Education in the Health Professions

ORIGINAL RESEARCH
Year
: 2020  |  Volume : 3  |  Issue : 2  |  Page : 54--62

Veterinary student experiences in a community- and competency-based primary care rotation: A case study


M Katie Sheats1, Traci Temple2, Dan Spencer2,  
1 Department of Clinical Science, College of Veterinary Medicine, North Carolina State University, North Carolina, USA
2 Department of Distance Education and Learning Technology Applications, North Carolina State University, North Carolina, USA

Correspondence Address:
Dr. M Katie Sheats
1060 William Moore Drive, Raleigh, NC 27607
USA

Abstract

Background: Over the past 10–20 years, health professions' education has increasingly utilized community-based models of distributive medical education (CBDME) and competency-based education (CBE) frameworks. Although programs combining CBDME and CBE have reported enhanced student education and professional development outcomes, health professions' educators have also noted challenges integrating these frameworks, including vague university expectations regarding student performance, issues balancing efficiency with student learning in the private practice environment, lack of private practitioner training in pedagogy, and limited university faculty involvement in community-based clinical training of students. Aims and Objectives: The current paper describes the efforts of one veterinary school to refine a 4-week community-based primary care clinical rotation. The 2-year project aimed (1) to incorporate tracked competencies, improve preceptor training, and enhance involvement of university faculty through online student learning (Year 1) and (2) to use focus groups to solicit students' feedback on the course (Year 2). Settings and Design: Descriptive and Case-study. Methods and Material: Focus group, semi-structured interview. Statistical Analysis Used: Content analysis method of qualitative data, open and axial coding. Results: Compared to other “hospital rotations”, students reported that the CBDVE-equine primary care course gave them more opportunity to voice their professional opinions, determine course(s) of treatment, and discuss concerns/questions regarding case management. CBE helped students distinguish between competencies they had completed themselves versus procedures they had only been able to observe. The technology meant to support competency tracking in the field presented significant challenges to the student learning experience, including lack of internet access in remote locations, concerns regarding use of technology and appearance of professionalism, and redundancy of competency documentation. Conclusions: Veterinary student perceptions towards CBE and CBDVE are positive. Incorporating technology to track clinical competencies and support student learning during distributed clinical training requires an iterative process of feedback and negotiation with stakeholders, including students, university faculty, and private practice partners. The project approach and study findings described will be of interest to health professions educators who participate in, or plan to use, competency- and/or community-based models of education.



How to cite this article:
Sheats M K, Temple T, Spencer D. Veterinary student experiences in a community- and competency-based primary care rotation: A case study.Educ Health Prof 2020;3:54-62


How to cite this URL:
Sheats M K, Temple T, Spencer D. Veterinary student experiences in a community- and competency-based primary care rotation: A case study. Educ Health Prof [serial online] 2020 [cited 2020 Oct 21 ];3:54-62
Available from: https://www.ehpjournal.com/text.asp?2020/3/2/54/290925


Full Text



 Introduction



Medical education has seen major changes over the last decade. There is increasing pressure on medical schools, as well as other programs of healthcare education, to ensure that students not only have learned the necessary medical knowledge but also have the reasoning, problem-solving, technical, and communication skills necessary to apply that knowledge in the clinical setting.[1],[2],[3] In response, medical school curricula are shifting toward the adoption of competency-based education (CBE). CBE is “an outcome-based approach to the design, implementation, assessment, and evaluation of healthcare training programs, using an organized framework of competencies.”[4] In turn, a competency is defined as “an observable ability of a health professional related to a specific activity that integrates knowledge, skills, values, and attitudes” (as adapted Frank et al., 2010).”[4] CBE shifts the focus from the time a learner spends on an educational unit, to the outcomes or abilities they gain,[5],[6],[7] with observable competencies being based on a predetermined, acceptable level of knowledge and/or performance.[8] As a result, CBE ensures that students graduate with the ability to apply the needed knowledge and skills in a clinical setting.[9],[10]

Medical and veterinary school faculty and practitioners have noted that it is critical to cultivate and develop professional competencies within trainee veterinarians.[7],[11],[12],[13],[14],[15],[16] The development of professional competencies has been linked to employer satisfaction, as well as success in the veterinary profession.[7],[13] However, the adoption of CBE practices at a program level has taken some time to occur, and the extent to which competencies are actually integrated into the curricula of programs labeled as CBE is unclear.[7]

Another increasing trend in health professions' education is the use of community-based models of distributive medical education (CBDME). CBDME transfers some or all of students' clinical training into community clinics that are geographically separated from their school or university.[17],[18],[19] Rooted in the overlapping frameworks of service–learning and community-based participatory research, CBDME emphasizes collaboration with local communities, developing shared knowledge through interactions, and personal reflection.[20] Additional reasons cited for increasing use of CBDME in the veterinary medicine have included decreasing state support for institutions of veterinary education [21] and increasing focus on specialty medicine in veterinary teaching hospitals, which has made primary care, case-based teaching, more challenging.[22] CBDME is viewed positively in the field.[23] Programs have exhibited positive student outcomes,[1],[24],[25],[26],[27] as well as benefits for the wider community.[2],[28] Researchers [2] have posited that by exposing students to a wider range of care and continuity in clinical skill development, CBDME provides a more enjoyable educational experience, and as a result, CBDME increases potential student outcomes. In addition, community benefits from CBDME include greater access to the trainee workforce, enabling local healthcare professionals to address potential shortages in their community.[2]

