“A Taste of Real Medicine”: Third Year Medical Students’ Report Experiences of Early Workplace Encounters

Background

In the senior years, medical students transition to the clinical learning environment, whereby they join their clinical team, and engage in experiential work-based learning.¹ Here students learn “real medicine,” as they develop socially and professionally with others who share the profession. There has been a considerable body of evidence to suggest that this transition is challenging, stressful and a huge learning opportunity. It is in this environment that their professional identity further develops by exposure to “real” medical situations, where they witness ethical dilemmas,² and the professional and/or unprofessional behaviours of other clinicians.

Theoretical Framework

This type of learning is known as workplace learning, situated learning,³ or situated cognition,⁴ and is an entry into what Lave and Wenger (1991) have described as a “community of practice”,³ Here, common interests are shared, members socialise and engage in collective learning in the context in which it is applied.

Students commence work as newcomers to their community of practice as “peripheral participants”;³ and by performing tasks appropriate for their level of training, students become more engaged within their workplace community. Their contribution allows them to become “legitimate peripheral participants” in the profession.³ This learning forms an upward trajectory over the duration of students’ training as they move towards a more central role, and become a full professional within their community of practice.³ This is illustrated in Figure 1.

Figure 1 The evolution of senior medical students in this study in their journey to becoming central members to their community of practice.3

To allow learning to occur in the work environment, students require opportunities that enable learning. Billet describes these opportunities as workplace affordances,⁵ which are closely aligned with communities of practice. Such affordances include clinicians seeking tasks for students which are within their level of educational development⁶ and will not pose any risk to patient safety. Along with affordances, students require the motivation and determination to initiate their learning, which Billet refers to as learner agency.⁷ Learning is ideally performed utilising “deliberate practice”,⁸ whereby supervision is provided by an experienced clinician and feedback is given.⁹ Although this feedback is invaluable in influencing students’ learning outcomes, it can be overlooked or omitted due to supervisor time constraints.¹⁰

There is an array of educational frameworks to explain medical students learning patterns,¹¹ and their experience of transferring their ‘preparatory’ or basic science knowledge to real-life, clinical application. In this study, we chose Lave and Wenger’s (1991) communities of practice theory³ to examine student integration into their team, and Billet’s (2009) workplace affordances¹² to investigate situations that permit student workplace engagement. Both theoretical frameworks help to describe the early learning experiences of senior medical students, through their reports on early encounters in the clinical workplace.

Lave and Wenger (1991) focused on the interaction between new learners, experts, and the evolution of the professional identity of newcomers, by emphasising the social nature of learning. This was characterised by three key elements: Joint enterprise; refers to people who share a domain of interest, are engaged and working together toward a common goal. Mutual engagement; describes the interaction between individuals, including joint activities that leads to the creation of shared meaning on issues, or problems. Shared repertoire; refers to the common resources, including tools and conversations that members use to negotiate meaning, and facilitate learning within the group.

Wenger (1998) revised the above three key elements of a community of practice and indicated that four inter-connected elements are necessary to make a community of practice work:

1. Meaning: Members' experience expands to gain a shared meaning.

2. Practice: In medicine, practice consists of clinical care, educational practices, research, and a perspective that will sustain mutual engagement.

3. Community: Refers to learning as “belonging” to the community such as joint enterprise.

4. Identity: Members experience how learning changes who they are.¹³

Context

The participants in this study were Year 3, medical students enrolled in a 4-year graduate entry degree in the Sydney Medical Program (SMP), at the University of Sydney School of Medicine, Australia. During years 1 and 2, students attended their “parent” hospital at Central Clinical School (CCS) Royal Prince Alfred Hospital (RPAH), one day per week. Over those two years, their contact with “real” patients was limited to tutor supervised Clinical examination and Communication Skills tutorials on the wards, plus Procedural skills tutorials, utilising simulated models, or standardized patients, in the Clinical Skills Laboratory.

Despite this limited contact with “real” patients during the first year of medical school, it is compulsory for students to engage in reflective writing tasks. This is termed “Personal and Professional Development” (PPD),¹⁴ and provides the opportunity for them to explore ethical and professional components from their own clinical observations.

Immediately prior to commencing Year 3, all RPAH medical students attend an intensive orientation program consisting of an overview of Stage 3 (ie, Years 3 and 4) at a faculty orientation, and a two-day orientation at their home Clinical School (RPAH). The latter included the revision of core procedural skills; cardiopulmonary resuscitation; revision of cannulation; scrubbing/gowning/gloving; suturing; venepuncture; plus an introduction to writing in the patients’ case notes.

