Medical student education
I use a piece of my own research, a realist synthesis [
12] of how medical students learn in workplaces [
13], to show how Dutch publications have contributed to the scholarship of workplace learning. Our team, which includes two Dutch researchers, six others, and myself identified papers published between 2000 and 2006 that form an evidence-base of how medical students learn in workplaces. Forty-seven percent of the 168 papers originated from the USA, 19% from Britain, 11% from mainland Europe and the Nordic countries, 7% from Canada, 9% from Australia or New Zealand, and 7% from other parts of the world. Looking more closely at the Dutch contribution, 14 papers (8%) were conducted solely in the Netherlands or Belgium, or had Dutch institutions as collaborators. After excluding the four papers of my own which were co-published with Maastricht University but conducted on British soil, 10 Dutch contributions remained [
14‐
23]. Fieldwork was done at the VU University, Amsterdam in four studies [
15,
17,
18], at Maastricht University in three studies [
16,
19,
20], and at the Erasmus University, Rotterdam [
21], Catholic University of Leuven [
22], and the University of Antwerp [
14] (one study each). Eight studies concerned clerkship learning [
14‐
18,
21‐
23], one concerned the transition to clerkship [
20], and one reported a longitudinal experience in primary care during the early curriculum years [
19]. Five of the clerkship studies were purely observational and three had an element of intervention [
18,
19,
23]. Nine were purely qualitative or used mixed methods whilst one used structural equations modelling to analyze numerical data [
21].
The findings of the Dutch studies were quite consistent with one another and similar to findings in other countries. The two main determinants of learning during clerkships were the quality of supervision and casemix [
16,
21]. Better supervision could influence and compensate for limited casemix [
21]. Supervision directly enhanced academic performance [
21]. Feedback was most effective when given by someone who knew the student and whom the student knew [
17]. Sympathetic and warm feedback had important positive effects on students’ emotions and harsh or absent feedback had negative effects [
17,
20]. Learning environments that were more orientated towards education (rather than pure service provision) were motivating, whereas learning environments in which education was not a priority left students feeling abandoned [
22]. Students did not always receive high-quality supervision and feedback [
15,
17,
18,
20]. When given, feedback was not always based on observation of their performance [
17]. The ‘learning by trial and error’ [
15] that resulted left students in doubt about their proficiency and whether they were attaining curriculum objectives. Being given clear learning outcomes [
19] and being coached in clinical skills [
14] helped students learn. The three studies that had an interventional component are very informative in that the interventions made little difference. The introduction of an in-training assessment scheme had little, if any, effect on supervision and feedback because residents were unclear about their roles and students were reluctant to reveal their weaknesses to their assessors [
23]. Attempts to improve the quality of supervision and feedback in a surgical clerkship had a limited impact on students’ hit and miss exposure to relevant casemix and the supervisory support to their learning [
17,
18].
The fieldwork on which the findings in the previous paragraph are based is now somewhat out of date so they may not reflect what is happening on the ground today. I suspect, however, they do. Changing the ‘tea-steeping’ model (blocks of experiential learning by immersion within functioning clinical units) to a more outcome-focused, structured, instructed, and supervised model means overcoming a lot of inertia, as discussed in Cooke and colleagues’ Flexner centenary monograph [
24]. Likewise, a recent review concluded that constructive feedback based on personal knowledge of students is generally absent in workplaces [
25]. So, the findings of our review ring true despite their age.
I have looked for Dutch lines of inquiry into undergraduate medical education since 2006. My (doubtless incomplete) scan identified several. One, conducted in general practice, explored the consequences of placing learners in supportive environments [
26,
27]. It is well established that two important dimensions of workplace instructional quality are high-quality supervision and access to appropriate patients. Promotion of independence, this research showed, is an important third dimension. High-quality supervision helps students learn independently from the casemix they have access to [
27]. The same authors explored medical students’ learning in primary care from a sociocultural perspective and found that students form their professional identities within a private ‘developmental space’ under the combined influence of their workplace context, personal interactions, and professional ones [
26].
Contemporary research into communication education again shows inertia. Communication skills training—mostly provided in the pre-clerkship years—aims to equip students with tools for patient-centred practice. Bombeke et al. [
28] found exposure to hospital environments in the clerkship years counteracted patient-centred orientations developed in the earlier years. Lack of student self-efficacy, pressures of working environments and negative role models contributed to this decline of patient-centredness. A lack of patient-centred, self-caring, and self-aware role models in clerkship learning environments, their research suggests, may be responsible. The findings of a second study by the same researchers, which compared students who had received communication skills training with students who had not, were really rather alarming [
29]. Students trained in communication skills showed a greater decline in patient-centredness during clerkships than students who had not been trained in communication skills. Communication skills training, the study suggested, may accentuate the clash between student idealism and workplace reality, which led to a decline in patient-centredness. Contemporary medical practice, it seems, is not patient-centred enough to serve as an educational model. One wonders, then, how it will ever be possible to make doctors more patient-centred. The study certainly suggests that communication skills education confined to the early curriculum years will not do the trick.
A third cluster of recent studies, from Groningen, concerned transition from pre-clerkship to clerkship education [
30], the influence of learning environments, [
31,
32] and how students learned within them [
33,
34]. van Hell et al. [
31,
32] found that feedback was most valued by students when it came from a doctor rather than an allied professional, was based on direct observation of their behaviour, and/or was initiated by themselves. Students’ ratings of the value of learning environments were higher when they spent more time in them and were more active participants [
32]. Clerkship students used diverse learning strategies [
33] and were motivated by comparing themselves with higher performing members of their peer group [
34].
Residency
I recently searched the international literature for empirical research into how residents learn. Remarkably little has been published. I judged two lines of enquiry to be particularly informative. Both were qualitative and both were Dutch [
35,
36]. Residents’ learning, according to those papers, always starts from experiences encountered in the course of clinical work [
35,
37], although the sheer pressure of clinical workload can easily reduce the value of workplace learning [
36]. So, residents’ most important learning is ‘informal’ [
36], as has been shown in other professions [
38]. One of those two studies [
36] was into how residents learn from deliberate practice while the other [
35] explored how residents gave personal meaning to their workplace experiences, supported by their supervisors [
37]. Teunissen et al. continued their research into personal meaning with two further studies. One was an experiment, which showed how ‘priming’ junior residents with an extraneous line of thought influenced their germane thinking about clinical problems [
39]. This experiment supported their theory that residents’ interpretations of workplace experiences are influenced by personal knowledge and showed that extraneous factors have a stronger influence in junior than senior residents [
39]. A second study by the same group evaluated two ‘dispositions’ of trainees and how they related to one another: One was being disposed to learn versus being disposed to make a good impression on others. The other disposition was towards seeking or not seeking feedback, given its perceived benefits and costs to the resident. The paper makes two important points: One is that residents are not passive recipients of feedback; feedback is an active discourse between supervisor and supervisee. The second point is that specialists’ style of giving feedback influences residents’ learning. Supportive specialists give feedback in a way that helps residents perceive more benefits and fewer costs [
40].
Returning to my international review of research into how residents learn, one of the four remaining papers—which contributed consensus data about important factors in workplace learning environments—was Dutch [
41]. The remaining three non-Dutch papers examined factors that influence residents’ participatory learning [
42], the exchange of tacit knowledge between anaesthesiologists [
43], and tensions between patient care and learning [
44].