While the CBDME model offers unique advantages, it, like other modes of distance education (i.e., externships and preceptorships), also comes with inherent challenges. These challenges include sometimes ill-defined learning objectives and outcome measures for students,[24] distance and time barriers that hinder the involvement of university faculty in community-based clinical training of students,[27],[29] lack of performance-based student assessment by private practitioners,[27],[30],[31] vague university criteria on the level of performance expected of students,[32] and lack of private practitioner training as facilitators of student learning.[33] Our veterinary college has faced these commonly cited challenges during the implementation of a new hybrid model of campus- and community-based clinical training for its equine primary care (EPC) program.

To address these issues of vague university expectations, lack of preceptor training, and lack of standardization of student learning outcomes, the course coordinator for this CBDME rotation engaged in a series of course revisions with the assistance of the university's Distance Education Learning Technologies and Applications (DELTA) group. The overall goal of this 2-year project was to revise a newly developed CBDME rotation in EPC to be competency based.

The current paper describes the changes to the course, made with the guidance of DELTA (Year 1), and then uses a case study approach to investigate student experiences, perceptions, and viewpoints regarding the course (Year 2). The specific goals for Year 1 were to remediate program challenges by (1) establishing clinical rotation competencies and aligning them with methods for evaluating competencies, (2) establishing “faculty onboarding” and guidelines for preceptors, (3) creating a web-based platform to track competencies, connect preceptors, students, and faculty and house resources, and (4) aligning course tools and clinical materials with the American Veterinary Medical Association (AVMA) requirements for distributive education.[34] In Year 2, focus groups were conducted. Relevant information relating to individuals' perceptions, attitudes, and beliefs about curriculum was utilized to understand students' lived experiences, perspectives, and viewpoints, as these have been noted as important in understanding engagement in CBDME courses/programs.[35],[36]

 Subjects and Methods



Course description

EPC is a 4-week course that equine-focused veterinary students at this college are required to take during their clinical year. The EPC rotation incorporates experiential learning and CBDVE to train 4th-year students in the fundamental aspects of veterinary medicine, relevant to the general health and wellness needs of equine patients. This course utilizes a hybrid model of distributed learning, placing students in both campus- and community-based clinical training. Students begin by completing a 1-week boot camp, followed by a 3-week rotation at an equine practice location. The course began with students from the Class of 2015 with the original program described below. In 2016, the course coordinator received a Blended Learning Grant from the College's DELTA, with the aim to develop an online learning community platform or “app” that would list and track student competencies, provide course information to students and preceptors, develop a faculty onboarding procedure, and facilitate online learning during CBDVE. The changes, presented in “Updated Course/Program,” were implemented with the Class of 2018, and focus groups were conducted in Fall 2017 and Spring 2018.

Original course/program (2015–2017)

In the original course/program, students were given information via a prerotation handout, which included overall expectations, content to review before the rotation, rotation requirements, and assessment/assignment information. Three major components were present in this course documentation: boot camp, case presentations, and case logs. Example materials are available upon written request to the corresponding author. The original course/program did not include competencies.

Boot camp

The 1st week of this hybrid distributed course is referred to as “boot camp.” As part of the experiential learning during this week, students spend the mornings participating in case simulations that cover a wide range of cases related to equine health topics (i.e., colic, lameness, and wounds). For each simulation, students have to diagnose, treat, and/or manage a disease or an injury with materials provided. Each case simulation is facilitated by an equine clinician acting in the role of the horse owner. The other aspect of this week is student participation in the delivery of authentic equine primary care delivered through farm calls.

Case presentations

Case presentations are used to promote clinical reasoning and student–faculty interaction during rotation. Students present a primary care case seen during their time in community practice to demonstrate their knowledge surrounding (1) the use of key data to refine a problem list, (2) development of a differential list, (3) consideration toward the cost/benefit of various diagnostics, (4) interpretation of findings/diagnostic results, and (5) communication of treatment options in light of case circumstances.

Case logs

Case logs document the types of cases seen, as well as procedures performed during rotation. Templates/examples of how to fill out the case log were provided to students before their rotation.

Preceptors

When the program was initially launched, selected equine veterinarians across the state were asked to serve as preceptors for the course. Preceptors facilitate student learning in a number of ways: goal setting, promoting engagement in authentic primary care, one-on-one teaching and learning, and formative and summative assessments. Before the beginning of the rotation, preceptors were given a statement of expectations regarding their participation.

Updated course/program (2018–present)

Initial reviews of the CBDVE EPC course over the first 2 years were primarily positive. However, both the course coordinator and students noted that the program had challenges and limitations, including ill-defined learning objectives and outcome measures for students, vague university criteria on the level of performance expected of students, and lack of private practitioner training as facilitators of student learning. Further, the course coordinator felt that there could be more done to align course tools and clinical materials with the AVMA requirements for distributive education.[34] To address these limitations, the course coordinator applied for an education grant to work with DELTA on a course revision.

