entry medical school. Additional questions explored students' perceptions of instruments for giving feedback. Numeric variables (DREEM score, MCPI score, ratings) were tested for normality and summarised. Pearson's correlation coefficient was used to measure the strength of the association between total DREEM score and total MCPI scores. Thematic analysis was used to analyse the free text comments., Results: The overall response rate to the questionnaire was 67% (n = 180), with a completed response rate for the MCPI of 60% (n = 161) and for the DREEM of 58% (n = 154). There was a strong, positive correlation between total DREEM and MCPI scores (r = 0.71, p < 0.001). On a scale of 0 to 7, the mean rating for how worthwhile students found completing the DREEM was 3.27 (SD 1.41) and for the MCPI was 3.49 (SD 1.57). 'Finding balance' and 'learning at work' were among the themes to emerge from analysis of free text comments., Conclusions: The present study confirms that DREEM and MCPI total scores are strongly correlated. Graduate entry students tended to favour this method of evaluation over the DREEM with the MCPI prompting rich description of the clinical learning environment. Further study is warranted to determine if this finding is transferable to all clinical medical student cohorts.

Purpose: Current knowledge about the interplay between emotions and professional identity formation is limited and largely based on research in Western settings. This study aimed to broaden understandings of professional identity formation cross-culturally., Method: In fall 2014, the authors purposively sampled 22 clinical students from Taiwan and the Netherlands and asked them to keep audio diaries, narrating emotional experiences during clerkships using three prompts: What happened? What did you feel/think/do? How does this interplay with your development as a doctor? Dutch audio diaries were supplemented with follow-up interviews. The authors analyzed participants' narratives using a critical discourse analysis informed by Figured Worlds theory and Bakhtin's concept of dialogism, according to which people's spoken words create identities in imagined future worlds., Results: Participants talked vividly, but differently, about their experiences. Dutch participants' emotions related to individual achievement and competence. Taiwanese participants' rich, emotional language reflected on becoming both a good person and a good doctor. These discourses constructed doctors' and patients' autonomy in culturally specific ways. The Dutch construct centered on "hands-on" participation, which developed the identity of a technically skilled doctor, but did not address patients' self-determination. The Taiwanese construct located physicians' autonomy within moral values more than practical proficiency, and gave patients agency to influence doctor-patient relationships., Conclusions: Participants' cultural constructs of physician and patient autonomy led them to construct different professional identities within different imagined worlds. The contrasting discourses show how medical students learn about different meanings of becoming doctors in culturally specific contexts.

Context: The use of point-of-care ultrasound (POCUS) in clinical care is growing rapidly and advocates have recently proposed the integration of ultrasound into undergraduate medical education (UME). The evidentiary basis for this integration has not been evaluated critically or systematically., Objectives: We conducted a critical and systematic review framed by the rationales enumerated in academic publications by advocates of ultrasound in UME., Methods: This research was conducted in two phases. First, the dominant discursive rationales for the integration of ultrasound in UME were identified from an archive of 403 academic publications using techniques from Foucauldian critical discourse analysis (CDA). We then sought empirical evidence in support of these rationales, using a critical synthesis methodology also adapted from CDA., Results: We identified four dominant discursive rationales with different levels of evidentiary support. The use of ultrasound was not demonstrated to improve students' understanding of anatomy. The benefit of ultrasound in teaching physical examination was inconsistent and rests on minimal evidence. With POCUS, students' diagnostic accuracy was improved for certain pathologies, but findings were inconsistent for others. Finally, the rationale that ultrasound training in UME will improve the quality of patient care was difficult to evaluate., Conclusions: Our analysis has shown that the frequently repeated rationales for the integration of ultrasound in UME are not supported by a sufficient base of empirical research. The repetition of these dominant discursive rationales in academic publications legitimises them and may preclude further primary research. As the value of clinical ultrasound use by medical students remains unproven, educators must consider whether the associated financial and temporal costs are justified or whether more research is required., (© 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Context: Patient care evokes emotional responses such as uncertainty, grief and pride in medical students. There is a need for opportunities to share and express such emotions because they influence students' professional development and well-being. There is a trend towards introducing mentor programmes into medical curricula. It remains unknown whether students are willing and able to share their emotional experiences within this formal setting. We set out to explore how medical students share their emotional experiences and why., Methods: We used thematic analysis, including purposeful sampling, parallel processes of data collection and constant comparative analysis, maintaining an audit trail for validation purposes. The study had a constructivist, interactional design and used Goffman's dramaturgical theory as an interpretive framework. Nineteen students participated in individual, semi-structured interviews., Results: Participants' narratives revealed a preference for sharing emotional experiences away from people who might expect them to uphold formal behaviour. They deliberately decided with whom to share their emotional experiences. Participants had a preference to talk to fellow students working in the same department, or family and friends outside medical school., Conclusions: Participants found it difficult to uphold behaviours that they thought patients, preceptors or the organisation expected of them as future doctors. In adjusting their behaviour to meet those expectations, they became attuned to how to best present themselves based on the people present. This influenced how they chose which emotional experiences to share with whom., (© 2016 John Wiley & Sons Ltd and The Association for the Study of Medical Education.)

