Outpatient learning perspectives at a UK hospital

Undergraduate students spend much of their training in the clinical workplace, increasingly in hospital outpatient settings; however, they report that this does not always yield the educational value that they expect. This study investigates ways in which outpatient learning can be enhanced from the perspectives of students and teachers, exploring which approaches may be most appropriate in different circumstances.


SUMMARY
Background: Undergraduate students spend much of their training in the clinical workplace, increasingly in hospital outpatient settings; however, they report that this does not always yield the educational value that they expect. This study investigates ways in which outpatient learning can be enhanced from the perspectives of students and teachers, exploring which approaches may be most appropriate in different circumstances. Methods: We conducted 14 semi-structured interviews with medical students from one UK medical school and consultants (specialists) at a single teaching hospital. We explored their experiences and perceptions of clinical teaching and learning in this outpatient setting. Transcripts were analysed through a consensual qualitative research approach. An evaluation of established frameworks for outpatient teaching was conducted and strategies were matched to stakeholder needs. Findings: A total of 24 core ideas were identified, which were categorised into: individual factors (student, doctor and patient), interpersonal factors, team factors and organisational factors. Teaching strategies that address stakeholder needs included: student-led clinics, case-based discussions, one-minute preceptor, the SNAPPS tool (summarize, narrow differential, analyse, probe preceptor, plan and select issues for self-learning), advanced organisers and supplementing. Discussion: There is a complex interplay between personal, interpersonal, team and organisational factors that contribute to the effectiveness of the outpatient setting as a learning environment. Strategies at the personal and interpersonal levels are unlikely to be successful or sustained without organisational resourcing and support. Further research is needed to implement and evaluate these suggested strategies. This setting presents educational challenges, however, including a lack of patient continuity, a lack of predictable learning opportunities and difficulty in actively participating in patient care. 1,3-5 Both students and teachers express concerns about the lack of opportunities for feedback from clinicians and the limited time spent alone with patients. [2][3][4]6 Clinical teachers worry about the impact of student presence on clinic flow and quality of patient care. [1][2][3] As clinicians prioritise patient care, the time invested in teaching often falls below student expectations. 2 The lack of clear educational criteria when employing teaching clinicians, the lack of employer support and the lack of perceived benefits for clinicians who teach are also highlighted as barriers to high-quality outpatient-based education. 3 There is a maturing literature on teaching methods in inpatient settings; however, research regarding effective outpatient learning is limited. The aforementioned learning barriers are discussed at length, but often in the absence of any clear solution. The limited literature on learners' perspectives indicates a preference for collaborative experiential learning. 5,7 The existing literature on teaching strategies offers limited evidence of efficacy, theoretical underpinnings or transferability. 1,2,4,8 There is a gap in the literature for research exploring stakeholder viewpoints on which educational strategies might work in the outpatient learning environment, in which contexts and why.

Methodology
We undertook this research within a social constructivist paradigm, adopting a consensual qualitative research approach to coding, described further below. 9 The interview topic guide (Appendix S1) was informed by our literature review. It was tested and refined through discussion with peer clinical teaching fellows.

Recruitment
A total of 28 teaching consultants at Hillingdon Hospital were approached via e-mail; 14 replied and seven participated. Reasons for non-participation included time and convenience. All 50 Imperial College medical students, undertaking a 6-year Bachelor of Medicine and Bachelor of Surgery (MBBS) programme, on clinical rotation at Hillingdon Hospital, were approached via lecture announcements and posters; seven replied and all were interviewed. All students had experience of outpatient learning.

Data generation
Interviews were conducted between January and April 2019 by PH, who was not involved in outpatient education at Hillingdon. Interviews lasted between 9 and 38 minutes and were recorded, professionally transcribed and checked for accuracy. All potentially identifying information was redacted prior to analysis.

Analysis
All 14 transcripts were double coded into core ideas by PH and JF; discrepancies were resolved through discussion and the coding was audited by DH. Discussion allowed for iterative changes to themes and categorisations, which were re-tested against the underlying data. No new major themes arose after six interviews and no new core ideas arose after eight interviews.

FINDINGS
We identified 24 core ideas, which were categorised into: individual, interpersonal, team and organisational factors. Themes are summarised in Table 1, with illustrative quotes.

Student
Students articulated a preference for direct involvement in patient assessment and care, which they felt enhanced both learning and enjoyment. Active participation in care and clinical skills was highlighted by students and clinicians as a motivating factor, being relevant to their future practice. Attending a clinic more than once allowed teachers to entrust students with incrementally harder tasks. Teachers expressed concern over student passivity, preferring them to arrive with an agenda for learning.
Some consultants found punctuality and attendance a barrier to student learning. One clinician commented that learning conversations often take place at the beginning or end of a clinic to maintain patient flow: Both students and teachers express concerns about the lack of opportunities for feedback from clinicians …

Patient
The importance of patient care and the delicate balance between clinical and teaching commitments were acknowledged. Clinicians expressed concern that patients may be delayed if assessed by students; students acknowledged that the intimate nature of some consultations might make their presence unwelcome. Nonetheless, students valued the breadth of patients in outpatient settings, which stimulated their desire to learn and gave context to their learning.