The boot camp, case presentations, and case logs remained similar to the original program. Significant changes to the course included (1) the creation of the list of course competencies, (2) creation and implementation of preceptor “onboarding,” and (3) the transition of the course to being fully embedded in the university learning management system (LMS). These updates were selected as priority changes to: satisfy AVMA requirements regarding CBDVE,[34] improve preceptor training regarding intended student learning outcomes and delivery of student feedback, better standardize student expectations for experiential learning and competency achievement, and increase the connectivity between students, preceptors, and university faculty during CBDVE. In addition, having read previously published descriptions of the use of technology for tracking medical student competencies and clinical performance assessments,[37],[38],[39] the course coordinator was interested in application of this concept to the currently described CBDVE course.

Course competencies

Ninety-five individual competencies were selected based on the published lists of activities and procedures performed in in equine private practice [40],[41] and were organized by seven domains of competence, consistent with the AAVMC CBVE framework.[4] The domains selected for this course were (1) clinical reasoning and decision-making; (2) individual horse care and management; (3) horse population care and management; (4) equine regulatory medicine; (5) communication and collaboration; (6) professionalism; and (7) financial and business management.

Faculty onboarding

To better familiarize practice partners with the formal role they adopt as instructors with the EPC program, an onboarding module was created using interactive, “clickable” Storyline software. The onboarding module consisted of three main sections that cover “Introduction, Boot Camp, and Preceptorship.” The onboarding module provided complete descriptions of the expectations for student involvement, competencies being tracked, methods of documentation, purpose for different learning activities, expected role of practice partners, and specific examples for how to involve students in authentic clinical cases. On completion (estimated to take 1 h), practice partners were prompted to print a certificate that was returned to the course coordinator. For their specific roles in documenting student learning, preceptors were asked to use the mobile Veterinary Education Tracker “VET” app to document their observation and assessment of student skills (i.e., intravenous injection, medical history-taking, physical examination, catheter placement); “sign off” case logs weekly; engage students in conversation prompts known as “truck talks” that focus on the student's professional development; and visit the EPC communication board. A certificate of onboarding completion was implemented as a requirement for community practice sites to receive rotating students.

Learning management system and the “Veterinary Education Tracker” app

The university LMS, Moodle, was used to create a new course website that served as the “VET” app, as well as a platform for students to participate in newly implemented course activities designed to enhance the online learning community. The app facilitates real-time tracking of student learning experiences in clinical practice. Through the app, students keep case logs and provide written and photographic documentation of the types of cases seen, procedures performed, and EPC competencies earned. The new course activities included written reflections of student–preceptor truck talks, course coordinator-led case/community discussion boards, and high-five boards. Finally, online quizzes were created to address competencies relevant to regulatory medicine.

Focus groups

The current study uses secondary data from four focus groups (including five students each) held at the end of rotation across the fall and spring. Due to the nature of the data, our study was deemed exempt from the Institutional Review Board process.

In the fall semester, the assessment team created a focus group guide consisting of semi-structured interview questions, using the project objectives and faculty input to outline questions to ask students enrolled in the course. Focus group questions were categorized using three main headings: (1) use and access; (2) instructions and support; and (3) perceived value. After brief introductions, the first part of these focus groups (”use and access”) encouraged students to provide more detail on how and when they accessed the LMS-based competency system, including the devices used (i. e., mobile or laptop) and students' general timeframe for uploading evidence of their learning. The LMS competency system was selected for students' feedback because the newly launched mobile version (Moodle Mobile) was being used by students as a tool to “check-off” competencies. Discussion then pivoted to students' perceptions of course resources related to providing evidence of their learning (”instructions and support”). In particular, questions focused on resource clarity, usability, and navigation, including materials related to downloading the VET app, submitting documents, and reviewing content. This portion of the focus group also asked students to reflect on which elements or resources within the course contributed most to their learning and skill development. Finally, focus group participants were asked to describe if and when the processes and systems used to document their learning helped them make connections to their prior learning experiences; and to describe the value, if any, they placed on documenting proof of their learning (i.e., competencies). Recommendations from the fall focus groups were used in the formative evaluation of the course, LMS, and VET app between the fall and spring semesters.[42]

In the spring, interview questions were (re) categorized based on The MUSIC Model of Motivation developed by Jones,[43] to reflect the use of the model in the instructor's promotion of CBE teaching strategies and measurable learning outcomes within the course.

Scripts for focus group interview questions are available upon written request to the corresponding author.

Data analysis

Content analysis was used to identify key themes, patterns, and categories from the open-ended feedback. Codes and categories were developed via open coding, linking different segments, and instances in the data and were a means to create categories that shared common properties or elements, relating to particular concepts (topic or theme). Axial coding was used to relate main categories with subcategories for the analysis.[44]

 Results



Results are presented under the same headings used for focus group questions: (1) use and access, (2) instructions and support, and (3) perceived value, and by semester (fall followed by spring) to compare students' experiences after formative changes were made. Student recommendations for improvements are provided at the end of each semester section.

