Letter to the Editor Regarding the Article “What Aspects of Supervised Patient Encounters Affect Students’ Perception of Having an Excellent Learning Outcome? A Survey Among European Medical Students” [Letter]

Dear editor

We have reviewed Thyness et al paper titled “What aspects of supervised patient encounters affect students’ perception of having an excellent learning outcome? A survey among European medical students” (Thyness et al, 2023)¹ and would like to express our gratitude for their findings. As medical students in the United Kingdom (UK), we would like to share our perspectives on the study.

The study aimed to investigate the association between supervisor behaviour, students’ participation and approach, and psychological safety with self-reported excellent learning outcomes in supervised patient encounters. The authors distributed a self-reported questionnaire among medical students and reported that only 17% of students perceived their most recent learning encounter as excellent. We find this result disappointing and propose potential explanations.

One limitation is that the students were instructed to recall their most recent supervised patient encounters. To mitigate recall bias, we suggest including information on the number of days since their last patient encounter in future studies.

Another concern relates to the methodology, which relied on self-reported questionnaires. Barnsley et al² found that medical students are largely poor judges of their own performance in self-reported assessments and there may have been a discrepancy in the way students judged the category “excellent”. Exploring the meaning of excellence as perceived by medical students could provide a more accurate representation of encounter quality.

The study employed the Clinical Learning Evaluation Questionnaire (CLEQ) to measure students’ approach to learning. However, the reliability of this questionnaire is limited, as evidence for its effectiveness is derived from a single study (Alnaami et al, 2020).³ Expanding the evidence base for the CLEQ would enhance its applicability across different contexts.

The study found negative associations between supervisor presence, discussion of thoughts and student participation with excellent learning outcomes. The authors highlighted a potential reason being a lack of experience-based learning (ExBL) in clinical settings. In the UK, workplace-based assessments such as directly observed procedures (DOPS) serve as a hallmark for ExBL. ExBL has been shown to have a positive influence on student motivation, confidence, and psychological safety (Dornan et al, 2019).⁴ However, the quality and nature of the DOPs can vary significantly depending on the teaching clinicians, which further influences students’ learning.

Quantitative research like this study provides a snapshot of a specific moment and offers a bird’s-eye view of experiences. However, it lacks the context of individual experiences and fails to delve into the reasons behind each supervisor’s behaviour, which could add value to the statistical analysis.

In summary, our review of Thyness et al¹ paper highlights certain limitations. These include recall bias, potential discrepancies in self-reported assessments, and limited reliability of the CLEQ. While the study sheds light on the discrepancy in teaching excellence within clinical medicine, there is a risk of infantilising medical students and underestimating their prior capacities. We encourage future studies to integrate ExBL in teaching to enhance psychological safety and motivation to learn.

We sincerely appreciate the authors’ insightful contributions to medical education.