The role of emergency medicine clerkship e-Portfolio to monitor the learning experience of students in different settings: a prospective cohort study

Emergency departments (EDs) provide rich clinical learning opportunities to medical students [1]. They increase confidence in both acute care and procedural skills [2]. Nevertheless, their exposure to recommended curriculum presentations and procedures are limited [3‐6]. In addition, their involvement level with clinical presentations and procedures varies [7]. Alignment of curriculum content, learning outcomes, teaching and learning activities, and assessments is critically important in reaching desired outcomes. Given this perspective, clinical environments providing learning opportunities for students should be monitored to determine if they meet expectations and are fit for purpose. Exposures including quantity and severity differ between various settings. Without understanding student exposure to presentations and procedures in the clinical environment, we cannot assure that they receive proper training in the clerkships [5], neither can we modify the curriculum to fit their needs.

Clinical logbooks document medical student clinical exposures and improve student performance of procedures [8, 9]. Timely student learning exposure is very important during short clerkships because it can provide feedback to students and guide them to achieve their required presentations and procedures. Hard copy logbooks may not be useful for this purpose. Our previous experience showed that collecting, evaluating, and analyzing logbook data at the end of the clerkship are difficult and not useful for timely feedback [7]. Electronic logbooks overcome many of these obstacles [10]. Proper monitoring and analysis of electronic logbooks can modify teaching and learning activities during the clerkship as well as provide guidance for future modifications of the curriculum.

In this study, we aimed to prospectively analyze student ED exposures and involvement levels in two hospitals during various shifts and units in order to improve curriculum teaching and learning opportunities in our clerkship.

Seventy-six students recorded 5087 chief complaints with more patients seen in Tawam Hospital, 2903 (57.1%). There were slightly more male patients logged by students (52.1%). Table 1 shows the comparison of patient demographics, chief complaints, and student involvement between the two hospitals. The total number of procedure encounters logged by students was 3721 with more procedures performed in Tawam Hospital 1971 (52.9%). Procedures were performed more often on male patients (55.8%). Table 2 shows the comparison of patient demographics, procedures, and student involvement between the two hospitals.

Students were exposed to younger patients in Tawam Hospital (Fig. 1). The distribution of chief complaints, procedures, and student involvement levels were significantly different between the two hospitals (P < 0.0001). There were 2216 (43.6%) encountered chief complaints in the “other” category which was not included in recommended curriculum topics (Appendix 1). Our students logged 2843 (76.4%) of procedures in the category of “other” (Appendix 2). Student involvement with chief complaints and procedures were significantly different between units (Table 3, P < 0.0001). The highest full involvement with presentations was seen in the pediatric unit (67.1%, P < 0.0001). Urgent care shifts demonstrated the highest area of “full involvement” with procedures for our students (73.2%, P < 0.0001). Student involvement with chief complaints and procedures were significantly different between shift times (Table 4, P < 0.0001). Students’ highest involvement with presentations and procedures were found during the night shifts (P < 0.0001, 66.5 and 75.1%, respectively).

Our study has shown that on average, the number of chief complaints and procedures exceeded the minimum required in our curriculum. However, e-Portfolio results showed that our students did not encounter all the recommended presentations and procedures of the curriculum in the clinical environment. The two hospitals showed differences in patient gender, age, chief complaint, procedure distribution, student involvement, and encounters related to shift time and location. Student involvement also varied depending on the location and clinical shift time.

We can enhance the learning experience of students in our curriculum in two ways. First, we can increase the feedback frequency to students regarding their logbook entries and guide them during the clerkship on recommended missing topics and procedures. In fact, this is what we did, individual feedback sessions included details of student logs at the midpoint of the course. Students were reminded about recommended presentations and procedures of the curriculum. In our recently published study, students who used hard copy logbooks encountered 57.8% of presentations in the “other” category [7]. This ratio decreased to 46.7% in the current study. It is possible that e-Portfolio record availability for students and individual feedback sessions using these records helped the students to focus on the recommended topics compared with students who used hard copies and did not have this feedback opportunity during the clerkship.

Second, we can modify teaching and learning activities by timely and focused feedback based on first-hand data and remediable issues will be beneficial for students [14]. Our results gave us a chance to modify our individual feedback sessions on a weekly basis. Students were exposed to a 1-hour case discussion session for each chief complaint and 90-min practical skills session for each procedure in the teaching program. However, they were exposed differently in the hospitals to these topics. As an example, our least encountered topics are cardiac arrest, gastrointestinal bleeding, shock, poisoning, and altered mental status in the chief complaint category and defibrillation/cardioversion, CPR, RUSH protocol, and airway management in the procedure category. It is obvious that the less exposed topics should be reviewed more in the classroom or trained on in the simulation/skills practices. In the classroom, interactive case discussions may connect knowledge with the clinical environment, encourage self-regulated learning, and identifies the gaps in knowledge or skills [15‐17]. Simulation activities improve students’ knowledge, performance, confidence, and satisfaction [18‐20]. Chakravarthy et al.’s systematic review concluded that simulation activities in clerkships are useful although future studies are needed to determine their efficacy [21].

Modifying shift times and locations can also be an option to improve teaching and learning. As an example, we reviewed the chest pain topic on the first day of the clerkship. This complaint was encountered more in Al Ain Hospital (12.0 vs 6.9%) although students have less shifts in this hospital. As a modification, students were given more shifts in this hospital in the first week of the clerkship. Al Ain Hospital has no EM residency program, and the ED is considered a community-based hospital ED. The average patients and procedure in a shift at Al Ain Hospital were more than those at Tawam Hospital. These results supported DeLahunta’s study in which they found that students assess more patients and perform procedures significantly more at a community-based hospital [22]. Furthermore, changing the distribution of shifts from one hospital to another will not affect the final exam results. Bernard reported that clerkship clinical site does not affect final exam score and using community hospitals for clinical teaching does not compromise education [23]. A similar approach can be applied to shift time. It is known that night shifts offer students extra educational opportunities [24]. Our students show significant full involvement during the night shifts. Therefore, increasing night shifts can improve student engagement with patients. However, modifying clinical schedules to improve performance requires higher and multi-level analysis and programming [25].

The electronic portfolio has proven to be a very useful tool in defining the learning activities of final year medical students during their emergency medicine clerkship and in comparing activities in two different clinical settings. Data collected and analyzed using this e-Portfolio has the potential to help medical educators and curriculum designers improve EM teaching and learning activities.