What evidence can we recruit to support inferences about the contribution of non-clinical community-based placements to medical education and practice made on the basis of my observations and reflections reported in this blog?
The answer would appear to be that the supporting evidence base is neither large nor particularly robust. However, what research there is paints a picture that is both reasonably consistent and encouraging.
A good place to start is with a fairly recent review of literature examining the potential contribution of early clinical and community experience to medical education (Dornan et al., 2006). The authors of this review conclude by asserting that such interventions make a positive contribution to students’ acquisition of some of the knowledge and skills sought in the modern doctor. Indeed, they identify 116 educational outcomes emergent from 38 of the 73 studies that met the eligibility criteria for inclusion in the review. They state that these intervention:
‘motivated and satisfied students…helped them acclimatize to clinical environments, develop professionally, interact with patients with more confidence and less stress, develop self-reflection and appraisal skill, and develop a professional identity. It strengthened their learning and made it more real and relevant to clinical practice. It helped students learn about the structure and function of the healthcare system, and about preventive care and the role of health professionals. It supported the learning of both biomedical and behavioural/social sciences and helped students acquire communication and basic clinical skills.’
Furthermore, the authors of this review suggest that these interventions have demonstrable positive outcomes no only for students but also for, ‘teachers, patients, populations, organizations and specialties’.
Possibilities and opportunities
While this is certainly encouraging, the authors sound a few notes of caution to which we should attend: very few of the studies included in the review relate to medical education in the UK, few have a comparative component, and very few indeed focus explicitly and solely on non-clinical community-based experience (5 of the 73 included studies involved attachment to a community).
This review exposes a number of difficulties with extracting information about non-clinical placements from the literature.
The first is there may not be much and it may be difficult to find in part for lexical reasons. As this review shows, and indeed any attempt to search the academic literature will demonstrate, identifying and disaggregating research relating to non-clinical and clinical education in community settings is fraught with problems associated with the use of the term ‘community-based’. As Richard Hays as noted, this of course embraces placements in clinical settings – hospitals, general practice as well as with an individual family or community and masks a variety different understandings of what community orientation means (Hay, 2007) . Furthermore, settings may not be allocated to clinical or non-clinical in a consistent way across the literature. Interesting, for example, this review couples hospice-based placements with those in hospitals as ‘clinical’. It is of course perfectly plausible for a placement in a hospice to be conceived as non-clinical dependent on the role and activities made available to a student. Clearly, searching the literature for information specific to non-clinical placements is difficult.
The second associated difficulty is the heterogeneity of projects. Indeed this is a prominent finding of the recent review of community-based learning in medical education in the USA (Hunt et al., 2011).
The third difficulty reflects the lack of confidence with which we can discern which if any outcomes are either solely associated or predominantly associated with clinical or non-clinical placements. This is partly about the lack of data comparing interventions but also because interventions do not take place in isolation (more on this in a moment).
If we consider evaluating to differentiate effects and outcomes of clinical and non-clinical placements I suggest the following:
That while both clinical and non-clinical placements contribute to the outcomes listed above, there are quantitative and qualitative differences in the ways that they do so, that with respect to some of these effects and outcomes the relationship may be more or less exclusive, and that there may be other effects and outcomes as yet un- or under-reported in the literature.
For example, I would hypothesis that there are differences in the outcomes, process and quality of student knowledge and understanding of the social determinants of health between clinical and non-clinical placements. Furthermore, I would go so far to hypothesis that non-clinical rather clinical placements will be associated with more and better outcomes around student knowledge and understanding of the informal, popular and non-statutory health sector and services. Students may well learn something quite different about multi- or inter-disciplinary activities and working. For a start, I would aver that non-clinical community placements provide students with opportunities to see professionals from agencies and backgrounds with whom they may not work regularly as doctors but from whose practice they may learn much.