Use and access

Fall semester

Overall, students reported experiencing difficulties with the mobile VET app, with many describing their ability to access and use the app to document competencies and skills as “unsuccessful” due to their inability to find adequate reception (cellular or wifi) during clinical visits at remote rural locations. As a result, students could not upload photographs using their cell phones during a visit. Further, some students received error messages when uploading large image files, indicating the image file type “was not compatible” with the app.

Due to this, students were forced to use their e-mail to transfer large files or wait until they had access to a desktop/laptop computer for easier and faster uploading of images. Some students said that this added extra steps when filling out the competency checklist and “… took time that could be better used for studying,” reporting a loss of motivation to upload documentation. Other students took a printout of the checklist to the clinic(s), so they could record the competencies they completed. While not all students knew they could do this, those who did said the printouts helped them feel “less overwhelmed” with the documentation process.

While some students reported being comfortable using the app on their cell phones, others were hesitant to use them for documenting competencies. Often, students' level of comfort was determined by the caliber of the client base. For example, owners of “high-end” horses (i.e., used for breeding and/or showing) or those selling a horse did not want students taking photographs of veterinary procedures. If a client asked why they were taking pictures, some students stopped using their smartphone cameras altogether to avoid being perceived as “rude” or “unprofessional.” Subsequently, some students thought that they needed to ask the preceptor(s) for permission to use their phones for photograph documentation. Students also reported a hesitation in using their cell phones after seeing veterinarians give “interns a hard time” because “they [the interns] were always on their phones.”

The requirement to take multiple pictures of their work was also cited as “breaking the flow” of appointment(s). This was especially prevalent when students were completing the same procedure in one visit (e.g., administering shots/vaccines). In these instances, students, instead, added one image and noted the number of times they had carried out the procedure.

When documenting competencies in Moodle, students noted that the interface design and the general outline of competencies were not necessarily user-friendly. Confusion on where to record their accomplishments led most students to miss a drop-down menu of subcompetencies under each main competency – and therefore, mistakenly thought that they had achieved full mastery of one or more competency when they had not.

Changes made

To avoid technical glitches when uploading files and navigating the online checklist in Moodle, the VET app used in the fall semester was replaced with an online Google form and the requirement for photographic “evidence” of skills was eliminated. To further aid students' submission process, and mitigate confusion when documenting competencies and subcompetencies, the professor provided the students with a spreadsheet detailing what procedures would count for meeting the requirements.

Spring semester

The switch to Google forms did not alleviate technical and internet access problems experienced in the fall. Students' remained frustrated with the time it took to check off all competencies and submit the pages online and continued to submit their evidence of learning at the end of the day.

However, more students compared to the fall said that documenting the EPC competencies using online technology was “adequate” or “worked” and made the process “easy.” Students explained that technology improved their accountability for completing the core competencies. Nevertheless, the procedure and the number of steps they needed to take “felt” redundant to them. They noted that the process of having to put a checkmark in the case log, share with the preceptor to review and sign off, and then fill out the Google form, made them feel like they were submitting the same thing in different ways to different people.

Student recommendations

Recommendations for improving the tracking of competencies and cell phone use centered around: (1) narrowing the number of required competencies and (2) altering the submission process for documenting competencies. In narrowing competencies, students suggested removing any competency that would be considered prerequisite/low-level and/or that would typically be mastered before beginning the EPC rotation.

In altering the submission system, students indicated a preference toward submitting photographic evidence for only the first instance they complete a procedure. Further, they suggested “flipping” the submission system to let students check off the competencies they complete before uploading photographs and other documentation, reducing cell phone usage whilst maintaining an adequate record of their work. Once completed, the online system could send an alert (e.g., e-mail or IM) to the preceptor asking for their validation that it was completed. Alternatively, instead of asking practitioners to sign off on each aspect, it was suggested that students could create an overview that practitioners verify at the end of an appointment. To ensure students complete all requirements, it was also suggested that faculty send e-mail reminders listing any “next steps” or missing subcomponents within the larger competency marked as complete.

In addition to changes to the current system, students also felt that it would be beneficial for future cohorts to have access to similar formats/technology before their clinical year. The main example used by students was their “yellow books:” A hardcopy book containing a list of core competencies they need to complete (checked off and initialized by CVM instructors) before graduation. Students felt transferring the yellow books into an online competency tracking system/interface would not only increase their comfort level in using the system before their EPC rotation but also alleviate issues faced by having a hardcopy (such as finding faculty, losing books, and transferring books online upon completion).

Instructions and support

Fall semester

When asked about the instructional support they received on how to document their learning, most students said that they looked at the instructional resources in Moodle during the 1st week only. However, students believed that it was good to have the resources available if needed.

In terms of accessing instructional tools and supporting documents, students indicated that navigating the course website was simple; “it worked.” They noted that the resources were easy to find and they used almost all of the instructional tools available online. Moreover, they found the resources/informational documents (i.e., drug guidelines) extremely valuable in their learning.