Background: Peer tutoring has been described as "people from similar social groupings who are not professional teachers helping each other to learn and learning themselves by teaching". Peer tutoring is well accepted as a source of support in many medical curricula, where participation and learning involve a process of socialisation. Peer tutoring can ease the transition of the junior students from the university class environment to the hospital workplace. In this paper, we apply the Experienced Based Learning (ExBL) model to explore medical students' perceptions of their experience of taking part in a newly established peer tutoring program at a hospital based clinical school., Methods: In 2014, all students at Sydney Medical School - Central, located at Royal Prince Alfred Hospital were invited to voluntarily participate in the peer tutoring program. Year 3 students (n = 46) were invited to act as tutors for Year 1 students (n = 50), and Year 4 students (n = 60) were invited to act as tutors for Year 2 students (n = 51). Similarly, the 'tutees' were invited to take part on a voluntary basis. Students were invited to attend focus groups, which were held at the end of the program. Framework analysis was used to code and categorise data into themes., Results: In total, 108/207 (52 %) students participated in the program. A total of 42/106 (40 %) of Year 3 and 4 students took part as tutors; and of 66/101 (65 %) of Year 1 and 2 students took part as tutees. Five focus groups were held, with 50/108 (46 %) of students voluntarily participating. Senior students (tutors) valued the opportunity to practice and improve their medical knowledge and teaching skills. Junior students (tutees) valued the opportunity for additional practice and patient interaction, within a relaxed, small group learning environment., Conclusion: Students perceived the peer tutoring program as affording opportunities not otherwise available within the curriculum. The peer teaching program provided a framework within the medical curriculum for senior students to practice and improve their medical knowledge and teaching skills. Concurrently, junior students were provided with a valuable learning experience that they reported as being qualitatively different to traditional teaching by faculty.

Prescribing tasks, which involve pharmacological knowledge, clinical decision-making and practical skill, take place within unpredictable social environments and involve interactions within and between endlessly changing health care teams. Despite this, curriculum designers commonly assume them to be simple to learn and perform. This research used mixed methods to explore how undergraduate medical students learn to prescribe in the 'real world'. It was informed by cognitive psychology, sociocultural theory, and systems thinking. We found that learning to prescribe occurs as a dynamic series of socially negotiated interactions within and between individuals, communities and environments. As well as a thematic analysis, we developed a framework of three conceptual spaces in which learning opportunities for prescribing occur. This illustrates a complex systems view of prescribing education and defines three major system components: the "social space", where the environmental conditions influence or bring about a learning experience; the "process space", describing what happens during the learning experience; and the intra-personal "cognitive space", where the learner may develop aspects of prescribing expertise. This conceptualisation broadens the scope of inquiry of prescribing education research by highlighting the complex interplay between individual and social dimensions of learning. This perspective is also likely to be relevant to students' learning of other clinical competencies.

Context: There is little room in clerkship curricula for students to express emotions, particularly those associated with the development of a caring identity. Yet it is recognised that competence, alone, does not make a good doctor. We therefore set out to explore the relationship between emotions and identity in clerkship education. Our exploration was conceptually oriented towards Figured Worlds theory, which is linked to Bakhtin's theory of dialogism., Methods: Nine female and one male member of a mixed student cohort kept audio-diaries and participated in both semi-structured and cognitive individual interviews. The researchers identified 43 emotionally salient utterances in the dataset and subjected them to critical discourse analysis. They applied Figured Worlds constructs to within-case and cross-case analyses, supporting one another's reflexivity and openness to different interpretations, and constantly comparing their evolving interpretation against the complete set of transcripts., Results: Students' emotions were closely related to their identity development in the world of medicine. Patients were disempowered by their illnesses. Doctors were powerful because they could treat those illnesses. Students expressed positive emotions when they were granted positions in the world of medicine and were able to identify with the figures of doctors or other health professionals. They identified with doctors who behaved in caring and professionally appropriate ways towards patients and supportively towards students. Students expressed negative emotions when they were unable to develop their identities., Conclusions: Critical discourse analysis has uncovered a link between students' emotions and their identity development in the powerful world of becoming and being a doctor. At present, identity development, emotions and power are mostly tacit in undergraduate clinical curricula. We speculate that helping students to express emotions and exercise power in the most effective ways might help them to develop caring identities., (© 2015 John Wiley & Sons Ltd.)