Students meet with their supervisors on a weekly basis to complete a protocol of scheduled tasks over the duration of their attachment. In addition, all Stage 3 students attend a weekly bedside teaching session, and additional structured teaching, including student-led presentations.

Methods

Developing of Study Instruments

Focus group questions were developed in collaboration with the co-author (C M), and two intern clinicians. The focus group questions asked about; students’ experience in working as part of the hospital team; encounters with clinician role models; observation of clinical professionalism; experience of interactions with patients; and opportunities to perform procedural skills under supervision. Focus group questions are in Appendix 1.

Sampling and Recruitment

Between 2015 and 2018, a convenience sample of Year 3 students at Central Clinical School Royal Prince Alfred Hospital (total n=200) was selected. All students were invited by e-mail to participate in focus groups regarding their first two 8-week rotations in the clinical work environment.

Data Collection and Analysis

After obtaining signed consent, five focus groups were conducted by the first author (SMcK). (Two in 2015 and one in subsequent years). Participants’ confidentiality was protected by the use of pseudonyms to conceal their identity.

Focus Groups

Focus groups were audio recorded, transcribed verbatim and thematically analysed¹⁵ by SMcK and AB, using framework analysis to code the date set within the conceptual frameworks of community of practice,¹³ workplace affordances.¹²

Ethical Considerations

Ethics approval was obtained from The University of Sydney Human Research Ethics Committee. Approval number 2024/182.

Results

Thirty-six students out of 200 (18%) attended focus groups over a four-year period. The results are presented using the theoretic frameworks of community of practice¹³ and Billet’s workplace affordances.¹²

The themes are summarised in Tables 1 and 2; Themes of: Meaning “learning as experience,” Practice “learning as doing,” Community “learning as belonging”, and Identity “learning as becoming” (Table 1). The themes of “workplace affordances”, (referring to situations that allow student learning), are presented in Table 2, under “clinical affordances,” “student agency” and “risks”.⁷

Table 1 Participants’ Responses Relating to Wenger’s Summarised Conceptual Framework for a Social Theory of Learning “Communities of Practice”

Table 2 Participants responses relating to Billet’s Workplace Affordances in Participants’ Experiences in Situated Learning: Clinical Affordances

Discussion

This study sought to investigate senior students’ perspective on their early experiences in workplace learning using the theoretical frameworks of communities of practice and workplace affordances. Interestingly, students did not explicitly discuss issues such as personal stress, and “the steep learning curve,” strong reoccurring themes in similar studies.¹⁶ Their reports focused on positive and negative clinician role models, their interaction with the patients and their teaching ability, as they further formulated their own professional identity. They were quick to identify ethical dilemmas, although as students they were powerless to take the initiative to modify such behaviours.

Theme of Meaning: “Learning as experience”

Participants reported many positive examples of enthusiasm in participating in workplace learning and being in a situation that enhanced their professional identities. This included performing the role of the doctor, by independently examining and taking patient histories. One reported witnessing optimum patient care by observing the activities of the inter-professional team. This learning experience highlights the value of exposure to inter-professional teamwork, to gain an understanding of the role of others in the healthcare team,¹² and suggests the need for this to be added to future curricular implementation.

Theme of Practice: “Learning as doing”

Although at first daunting, participants found workplace learning to be the best learning experience, as they “learn by doing” in everyday work activities. Evidence suggests that actively engaging in learning promotes a greater depth of understanding, and increased knowledge retention, as well as further development of their own professional identity. For example, entrustment in performing the professional procedure of cannulation (See Table 1). This concept of entrustment was first proposed by Ten Cate (2005) as Entrustable Professional Activities, (EPAs),¹⁷ to describe trainees who have the knowledge and skills to perform a particular procedure under varied levels of supervision. This enabled some study participants to assist their team and become legitimate peripheral participants in their community of practice.

Theme of Community: “Learning as belonging”

Participants who had a formal introduction to the learning environment reported better team integration, and a stronger framework for learning. In contrast, the absence of an induction left some respondents feeling unwanted, unwelcome, and ignored.

