|Year : 2019 | Volume
| Issue : 2 | Page : 81-90
Part I: Perceptions of clinical experience in the veterinary teaching hospital: Views of students, staff, house officers, and faculty in veterinary medicine clinical education
Candice Stefanou1, Juan Samper2, Marina McConkey3, Hailey Carter4
1 Department of Small Animal Clinical Sciences, College of Veterinary Medicine; Department of Family, Youth and Community Sciences, College of Agricultural and Life Sciences, University of Florida, Gainesville, Florida, USA
2 Department of Large Animal Clinical Sciences, College of Veterinary Medicine, Gainesville, Florida, USA
3 Department of Small Animal Clinical Sciences, College of Veterinary Medicine, Gainesville, Florida, USA
4 Department of Family, Youth and Community Sciences, College of Agricultural and Life Sciences, University of Florida, Gainesville, Florida, USA
|Date of Web Publication||5-Nov-2019|
Dr. Candice Stefanou
University of Florida, Gainesville, Florida
Source of Support: None, Conflict of Interest: None
Background: The clinical portion of the education of health professionals occurs through the combined efforts of staff, interns, residents, and faculty in the teaching hospital. Exposure to the clinical environment is an essential element in shaping the emerging medical professional's development as a competent practitioner for their 1st day of independent practice. Although high value is placed on clinical education by students and educators alike, the expectations of what educational activities will occur, and the value of each to professional development varies. Thus, this study sought to explore the perceptions of students, faculty, and staff in clinical veterinary medical education regarding their expectations about what students would experience during clinical training and how important those experiences are believed to be. Methods: This study utilized survey research methods. Results: The results reveal a complex picture of competing expectations and experiences that differ based on the status of the respondent as a student, veterinary technician, resident, or clinical faculty. Conclusion: Varied perspectives speak to the complexities of clinical education in the authentic environment of the hospital.
Keywords: Expectations, veterinary clinical education, veterinary teaching hospital
|How to cite this article:|
Stefanou C, Samper J, McConkey M, Carter H. Part I: Perceptions of clinical experience in the veterinary teaching hospital: Views of students, staff, house officers, and faculty in veterinary medicine clinical education. Educ Health Prof 2019;2:81-90
|How to cite this URL:|
Stefanou C, Samper J, McConkey M, Carter H. Part I: Perceptions of clinical experience in the veterinary teaching hospital: Views of students, staff, house officers, and faculty in veterinary medicine clinical education. Educ Health Prof [serial online] 2019 [cited 2020 Jan 28];2:81-90. Available from: http://www.ehpjournal.com/text.asp?2019/2/2/81/270286
| Introduction|| |
The clinical education of veterinary medical students in a teaching hospital occurs through the combined efforts of staff, interns, residents, and faculty. This experience typically occurs at different stages of their education, more often at or near the 4-year training program. These clinical exposures provide the emerging veterinarian with the experiences that will shape their development as a competent practitioner during their 1st day of independent practice. After a 4-year program, all veterinary students must be ready to enter general practice, unlike their counterparts in human medicine who are required to do at least 1 year beyond medical school. The majority of veterinarians do not go on for advanced training beyond their veterinary degree marking an additional difference with human medicine. Over the past 3 years, approximately 27% of the graduates from this institution entered into an internship program, leaving the remainder entering as practitioners. Thus, what happens in the veterinary teaching hospital (VTH) to prepare students as competent day 1 practitioners is vitally important.
While there are various methods teachers employ when teaching, the typical ways students learn to fall into one of the general categories as follows: (a) learning by receiving information often through lecture, (b) learning by observing and modeling the behaviors of experts, (c) learning by doing often through problem-solving and case conceptualization, and (d) learning by communicating what one understands to another typically through oral presentations or written records. Each approach to learn serves a different purpose, and each has value depending on the goal of the teacher and the student and the level of development of the student with regard to knowledge and skill in a particular field. In the VTH clinics, students might experience all of these to some degree.
