Education for Health

GENERAL ARTICLE
Year
: 2014  |  Volume : 27  |  Issue : 1  |  Page : 47--50

Community-based medical education: Is success a result of meaningful personal learning experiences?


Len Kelly1, Lucie Walters2, David Rosenthal3,  
1 Professor, Division of Clinical Sciences, Northern Ontario School of Medicine, Sioux Lookout, ON, Canada
2 Associate Professor, Academic Director, Flinders University Rural Clinical School, Adelaide, South Australia
3 Senior Lecturer and Assessment Coordinator, Flinders University Rural Clinical School, Adelaide, South Australia

Correspondence Address:
Prof. Len Kelly
Division of Clinical Sciences, Northern Ontario School of Medicine, Sioux Lookout, ON
Canada

Abstract

Background: Community-based medical education (CBME) is the delivery of medical education in a specific social context. Learners become a part of social and medical communities where their learning occurs. Longitudinal integrated clerkships (LICs) are year-long community-based placements where the curriculum and clinical experience is typically delivered by primary care physicians. These programs have proven to be robust learning environments, where learners develop strong communication skills and excellent clinical reasoning. To date, no learning model has been offered to describe CBME. Methods: The characteristics of CBME are explored by the authors who suggest that the social and professional context provided in small communities enhances medical education. The authors postulate that meaningfulness is engendered by the authentic context, which develops over time. These relationships with preceptors, patients and the community provide meaningfulness, which in turn enhances learning. Results and Discussion: The authors develop a novel learning model. They propose that the context-rich environment of CBME allows for meaningful relationships and experiences for students and that such meaningfulness enhances learning.



How to cite this article:
Kelly L, Walters L, Rosenthal D. Community-based medical education: Is success a result of meaningful personal learning experiences?.Educ Health 2014;27:47-50


How to cite this URL:
Kelly L, Walters L, Rosenthal D. Community-based medical education: Is success a result of meaningful personal learning experiences?. Educ Health [serial online] 2014 [cited 2020 Oct 20 ];27:47-50
Available from: https://www.educationforhealth.net/text.asp?2014/27/1/47/134311


Full Text

 Background



Community-based medical education

Community-based medical education (CBME) refers to medical education, which situates the learner's clinical training in a community setting. It exposes students to patients who are managing their illnesses within their own family, social and community contexts. [1],[2],[3],[4] Primary care clinicians and other healthcare providers accept learners into their practice, professional community and local community, where they take on the role of delivering much of the curriculum and precepting learners. Essentially, learning occurs in the community. [3] Such programs typically include having the student follow the patient from office setting into hospital care and back home to community-based homecare. [5]

To date no learning model has been proposed to explain the level of success achieved by CBME initiatives. Developing a learning model to explain successful education programs for healthcare professionals seems like an afterthought. These programs are expanding internationally, and greater thoughtfulness around why this decentralized form of medical education works may teach us something about how we learn to be physicians. A learning model that identifies key components of a new learning environment can allow us to adapt to it and its challenges, as well as dissect failures when they occur. We may further learn important lessons about medical education, which can be transferred or adapted to new learning environments.

Longitudinal integrated clinical clerkships

One of the recent examples of CBME are longitudinal integrated clerkships (LICs). These year-long clinical placements were pioneered in Australia in the late 1990s. [3],[5],[6] Canada's newest medical school, the Northern Ontario School of Medicine, places students in rural communities for their third year of 'clinical clerkship'. To date, the outcomes of these LICs have been positive. Students gain strong communication skills and excellent clinical reasoning and management skills and are more likely to subsequently apply to primary care and rural training programs. [7] We suggest in our proposed learning model that CBME and longitudinal integrated programs provide medical students with some key elements that support meaningful personal learning experiences: An authentic professional and social community context for learning. The experience of community, both medical and social, sets up a rich environment for relationships, meaningfulness and, we propose, learning.

Existing learning theories

As learners participate in medical education they change. Learning is both emotional and socially embedded. [8] It is not merely a knowledge acquisition process, but also a socialization process. [9] Upon entering clinical rotations and working regularly alongside clinical teachers seeing patients, learning is facilitated by the students becoming embedded in the subculture of medical practice and the culture of the local community.