Objective: Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility?, Methods: Six focus groups were conducted with (pre-)/clerkship students., Results: Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models., Conclusion: Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor., Practice Implications: When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Clerkship education has been called a 'black box' because so little is known about what, how, and under which conditions students learn. Our aim was to develop a blueprint for education in ambulatory and inpatient settings, and in single encounters, traditional rotations, or longitudinal experiences. We identified 548 causal links between conditions, processes, and outcomes of clerkship education in 168 empirical papers published over 7 years and synthesised a theory of how students learn. They do so when they are given affective, pedagogic, and organisational support. Affective support comes from doctors' and many other health workers' interactions with students. Pedagogic support comes from informal interactions and modelling as well as doctors' teaching, supervision, and precepting. Organisational support comes from every tier of a curriculum. Core learning processes of observing, rehearsing, and contributing to authentic clinical activities take place within triadic relationships between students, patients, and practitioners. The phrase 'supported participation in practice' best describes the educational process. Much of the learning that results is too tacit, complex, contextualised, and individual to be defined as a set of competencies. We conclude that clerkship education takes place within relationships between students, patients, and doctors, supported by informal, individual, contextualised, and affective elements of the learned curriculum, alongside formal, standardised elements of the taught and assessed curriculum. This research provides a blueprint for designing and evaluating clerkship curricula as well as helping patients, students, and practitioners collaborate in educating tomorrow's doctors.

Background: Recent years have seen a significant drop in applications to surgical residencies. Existing research has yet to explain how medical students make career decisions. This qualitative study explores students' perceptions of surgery and surgeons, and the influence of stereotypes on career decisions., Methods: Exploratory questionnaires captured students' perceptions of surgeons and surgery. Questionnaire data informed individual interviews, exploring students' perceptions in depth. Rigorous qualitative interrogation of interviews identified emergent themes from which a cohesive analysis was synthesized., Results: Respondents held uniform stereotypes of surgeons as self-confident and intimidating; surgery was competitive, masculine, and required sacrifice. To succeed in surgery, students felt they must fit these stereotypes, excluding those unwilling, or who felt unable, to conform. Deviating from the stereotypes required displaying such characteristics to a level exceptional even for surgery; consequently, surgery was neither an attractive nor realistic career option., Conclusions: Strong stereotypes of surgery deterred students from a surgical career. As a field, surgery must actively engage medical students to encourage participation and dispel negative stereotypes that are damaging recruitment into surgery., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Dealing with emotions is a critical feature of professional behaviour. There are no comprehensive theoretical models, however, explaining how medical students learn about emotions. We aimed to explore factors affecting their emotions and how they learn to deal with emotions in themselves and others. During a first-year nursing attachment in hospitals and nursing homes, students wrote daily about their most impressive experiences, explicitly reporting what they felt, thought, and did. In a subsequent interview, they discussed those experiences in greater detail. Following a grounded theory approach, we conducted a constant comparative analysis, collecting and then interpreting data, and allowing the interpretation to inform subsequent data collection. Impressive experiences set up tensions, which gave rise to strong emotions. We identified four 'axes' along which tensions were experienced: 'idealism versus reality', 'critical distance versus adaptation', 'involvement versus detachment' and 'feeling versus displaying'. We found many factors, which influenced how respondents relieved those tensions. Their personal attributes and social relationships both inside and outside the medical community were important ones. Respondents' positions along the different dimensions, as determined by the balance between attributes and tensions, shaped their learning outcomes. Medical students' emotional development occurs through active participation in medical practice and having impressive experiences within relationships with patients and others on wards. Tensions along four dimensions give rise to strong emotions. Gaining insight into the many conditions that influence students' learning about emotions might support educators and supervisors in fostering medical students' emotional and professional development.

Purpose: To explore how undergraduate medical students learn from real patients in practice settings, the factors that affect their learning, and how clerkship learning might be enhanced., Method: In 2009, 22 medical students in the three clerkship years of an undergraduate medical program in the United Kingdom made 119 near-contemporaneous audio diary entries reflecting how they learned from real patients. Nineteen attended focus groups; 18 were individually interviewed. The authors used a qualitative theory-building methodology with a conceptual orientation toward Communities of Practice theory. A learning theorist guided selective coding of a constant-comparative analysis., Results: Participants learned informally by participating in the communicative practices of workplaces. Two overlapping practices, patient care and education, were identified. Patient care created learning opportunities, which were enriched when practitioners intentionally supported participants' learning. Education, however, was not always coupled with patient care. So, talk positioned the boundaries of two practices in three configurations: education without patient care, education within patient care, and patient care without education. The nature and quality of participants' learning depended on how practitioners entered dialogue with them and linked the dialogue to authentic patient care., Conclusions: Findings strongly suggest that medical students learn from real patients by participating in patient care within an educational practice. Their learning is affected by clinicians' willingness to engage in supportive dialogue. Promoting an informal, inclusive discourse of workplace learning might enhance clerkship education. This approach should take its place alongside-and perhaps ahead of-the currently dominant discourse of "clinical teaching."

