Outpatient education, a momentous in clinical education: a qualitative study of medical students’, faculty members’, and residents’ perspectives | BMC Medical Education

Out of 21 participants, seven were faculty members, nine were medical students, and the remaining were residents. The experiences and perceptions of participants were extracted and analyzed. Based on the results of the analysis, 14 categories were extracted within four main themes after coding and comparing the codes based on similarities and differences: “preparation for outpatient education” (Table 2), “outpatient education implementation requirements” (Table 3), “challenges of outpatient education,” and “facilitators of outpatient education.”

Theme 1. preparation for outpatient education

The theme “preparation for outpatient education” refers to what should be considered and what preliminary planning should be done before implementing an outpatient education program. Based on the participants’ experiences, this concept pertains to the four basic components: physical space and equipment, prerequisites related to the curriculum, teaching skills, and near-peer clinical teachers (Table 2).

Physical space and equipment

This indicates that in designing a successful educational clinic, we should pay attention to the number of rooms, the connection of rooms, the quantity and quality of examination equipment, the number of examination beds and chairs.

“It seems that three rooms are necessary for each clinic; a clinic that is large or includes several departments has enough space for students to move between the rooms, see examinations, and even rest.” [S7].

Prerequisites related to the curriculum

Before implementing a curriculum, it is important to consider several factors based on the participant’s experiences to organize the program efficiently. These factors, as subcategories, are listed below.

Elective programs

The clinical elective course can be a valuable, highly regarded experience with benefits in providing better learning and academic success and gaining clear insight into their future postgraduate specialty. According to interviewee perceptions, some specialized and sub-specialized clinics can be considered locations for elective programs.

“It happened to me that I went to the ophthalmology clinic and saw the patients next to the teacher, and I thought this field was very interesting, but because my attendance was optional, not mandatory.” [S1].

Learning objectives and educational content

Learning outcomes and expected skills must be defined to devise a program that makes the most of the learning opportunities for the students. According to the participants’ perceptions, student learning opportunities in outpatient clinics usually focus on history-taking, physical examination, pharmacology, drug prescription, clinical approach, interpretation of paraclinical data, counseling the patient’s family, patient education, and professionalism.

“The faculties insist, and it is true in my opinion, that the student takes a history first; usually, the students do a clinical examination after the history taking.” [R2].

“In my opinion, drug prescription is very important. Because, when we graduate, we must prescribe these drugs ourselves. In the clinic, the teacher’s approach to the patient is very important. That is, how does he diagnose, how does he manage, and how does he follow up?” [S3].

Besides, learning objectives should genuinely prepare students for the demands of professional practice.

“In fact, I do a needs assessment based on what skills my students will need when they become a doctor.” [F3].

Instructional strategies

A program needs to have an efficient and dynamic set of teaching tools to be effective. According to the experiences of participants, a variety of strategies can be applied: a brief overview of the disease shortly before the patient enters, structured observation, active and gradual student participation, content delivery from simple to complex, consideration of differences in the knowledge level of learners, supervision and feedback, practical teaching, lecturing, conferences, and debriefing.

“Always, in the clinic, before a patient comes in, I talk to the students about that patient for 5–10 min and overview the disease.” [F4].

“In my teaching sessions, I first determine my audience. If they are students, interns, residents, or fellows, I tailor my goals, vision, and educational content accordingly.” [F5].

“Sometimes, teachers provide us with conferences that feature common clinical cases.” [S2].

“We review the patient’s history with the teacher, who provides additional explanations as needed. I keep track of feedback to address any issues.” [S3].

Supplementary resources

Experience has shown that readily available additional resources or instructional aids can be used to enhance learning. These resources, based on interviewees’ experiences, include a summary of the cases of that day, laboratory reports and radiographs of patients, and internet-based resources.

“As part of our course, I instruct students to access dermatology atlases online.” [F2].

Patient as an educational case

Learning in clinical settings heavily relies on patients as a valuable resource. Participants believed that an ideal volume of patient encounters, pertinent to learning objectives and expected qualifications of a doctor, is important.

