Experiences of medical students and faculty regarding the use of long case as a formative assessment method at a tertiary care teaching hospital in a low resource setting: a qualitative study | BMC Medical Education

Socio-demographics

A total of 36 medical students participated in the FGDs, comprising 18 junior clerks and 19 senior clerks. The participants were aged between 21 and 25 years except two participants who were aged above 25 (30 and 36 years old). Among the third-year students, there were 10 male and 9 female participants while the fifth-year student comprised of 8 male and 10 female participants.

Five lecturers participated in the Key Informant Interviews, three of whom were females and two male participants. They were aged between 40 and 50 years, and all had over 10 years of experience with the long case. The faculty members included one consultant physician, one associate professor, two senior lecturers, and one lecturer.

Themes that emerged

Three themes emerged from the study: ward placement, case presentations, and case assessment and feedback.

Theme 1: Ward placement

The study findings disclosed that medical students are assigned to specific wards for the duration of their clerkship. The specialization of medical wards was found to significantly restrict students’ exposure to limited disease conditions found only in their allocated ward.

With the super-specialization of the units, there is some bias on what they do learn; if a particular group is rotating on the cardiology unit, they will obviously have a bias to learn the history and physical exam related to cardiovascular disease (KII 1).

The students, particularly junior clerks, expressed dissatisfaction with the lack of proper and standardized orientation to the long case on the wards. This deficiency led to wastage of time and a feeling of being unwelcome in the clerkship.

Some orient you when you reach the ward but others you reach and you are supposed to pick up on your own. I expect orientation, then taking data from us, what they expect us to do, and what we expect from them, taking us through the clerkship sessions (FGD 4 Participant 1).

Students’ exposure to cases in other wards poses significant challenges; the study found that as some lecturers facilitate visits to different wards for scheduled teaching sessions, others don’t, resulting in missed learning opportunities. Additionally, some lecturers leave the burden on students’ personal initiative to explore cases in other wards.

We actually encourage them to go through the different specialties because when you are faced with a patient, you will not have to choose which one to see and not to see (KII 4).

Imagine landing on a stroke patient when you have been in the infectious disease ward or getting a patient with renal condition when you have been in the endocrinology ward can create problems (FGD 6 Participant 3).

Theme 2 Case presentation

Medical students present their long case to lecturers and postgraduate students. However, participants revealed variations among lecturers regarding their preferences on how they want students to present their cases. While some prefer to listen to the entire history and examination, others prefer only a summary, and some prefer starting from the diagnosis.

The practice varies depending on the lecturer, as everyone does it their own way. There are some, who listen to your history, examination, and diagnosis, and then they go into basic discussion of the case; others want only a summary. Some lecturers come and tell you to start straight away from your diagnosis, and then they start treating you backward (FGD 6 Participant 3).

The students reported limited observation of their skills due a little emphasis placed by examiners on physical examination techniques, as well as not providing the students with the opportunity to propose treatment plans.

When we are doing these physical examinations on the ward no one is seeing you. You present your physical examination findings, but no one saw how you did it. You may think you are doing the right thing during the ward rotations, but actually your skills are bad (FGD 4 Participant 6).

They don’t give us time to propose management plans. The only time they ask for how you manage a patient is during the summative long case, yet during the ward rotation, they were not giving us the freedom to give our opinion on how we would manage the patient.(FGD 2Participant 6).

Supervision was reportedly dependent on the ward to which the student was allocated. Additionally, the participants believe that the large student-to-lecturer ratio negatively affects the opportunity to present.

My experience was different in years three and five. In year three, we had a specialist every day on the ward, but in year five, we would have a specialist every other day, sometimes even once a week. When I compare year five with year three, I think I was even a better doctor in year three than right now (FGD 1 Participant 1).

Clinical training is like nurturing somebody to behave or conduct themselves in a certain way. Therefore, if the numbers are large, the impacts per person decrease, and the quality decreases (KII 5).

Theme C: Case assessment and feedback

The study found that a student’s long case is assessed both during the case presentation on the ward and through the case write-up, with marks awarded accordingly.

They present to the supervisor and then also write it up, so at a later time you also mark the sheet where they have written up the cases; so they are assessed at presentation and write up (KII 2).

The mark awarded was reportedly a significant motivator for students to visit wards and clerk patients, but students also believe that the pressure to hunt for marks tends to override the goal of the formative assessment.

Your goal there is to learn, but most of us go with the goal of getting signatures; signature-based learning. The learning, you realize probably comes on later if you have the individual morale to go and learn (FGD 1 participant 1).

Feedback is an integral part of any formative assessment. While students receive feedback from lecturers, the participants were concerned about the absence of a formal channel for soliciting feedback from students.

Of course, teachers provide feedback to students because it is a normal part of teaching. However, it is not a common routine to solicit feedback about how teaching has gone. So maybe that is something that needs to be improved so that we know if we have been effective teachers (KII 3).

Whereas the feedback intrigues students to read more to compensate for their knowledge gap, they decried several encounters with demeaning, intimidating, insulting, demotivating, and embarrassing feedback from assessors.

Since we are given a specific target of case presentation we are supposed to make in my training, if I make the ten, I wouldn’t want to present again. Why would I receive other negative comments for nothing? They truly have a personality effect on the student, and students feel low self-esteem (FGD 1, Participant 4).