"Curricula-in-action" generally differ from "official" curricula. That is particularly true of clerkship curricula because the practising doctors who supervise medical students' clinical activities are only secondarily educators. Clerkship education is evaluated, however, according to benchmarks set by official curricula. As a result, clerkship evaluations are important points of contact between clinical teachers and medical schools. We reasoned that an evaluation instrument is part of a medical school's official curriculum discourse and clinical teachers' reactions to it are a discourse of curriculum-in-action. We set out to answer the questions: What are clinical teachers' discourses of curriculum-in-action and how do they relate to an official curriculum discourse? Nineteen clerkship placement leads from two hospitals contributing to a single undergraduate medical programme participated. The evaluation instrument was the Manchester Clinical Placement Index, for which validity evidence has been published. Respondents were asked to say how they would react to junior students giving their placements low or high scores for each of 12 items from the Index. After transcription, we conducted a critical discourse analysis (CDA) of their audio-recorded answers. We purposefully selected the six items that elicited the widest spectrum of responses for analysis because quantity of material can compromise the quality of CDA. A dominant discourse of curriculum-in-action defined how teachers should "really" teach and junior students should learn. It deconstructed the need for teachers to be present when students performed clinical tasks because teachers' role was to give critical feedback on case presentations that were coincidental to clinical care. It positioned students at the bottom of a power hierarchy so they had to "struggle" to be taught. It placed respondents in a powerful position relative to "the hospital" and "the university", though there were tensions between respondents, patients, and nurses. Respondents dismissed criticism that was invalid according to their curriculum-in-action, which included most items in an evaluation instrument. There was a contrasting, non-dominant discourse of responding reflectively to feedback, which generated realistic ways of improving students' learning. The strength of respondents' emotions shows just how committed doctors are to students' learning. The strength of their expressions of power, however, explains why many of them teach in their own way rather than according to official curricula. Changes to clinical curricula, our findings suggest, will not be successful unless they are carefully negotiated with practising doctors.

Context: The under-representation in medical education of students from lower socio-economic backgrounds is an important social issue. There is currently little evidence about whether changes in admission strategies might increase the diversity of the medical student population. Denmark introduced an 'attribute-based' admission track to make it easier for students who may not be eligible for admission on the 'grade-based' track to be admitted on the basis of attributes other than academic performance. The aim of this research was to examine whether there were significant differences in the social composition of student cohorts admitted via each of the two tracks during the years 2002-2007., Methods: This prospective cohort study included 1074 medical students admitted during 2002-2007 to the University of Southern Denmark medical school. Of these, 454 were admitted by grade-based selection and 620 were selected on attributes other than grades. To explore the social mix of candidates admitted on each of the two tracks, respectively, we obtained information on social indices associated with educational attainment in Denmark (ethnic origin, father's education, mother's education, parenthood, parents living together, parent in receipt of social benefits)., Results: Selection strategy (grade-based or attribute-based) had no statistically significant effect on the social diversity of the medical student population., Conclusions: The choice of admission criteria may not be very important to widening access and increasing social diversity in medical schools. Attracting a sufficiently diverse applicant pool may represent a better strategy for increasing diversity in the student population., (© 2013 John Wiley & Sons Ltd.)

The drive to quality-manage medical education has created a need for valid measurement instruments. Validity evidence includes the theoretical and contextual origin of items, choice of response processes, internal structure, and interrelationship of a measure's variables. This research set out to explore the validity and potential utility of an 11-item measurement instrument, whose theoretical and empirical origins were in an Experience Based Learning model of how medical students learn in communities of practice (COPs), and whose contextual origins were in a community-oriented, horizontally integrated, undergraduate medical programme. The objectives were to examine the psychometric properties of the scale in both hospital and community COPs and provide validity evidence to support using it to measure the quality of placements. The instrument was administered twice to students learning in both hospital and community placements and analysed using exploratory factor analysis and a generalizability analysis. 754 of a possible 902 questionnaires were returned (84% response rate), representing 168 placements. Eight items loaded onto two factors, which accounted for 78% of variance in the hospital data and 82% of variance in the community data. One factor was the placement learning environment, whose five constituent items were how learners were received at the start of the placement, people's supportiveness, and the quality of organisation, leadership, and facilities. The other factor represented the quality of training-instruction in skills, observing students performing skills, and providing students with feedback. Alpha coefficients ranged between 0.89 and 0.93 and there were no redundant or ambiguous items. Generalisability analysis showed that between 7 and 11 raters would be needed to achieve acceptable reliability. There is validity evidence to support using the simple 8-item, mixed methods Manchester Clinical Placement Index to measure key conditions for undergraduate medical students' experience based learning: the quality of the learning environment and the training provided within it. Its conceptual orientation is towards Communities of Practice, which is a dominant contemporary theory in undergraduate medical education.

