CBP: similarities and differences in student experience
As I demonstrated in ‘seeing it differently’ it is possible to identify some outcomes commonly experienced by students undertaking community placements. I argued that these similarities arise in part as a result of the nature of placements, in part as a function of the structuring and organisation of learning experience, reflect its stated aims and objectives, and the dialogic between CBP and medical education, cultural, institutional and professional ideas about medicine, about clinical practice and role and identities of doctors.
These similarities are striking given the differences in the settings, population groups, communities and activities in which students engage and the fact that experiential learning invokes ‘deep’ parts of the self – prior experience, feelings, assumptions, ways of seeing and knowing and so on – and, it is assumed, produces learning specific to the individual.
These differences matter.
They present challenges to us as providers of CBP associated with ensuring equity of student experience and opportunity to fulfil the learning outcomes prescribed for community-based placements. They also present us with the challenge of being mindful of the individual learner at the same time as managing the learning process for a group of students.
Students also have views about both the equity of placement experiences, the associated learning opportunities and their similarities and differences. They may envy the experiences of peers (especially where they seem to be particularly exciting). They may feel that they level of involvement they are offered in organisational activities is different and that the demands on them and opportunities available to them are not comparable. In some cases, they may recognise that differences in learning arise not only from the differences in what is on offer to them but are associated with their engagement with the placement and the prior experience, assumptions and personal attributes that they bring to that involvement. They may, in short, want to experience what one of their peers has experienced while on placement. This desire may be compelling: I heard of at least one Monash medical student who was sufficiently interested in what a friend’s placement had to offer that they worked as volunteer with the agency during the third year of their studies.
Given these issues, how can we enable students to make best use of the differences and similarities between their experiences and associated learning, arising from placements? How we can balance the benefits of providing for intense immersive engagement with a single agency with the limitations that this places on students’ opportunities to experience multiple environments?
Implications: make use of diversity of experience and learning
We could consider structural solutions. For instance, creating more space in the curriculum for CBP perhaps through the use of electives (as already happens in some schools). The experience of the student who created a placement opportunity from them self through volunteering could be made more easily available by incorporation of additional placement time into our curricula through Special Study Modules available in Phase 2 programmes. Of course, there will be issues to consider around the capacity of placement providers, the duration, aims, objectives, structure and assessment of any such arrangement.
But, even we took this step we could not create enough space in a curriculum for a student to sample more than a couple of placements.
The answer, I think, lies in creating contexts in which students can pay explicit attention to and share their learning around their community placement experience. I consider this to have two dimensions.
First, comparing and sharing the process and experience of experiential learning; and second, comparing and sharing new knowledge, skills and understanding of other health, people, agencies and communities.
In terms of the former we would create opportunities for students to comment on and share their experience of learning in order to facilitate the adaptive process of synthesising and negotiating the relationship between prior knowledge and understanding and new experience.
In terms of making explicit and useful the similarities and differences in students’ knowledge, skills and understanding of health, people, agencies and communities derived from community placements, I would suggest a focus on thinking about social determinants of health and implications for the doctor’s practice in response to them.
This focus could have many benefits. In the UK it would help students meet the requirement spelt out by the General Medical Council that they understand how health is socially determined and inequitable distributed. This is sometimes described as understanding ‘the cause behind the causes’ of ill-health and how they are linked to environment, culture, lifestyle, and so on. The effects of social determinants on ‘real’ lives are exactly what students are exposed in community placements. I suggest that they are especially discernable in these contexts because of the tendency of organisations that provide community placement to be working with vulnerable and marginalised groups and individuals who experience inequalities in health as a result of the negative influence social determinants.
With respect to organising students’ experience around consideration of social determinants of health, the differences in topical focus, group, community, and field of endeavour to be found between community placements is not problematic but on the contrary useful. A social determinants approach can both contain differences and also show the inter-play of factors. It represents a way of enabling students to bring into comparison and relation their experiences of the needs and issues faced by specific individuals, groups and communities under one unified model. That is not to suggest that encouraging students to think about differences within a single approach should diminish the significance or importance of those differences but enable them to insert them into their understanding of a broader conceptual model.
With regard to exploiting opportunities for students to think about the skills that they have developed and those developed by their peers, the social determinants approach my again have utility. It can be employed as a way of considering how various skills – development of communication skills with regard to cultural differences, or skills in community-mobilisation – may be important in relation to responding to the factors which influence social determinants. It may also be that creating opportunities to compare skills development in relation to factors that influence social determinants is a useful way of demonstrating to students the limits of medical intervention and the benefits of health promotion or public health approaches.
Contexts and means of sharing learning
Medical students are generally enthusiastic about comparing their experiences and sharing their knowledge and skills; good academic practice in medical education ought to build on this. I would be thinking about the following:
- Creating multiple points and means during the placement experience at which students ‘compare and share’: presentations, feedback and reflections during tutorials and the creation of posters, newsletters, artefacts, materials and resources, podcasts and so on.
- The use of information technology to enable asynchronous teaching and learning thus allowing students to respond to prompts to reflection on and share experience and learning at times which suit them.
- Creating contexts for sharing learning that go beyond the profession and beyond the individual campus. Of course, I am inspired to think about linking students in the UK and Australia – I suggest that being able to ‘compare and share’ learning will per se stimulate reflection on it and also has the potential to lead to further production, clarification and sedimentation of knowledge and ideas. Sharing across programmes and institutions has the potential to bring into even stronger focus differences and similarities both in learning processes and indeed in the local, regional and global social determinants of health. I suggest involving students in other healthcare professionals and perhaps even those in the social and welfare sector in this enterprise.
- The role that students now further into their education or those who have graduated into the medical profession might play in this process. What reflections might they have on their community-based learning and indeed, what might they learn from students currently in the throes of the experience?
- The potential for involvement in a community placement scheme as a means of enhancing links between the agencies that provide placements so that their learning about and from student involvement can be compared, contrasted and shared.
- Increasing the opportunities for community involvement in medical education. Why not increase the involvement of community organisations in teaching within the programme on campus? Why not give or enhance their role in the management and development of programmes?
- If enhanced involvement of the community could be effectively linked to widening participation. For example, the University of Western Sydney rural clinical school that I saw at Bathurst is underpinned by community involvement in the sponsorship, support, management and provision of teaching. The purpose is not only to promote rural medicine to students but also make medical education available and accessible to rural populations. Is this a model for engagement and participation of under-served and under-represented populations in medical education? You can find out about the rural clinical schools and also UWS work with widening participation among young people from indigenous populations via these links.