Responses also gave insight into the preceptor's use of instruction and support. Students noted that preceptors showed a low level of knowledge of the instructions and support built into the course. Some did not know the competency checklist existed until students told/showed them, and one practice partner did not know what the expectations were until the student explained that they needed to use the checklist to document completed competencies. Students also noted that not all veterinarians provided instructional support in the form of feedback. Students reported these issues, despite implementation of the new preceptor onboarding, which all preceptors were required to complete to receive rotating students.

Changes made

In response to the student feedback, and to recognize the fact that students' abilities to perform competencies varied depending on their site, students were reassured that there were no grading criteria that required a number of competencies to be completed for a certain grade in the course.

Spring semester

Students found the online resources to be useful as review materials. However, some wanted more clarification on when to submit evidence and check off completed competencies. Although students were informed that photographic evidence was no longer required, its inclusion is an option on the Google form caused confusion. Instructor assurance that competency completion was not tied to their course grade was seen to have a positive effect, with students' saying that the requirements were more reasonable than previously thought.

Student recommendations

Students' recommendations for further improving instructions and were focused on updating submission guidelines as technology improves or changes, as well as utilizing prior experiences of former students (i.e., a FAQ page) to help future students navigate the initial phases of the course. To aid the adjustment to the competency-based system, they suggested an initial student and preceptor training for how to use the technology. Students also believed that clearer communication with preceptors and clients was needed regarding the use of cell phones for photographing evidence of student competencies. This was despite the previous implementation of faculty onboarding and the addition of a submission guide to the LMS course site.

Perceived value

Fall semester

It is important to note that this CBDVE EPC rotation is the first course within our college to list and track competencies. Students reported that they initially did not connect the competency tracking in the EPC rotations with their learning experiences in other CVM courses. However, responses indicated that they saw the course model/structure as valuable when thinking about experiences they may have missed. Further, the use of competencies was viewed by the students as a way to provide an equitable learning experience. Students also indicated that their competencies motivated them to become proficient in all areas, including those of lower interest. Students also viewed the model as useful for in-clinic experiences, giving practitioners an understanding of a student's knowledge and skill level, and allowing them to tailor clinical learning to a student.

In relation to particular course elements, EPC case presentations were viewed as providing valuable learning experiences. In particular, conducting research was viewed as useful and helped students spend more time on a specific case by doing extra work to prepare for their case presentations. For about half of the students, the building of case logs helped students reflect on their learning progress during their EPC rotation by pausing and breaking down the process using the checklist. Reviewing their completed competency list in Moodle also aided their progress by helping them distinguish between the competencies they had completed themselves versus procedures they had only been able to observe.

Smaller veterinary practices gave students ample opportunities to learn and meet the course objectives and competencies required. Students who were assigned to larger equine clinics reported having limited hands-on learning. Consequently, students “could not document what the [preceptors] would not let them do/perform.” Some students said that they had more opportunities to gain proficiency with cases and case logs during boot camp week, but not in the actual practicing clinics, and that some preceptors treated the student(s) as a “tech” so s/he did not get to “see a case through to the end.”

Changes made

To help students appreciate the competencies fulfilled during boot camp “stations,” the course instructor modified the student evaluation forms for each Entrustable Professional Activity (EPA; see AAVMC Working Group, 2018 for definition)[45] station to include feedback on subcompetencies within the overall EPA and help students see the learning value in each EPA station.

To increase value for preceptors, registration waivers were offered to a CVM Symposium (counting as 8 h of continuing education). Further, the opportunity for adjunct appointments for participating preceptors, including the advantages of access to library resources, was highlighted as a key benefit in e-mail communications with preceptors. Formal student evaluation of preceptorships was also implemented as a key change; and individual preceptor feedback to the course coordinator attested to the value preceptors placed on receiving these student evaluations.

Spring semester

In comparison to other course structures, students said the course was “better” because they could voice their professional opinions, determine course(s) of treatment, conducte examinations and procedures multiple times, and had more opportunities to discuss concerns regarding case management. Students highlighted the benefits of the hands-on learning opportunities during the 1-week “boot camp.” They explained that faculty teaching the course helped students feel like “a doctor on their own.” As a result, students said that they gained more confidence answering real clients' questions.

Contrary to the fall semester, students in the spring described preceptors as understanding and valuing the course competencies. This understanding resulted in the preceptors allowing for added structure and effort to get students involved in more clinical cases. Hands-on care gave those students who planned to enter large animal veterinary medicine valuable real-world skills—something they were unable to fully gain from experiences with in-hospital cases.

Mixed experiences in the level of, and expectation of, student involvement on clinical cases were still present in the spring due to the varying size of the clinics, which correlated with the preceptor's inclusion of the student, and the time of year they took the course. This meant that students carried out “seasonal” types of appointments and possibly missed other clinical cases. Photographing competencies completed was still ultimately based on the level of comfort students had with the clients. There were clients who, despite understanding that students were learning, did not want pictures taken of their horses being treated.