These findings are consistent with the studies of Boor (2008), in that the clinical learning climate “affects undergraduate medical students’ behaviour, satisfaction and success.”¹⁸ In accordance with Gordon (2000), “learners need adequate briefing prior to moving into new clinical experiences”,¹⁹ and “leaders should make the rotation supportive for their students”.^20,21

Theme of Identity: “Learning as becoming ”

By exposure to positive and negative role models, participants were able to identify with the kind of doctor that they would like to become. Positive role models demonstrated good teaching skills, knowledge, communication skills and patient-centred skills. These findings are in line with Ginsberg et al (2011) who found that through witnessing professional decision making, students developed their own professional judgment. Clearly, this is “not something that can be learned in a lecture”.² This highlights that professional ethos has been developing not just in clerkship, but also in the preparatory years. Cruess et al assert that:

A physician’s identity is a representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized, resulting in an individual thinking, acting, and feeling like a physician.²²

Affordances

Some clinicians offered workplace affordances, such as permitting participants to write in the case notes and perform rudimentary procedural skills – thus allowing them to experience a sense of autonomy from day one. This contribution to the team allowed students to be legitimate participants in their community of practice. Furthermore, students enhanced their learning experience by contributing to workplace goals through participatory practice.¹² One participant reported optimising their contributions to their team by being agentic and announcing that “they were there to learn”; therefore, rather than remain a passive observer, they facilitated active workplace involvement (Table 2). Whilst a challenge, agentic, participatory practice of this kind was reported as effective,¹² and obviously, this self-regulated learning can help prepare students for lifelong learning.²³

The Risks of Learning in a Community of Practice

Lave and Wenger (1991) acknowledged that there are risks involved in learning in a “community of practice,”³ as the learning community can be weak, or learning situations can be tied to organisational or power inequalities,²⁴ Furthermore, the clinical work environment is “real,” highly complex, and varied, as students interact with an array of clinicians and patients to engage in first-hand clinical experiences. This informal learning is a sharp contrast to students’ structured preparatory experience of learning basic procedural and communication skills in the controlled simulated setting of the Clinical Skills Laboratory.²⁵ Outside of the formal university curriculum students learn in an informal manner, Haffery and Franks describe this as the “hidden curriculum”,²⁶ which has positive and negative aspects. Participants were unprepared for the negative aspects of the “hidden curriculum.” For example, workplace risks involving “mean teams”, and clinician lapses in professionalism that could compromise both patients and students’ physical and emotional safety. Others reported being coerced into performing tasks beyond their level of experience, and conflicting with learned values from their formal curriculum²⁶. That is, performing invasive procedures on patients without adequate supervision. This has been described by Vygotsky (1990) as, beyond the “Zone of proximal commencing development.”²⁷ There were also unexpected hidden risks for students in the workplace. For example, the teams' amusement regarding a student’s exposure to an infectious patient. Also, team constraints, resulting in missed opportunities to perform skills – such as the team completing procedural skills work to avoid the student slowing them down; and students lack of agency to initiate situations that would enhance their learning.⁷

What This Study Adds

This study highlights the curricular need for future learners to have an understanding of their novice role, the roles of others, and “hidden risks” when entering the workplace as peripheral participants. Having an awareness of workplace affordances and being agentic, promoted engagement into their team as students moved towards becoming legitimate participants.

Orientation sessions, worksite inductions, and an awareness of their responsibility to the team assist students in attaining their workplace goals. Dealing with “real patients”, ethical dilemmas, positive and negative role models all contribute to the development of professional identity, and of achieving their ultimate goal of becoming a competent doctor.

Limitations

The sample size was smaller than intended as students had other, unforeseen obligations to remain in the clinical area. Consequently, this study may not reflect the opinions of all Year 3 students.

Conclusion

By using the theoretical frameworks communities of practice and workplace affordances, we found that participants reported enthusiasm and a sense of autonomy in workplace learning. They became legitimate peripheral participants to their community of practice by performing appropriate tasks for their team. Workplace affordances can facilitate, or hinder students’ progress. Those who were agentic were able to express their motivation and effectively join the team, thus avoiding the risk of being ignored. Students were exposed to unexpected hidden risks in the workplace, such as lack of site induction; unsupportive teams; ethical dilemmas; risks to patient safety; and lack of adequate supervision. Role models, both positive and negative, allowed participants to reflect on the further development of their own professional identity, and explore the traits of the kind of doctor they aspire to be.

Future Research

Further research in this important area of learning is needed. Future similar studies in other medical schools (both nationally and internationally), utilising larger sample sizes should further clarify many of the issues raised by our study.