Introduction:
In the past two decades the content and delivery of medical education both in Australia and abroad has been rapidly changing from its traditional past.(1-3) These reforms have been instigated for a number of related reasons notably through necessity due to the changing nature of medical practice, rapid increases in medical knowledge and the need for graduands that are independent learners.(3)
That is contemporary models of medical delivery have moved to a more community based model.(2,3) The additional imperative that has shaped this reform is the continuing expansion of medical knowledge hence students cannot rote learn all the necessary knowledge.(3) Rather they need to be equipped with the ability to be able to independently learn and solve problems.(3)
The importance of student’s perspectives in informing curricula and pedagogy has long been recognised (1,4), however pragmatically student’s viewpoints are under-utilised. If students perspectives are drawn on; this knowledge is utilised on an institutional basis and is rarely disseminated in the academic literature.
The importance of student’s perspectives and experiences was highlighted by Ludwig Eichna who after retiring from his Chair in 1974 in the Department of Medicine at the State University of New York undertook the medical course in order to inform the evolution of the curricula.(5) Eichna’s (5) view is summarised in a quotation below.
“...curricula, the basis of education, are devised by committees of faculty members according to their own concept of what is best, from their own outlook and their own level of knowledge...Little thought is given to what students go through – people who are one-third to one-half the age of the faculty, differently educated, from a different culture, with different goals. No one on the faculty experiences what students go through."(5)
Within the sphere of psychiatry education the published literature predominantly focuses upon students attitudes.(6,7) Although this is an important area of inquiry it does little to inform us of how the students broadly experience the educational process in psychiatry. Thus in the context of the rapid changes that have taken place in medical education such knowledge will assist in both evaluating and evolving educational strategies. Further Prideaux (8) ascertains that curriculum is comprised of three distinctive components; what is planned and intended for the students to learn, what is taught and delivered to the students and lastly what the students actually experience. This final component is the focus of the current study and is often referred to as the hidden or informal curriculum.(9-11) Therefore this study explores medical student’s experiences and perspectives of their first clinical psychiatry rotation in a ‘new’ era medical school in Australia.
Methodology
Background: The University of Wollongong’s (UoW) Graduate School of Medicine (GSM) is a new medical school that provides a 4 year graduate entry degree. The school employs an integrated curriculum. Specifically students receive psychiatry training within each of the three phases. Namely students learn the neurobiological basis of psychiatry in the first phase, mental health presentations in a hospital based rotation in the second phase and in the final phase learning is centred on primary care psychiatry. This study pertains to phase two of the curriculum where students take part in a mandatory hospital based rotation and non-mandatory option however highly recommended option to further their experience through exposure to other psychiatric services.(12)
Participants: Seventy-three of a possible 79 graduate entry Phase 2 medical students participated in this study, a response rate of 92%. Of which 40 are female and 33 are male; with a mean age of 26.5 years(sd= 3.4).
Procedure: Upon completion of their first Psychiatry Hospital-Based Clinical Rotation the students completed a brief open-ended questionnaire about their experiences and views of the rotation. An open-ended questionnaire was utilised as we did not wish for the students responses to be limited by a forced choice methodology. Students were asked to comment on their experiences pertaining to each of the areas outlined in Table 1 below. Completion of the questionnaire was voluntary.
Table 1: Summary of Questionnaire Content |
| 1. Learning Objectives |
| 2. Patient Access |
| 3. Preceptor Access |
| 4. Access to Allied Health Clinicians |
| 5. Feedback from Preceptor/Clinicians |
| 6. Rotation Handbook |
| 7. References |
| 8. Tutorials |
9. Additional Experiences |
10. Positive Aspects of Rotation |
11. Areas for Improvement |
12. Other Comments |
Analysis: The qualitative feedback were read and re-read by two of the authors who grouped the responses independently into thematic categories. The authors than collaborated and compared the thematic categories that were coded. It was evident that the authors classified the content into similar themes; where inconsistencies were apparent the authors discussed the excerpts till a resolution was reached. The authors than collaborated to devise descriptive names for each of the thematic categories; each category contains both positive and negative viewpoints.