Student recommendations

Students suggested four minor alterations to the course to further demonstrate the value of the course: (1) Provide students with access to case logs from previous academic terms, which would give students an understanding of each preceptor, his/her clinical practice, caseloads, and so on; (2) provide clearer communication with preceptors to improve their understanding of the value of the preceptorships; (3) provide clearer communication with practitioners, and in-turn their clients, on why students use cell phones for taking pictures; and (4) create an overview that practitioners can use to verify completed competencies at the end of each appointment, which may also result in the reduced usage of cell phones for documentation while still maintaining an adequate record of a student's learning.

 Discussion



While the needs for innovation in veterinary medical education are widely recognized, and consensus around CBE is growing, the development and implementation of new curricula in the varied settings in which veterinary students train can be challenging. The current paper describes opportunities for the improvement in a newly developed hybrid distributive model of EPC training, from the perspective of student experiences and perceptions. While it should be noted that use of focus groups is unlikely to produce a sample that is representative of the broader population, and transference of our findings may be limited due to differences in institutions goals and outcomes,[36] the current study provides valuable insight for those trying to implement both competency- and community-based training in their clinical rotations.

The ability to consistently and easily use and access course technologies provided some challenges for students when recording competencies (e.g., the inability to upload large image data files while in remote locations). Our observations are in line with studies describing technological challenges when medical students' are working in remote environments, as well as misinterpretation of students' use of mobile devices and patient concerns regarding privacy.[39] Because these clinical environments are key for community-based programs that strive to serve local and rural areas, solutions to these challenges are needed and worth addressing.

In the current study, feedback from students in the spring shifted away from the technology itself, to a focus on how to eliminate what students referred to as redundancy in the competencies documentation processes, posing another interesting area for discussion. As veterinary medicine shifts to CBE, how many instances, and what type of “evidence” will count toward documentation of student competency? What are the standards and relevant descriptors that designate developing levels of competence? This question is addressed in the recent AAVMC Working Group publication on CBVE Milestones. This document describes milestones as a “shared mental model for learners and educators regarding the progressive development of competency”[9] and explains that for each competency and learners skill level is novice, advanced beginner, competent, or proficient. Within this document, the AAVMC Working Group describes the observable characteristics of learners at each of these four skill levels for 32 competencies. Training veterinary teaching faculty to perform these assessments will certainly be challenging, but this task will be even more complex in models of CBE when private practice partners, and not university faculty, are responsible for verifying that student skills and/or knowledge was demonstrated to university standards. Although our team is still working to address these complex and forward-facing issues, we hope that by continually including a student voice in our examination of the course, we can tailor the use of instructional technology to meet both the students' needs as learners, and members of the educational community, including university faculty, private practice partners, and their clients.

Although students voiced frustration with the use of, and access to, instructional technologies, they did voice positive opinions relating to the course structure and even suggested the adoption of a similar approach prior to the EPC rotation/earlier in their degree. Students spoke positively about the online resources and instructions kept in the course website. In comparison to other courses, students felt that they could voice their professional opinions, could determine course(s) of treatment, and had more opportunities to discuss concerns regarding case management. Competencies showed them that students were getting a similar learning experience and helped distinguish between the competencies they had completed themselves versus procedures they had only been able to observe. Boot camp provided hands-on learning opportunities, and the building of case logs helped students reflect on their learning progress. Overall, we view these perspectives as evidence of positive impact of utilizing a hybrid model of campus- and community-based clinical training and as support for the prior literature that has advocated for the use of CBDME in veterinary medicine education.[1],[29]

Our findings did indicate some variation in student rotation experience, with students rotating at larger practices (or those with more “high-end” horses) reporting a lower level of inclusion and less hands-on learning. This finding highlights the conflict in priorities that can arise in CBDVE, when student education and client expectations intersect. However, this aspect of veterinary medical education is not unique to community-based training, as similar issues are reported with increasing case complexity and cost in tertiary care at academic teaching hospitals. One issue that is unique to mobile veterinary practice, however, is the fact that the client is “always watching,” as there is no “back room” to take the patient to for difficult procedures or teaching opportunities. As a result, mobile practice preceptors who serve a “high-end” clientele may require (either consciously or unconsciously) a higher level of student competence before skills can be performed with the client watching.

These findings indicate that further work is needed to address variations in student experiences in the EPC program. Alongside the course-related suggestions, relating to opening up and extending communication channels between students, preceptors, and faculty, we would also recommend that those examining campus- and community-based clinical training collate information from the preceptors themselves. While our current findings do provide some insights into preceptor relationships from the student perspective, our conclusions and the recommendations we can make are limited due to the lack of preceptor perspectives. Prior research [31] has suggested that dynamic interactions among preceptors regarding motivations, enjoyment, and challenges, influence their teaching and student–teacher interactions. A preceptor focus group approach, similar to the one we used for EPC students, may provide a fruitful lens to further contextualize students' perceptions of the course, as well as create useful information for EPC program faculty and coordinators to use in their ongoing efforts to maximize effective preceptor onboarding and preceptor–student interactions.