I would also expect the potential for outcomes that benefit communities to be different and moreover these outcomes to be different according to whether placements are clinical or non-clinical. For example, it may be that opportunities for engagement in and support of effective health advocacy will be differently available and operationalised to different effects in the context of clinical and non-clinical placements. Interestingly, although community-based placements often aim to improve health in the community they may not be routinely driven by or founded on knowledge, understanding and need arising from the community (Hunt et al, 2011)
I wonder too if student insight into self and other has a different quality when facilitated from a non-clinical context. It might be that medicine and medics look different from ‘outside’ health services and also that the ways that power operates and is used within clinical contexts and within interactions between medics and others is perceptible in a different way. Consequently, student learning about medicine and power might be quite different.
Finally, we are left with an interesting challenge of disaggregating the effects of one or other sort of community-based experience in contexts where both occur. This is more than a technical problem to be approached from the point of view of evaluation design. I think it raises an epistemological question that warrants consideration before we begin to think about technical measures. That is, if we believe that community-based education partakes of experiential learning theory and as I have suggested, this involves the dialogic between aspects of medical education, then finding ways of exploring and knowing about this should reflect the holistic conceptualization of learning that it implies.
Another list of things to do
When we think about the evidence around non-clinical community-based placements opportunities abound. Here are a few:
Think about what a taxonomy of community-based education would look like and how this might help with clarity of definitions in the field, the organization of interventions and, ultimately, linking them to outcomes.
- For example, if the overarching category of activity in medical education into which non-clinical placements are to be placed is to be referred to as ‘community-based’ are the two sub-categories ‘clinical’ and ‘non-clinical’ and/or are there to be others?
- Furthermore, should non-clinical placements be distinguished according to whether they focus on communities or families and individuals?
- And, how is non-clinical placemen defined in terms of duration? Is half a day visiting a community organization really a placement at all? Should there be a minimum level of engagement in terms of time?
Think about where aims and objectives and projected outcomes are situated within this taxonomy. Do clinical and non-clinical placements have different aims, and do these result in different outcomes? This might help us to think about he importance of process as well as outcomes in designing evaluation of interventions
Think about the theoretical drivers underpinning community-based learning and particularly non-clinical placements and the implications for aims, objectives and outcomes. For exmaple, where does the community-based non-clinical placement connect to recommendations around increasing experiential learning in medical curricula? (Illing et al, 2008)
Think about the history of non-clinical placements in medical education. How and where did they arise and with what purposes in mind? Again, what are the implications for aims, objectives and outcomes?
Think about the epistemological issues raised by working within a particular theoretical and historical context and how these inflect the design of evaluative research. In particular, how can one seek to know about processes that are complex, individualized, adaptive and ongoing?
Ultimately, what if any new theory or thinking might we need to develop to reflect our practice and student and community experience?
The work might look like this:
- Map non-clinical community-based practice to create the taxonomy;
- Compile the history of non-clinical CBP;
- Explore more fully its theoretical drivers and their inflection into programmes;
- Undertake a further review of the literature related specifically to non-clinical community placements in medical education
- Contribute to the generation of hypotheses about CBP and then seek to increase the number and rigour of evaluate of CBP interventions;
- Reflect on what this tells is about the adequacy of otherwise of available explicative theory and descriptive research
Dornan, T. Littlewood, S., Margolis, S.A., Scherbier, A., Spencer, J. and Ypinazar, V. (2006) How can experience in clinical and community settings contribute to early medical education? A BEME systematic review, Medical Teacher 28(1) 3-18
Hays, R. (2007) Community-oriented medical education, Teaching and Teacher Education 23: 286–293
Hunt, J.B., Bonham, C. and Jones, L. (2011) Understanding the Goals of Service Learning and Community-Based Medical Education: A Systematic Review, Academic Medicine, 86(2): 246-251
Illing, J et al. (2008) How prepared are medical graduates to begin practice? A comparison of three diverse UK medical schools, London; GMC available at, http://www.gmc-uk.org/about/research/research_commissioned_1.asp