Results
The results of the study indicated five thematic categories namely; staff, breadth or range of experience, course materials and structure, attitudes towards mental health or illness and professional development. An overview of these themes and the frequency with which they were represented in the qualitative data set is illustrated in Figure 1 below. The two most prominent themes being staff and breadth of experience are illustrated at the bottom of the pyramid. Each of these thematic categories is described below and illustrated with excerpts that represent both positive and negative viewpoints.
 |
Figure 1: The Themes Evident in the Student’s Views of their First Psychiatry Clinical Rotation. |
The theme at the base of the pyramid was the mostly frequently citied and the remaining themes frequency is indicated by the level they are represented on in the pyramid.
Staff
One of the most prominent themes in the analysis pertained to the staff the students were exposed too, worked with and educated by during their clinical rotation. Overwhelmingly the feedback was positive with the majority of students commenting on support and help provided by the staff.
All staff were very approachable and supportive, keen to share their knowledge and experience.
Within this category the students also commented on the knowledge and guidance provided by their preceptor and other staff.
The Doctors at **** were helpful and gave up quite a lot of their time to teach which was much appreciated.
Also evident within this category were comments pertaining to the enthusiasm of the staff members.
The preceptors were fantastic. They were enthusiastic and approachable and very generous with their time and knowledge.
Although the majority of the feedback pertaining to the staff was positive the following excerpts reflect the negative experiences of some students during the rotation. The vast majority of the negative viewpoints expressed within this category pertain to the accessibility of clinical staff.
Greater access to preceptors would be useful.
Would have preferred to have a regular registrar/intern/resident on the ward.
One student reported issues with the teaching style of one preceptor as is evident in the excerpts below.
Dr **** was always available however I found that I could only engage with him to a certain level as he is immovable in his encouragement of self reflection.
Breadth of Experience
The other most prominent theme that was evident in the analysis pertained to the amount of exposure the students had to patients with different conditions and the opportunity to acquire and practice different mental health skills. Most students reported being exposed to a range of patients with different conditions however some students reported that their experiences were limited, as illustrated in the excerpts below.
I was exposed to a variety of patients that I felt met the learning requirements.
Not as much turnover of patients as intended.
The patients on our ward were predominantly depressed older patients so we had to venture further afield.
Furthermore the majority of students reported undertaking a variety of experiences other than the mandatory hospital based component of their rotation. However some students reported issues with accessing some services. It should be noted though that students were required to be proactive in their pursuit of the recommended additional experiences. The text in the brackets indicates the nature of the facility attended.
Awesome to see a positive side in schizophrenia treatment. (Clozapine Clinic)
Good to see how mental health patients function in the community (Community Mental Health)
Good to see how the systems interact - health, legal etc (Mental Health Review Tribunal)
Great exposure to the low prevalence illnesses (Psychiatric ICU)
Good to witness - breaks many of the myths when witnessed (Electroconvulsive Therapy)
The Dr there was very helpful and gave good overview of D&A detox (Drug & Alcohol Services)
Another issue that was apparent in this thematic category were excerpts pertaining to the student’s ability to acquire and practice a range of mental health skills. These comments were only positive.
Extensive experience interviewing patients with mental illness. V. important! Especially acutely ill patients.
Plenty of opportunities to interact with patients. Lots of practice on history taking, mental state exams etc. Experiences outside the hospital was also helpful to broaden my knowledge of mental health in the broader community
I received excellent feedback from the clinicians that helped me grow. When I first started I had little confidence in my ability to conduct MSEs, Risk Assessments and Psychiatric histories. Now I feel very confident.
Course Materials & Structure
The theme pertaining to the course materials and structure of the course contains feedback relating to the learning objectives, handbook and structure of the tutorials. Both positive and negative viewpoints were evident in each of these areas. The following excerpts display the student’s opinions in regards to the learning objectives and course handbook which were overwhelmingly positive.
Very clear learning tasks made it easy to relax into the rotation and cover the important points.
Great handbook with very clear information on what is expected, how to get started and where to go/look for help.
Objectives clearly outlined. Handbook is fabulous, gives great insight into what is expected from the rotation. Community links are immensely helpful.