Context: During early clinical exposure, medical students have many emotive experiences. Through participation in social practice, they learn to give personal meaning to their emotional states. This meaningful social act of participation may lead to a sense of belonging and identity construction., Objectives: The aim of this study was to broaden and deepen our understanding of the interplay between those experiences and students' identity development. Our research questions asked how medical students give meaning to early clinical experiences and how that affects their professional identity development., Methods: Our method was phenomenology. Within that framework we used a narrative interviewing technique. Interviews with 17 medical students on Year 1 attachments to nurses in hospitals and nursing homes were analysed by listening to audio-recordings and reading transcripts. Nine transcripts, which best exemplified the students' range of experiences, were purposively sampled for deeper analysis. Two researchers carried out a systematic analysis using qualitative research software. Finally, cases representing four paradigms were chosen to exemplify the study findings., Results: Students experienced their relationships with the people they met during early clinical experiences in very different ways, particularly in terms of feeling and displaying emotions, adjusting, role finding and participation. The interplay among emotions, meaning and identity was complex and four different 'paradigms' of lived experience were apparent: feeling insecure; complying; developing, and participating., Conclusions: We found large differences in the way students related to other people and gave meaning to their first experiences as doctors-to-be. They differed in their ability to engage in ward practices, the way they experienced their roles as medical students and future doctors, and how they experienced and expressed their emotions. Medical educators should help students to be sensitive to their emotions, offer space to explore different meanings, and be ready to suggest alternative interpretations that foster the development of desired professional identities., (© Blackwell Publishing Ltd 2012.)

Context: It is important to know how patients are affected by becoming opportunistically involved in medical student education. In previous studies, researchers rather than patients set the research agenda and expert patients or people well known to teachers were more often involved than ordinary people., Objectives: This study aimed to explore how ordinary patients experience undergraduate medical teaching when they become involved in it opportunistically and to derive practical insights from the lived experiences of these patients., Methods: The research was conducted in line with a conceptual orientation towards communities of practice theory and used phenomenology as a way of exploring patients' lived experiences in depth. Minimally structured interviews were carried out with 10 patients following ordinary out-patient or general practice appointments in which students were being taught. Template analysis was used to generate provisional themes and a process of phenomenological reduction was used to distil individual respondents' lived experiences to their essence., Results: The presence of students in ambulatory consultations was normal. Nine respondents described transactional relationships in which they remained outside the community of practice of which the doctor and student were members. Only an intimate problem would engage them deeply enough for a student's presence to 'bother' them. One patient's personal and professional background led her to regard doctors' handling of consultation dynamics as factors contributing to whether teaching consultations were negative or positive experiences. When doctors' sensitive and inclusive behaviour drew her into a triadic relationship with the student and doctor, she experienced mutual benefits with students. When it did not, she felt objectified and alienated., Conclusions: Provided they receive the clinical care for which they are attending a consultation and are treated respectfully, patients may sometimes willingly become 'objects' from which students learn. They may, however, become more deeply engaged in teaching consultations in which they participate actively in a triadic relationship of mutual benefit with a doctor and student. Teaching consultations call for doctors to be sensitive and adaptable., (© Blackwell Publishing Ltd 2012.)

Background: Reflection is a meta-cognitive process, characterized by: 1. Awareness of self and the situation; 2. Critical analysis and understanding of both self and the situation; 3. Development of new perspectives to inform future actions. Assessors can only access reflections indirectly through learners' verbal and/or written expressions. Being privy to the situation that triggered reflection could place reflective materials into context. Video-cases make that possible and, coupled with a scoring rubric, offer a reliable way of assessing reflection., Methods: Fourth and fifth year undergraduate medical students were shown two interactive video-cases and asked to reflect on this experience, guided by six standard questions. The quality of students' reflections were scored using a specially developed Student Assessment of Reflection Scoring rubric (StARS®). Reflection scores were analyzed concerning interrater reliability and ability to discriminate between students. Further, the intra-rater reliability and case specificity were estimated by means of a generalizability study with rating and case scenario as facets., Results: Reflection scores of 270 students ranged widely and interrater reliability was acceptable (Krippendorff's alpha = 0.88). The generalizability study suggested 3 or 4 cases were needed to obtain reliable ratings from 4th year students and ≥ 6 cases from 5th year students., Conclusion: Use of StARS® to assess student reflections triggered by standardized video-cases had acceptable discriminative ability and reliability. We offer this practical method for assessing reflection summatively, and providing formative feedback in training situations.