Interpersonal factors
Students felt that some consultants pitched their teaching incorrectly. They felt that teaching strategies should vary depending on students' prior understanding and the time available. Several students remarked on the value of having expert consultants fill in the 'gaps' in their knowledge. One clinician reported using a one-to-one 'lecture'-style approach, where time allowed. Some teachers discussed 'advanced organisers' to keep students active during a consultation. One highlighted that such prescriptive approaches may blinker students to unplanned experiential learning opportunities. Participants described a variety of facilitative strategies, including questioning, case-based discussions, relationship building, feedback and agreeing expectations. These are expanded on in our discussion.

Team factors
Students felt that the workplace culture impacted on their learning; they appreciated settings where they felt included as part of the wider clinical team, which was a motivator for engagement and attendance. Attitudes and approaches towards medical students from the wider team were described as variable.  possible, organisations must also protect time and space for education. One consultant described feeling 'buried between teaching and service' . Suggestions for organisations included: clinics with a lower patient load; settings with more rooms for students to consult independently; double appointments; and blocked-out appointments for debriefing.

DISCUSSION
The outpatient clinic presents multiple advantages as an undergraduate educational setting, including rich learning opportunities related to clinical presentations, clinical reasoning and consultation skills, which all enhance student learning. Our analysis, however, confirms that their educational value remains variable. Students expressed a desire for more active involvement, tailored to their level of understanding, with feedback on performance, and clinical teachers expressed a desire for commitment from learners and guidance on effective educational strategies that maintain patient satisfaction and flow in their clinic.
For improvements to happen, our analysis suggests that support for education must be facilitated at multiple levels of an organisation as well as between individual learners and teachers. Our findings support other research suggesting that workplace factors, such as attitudes to the presence of medical students and the prioritisation of resources, including protected time and space, need to be addressed alongside effective teaching strategies. 3,7 There are calls for teaching clinics to be structured and supported differently to normal outpatient clinics. 3,10 Student-led clinics (SLCs) are one such strategy, reported to increase students' stimulation and responsibility to learn, as well as increasing their sense of responsibility for patient care and perceived level of competence. 11,12 Reassuringly, when patients are appropriately chosen, consented and reviewed, research demonstrates that SLCs do not adversely affect patient care or satisfaction. 10,11 Several participants highlighted the value of case-based discussions and questioning. According to the literature, appropriate questioning can support the activation of prior knowledge and identify learners' needs, eliciting students' own strategies for approaching a clinical scenario. 2,13 The oneminute preceptor is recommended as a tool that encourages students to commit to an answer and articulate their reasoning prior to feedback and more generalisable learning. 2 This strategy mitigates time concerns, meets teachers' desire for a framework and facilitates the provision of personalised feedback, which was a frequent request from students.
The SNAPPS tool similarly encourages learners to summarise, narrow the differential, analyse the possibilities, probe the preceptor, and plan for the patient's problem and their own self-directed study needs. 3,14 This tool supports teachers' articulated desire for structure and encourages students to be active participants. 15 Where time is less restricted and learners have a good knowledge base, research suggests that 'supplementing' may be effective. 13 This involves students leading all or part of a consultation, with the clinician supporting and concluding as necessary. This addresses students' preference to be more active whilst allowing the clinician to maintain flexible control over clinic flow.
'Advance organisers' involve the teacher identifying key topics for learners to focus on during the clinic, e.g. a concept map of respiratory failure, and may be used to guide subsequent learning conversations. 8 This strategy drives the active participation of students in their own learning whilst maintaining effectively normal flow and patient experience. Advance organisers may be balanced with teacher responsiveness to unplanned learning opportunities, such as role modelling how a consultant handles a difficult conversation, for example. 13 Strategies that address the educational preferences of teachers and learners in outpatient settings are summarised in Figure 1.

Limitations
The number of participants is small and from a single institution, but the saturation of themes was achieved within this context. The findings may be applicable to teachers and learners in similar settings; however, this will need to be evaluated locally.

CONCLUSION
There is a complex interplay between personal, interpersonal, team and organisational factors that contribute to the effectiveness of the outpatient clinic as a learning environment. Examining the perspectives of learners and teachers enables us to deconstruct how and why certain educational strategies work in this context. Teachers and learners can take steps to enhance the value of outpatient clinics by modifying their approaches and adapting to individual circumstances. For sustainable changes to be seen, however, organisations need to take an active role in disseminating effective educational strategies, creating a supportive workplace culture, and protecting time and space for learners. Further translational research is needed to establish the Consultants articulated a desire for guidance or consensus on how to teach in this setting, and to see how their peers taught effectiveness of these strategies in different outpatient contexts.