The student experience in the VTH is not standardized across various rotations or disciplines, and certainly not across educational institutions. The student experience on the same rotation at a single institution may even be vastly different from week to week depending on the type and volume of cases that present to the hospital. Students are expected to acquire clinical skills in this diverse environment through a variety of activities, as is appropriate on each rotation for patient safety and the functional needs of the hospital. These activities include observation, supervised practice, one-on-one expert-to-student interactions, small group discussions and rounds, completion of the medical record, and more traditional learning activities such as presentations and quizzes. Participants in the VTH environment (faculty, residents, students, and referring veterinarians) agree that enthusiasm, competence/knowledge, and clarity are the most important attributes of a clinical teacher. Veterinary students see clinical learning opportunities as vital for them to apply their professional knowledge and skills in a safe yet authentic environment, and clinical training improves veterinary students' self-perceptions of competence. Veterinary students tend to especially value hands-on skills teaching, primary case responsibility, and communication (or nontechnical skills) training. These preferences are shared with their human medical school counterparts who also further place an emphasis on purposive and planned teaching experiences. It is interesting to note, however, that not all of the teaching strategies employed by clinical educators in medical schools are perceived to be teaching per se by students.
The formal training in clinical teaching is recommended to benefit the veterinarians working in our teaching hospitals. However, our clinical educators have roles beyond teaching, such as patient and client service, as well as scholarly activity, that may conflict with their teaching mission, and the pressure of conflicting career demands is not unique to veterinary medicine. As such, interns and residents, collectively known as veterinary house officers, such as human medicine house officers, typically assist in the hospital with the demands of patient care, meeting client expectations, and student education; while at the same time, these individuals pursue their own advanced education. Interns and residents are fundamental to the veterinary education system as a whole.
Medical school students actually prefer resident clinical instructors over faculty for bedside patient rounds as residents are less intimidating and are perceived to offer more standardized teaching that may more accurately reflect the current educational requirements. A survey of teaching in a 3rd year medical school general surgery clerkship found that students perceived residents to be the primary clinical educators for patient care. Furthermore, both faculty and residents in this study felt that the student learning role should primarily be observational and involved with medical record keeping and that it would be inappropriate to rely on students to gather accurate patient information. A more recent prospective study of student perceptions of clinical teaching on an emergency medicine clerkship  also showed that students perceived residents to be responsible for the vast majority of their clinical training. Studies examining perceptions regarding clinical training responsibilities in veterinary medicine are lacking.
Our goal was to determine the perceptions of which learning activities on veterinary clinical rotations were the most valuable, which occurred with the most frequency, and who was responsible for delivering these learning activities. We gathered opinions from all groups with essential connections to students within the teaching hospital: students themselves (both those with no prior clinical experience and those finishing their clinical rotations), residents, veterinary technicians, and faculty. Our hypothesis was that residents would be primarily responsible for the vast majority of clinical teaching activities and that these activities would largely be observational. However, we also believed that participants would place the greatest value on learning by doing.
| Methods|| |
A preliminary survey (IRB201801087) was distributed through Qualtrics to graduating veterinary students, 4th year students who had just completed their clinical curriculum, 3rd year students who were entering the initial phase of their clinical curriculum, faculty, house officers, and veterinary technicians in one veterinary education program. The clinical phase of the 4-year program is divided between the 3rd and 4th years, with 7.5 months occurring at the beginning of the 3rd year study and 4.5 months occurring in the final months of the 4th year. We collected data for approximately 2 weeks starting at the beginning of May with a reminder sent mid-way through to encourage participation. The purpose of the survey was to understand what each group thought of the educational value of typical activities that occur in clinical rotations and to explore perceptions regarding which professional group was the primary group involved in delivering those educational clinical activities. The data from this survey provided the starting point for the more extensive observational study of teaching in the clinics (IRB201801174).
We sent invitations to complete the survey to approximately 110 graduating students, 110 4th year students who completed the first phase of clinical rotations, 110 3rd year students who were beginning the first phase of clinical rotations, 12 interns, 70 residents, 136 veterinary technicians, and 105 faculties. Data were collected from 41 graduating students (37%), 34 rising 3rd and 4th year students (31%), 1 intern (8%), 10 residents (14%), 21 veterinary technicians (15%), and 35 faculties (33%).
We created a 22-item survey accounting for typical experiences students would have while on clinical rotations. Each participant group was asked to respond to the following three questions regarding the 22 experiences: (a) what value did the following educational experiences have as preparation for your career (none, a little, some, a fair amount, a great deal), (b) how often did you have this experience during your clinical training (very infrequently, infrequently, somewhat, quite frequently, all the time), and (c) who did you primarily interact with during this experience while in clinical training (veterinary technician, intern, resident, faculty). The experiences ranged from observing professionals interacting with clients or performing procedures to complete quizzes as part of the clinical rotation requirements. We altered the wording of the three questions slightly to account for the perceptions of value, frequency, and with whom the students interacted if the respondent was a member of one of the nonstudent groups surveyed.