It should be noted that the transition to adopting such an approach at our institution was aided by a wider push for curricula change from the school of veterinary medicine (and the broader academic community). Implementation of CBDVE may not be feasible in areas in which its core principles are not valued, based on the considerable time it takes to develop such a program. Further, instructional-, technical-, and assessment-related support was crucial in the timely completion of the course components and the acquisition of actionable data that have enabled the instructor to implement a continuous improvement cycle moving forward.

 Conclusion



The current project aimed to improve transparency and documentation of intended student learning outcomes by defining and tracking competencies, improve preceptor training with required onboarding, and improve student–faculty–preceptor connectivity during distributed learning through creation of the “VET” app. The project also aimed to solicit student feedback to get a snapshot of program perceptions and then incorporated these data into the continuous improvement cycle, thereby empowering students by including their voices in instructional course design. We view the collation of students' perspectives as being invaluable for program development. As noted in prior literature, students' perspectives and viewpoints are important in understanding engagement in CBDME courses/programs.[35] The next goal for improving this CBDVE competency-based course will be backward design of the veterinary curriculum in years 1–3, to better align intended learning outcomes of earlier courses with competency-based assessments in the 4th clinical year.

Acknowledgment

We would thank members of DELTA, including Bethanne Tobey, Chris Willis, Mike Cuales, and Merranie Zellweger, for their work developing and implementing the VPC redesign project.

Financial support and sponsorship

NCSU DELTA Blended Learning Grant supported the study.

Conflicts of interest

There are no conflicts of interest.