“During the week, if I have patients suitable for learning, I postpone their appointments to a day when my clinic is educational.” [F1].

“In the tumor clinic, only tumor cases are visited, and if I, as a GP, am going to see a few tumor patients, this does not truly help me.” [S9].

“In clinic A, the number of admitted patients was low, and we could easily communicate with the patient and receive training.” [S2].

The appropriateness of the number of patients compared to the number of students in a clinic was also highlighted.

“In a certain clinic, the number of interns and students was small, allowing us to examine each patient for at least 20 min.” [S4].

Organizing student, patient, and faculty communication models

A variety of different models for organizing student, patient, and teacher interactions in outpatient clinics have been described, according to the participants.

“I use different models. Sometimes, we visit the patient together, and the student observes. Sometimes, the students visit the patient alone, and then they present the important points of the patient to me.” [F1].

Teaching skills development

To achieve competence in teaching, faculty members must acquire knowledge and skills in educational principles. Participants’ experiences reflected the view that the teaching competencies of faculty members can be achieved through their experience over time or through formal teacher training programs.

“A teacher gains appropriate experiences over time, which improve his/her teaching skills.” [F7].

“Training can help faculty members be better teachers.” [F4].

Near-peer clinical teachers

It is known that residents play an important role in teaching undergraduate medical students, and based on the experiences of most participants, the resident performs his/her teaching role better if this role is defined as a duty and commitment in the educational system.

“If residents understand their teaching roles from the beginning and take responsibility for educating, it will improve our education.” [S3].

Theme 2. outpatient education implementation requirements

Based on the participants’ experiences, the concepts of implementation requirements refer to the three basic components. The first two relate to the students’ and faculty’s commitment to planning, and the last is program supervision (Table 3).

Student dimension

Actions related to students must be taken while present in the clinic for effective learning. This includes familiarization and assessment.

Students’ familiarization

According to the participants’ statements, a briefing session on the initial day of each clinic is indispensable.

“From the very first day of the course, our teachers informed us about the topics that would be taught, the conferences that would be held, and the presenters who would be delivering the lectures. This helped us immensely.” [S5].

Students’ readiness for apprenticeships or internships was affected by how clearly their duties and expectations were outlined.

“What I wanted to say is that it should be clear what they want from me, that is, when I come in the morning, I should know what I should do to be in the norm and what I should not do. Well, this increases productivity, in my opinion.” [S1].

Students’ assessment

According to participants’ experiences, a continuous assessment of students’ clinical skills is important for switching from a static to a dynamic education.

“On-the-spot assessment can be more effective than evaluation at the end of a three-month internship. The teacher may not even remember who I was or what I did. In any case, I went to the clinic today and spent 2 or 3 h there, so how I performed should be considered.” [S6].

Faculty’s commitment to planning

Based on participants’ statements, it refers to allocating enough time to teaching and the teacher’s management skills.

“Some teachers extended the training period to work with fewer patients, leading to more detailed examinations and benefiting both the patient and our learning.” [S7].

“A faculty member in a clinic is not just a teacher but must manage her environment; for example, he or she should make sure that the clinic is not crowded, patients are visited on time, students are satisfied, have a scheduling secretary, and no one is late.” [F2].

Program supervision

A list of supervisory considerations must be considered to minimize errors and resolve problems. These include teacher performance, student attendance, and patient quantity and quality.

“In terms of the educational system, there should be a difference between a teacher who spends time teaching students and a teacher who does not.” [S4].

“Sometimes, the student would leave the clinic or not participate without anyone noticing. This is not acceptable.” [S8].

“Of course, it is necessary to give feedback to the teacher about his performance…” [F4].

“Someone, somewhere, must specify that a clinic supposed to be educational only accepts up to 10 patients[S3].

Theme 3. challenges of outpatient education

It refers to barriers that interfere with valuable and effective education in clinics. This theme can be described in five related categories, including curriculum implementation challenges, student challenges, faculty challenges, system-related challenges, and patient-related challenges.