We analyzed responses to the questions by calculating frequencies and comparing the frequencies across the groups.
| Results|| |
Students, faculties, interns, residents, and veterinary technicians responded to three questions about the value of a clinical experience, frequency of occurrence of the clinical experience, and with whom the experience occurred with regard to 22 educational experiences. The values obtained for the group “interns” were not included in any analyses as there was only one respondent in this group.
Value and frequency of experiences
We analyzed responses by looking for areas of agreement and disagreement among the responding groups for value and frequency of experiences. We chose a threshold of 60% to determine points of agreement and disagreement to avoid over- or under-estimating differences of opinion and experience. This threshold suggested to us that when met, we could be reasonably confident in our interpretations.
The wording of the question about the value of experience posed to veterinary technicians, interns, residents, and faculty was “What value do you believe the following educational experiences have in preparing students for careers as veterinarians.” The wording for graduating students was “What value did the following educational experiences have as preparation for your career;” and for students entering clinical training, the question was worded as “What value do you expect the following educational experiences to have as preparation for your career.”
The wording for the question about frequency of educational experiences was “How often do you believe students have this experience during their clinical training” for veterinary technicians, interns, residents, and faculty. The question was worded as “How often did you have this experience during your clinical training” for graduating students; and for students entering clinical training, the question was phrased as “How often do you expect to have this experience during your clinical training.” We combined the two response categories of “all the time” and “quite frequently,” since it is unreasonable to expect that an educational experience happens all the time. [Table 1] presents the percentages for the value and frequency of each educational experience for each group. Plus signs (+) indicate percentages above the 60% threshold and minus signs (−) indicate percentages below the 60% threshold. We grouped the educational experiences in the table according to the types of experiences.
With whom the experience occurred
The question asked was “Who did you observe the student primarily interacting with during this experience while in clinical training” for veterinary technicians, interns, residents, and faculty. For graduating students, the question was phrased as “Who did you primarily interact with during this experience while in clinical training” and for students who were entering clinical training, the question was “Who do you expect to primarily interact with during this experience while in clinical training.” We included the intern group only with regard to the frequency with which they were seen as interacting with a student in an educational experience. [Table 2] shows each educational experience and the proportion that each group indicated as actors for the experience.
|Table 2: Primary instructors for each clinical experience from most to least for each|
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| Discussion|| |
We sought to understand the perceptions of the various stakeholders in clinical veterinary medical education regarding their expectations in one case (students entering clinical rotations) and the actual perceptions in the other cases (students with clinical rotation experience, house officers, veterinary technicians, and clinical faculty) of 22 typical activities occurring in clinical rotations that are believed to prepare emerging veterinarians for independent practice. The clinical faculty in this teaching hospital is undertaking a major review of how teaching occurs in the clinics and considering alternatives for common practices. There is speculation that some activities, for example, requiring students to be responsible for writing the medical record or discharge instructions, might not actually be the best use of time in preparing students for their ultimate role as a practitioner of veterinary medicine. Further, there is anecdotal evidence that the teaching functions are not necessarily distributed across the teaching groups (veterinary technicians, house officers, and clinical faculty) in ways that maximize the students' access to potential learning opportunities. The data from this survey research provided the first step in the process of understanding the perceptions of the students and staff in this VTH regarding educational activities during clinical rotations.
The data on the perceptions of the value and frequency of the 22 activities provided an interesting lens for understanding what students expect to experience and what they say they ultimately did experience, as well as an understanding of the value and frequency of the activities from the perspectives of the clinical teaching staff. The activities can be organized into the following categories: (a) learning by observing, (b) learning by doing, (c) learning by communicating, and (d) learning by traditional knowledge reception.
Learning by observing
The educational role of observing others provides an interesting point of departure in perspectives between the students and the teaching staff in terms of the value placed on this mode of instruction and learning. Teaching staff generally place a high value on having students observe them make clinical decisions, carry out procedures, and communicate with clients. This is consistent with the work of De et al. who found that faculty and residents in human medicine believed that the student role should be primarily observational. However, students in our survey reported that simply watching has little value for their learning with the exception of how the teachers communicate with clients. All groups in our survey reported these activities to occur quite frequently and predominantly with the residents as the models. This too is consistent with the results of De et al.'s  study that found students perceived the residents as the primary clinical educator. Despite the reports from these students that observational learning is not their preferred mode, there is a rich research base explaining the value played by observation for learning, starting with Bandura's Social Learning Theory. Social learning theory explains that observational learning and modeling others are essential for learning, as we cannot expect to learn, all we need to know by trial-and-error alone or by personally handling every case. This point is especially relevant when considering the preparation of health care professionals. To suggest that all clinical veterinary medicine learning should occur by allowing students to actively engage with the patient without first observing a professional would be unrealistic. However, a balanced approach that moves from observing and being provided with explanations for the approaches taken, to assisting with specific aspects of the case, to performing independently might provide the emerging veterinarian with critical opportunities to receive not only access to expert reasoning but also feedback from seasoned professionals in terms of performance, clinical reasoning, and communication.