Evidence that medical error can cause harm to patients has raised the attention of the health care community towards patient safety and influenced how and what medical students learn about it. Patient safety is best taught when students are participating in clinical practice where they actually encounter patients at risk. This type of learning is referred to as workplace learning, a complex system in which various factors influence what is being learned and how. A theory that can highlight potential difficulties in this complex learning system about patient safety is activity theory. Thirty-four final year undergraduate medical students participated in four focus groups about their experiences concerning patient safety. Using activity theory as analytical framework, we performed constant comparative thematic analysis of the focus group transcripts to identify important themes. We found eight general themes relating to two activities: learning to be a doctor and delivering safe patient care. Simultaneous occurrence of these two activities can cause contradictions. Our results illustrate the complexity of learning about patient safety at the workplace. Students encounter contradictions when learning about patient safety, especially during a transitional phase of their training. These contradictions create potential learning opportunities which should be used in education about patient safety. Insight into the complexities of patient safety is essential to improve education in this important area of medicine.

Context: Conceptualisations of self-assessment are changing as its role in professional development comes to be viewed more broadly as needing to be both externally and internally informed through activities that enable access to and the interpretation and integration of data from external sources. Education programmes use various activities to promote learners' reflection and self-direction, yet we know little about how effective these activities are in 'informing' learners' self-assessments., Objectives: This study aimed to increase understanding of the specific ways in which undergraduate and postgraduate learners used learning and assessment activities to inform self-assessments of their clinical performance., Methods: We conducted an international qualitative study using focus groups and drawing on principles of grounded theory. We recruited volunteer participants from three undergraduate and two postgraduate programmes using structured self-assessment activities (e.g. portfolios). We asked learners to describe their perceptions of and experiences with formal and informal activities intended to inform self-assessment. We conducted analysis as a team using a constant comparative process., Results: Eighty-five learners (53 undergraduate, 32 postgraduate) participated in 10 focus groups. Two main findings emerged. Firstly, the perceived effectiveness of formal and informal assessment activities in informing self-assessment appeared to be both person- and context-specific. No curricular activities were considered to be generally effective or ineffective. However, the availability of high-quality performance data and standards was thought to increase the effectiveness of an activity in informing self-assessment. Secondly, the fostering and informing of self-assessment was believed to require credible and engaged supervisors., Conclusions: Several contextual and personal conditions consistently influenced learners' perceptions of the extent to which assessment activities were useful in informing self-assessments of performance. Although learners are not guaranteed to be accurate in their perceptions of which factors influence their efforts to improve performance, their perceptions must be taken into account; assessment strategies that are perceived as providing untrustworthy information can be anticipated to have negligible impact., (© Blackwell Publishing Ltd 2011.)

Objectives: This study aimed to explore how medical students experience contacts with real patients and what they learn from them., Methods: We carried out a post hoc, single-group study in one teaching sector of a 5-year, problem-based, horizontally integrated, outcome-based and community-oriented undergraduate programme, in which students lacked clinical exposure in the pre-clerkship phase. Subjects comprised five cohorts of students on their first clerkships. Data consisted of purposively selected, voluntary, self-report statements regarding real patient learning (RPL). Constant comparative analysis was performed by two independent researchers., Results: Respondents valued patients as an instructional resource that made learning more real. They reported learning through visual pattern recognition as well as through dialogue and physical examination. They more often used social than professional language to describe RPL. They reported affective outcomes including enhanced confidence, motivation, satisfaction and a sense of professional identity. They also reported cognitive outcomes including perspective, context, a temporal dimension, and an appreciation of complexity. Real patient learning helped respondents link theory learned earlier with reality as represented by verbal, visual and auditory experiences. It made learning easier, more meaningful and more focused. It helped respondents acquire complex skills and knowledge. Above all, RPL helped learners to remember subject matter. Most negative responses concerned the difficulty of acquiring appropriate experience, but RPL made a minority of respondents feel uncomfortable and incompetent., Conclusions: Real patient learning led to a rich variety of learning outcomes, of which at least some medical students showed high metacognitive awareness. Sensitivity from clinical mentors towards the positive and negative outcomes of RPL reported here could support reflective clinical learning.