The other component of this thematic category relates to the structure of the tutorials, the students views were split between enjoying the student driven structure and others wanting more formal structure to the tutorial schedule.
Liked the opportunity to ask my questions without feeling stupid
Would be good if there was a little more structure, but on the other hand it is good to nut out where we need help with.
They inevitably developed into good tutes each week, but perhaps some original structure for each of the five tutes would be useful.
Attitudes towards Mental Health
Another theme evident in the analysis although not as common as the above three already discussed related to the student’s attitudes to MH. Notably it was evident from some of the student’s perspectives that their attitude towards MH and psychiatry changed throughout the rotation.
So much fun! I believe from this rotation I would consider a career in psychiatry. Thank you!!
Enjoyed learning about mental health issues that few people would know. Feel privileged to be less ignorant.
Really enjoyed this experience and understand from having it that you can't understand psychiatric illness from a textbook and need to have experience with patients.
Enjoyed it, changed my conception of psychiatry and mental health practice.
Good to confront my personal stigma associated with mental health.
Professional Development
The final theme that was evident pertained to professional development; the content of this theme reflected the students being exposed to and acquiring general skills and abilities that will be required throughout their career.
I was able to build ward skills such as writing in notes, checking bloods and giving ward handovers which will help in future rotations and throughout my career.
Consultant involved us as a team, getting us to present cases in handover, phoning family members, interviewing and writing in the patient’s notes. It was a good experience to be involved in that way. Our consultant made sure that we were the only ones involved in **** and expected us to act like 'mini-interns'.
Discussion
It is evident from the results of this study that the most important aspects of the student’s educational experiences in their first psychiatry clinical rotation pertained to the staff and range of experiences they had the opportunity to partake in. The next most significant theme related to the course structure and materials. The other two themes that were the least evident in the student’s perspectives were attitudes towards mental health and professional development. Interestingly it is apparent that the themes identified within the current study reflect the current academic recommendations for educating medical students generally as well as in psychiatry specifically. Also the themes’ evident reflect previous empiric findings about the nature of the hidden or informal curriculum.(9-11) The results are discussed in the context of the academic literature.
The most prevalent theme identified; staff is well recognised in the academic literature. With the notion of enthusiastic teaching academics and clinicians being evident in our findings. Furthermore it was also apparent within the staff theme that the student’s felt supported in their learning, thus highlighting the commitment of staff to the teaching of psychiatry. This perception of support is imperative with the recent paradigm shift to student centred learning where academics and clinicians act as facilitators as oppose to subject matter authorities.(4)
In addition the quality of teaching staff and their commitment to teaching are known to be strongly influential on psychiatry recruitment rates; with the field of psychiatry currently suffering from workforce shortages.(13-15) Further the importance of enthusiastic teaching has also been highlighted as an influential factor in recruitment into psychiatry.(13,14) Recently Hoschl and van Niekerk (14) reported that the commitment and enthusiasm of staff are the most important factors impacting upon recruitment levels into psychiatry. Thus quality teaching staff, both academic and clinical are imperative in overcoming the current workforce shortages in psychiatry.
The importance of quality, supportive staff has also been highlighted in prior research into the hidden curriculum.(9,11) A study conducted by Lempp and Seale (11) found that medical students experiences of personal encouragement and support provided by staff is a fundamental component of the informal medical curriculum. Further this qualitative investigation found it was important to medical students who had benefitted from staff support as well as those whose experiences had lacked staff support.(11) Gaufberg and colleagues (9) in their study found that staff as role models, both positive and negative, were rated as highly influential by students for their learning.
The next theme breadth of experience pertains to the range of conditions and the amount of experiential learning the student’s had the opportunity to partake in during the rotation. O’Connor and colleagues (16) conducted a review of psychiatry medical education in Australia and New Zealand finding a vast difference between the amount and content taught in undergraduate psychiatry. Furthermore O’Connor and colleagues (16) found a significant disparity in the amount of time spent in the acquisition and practice of important mental health skills. This lack of consistency in the psychiatry curriculum content and the proportionate amount of time devoted to psychiatry education and skill development is also evident internationally.(18)
The majority of students reported being exposed to a variety of conditions and having plenty of opportunity to practice specific skills such as mental state exams and history taking. Thus it is encouraging to determine that the majority of students had good access to patients with distinct conditions as well as the opportunity to practice specific skill sets.