Curriculum implementation challenges

It refers to factors affecting curriculum delivery. Inappropriate implementation of near-peer clinical teaching was identified as one of the program’s challenges. Participants defined turbulence as incompatible integration of trainees, lack of resident commitment to teaching due to lack of sleep and long shifts, and lack of knowledge and self-confidence to teach students.

“When residents and fellows are present in the clinic simultaneously as students, we do not receive any teaching. The cases suitable for residents or fellows are boring for students.” [S8].

“A resident is a person who hasn’t slept for 48 h, hasn’t drunk a drop of water, hasn’t eaten, and has been struggling for the past 12 h. How can such a person be expected to teach.” [S2].

“My experience is that I should not trust what the resident says. I don’t know how much they read from reference books and how much is based on experience; their working time is long and, they don’t have time to update their knowledge.” [S5].

One of the problems with designing and implementing the educational tool was the lack of involvement from all stakeholders, as well as the logbook being reduced to just a tool for roll calls.

“We did not use a log book. On the last day of the rotation, we would go to one of the residents, get his stamp, and stamp all the activities, of course, if there was a log book.” [S9].

“In most departments, only one person creates the logbooks by copying and pasting from other sources.” [F3].

Reducing students’ educational duties to the level of secretarial work, prioritizing the health system over education, and the small share of outpatient education in total clinical education were other stated challenges emphasized by most participants.

“We and sometimes residents are responsible for filling out forms and recording documentation without prior guidance.” [S7].

“There were many times when I felt like the teacher was assigning us menial tasks instead of teaching.” [R2].

“According to one of our clinical teachers, our top priority should be the health system and patient care. If time allows, we can also focus on medical education, which is secondary to our primary goal.” [S4].

“Our clinical education mostly takes place in the hospital, with very limited outpatient education opportunities.” [S1].

Several students also mentioned patients with specialized conditions as a noteworthy challenge.

Student challenges

It refers to problems that students struggle with. One of the most critical obstacles raised by the participants in this category was related to unsystematic and irregular student assessment. These unsatisfactory experiences include lack of a plan or objective criteria for student assessment.

“Outpatient education lacks a specific assessment program. Students are typically evaluated at the end of each department rotation.” [F3].

“They only tell us that we will give you a score out of 20. It is not clear on what basis they give this score.” [S6].

In turn, student assessment has been limited to students’ attendance.

“During an evaluation, the clinic secretary asks attendees to raise their hands. This becomes their score at the end of the course.” [S9].

The incongruity of the student assessment method with the educational program or content was another challenge stated by participants.

“Most of our assessments are only theoretical, even though the internship training is practical, but they take a multiple-choice exam, with questions more related to teaching in the inpatient ward than in the clinic.” [S5].

The students were unhappy that the resident assessed them without being involved in their teaching.

“The score of the students’ exams is often in the hands of the residents, while the residents do not teach. Some students try to maintain their relationship with the resident to get a better score.” [S2].

Other issues, such as lack of awareness of learning objectives, lengthy clinic duration, student fatigue, and neglect of student welfare, were declared along with the challenges of student assessment.

“During the teaching session, we must be on our feet; we don’t have time to drink water or go to the bathroom. In terms of comfort, I would like to point out one simple thing: the presence of a chair. We must stand for at least three hours. In such cases, we do not pay attention to the learning. In the last clinic I went to, we were on our feet for four and a half hours; I could not feel my legs, and it did not have a learning aspect.” [S6].

Eventually, the students complained about feeling invisible in clinics and uncertain about their future job prospects.

Faculty challenges

The presence of supportive teachers can significantly improve trainees’ experiences in the clinic. However, outpatient clinician-educators face several challenges.

The diversity and multiplicity of the roles of academic staff, a lack of motivation (inadequate financial and spiritual incentives), and a lack of commitment to teaching were issues stated by all three participant groups.

“A faculty member is expected to be a therapist, teacher, publisher, administrator, and make economic demands. This workload can reduce their motivation and make them feel like robots.” [S4].