Two existing learning theories are relevant to our discussion. Kolb's Experiential Learning Theory combines experience, observation and reflection as elements of medical learning in a clinical setting. Lave and Wenger's Situated Learning Theory describes the apprenticeship model of clinical experience as a participation in a set of social relationships. Learning, they propose, is dependent on participation in these relationships. Their Situated Learning Theory suggests that learning is a by-product of engaging in problem solving 'situated' in a real world environment, enhanced by social interaction and collaboration. [9] This apprenticeship learning model may explain how students adopt values and attitudes of their clinician preceptors and mentors as they seek to 'be' doctors rather than to 'do' medicine. How can experience and socialization in a learning theory best apply to CBME?

Community, relationships with clinicians and graded responsibility

In CBME, particularly longitudinal experiences, medical students are embedded within a small group of clinicians with whom they work closely and come to know well as their professional community. The close working relationships between learners and their clinical supervisors over time allows for the maturation of an apprenticeship relationship. [10] Students judged to be safe and respectful of patients are often able to take on more clinical responsibilities sooner in a known, safe environment. [10] While short term placements result in shared enthusiasm and social inclusion of students by preceptors, students in extended CBME programs describe developing a "sense of companionship". [11] We propose that a personal relationship between student and preceptor, which develops over time, can mature more rapidly in CBME programs, where there are fewer health professionals working closely together and working relationships are more consistent than in most tertiary hospital settings. By contrast, in tertiary care medical education center, students risk experiencing rapidly changing collections of health professionals known as 'negotiated knotworks' rather than teams. [12] This dynamic, depersonalized context risks students experiencing depersonalization themselves. [13]

In CBME, relationships between students and clinical preceptors quickly mature, facilitating preceptor awareness of the clinical growth of their learner. Students are taught and delegated tasks and begin to contribute meaningfully to the healthcare team. Clinical supervisors receive positive reinforcement through effective performance of these clinical tasks by students. [10] Students are likely to receive consistent instruction and feedback because of the continuity of supervision. This consistency of the apprentice relationships enhances entrustment of professional activities, [14] resulting in critical functional changes in the three-way relationship between the preceptor, student and patient during the consultation as students moved from passive to active members of the clinical team. [10]

CBME placements can provide students with a small group of primary care and specialty physicians, nurses and allied health professionals who can welcome a student as a novice member of their team. The student's sense of belonging is enhanced in rural areas where professional and social boundaries are less exclusive. [11] These relationships are enhanced on longer placements, [15] which may explain the success of LICs in community versus tertiary care settings. [7] Length of rotation, continuity of the clinical and teaching team and a welcoming professional environment are key components in this learning environment.

Community, relationships with patients and professional development

In CBME placements, students are introduced to individual patients and to the community in which these patients live. Many CBME programs have developed in areas of workforce need, such as rural locations and low socio-economic outer urban areas. [6],[16] Students are recognized as potential future workforce members and are welcomed into the town. [11] Patients are mostly very accepting of having a student involved in their care. [17],[18] Within the primary care context, students can be given the opportunity to see patients on their own before the general practitioner joins the consultation. This process enables students to develop a relationship with individual patients and contribute to their care. [19] Even in short CBME placements, students have opportunities to follow individual patients through different healthcare contexts (such as clinic to hospital to nursing home) from presentation, investigation, treatment and convalescence. Clinical preceptors are also able to provide students with an entrée into significant patient events such as birth and palliative care journeys. CBME students gain insight into the provision of care to people within the context of their lives, while students in the tertiary hospital setting risk understanding medicine as a context-void skill. Learning from real people with medical conditions who live within a student's own community, rather than about pathology in patients who are short term residents in the tertiary hospital setting, is likely to prevent them losing empathy and objectifying patients, a common outcome in traditional clinical clerkships. [13]

Students in CMBE placements witness and are influenced by leadership roles rural doctors and other health professionals have within their community. They learn about primary care from a broad societal perspective as their preceptors participate in public health programs, health promotion campaigns and advocate to change the social determinants of health within their communities. CBME placements see medical care as a part of the holistic picture of a person's health status and come to recognize how the social determinants of health impact on patient outcomes [Figure 1]. Hence, meaningfulness in the clinical role of the learner, the relationships with clinical team members and the community itself contribute to learning.{Figure 1}

 Conclusion



We propose that longitudinal clinical placements provide a breadth of experience, which enhances learning through the development of rich relationships (with preceptors, other healthcare providers, patients and the general community). These relationships can thrive in a community setting and engender meaningfulness, a term not typically associated with medical education. We suggest that this social, personal and professional context enhances learning through the provision of a uniquely meaningful personal learning experience, which matures a learner personally and clinically. A CBME theory needs to encompass the continuity and depth of relationship development as it applies to learning. Meaningfulness is the term we propose to describe the nature of this authenticity and its effect on learning.

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