Learning by doing
The value of the supervised practice of procedures is acknowledged as high by all groups, while the supervision of communicating with clients as ranked as high by some groups. These results are consistent with the findings of Jaarsma et al., Magnier et al., Schull et al., and Jayasuriya-Illesinghe et al. Regrettably, all groups in our study acknowledged that these occur infrequently. Only the student groups indicated there was high value in making decisions about patient care without supervision. Once again, the residents were perceived to be the primary teaching staff involved in supervising veterinary students. Studies show that students' experiences of autonomy and authenticity have a role in in-depth learning and professional development of students as medical practitioners.,,, Increasing the opportunities for supervised practice could be an area where changes in clinical teaching practices might yield beneficial results for emerging veterinarians as well as for practitioners in the clinical teaching hospitals. If students receive more supervision as they build their clinical skills, they can build their skills to the point where teaching staff can trust them to perform independently. As students develop greater clinical competency, they would add to the overall productivity of the hospital and increase their autonomy as day-one practice-ready veterinarians. Additional teaching method to support students' independent clinical decision-making is virtual learning environments that allow students to make mistakes without the threat of harm. Such environments can provide opportunities for students to develop sound clinical reasoning skills in a low-stakes situation. Regardless of the environment, virtual or actual, supervised practice provides the opportunity for clinical educators to provide feedback to the student about skills, reasoning, decision-making, and communication, although in this study, only rising clinical students and veterinary technicians place much value on real-time feedback on performance. The feedback can be seen as a form of debriefing, which Rivière et al. refer to as “a multilateral reflective experience in which discussion results from the interaction between debriefer(s) providing expert-guided feedback and participants providing self and peer feedback” (published ahead of print). Gibbs and Simpson  provide conditions under which feedback can influence learning. They suggest that feedback should be frequent, immediate, specific to what was done well and where improvements can be made, appropriate to the task with clear performance criteria, support a conception of learning as understanding, and support a conception of knowledge that can handle some degree of ambiguity or relativity. They further note that students must receive and attend to the feedback and act on it. These conditions of what learning can look like in the veterinary medical clinic seem to provide an environment where these feedback conditions should be readily present.
Learning by communicating
This category includes communication as not only a means of demonstrating what the student has learned but also as using communication as a means of learning. This category includes collaborating with an expert, discussing with experts and peers, engagement in rounds, and record-keeping activities. Interestingly, the value placed on each of these is fairly uneven, both within and between groups. Only those communications involving students interacting with professionals held value for students. Peer learning was not seen as a valuable use of time for learning by any group. This might be understandable in the sense that clinical rotations provide the first opportunities for students to engage with their teachers in authentic settings. Previous engagement with faculty occurred in the classroom, where knowledge accretion is typically regarded as the key objective. In the clinics, professional practice and decision-making are core activities. Students most likely feel that they can learn the most from their teachers and place a lower value on peer learning. The professional staff also regarded peer learning as a low-value activity in clinical education. Regarding written forms of communication, only the residents and veterinary technicians place a high value on this for student learning; although students report they do quite a bit of record-keeping. This too is partially consistent with the findings of De et al. who found that residents and faculty both believe medical record keeping is a primary student role. Students might not value these tasks because when they are writing, they might miss out on actual procedures and cases because of the paperwork. Contrary to De et al.'s  findings, the clinical faculty in our study might perceive having students complete tasks associated with medical record-keeping as irrelevant to student learning because students tend to use this activity as a way to demonstrate their knowledge, but this is not useful to the patient and is not necessary for the medical record. One reason veterinary technicians and residents might place such high value on this activity for student learning is that daily practice depends on this information being accurate, and this directly affects their ability to perform well in the clinic. Additionally, if students write these, house officers and veterinary technicians will not need to. These differences in opinions about the educational value of writing medical records speak to the importance of effectively communicating with students our learning expectations of them in their various activities within the clinic. Making our expectations explicit may alleviate frustration on behalf of the learner and provide a more cohesive team approach to the various teaching moments (both expected and spontaneous) that are presented in the clinic.