Scant knowledge and skills and inadequate or low-quality teacher training programs in outpatient teaching were other challenges.

“Many teachers taught us based on their experiences as students, and they did not know how to teach in a clinic.” [S7].

“Faculty development programs are often in the form of lectures and are not taught very practically.” [F7].

Based on some students’ views, little knowledge or not up-to-date or evidence-based knowledge of faculties in the specialized and professional field of medicine was a serious issue.

“We felt that the teacher was not scientifically up-to-date, which was why he did not answer our question.” [S9].

A lack of feedback and supervision on student performance was also highlighted.

“We were taking the patient’s medical history, but the teacher was not paying attention. I may have made some errors in my history taking, and there was no one to provide feedback or guidance on improving.” [S1].

Another challenge was the lack of skills to communicate safely and without anxiety with students and residents.

“In certain fields, teachers humiliate residents and interns to the point where they cannot sleep due to fear.” [S6].

System-related challenges

Institutional policies fail to support outpatient education due to a lack of resources, incentives, and evaluation criteria for clinician educators.

“The university (system) looks at students and us as cheap labor; practically, the burden of the system (hospital) is on our shoulders. If we want to go to the clinic to be taught, then who will do the work of the hospital?” [R5].

“When the research activities of a faculty member are evaluated, an h-index is used. His/her therapeutic activities are based on the number of patients visited, operations performed, etc., so how are his teaching activities measured? or where are they included at all?” [S3].

Patient-related challenges

In this category, we describe two main issues related to patients as one of the main components of clinical education that can pose challenges. One of them is the difficulty of respecting the patient’s privacy.

“In the clinic, there are typically ten students for every patient. It can be difficult for a patient to discuss personal problems, such as a perirectal abscess.” [S1].

The other challenges are the excessive number of patients and their specialized conditions in most clinics.

“One day, 80 patients were visited in a clinic within 5 h; we could not see or hear anything anymore.” [S8].

“In the tumor clinic, only tumor cases are visited, and if I, as a GP, am going to see a few tumor patients, this does not really help me.” [S9].

Theme 4. facilitators of outpatient education

Two categories emerged regarding facilitators of outpatient education: internal and external facilitators. It refers to factors that can facilitate learning and teaching in outpatient education, improve effectiveness, and be associated with greater student and faculty satisfaction.

Internal facilitators

The internal factors affecting outpatient education refer to the subjective preferences, contentment, and pleasure experienced by an individual. Individuals acquire or impart knowledge without expecting rewards such as grades or commendations. In expressing the participants’ experience, students’ personal interest in learning was one of the issues that emerged.

“My motivation to learn, even if the teacher isn’t willing to teach, drives me towards becoming a good doctor.” [S4].

“In my opinion, a significant aspect of teaching is personal; a teacher must possess an intrinsic concern for education. Teachers devote enough time based on their conscience and personality.” [S3].

Faculty members’ positive personality traits, such as compassion, friendliness, and humor, in their relationships with students and patients are among three factors that are related.

“The teacher had a very intimate and warm relationship with the patient and us; he joked, which made us more interested and involved in the issues.” [S1].

“She taught and listened not only to student criticisms and suggestions, but also to their stories, which greatly aided learning.” [R3].

The faculty’s personal interest in teaching and desire for self-improvement were other components.

“I believe the teaching profession should only be pursued by those with a positive attitude towards education. Otherwise, the prevailing mindset is to prioritize healthcare and treatment.” [F6].

External facilitators

Participants in the current study identified external factors affecting outpatient education, including faculty salary support, clinician educator job promotion, bonuses, teacher training programs, and accommodations for patient volume.

“Part of the difference in the quality of teachers’ teaching is related to the system. I mean, the amount of support the system gives to the faculty influences his or her quality of performance.” [R5].

“Schools must manage the teacher’s teaching time in such a way that the financial loss of the teacher is compensated, for example, to give a special privilege to teaching, either financially or professionally.” [F2].