The medical students in this study felt significantly more confident after the simulated clinic in their ability to safely and effectively assess breast lumps, with greatest confidence gains in awareness of how to ask patients about their risk factors of breast cancer, performing and documenting a breast examination, and confidence in ordering the correct investigations in the triple-assessment clinic. Domains where there were significant improvements in confidence but to a lesser degree included the ability to take a focused history, the ability to recognise presenting symptoms of breast cancer, and how to interpret investigation results. These former domains, which saw the greatest gains in confidence, require the application of knowledge assimilated from textbooks or classroom-based teaching to clinical practice, and these seemed to improve most from the simulated clinic sessions. Simulated clinics may therefore help to bridge the gap between acquiring knowledge during medical school and applying this knowledge in clinical practice.
Inductive thematic analysis revealed four key themes related to student motivations for learning. These consisted of fear of existing systems, the need to pass examinations, the desire to acquire core medical knowledge and to become clinically competent. Furthermore, four key themes relating to student reflections on the processes of learning were identified including; active learning techniques, learning through simulation, learning through feedback and appropriateness of teaching environments. Students felt that simulated surgical clinics would be a welcome addition to the surgical curriculum, allowing practical application and consolidation of knowledge. However, they suggested that simulated clinics should not replace classroom-based teaching, which they felt was more appropriate for the delivery of high-volume semantic knowledge. In a discrete choice situation, they felt the simulated clinics were more valuable as this type of learning was not possible through self-study.
The themes surrounding learner motivation and preferences presented in this study align with previously published characteristics of adult learning in undergraduate surgical curricula . These characteristics include the need for learning to be perceived as relevant, experiential, participatory, problem-based, applicable to practice and based on active, high quality feedback .
Research has shown that engagement in educational processes is strongly linked to learner motivation . Motivation can be categorized according to self-determination theory as either intrinsic or extrinsic . Intrinsic motivation is driven by inherent enjoyment and satisfaction in the task, whereas extrinsic motivation usually involves external or introjected regulatory factors . Examples of extrinsic motivators identified in this study include the need to pass examinations and fear of failure at work or on placement. Concern about examination performance has previously been identified as a strong motivator for learning . Enjoyment of the session and interest in medicine was identified by the students as an intrinsic motivator, in accordance with previous research .
Cook and Artino proposed five contemporary theories for motivations to learn in medical education, including self-determination, goal orientation, social-cognitive, attribution and expectancy-value . Goal orientation was an important motivator in this study, with students highlighting the desire to become clinically competent, knowledgeable and adept at practical skills, both in the context of performing well as junior doctors (performance approach goal) and avoiding mistakes in examinations and on placement (performance avoidance goal). Social-cognitive theory describes reciprocal interactions between learners and their environment. In this study, students consistently praised the ability to learn through simulation, which provided an opportunity to communicate with mock patients in a realistic setting, observe their peers’ performance, and practice ‘soft skills’ such as asking for senior advice. Students placed higher task value on the simulated clinics after having had a preparatory didactic session the week before, which made them feel more confident that they could achieve their learning goals (expectancy-value theory).
During the debrief sessions, the students’ responses suggested that the simulated clinics impacted their motivation, with a shift towards intrinsic motivation. Simulation-based teaching has been reported to improve intrinsic motivation in medical students [26, 27]. Whilst passing examinations was still highly prioritized, students had a greater consideration that passing medical school examinations was only one aspect of becoming a clinically competent doctor. Use of techniques to drive intrinsic motivation is important, having been associated with improved learning outcomes, quality of care, doctor-patient relationships and reduced physician burnout and job dissatisfaction [24, 28, 29].
The students’ preference for active learning in a small-group, simulated environment is supported in the literature and has been shown to improve skill acquisition in comparison to traditional clinical education [30–32]. Previous research has also shown that medical students value the ability to learn through realistic clinical scenarios in a ‘safe’ environment . In recent decades, a greater emphasis has been placed on active learning in small groups, with the uptake of problem-based learning (PBL) in most UK medical schools . Moreover, simulation-based learning is becoming more commonplace in postgraduate medical education and is promoted by Health Education England for Core Medical Trainees . Whilst the medical students in this study supported the integration of simulated clinics within the undergraduate curriculum, they did not feel they could replace didactic teaching entirely. This was mostly related to concerns regarding the inability of simulated clinics to deliver large volumes of knowledge required to pass examinations. However, the students noted that this could be overcome with a prior didactic session, and that the two teaching modalities complimented one another.
Strengths and limitations
The findings of this study should be interpreted in the context of its strengths and limitations. The sample size was small (n = 17) and participants were recruited from one teaching hospital, limiting generalisability. Furthermore, whilst we asked the students to directly compare the classroom-based teaching session with the simulation session, the former session was always held before the latter, due to timetabling constraints. This may have confounded student opinion and comparisons between the sessions. However, despite the small sample, the rich qualitative data collected provided a valid substrate for thematic analysis performed using rigorous published methodology by three independent coders. Moreover, the transcripts reached a point of data saturation with respect to code generation, suggesting adequate exploration of these students’ views.