Background: Medical education has been characterized in terms of points of transition, which are accentuated by lack of relevant prior experience and can lead to extreme positive and negative emotions., Aims: Quantify the effect of maturity on medical students' transitions into the clinical environment and identify how experiences of transition might be improved., Method: Eleven weeks after entering the clinical environment, 29 mature students (age over 21 at entry, median age 22) in a horizontally-integrated, predominantly undergraduate entry, problem-based curriculum offering little early clinical exposure and 58 matched non-mature students (median age 18 years) rated their experiences of transition and wrote free text comments about them., Results: 62% of mature students compared with 24% of controls described 'good transitions' (odds ratio [OR] for a good transition 6.1; p = 0.002) and mature students were more likely than controls to describe how they drew on their previous years in medical school (OR 2.7, p = 0.04) and their wider life experiences in making the transition (OR 3.9, p = 0.01). They were less likely to feel confused or daunted. Whether mature or not, prior workplace experience, having learned the theory of medicine by PBL, and being confident in their knowledge and skills helped students' transitions. Both mature and non-mature students valued the support of teachers and peers and would have valued clinical experience earlier., Conclusions: The fact that just a few extra years of life experience made such a large difference to students' experiences of transition illustrates how important social factors are in the personal development of medical students. In respondents' views, early clinical experience and early skills training could ease students' passage into the clerkship phase of their education.

Background: The dynamics of effective teaching consultations need to be better understood., Aim: Find from medical students, patients and doctors how to optimize learning in ambulatory consultations., Methods: Patients and students independently gave semi-structured exit interviews after 25 ambulatory teaching consultations during a clinical attachment set up experimentally to strengthen students' ambulatory learning. The results of an abbreviated grounded theory analysis were checked in three focus group discussions with teachers and students., Results: Patients and students identified strongly with one another and benefited from teaching consultations in parallel ways yet defaulted to passive roles. Patients deferred to professional expertise whilst students were uncertain what was expected of them, feared harming patients and feared being showed up as ignorant. The educational value of consultations was determined by doctors' ability to promote student-patient interaction., Conclusions: In the most effective teaching consultations, doctors promoted a level of participation that realized patients' and students' mutual sense of responsibility by orientating them to one another, creating conditions for them to interact, promoting and regulating discourse, helping students to perform practical tasks and debriefing them afterwards. Those broad conclusions translate into 18 practical recommendations for supervising a medical student in an outpatient clinic or surgery.

Objective: This study aimed to explore the effect of gender on medical students' aspirations., Methods: The study design included purposive sampling and interim data interpretation to guide recruitment of medical students with a wide spectrum of opinions. Data were collected through audio-recorded, semi-structured, in-depth exploratory interviews, which were transcribed verbatim. Qualitative analysis was carried out by a female medical student researcher. Her evolving interpretation was constantly compared against the original data by male (doctor) and female (pharmacist) staff researchers in a systematic search for internal corroboration or disconfirmation. Causal associations consistently present in the data are reported., Results: Six male and six female medical students in Years 3 and 4 shared a wish to achieve a work-life balance that allowed them to devote time to bringing up children while contributing usefully to society as doctors. However, women were readier to compromise professional attainment within their personal work-life balances. Their readiness derived from gendered stereotypes of women's social and professional roles, a lack of female professional role models, womens' greater awareness of the tensions between career and family, various other informal social influences, and a lack of positive career advice to counterbalance these influences., Conclusions: Better career advice and more flexible work opportunities are needed if the two-thirds of medical students who are women are to contribute specialist as well as generalist expertise to the medical workforce.

Objective: To develop a model linking the processes and outcomes of workplace learning., Methods: We synthesised a model from grounded theory analysis of group discussions before and after experimental strengthening of medical students' workplace learning. The research was conducted within a problem-based clinical curriculum with little early workplace experience, involving 24 junior and 12 senior medical students., Results: To reach their ultimate goal of helping patients, medical students must develop 2 qualities. One is practical competence; the other is a state of mind that includes confidence, motivation and a sense of professional identity. These 2 qualities reinforce one another. The core process of clinical workplace learning involves 'participation in practice', which evolves along a spectrum from passive observation to performance. Practitioners help students participate by being both supportive and challenging. The presentation of clear learning objectives and continuous periods of attachment that are as personal to the student(s) and practitioner(s) as possible promote workplace learning., Conclusions: The core condition for clinical workplace learning is 'supported participation', the various outcomes of which are mutually reinforcing and also reinforce students' ability to participate in further practice. This synthesis has 2 important implications for contemporary medical education: any reduction in medical students' participation in clinical practice that results from the patient safety agenda and expanded numbers of medical students is likely to have an adverse effect on learning, and the construct of 'self-directed learning', which our respondents too often found synonymous with 'lack of support', should be applied with very great caution to medical students' learning in clinical workplaces.