Learning by traditional knowledge reception
Everyone agrees that quizzes, modules, and presentations have low value, perhaps due to the fact that quizzes, modules, and presentations are not necessarily connected to overall student learning objectives in clinical rotations. When these methods are used, they might be used as default methods to measure how much students have learned on the rotation. Assessing student performance in the clinics can be difficult. Some methods are of questionable value, and opportunities to assess actual performance are infrequent. In busy rotations, these activities may provide a way to document learning.
Primary teachers for the various instructional activities
The data on perceptions of which professional group are most often seen as the primary teaching group provides interesting insights on the roles perceived and perhaps played by the professional staff in the teaching hospital rotations. Because of the role that they play and because they were the only ones who actually reported on each of the four teacher groups (interns, residents, veterinary technicians, and clinical faculty), we are tempted to suggest that the observations made by the veterinary technicians might be the least biased in terms of teaching. The clinical faculty, interns, residents, and students often did not account for one or more of the teaching groups as having any role for some of the learning opportunities. Veterinary technicians also are the ones who might have the most opportunity to observe. Interestingly, the veterinary technicians reported the residents as having primary teaching responsibility for all activities other than rounds in all its forms, providing real-time feedback on student performance, and traditional methods of knowledge transmission, which they note belongs to the clinical faculty. Residents and graduating students mirrored the veterinary technicians in terms of assigning responsibility to clinical faculty for teaching in terms of rounds and providing feedback to students on their performance, but residents split responsibility for the more traditional modes of instruction between themselves and the faculty. This might indicate that veterinary technicians, residents, and graduating students see the clinical faculty as the educators in the more formal educational activities. Students who were either beginning their clinical phase or had completed the first portion of the clinical phase tended to mirror the graduating students, resident, and veterinary technicians but believed they would have more interaction with the clinical faculty as their primary educators. The clinical faculty, however, saw themselves as the primary teachers for everything except activities having to do with record keeping and students learning by observing them carry out procedures and communicating with a client or other professional, which they ascribed to the residents. Interestingly, all groups ascribed considerable educational presence to residents and faculty, but none did so for interns or veterinary technicians. Perhaps this can be interpreted to mean that clinical faculty and residents are blind to the value that veterinary technicians and interns can provide to the educational objectives of the clinical rotations. This might be an indication of implicit bias on the part of the clinical faculty and residents. Additional studies are needed to determine if this is actually the case. Further, where the veterinary technicians were seen as a secondary or even a tertiary part of the educational staff, it was primarily in terms of observing, providing, or supervising another carry out a technical procedure. They were only harnessed as technical staff in the educational process, and this could mean we are under-utilizing veterinary technicians for helping to teach the students and losing out on opportunities to model teamwork as a central activity of the veterinary profession.
| Conclusion|| |
As a team of veterinary professionals, we are not certain that we agree on who is the primary teacher during clinical rotations as there is not a consensus among the groups in this regard. The overall value placed on different learning opportunities in the clinical rotations does not appear to match the frequency with which they occur. What we think is educationally important is not necessarily how the different groups spend time teaching. Additional studies of this sort would help to provide a more global picture of the nature of the educational activities in clinical veterinary medicine. Observations of teaching during clinical rotations would help to verify the perceptions of teaching. Based on the findings of this study, a second study using only observation of teaching techniques was completed. The purpose of the observational study was, in part, to verify the results of the perception study but also to document the types of teaching techniques used by the different teaching groups (clinical faculty, house officers, and veterinary technicians). We were interested to understand how different services use different teaching techniques and to what extent the techniques are used. The observational study defined the teaching techniques using the educational opportunities as defined in this survey study.
This study captures only student and professional staff perceptions of what educational activities occur and under whose tutelage. Attaining a higher response rate would help the validity of our interpretations, especially when considering residents and veterinary technicians which had the lowest response rate of those surveyed. The 22-item survey was developed with the assistance of the veterinary clinical professors at the VTH. Asking clinical educators at other VTHs about typical practices in clinical education would help us understand whether these practices are ubiquitous or if some are unique to our particular teaching hospital. The second part of this project which was an observational study of actual educational practice in clinical education provides some validation of the responses from this study but in some cases, does not support the perceptions from the respondents in this current study. Replication of this study could lead to discussions about how to structure learning opportunities in clinical medicine that could lead to stronger experiences for veterinary students.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]