MEDEV

School of Medical Sciences Education Development

Introduction

The graduate entry programme in medicine started in 2004 as collaboration between Cardiff and Swansea Universities. The first two years are based at Swansea University and consist of a series of integrated learning weeks based round a clinical case and include lectures and practical clinical skills training. Formal ward based teaching is limited to the last nine weeks of year two, although students experience primary care through regular attachment at a GP buddy practice and complete a one week nursing attachment. It was recognised early in the course development that there were few clinical learning opportunities in these first two years and that a new method of delivering this experience was equired. 

Method

The LOCS (Learning Opportunities in the Clinical Setting) system consists of almost 300 half day clinical learning opportunities that are listed in a database accessible through the administrative offices of the three local hospitals of our partner NHS Trust. Each has details of the speciality, clinical area, likely clinical exposure and days and times available. They range from out-patient clinics, theatre lists, post-take ward rounds, multi disciplinary meetings, community drug clinic or prison visit. All LOCS allow students to observe clinical practice but, active student participation is possible. Each session is strictlyl imited to one or two students to ensure individual attention and feedback.

Students are able to read through the database, choose an activity and complete a paper request. The administrative staff then contact the relevant health professional to confirm that the LOCS is available and the student is sent an email to confirm the booking.

Although there is no upper limit to the number of LOCS an individual student can complete (provided other teaching is not missed), students are required to complete 12 LOCS in the first year and 8 in their second year. In addition, LOCS on the labour ward, accident and emergency department, general medicine, general surgery and elderly care are compulsory for every student.

LOCS are recorded by students via the BlackBoardTM virtual learning environment. Each page allows the student to enter the code number of the LOCS, to enter their reflections and to rate the session on a 3 point scale of "very useful", "useful" and "not useful". An administrative screen shows each year group of students in order of the number of LOCS completed and highlights those who have failed to complete the required number. Completion of the required number of LOCS is part of the assessment of professionalism and an incomplete record results in failure to progress to the next year of the course. Failure is redeemed by completion of the missing LOCS.

Health professionals are not reimbursed for LOCS and clinical workload is unaffected. This limits many of the LOCS to observation rather than active participation or the provision of any teaching for the students.

Although it is difficult to quantify the administrative workload due to the distributed nature of the work, it probably equates to a full time member of staff. 

Results

The system has run successfully for the last four years. There are currently 297 LOCS available in the database leading to 1,555 LOCS per year with an average 1 (range 8-27) LOCS per student completed each year.

All students complete a survey at the end of the year. Ratings have been positive, with 55% "very useful", 42%"useful" and only 3% "not useful". Negative comments usually relate to the personal interaction between the clinician and student. Although rated as "not useful" byt he students, these may nevertheless provide students with valuable experiences of day-to-day health care delivery as provided by NHS staff.

Problems have occurred early in each year as students have failed to complete either their Hep B vaccination programme or criminal records check, both of which preclude clinical contact.

There has been a small but persistent proportion of LOCS that fail to happen, or example, due to a cancelled theatre list. However, staff can usually find a replacement at short notice. Changes to timetabled lectures are a persistent rpoblem as the new time frequently clashes with previously booked LOCS.

We were initially concerned that the LOCS system did not allow all students to attend sessions appropriate to the case of the week. For example, in the stroke' week, there would not be enough places for all the students to attend neurology or rehabilitation related sessions. However, students seem entirely capable of attending, for example, labour ward in the middle of a week studying pneumonia and vice versa. 

A further problemis that the structure of the learning weeks means that certain sessions are almost always occupied by large group teaching, for example, Monday mornings. This means that the uptake of LOCS during those sessions is extremely low. For the opposite reasons, LOCS on a Wednesday faternoon (when lectures cannot be scheduled) are often heavily over subscribed.

The recorded student reflections indicate a generally excellent educational experience, with students being able to interact with both patients and staff. Feedback from clinicians is generally very positive, although there have been a few instances of clinicians telling students that theycan see no point in first year tudents coming to clinical areas because they don't know enough basic science.

The LOCS systemf eatures many highly desirable educational features, in that the learning is active, student led and based entirely in the clinical environment. Although it is difficult to map such learning to formal learning objectives, students appear to find them valuable to consolidate their theoretical knowledge, practice clinical skills and to learn about the wider aspects, such as exposure to role models and identifying possible career choices. 

Further developments

We feel that these sessions have potential as formal assessment tools .Many students are already performing clinical activities in a clinical area observed by clinicians.The addition of a formalised marking scheme and recording system could onvert the existing process into an efficient summative assessment. Although it would require major investment in the training of clinicians, a series of "assessment OCS" could provide a highly valid assessment of the ability of individual students in the clinical environment.