Aim: To examine how students' evaluations of the environment, process and outcome of clinical learning interrelated and correlated with assessment results., Method: A post hoc study in the 3rd of 5 years in a student-centred, horizontally integrated, objective-based medical curriculum. In the last week of each module, students evaluated what they had learned and how they had learned it using a previously validated, web-based scale. The interrelationships between scale variables and their relationships with summative assessment results were tested using factor analysis, correlation analysis and stepwise multiple regression analysis., Results: Student evaluation yielded 4 summary measures: 2 reflected learning outcomes ('real patient learning' and 'curriculum coverage'), 1 reflected process ('quality of instruction') and 1 reflected environment ('conditions for learning'). They fitted a causal model according to which instruction, conditions for learning and curriculum coverage favoured real patient learning. Real patient learning was rated higher in women than men, and the measures were associated more strongly in women. Performance in end-of-year summative assessments was predicted strongly by mid-year performance but by no other measure., Conclusions: Students' evaluations of their learning environment and instructional processes correlated with their assessments of 2 outcomes of the curriculum in action: curriculum coverage and real patient learning. There was little shared variance between those measures and students' performance in summative assessments. Given its formative potential, students' evaluation of their curriculum in action could play a useful part in learner-centred clinical education. There is a possibility, which needs further research, that women's evaluations have greater predictive validity than men's. Assessment performance should be regarded not as a solitary gold standard but as just 1 measure of educational outcome.

Objectives: To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence., Design: A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001., Data Sources: Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration., Selection of Studies: All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication., Results: Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations., Conclusion: Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Aim: This study aimed to establish whether and under what conditions medical students can learn in a self-directed manner in the clinical environment., Method: A web-based learning management system brought 66 placement students, in a problem-based learning (PBL) medical curriculum, into closer touch with their clinical learning objectives and ways of achieving them. Free response comments from 16 of them during the 7 weeks they used it, transcripts of group discussions before and after the period of use, and responses from all 66 students to a questionnaire were analysed qualitatively., Results: Students were rarely fully autonomous or subservient. They valued affective and pedagogic support, and relied on teachers to manage their learning environment. With support, they were motivated and able to choose how and when to meet their learning needs. The new system was a useful adjunct., Conclusions: Self-direction, interpreted literally, was a method of learning that students defaulted to when support and guidance were lacking. They found "supported participation" more valuable. Learning in the clinical environment was a social process with as many differences from, as similarities to, PBL.

Objective: To provide a rationale for integrating experience into early medical education ("early experience")., Design: Small group discussions to obtain stakeholders' views. Grounded theory analysis with respondent, internal, and external validation., Setting: Problem based, undergraduate medical curriculum that is not vertically integrated., Participants: A purposive sample of 64 students, staff, and curriculum leaders from three university medical schools in the United Kingdom., Results: Without early experience, the curriculum was socially isolating and divorced from clinical practice. The abruptness of students' transition to the clinical environment in year 3 generated positive and negative emotions. The rationale for early experience would be to ease the transition; orientate the curriculum towards the social context of practice; make students more confident to approach patients; motivate them; increase their awareness of themselves and others; strengthen, deepen, and contextualise their theoretical knowledge; teach intellectual skills; strengthen learning of behavioural and social sciences; and teach them about the role of health professionals., Conclusion: A rationale for early experience would be to strengthen and deepen cognitively, broaden affectively, contextualise, and integrate medical education. This is partly a process of professional socialisation that should start earlier to avoid an abrupt transition. "Experience" can be defined as "authentic human contact in a social or clinical context that enhances learning of health, illness or disease, and the role of the health professional."

Aim To help students in a self-directed, problem-based learning (PBL) curriculum learn from a breadth of hospital experience. Methods Clinical units were asked to identify what clinical activities they could make available to interested students on a ‘first-come, first-served’ basis. A centralised, electronic system was developed that allowed students to book a fair, but not excessive, share of those learning opportunities. This web-based programme evolved into a comprehensive timetabling system that managed activities for whole classes of students as well as ‘sign-ups’ booked by individuals. Results The sign-up system offered 1792 hours/week, or 6 hours/student/week, to the hospital's 291 students of learning opportunities additional to firm-based teaching and learning. There were sign-ups in all major specialties and they included rounds, clinics, theatre/investigation sessions and conferences. Students accessed the system as commonly from outside the hospital as within it, and used it to view their timetables as well as to book learning opportunities. The system was used particularly heavily when examinations were imminent, indicating that students found it supportive to their learning. Conclusions We have developed an innovative way of providing experience that is relevant to problem-based, integrative clinical education. Students, as judged by their heavy use of it, value the system. [ABSTRACT FROM AUTHOR]