Furthermore it should be noted that students had the option of furthering their experiences outside of the hospital ward. However these experiences were not mandatory instead they were highly recommended. However; the vast majority of students opted to participate in the additional, mostly community-based experiences. Prior research has highlighted the importance of community-based education for medical students.(2-4,6,17) Since medical care is now routinely delivered in a community-based setting.(2,4,6,17)
The next most prominent theme pertained to course materials and structure. Overall the students enjoyed the clarity of the handbook and objectives. Recently McLean and Gibbs (4) emphasized the importance of clear explicit learning outcomes within learner-centred curricula. Further a study conducted by Henning and colleagues (19) found that clearer more decisive learner objectives were one of the most prominent issues identified by medical students that could improve the quality and usability of the curricula.
In regards to course structure the students were divided in their responses. Some students reported enjoying the student driven structure of the tutorials while others requested a more systematic structure. Providing the students with the opportunity to inform the content of the tutorials is a component of the learner-centred paradigm. Therefore perhaps the students that requested more structure require more support with the learner-centred ideology to education. McLean and Gibbs (4) recommend ensuring that all stakeholders involved understand the philosophy behind learner-centred pedagogy.
The themes that were the least prominent pertained to attitudes towards mental health and professional development. It is notable that the results indicated themes pertaining to attitudinal change as well as professional development. Since the questionnaire did not contain any items related to either of these phenomena therefore the student’s were not primed to respond to these topics.
Prior research has indicated the salience of attitudes towards psychiatry and mental illness in both clinicians and medical students.(4,6,7,14,20) That is previous research has indicted that students hold negative stigmatised attitudes towards the pursuit of psychiatry and towards mental illness.(14) However it has been found that emersion in a psychiatric clinical rotation can foster positive attitudinal change.(14,20) This was clearly evident in the current study for those students who contributed perspectives reflecting attitudinal change devoid of priming.
Finally the notion of professional development was also evident with students recounting learning experiences that will assist them beyond the delivery of psychiatry skills; comprising fundamental components of their future careers. The provision of opportunities for professional development is endorsed in the academic literature relating to the development of learner-centred curricula.(4,21) Further the opportunity for professional development and being treated as a doctor within the rotations is known to be fundamental in assisting medical students to successful develop their professional identity.(21)
Although this study contributes to the literature especially in regards to medical students perspectives of their educational experiences there are some inherent limitations. Firstly this study is limited by the generalizability of the results due to the contextual basis of this study as well as the moderate sample size. Further the themes evident may have partially resulted from the areas they were asked to comment on. However additional topics that were not mentioned (attitudes towards mental illness and professional development) did emerge from the results. Therefore it is recommended future research further seek to delineate the perceptions of medical student’s educational experiences both in psychiatry and other disciplines. This will assist with understanding both the experiences of medical students as well as the hidden curriculum they are exposed too.
Specifically future studies should seek to ascertain the importance of staff and whether the importance staff decreases for students throughout their medical education career as their level of independence increases. Additionally future studies should investigate longitudinally the impact of enthusiastic staff on recruitment rates into specific specialities’ (such as psychiatry).
Further research should also seek to investigate the impact of implementing student feedback to inform curriculum development and pedagogy and the resulting impact upon student performance. These endeavours could further inform the academic aims and recommendations for the teaching of medicine. As such feedback is invaluable to informing the rapidly evolving domain of medical education.
In conclusion it is apparent that student’s perspectives can offer a valuable contribution; to the development of curricula, clinical placements as well as an understanding of the hidden or informal curriculum. It is suggested that student perspectives be utilised to understand the experiences of medical students and the hidden curriculum and thus inform the development and delivery of the curriculum. Furthermore it is recommended that academics look beyond their specific discipline and utilise student feedback from other specialities as well as share their students’ experiences with their colleagues. In our case we have utilised some of the general feedback for example regarding clarity of learning objectives and the rotation guide book to inform clinical rotations in other disciplines.
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