References

1Burns K. The experience of rural medicine. J Am Vet Med Assoc 2007;230:177-9.
2Farnsworth TJ, Frantz AC, McCune RW. Community-based distributive medical education: Advantaging society. Med Educ Online 2012;17:8432.
3Parker L, Watts LD. How we involved rural clinicians in teaching ethics to medical students on rural clinical placements. Med Teach 2015;37:228-31.
4Molgaard LK, Hodgson JL, Bok HG, Chaney KP, Ilkiw JE, Matthew SM, et al. AAVMC Working Group on Competency-Based Veterinary Education) Competency-Based Veterinary Education: Part 1-CBVE Framework. Association of American Veterinary Medical Colleges; 2018.
5Bok HG, Jaarsma AD. Competency-based education. In: Hodgson JL, Pelzer JM, editors. Veterinary Medical Education: A Practical Guide. New York: Wiley Blackwell; 2017. p. 24-35.
6Gruppen LD, Burkhardt JC, Fitzgerald JT, Funnell M, Haftel HM, Lypson ML, et al. Competency-based education: Programme design and challenges to implementation. Med Educ 2016;50:532-9.
7Hodgson JL, Pelzer JM, Inzana KD. Beyond NAVMEC: Competency-based veterinary education and assessment of the professional competencies. J Vet Med Educ 2013;40:102-18.
8Welsh PJ, Jones LM, May SA, Nunn PR, Whittlestone KD, Pead MJ. Approaches to defining day-one competency: A framework for learning veterinary skills. Rev Sci Tech 2009;28:771-7.
9Salisbury SK, Chaney KP, Ilkiw JE, Read EK, Rush BR, Bok HGJ, et al. (AAVMC Working Group on Competency-Based Veterinary Education) Part 3 – Milestones. Association of American Veterinary Medical Colleges; 2019.
10Garfolo BT, L'Huillier B. Competency based education (CBE): Baby steps for the United States. Acad Bus Res J 2016;1:100-16.
11Molgaard LK, Hodgson JL, Bok HGJ, Chaney KP, Ilkiw JE, Matthew SM, et al. (AAVMC Working Group on Competency-Based Veterinary Education) Part 2 – Entrustable Professional Activities. Association of American Veterinary Medical Colleges; 2018.
12Bok HG. Competency-based veterinary education: An integrative approach to learning and assessment in the clinical workplace. Perspect Med Educ 2015;4:86-9.
13Bok HG, Teunissen PW, Boerboom TB, Rhind SM, Baillie S, Tegzes J, et al. International survey of veterinarians to assess the importance of competencies in professional practice and education. J Am Vet Med Assoc 2014;245:906-13.
14Lewis RE, Klausner JS. Nontechnical competencies underlying career success as a veterinarian. J Am Vet Med Assoc 2003;222:1690-6.
15Walsh DA, Osburn BI, Christopher MM. Defining the attributes expected of graduating veterinary medical students. J Am Vet Med Assoc 2001;219:1358-65.
16Bok HG, Jaarsma DA, Teunissen PW, van der Vleuten CP, van Beukelen P. Development and validation of a competency framework for veterinarians. J Vet Med Educ 2011;38:262-9.
17Mahoney S, Walters L, Ash J. Urban community based medical education-general practice at the core of a new approach to teaching medical students. Aust Fam Physician 2012;41:631-6.
18Mennin SP, Kaufman A, Urbina C, McGrew M. Community-based medical education: Toward the health of the public. Med Educ 2000;34:503-4.
19Mennin S, Petroni-Mennin R. Community-based medical education. Clin Teach 2006;3:90-6.
20Hunt JB, Bonham C, Jones L. Understanding the goals of service learning and community-based medical education: A systematic review. Acad Med 2011;86:246-51.
21Schurig G, Osburn BI. The North American Veterinary Medical Education Consortium (NAVMEC) looks to veterinary medical education for the future: “Roadmap for veterinary medical education in the 21st Century: Responsive, collaborative, Flexible”. J Vet Med Educ 2011;38:320-7.
22Gordon-Ross PN, Schilling EF, Kidd L, Schmidt PL. Distributive veterinary clinical education: A model of clinical-site selection. J Vet Med Educ 2014;41:179-88.
23Kelly L, Walters L, Rosenthal D. Community-based medical education: Is success a result of meaningful personal learning experiences? Educ Health (Abingdon) 2014;27:47-50.
24Mokhtarpour S, Amini M, Mousavinezhad H, Choobineh A, Nabeiei P. Evaluation of the strengths and weaknesses of community-based education from the viewpoint of students. J Adv Med Educ Prof 2016;4:195-201.
25Walters L, Stagg P, Conradie H, Halsey J, Campbell D, D'Amore A, et al. Community engagement by two Australian rural clinical schools. Australas J Univer Community Engagem 2011;6:37-56.
26Walters L, Greenhill J, Richards J, Ward H, Campbell N, Ash J, et al. Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ 2012;46:1028-41.
27Fuentealba IC, Hecker KG. Clinical preceptor evaluation of veterinary students in a distributed model of clinical education. J Vet Med Educ 2008;35:389-96.
28Carney PA, Eliassen MS, Pipas CF, Genereaux SH, Nierenberg DW. Ambulatory care education: How do academic medical centers, affiliated residency teaching sites, and community-based practices compare? Acad Med 2004;79:69-77.
29Latessa R, Beaty N, Royal K, Colvin G, Pathman DE, Heck J. Academic outcomes of a community-based longitudinal integrated clerkships program. Med Teach 2015;37:862-7.
30Fuentealba C, Mason RV, Johnston SD. Community-based clinical veterinary education at Western University of Health Sciences. J Vet Med Educ 2008;35:34-42.
31Turnwald G, Stone E, Bristol D, Fuentealba C, Hardie L, Hellyer P, et al. Assessing clinical competency: Reports from discussion groups. J Vet Med Educ 2008;35:343-53.
32Hashizume CT, Hecker KG, Myhre DL, Bailey JV, Lockyer JM. Supporting veterinary preceptors in a distributed model of education: A faculty development needs assessment. J Vet Med Educ 2016;43:104-10.
33Hashizume CT, Myhre DL, Hecker KG, Bailey JV, Lockyer JM. Exploring the teaching motivations, satisfaction, and challenges of veterinary preceptors: A qualitative study. J Vet Med Educ 2016;43:95-103.
34American Veterinary Medical Colleges Center for Veterinary Education Accreditation. Schaumburg, IL: American Veterinary Medical Association. Available from: https://www.avma.org/ProfessionalDevelopment/Education/Accreditation/Pages/default.aspx. [Last accessed on 2020 Mar 12].
35Matthew SM, Ellis RA, Taylor RM. Evaluating the quality of veterinary students' experiences of learning in clinics. J Vet Med Educ Summ; 44:369-80.
36Weijs CA, Coe JB, Hecker KG. Final-year students' and clinical instructors' experience of workplace-based assessments used in a small-animal primary-veterinary-care clinical rotation. J Vet Med Educ 2015;42:382-92.
37Maudsley G, Taylor D, Allam O, Garner J, Calinici T, Linkman K. A Best Evidence Medical Education (BEME) systematic review of: What works best for health professions students using mobile (hand-held) devices for educational support on clinical placements? BEME Guide No. 52. Med Teach 2019;41:125-40.
38Ferenchick GS, Solomon D. Using cloud-based mobile technology for assessment of competencies among medical students. PeerJ 2013;1:e164.
39Payne KB, Wharrad H, Watts K. Smartphone and medical related App use among medical students and junior doctors in the United Kingdom (UK): A regional survey. BMC Med Inform Decis Mak 2012;12:121.
40Hubbell JA, Saville WJ, Moore RM. Frequency of activities and procedures performed in private equine practice and proficiency expected of new veterinary school graduates. J Am Vet Med Assoc 2008;232:42-6.
41Smeak DD, Hill LN, Lord LK, Allen CV. Expected frequency of use and proficiency of core surgical skills in entry-level veterinary practice: 2009 ACVS core surgical skills diplomate survey results. Vet Surg 2012;4:853-61.
42Flagg B. Formative Evaluation for Educational Technologies. Hillsdale, NJ: Lawrence Erlbaum Associates; 1990.
43Jones B. Motivating students to engage in learning: The MUSIC model of academic motivation. Int J Teach Learn 2009;21:272-85.
44Coffey A, Atkinson P. Making Sense of Qualitative Data. Thousand Oaks: Sage Publications; 1996.
45Molgaard LK, Chaney KP, Bok HGJ, Read EK, Hodgson JL, Salisbury SK, et al. Development of core entrustable professional activities linked to a competency-based veterinary education framework. Med Teach 2019;41:1404-10.