A total of 12 LIC and 14 TBR students participated in the interviews. Table 1 presents the demographics of the sampled students.
On the basis of the content of the student interviews, four primary themes were identified: clinical learning, interactions with patients, interactions with the preceptor team, and doctor-patient interactions. Table 2 shows the similarity and dissimilarity between the perceptions and experiences of LIC and TBR students.
Both LIC and TBR students acknowledged that self-directed learning is crucial during clerkships. Learning in the hospital was usually scattered and incidental. Clinical teaching generally occurred during ward rounds and clinical encounters, and the contents were situation related, focusing on diseases or symptoms of real patients present at that moment. A substantial amount of free time was available between teaching activities; thus, students had to search for opportunities for learning, because without any active learning, they might have learned less. Except for the didactics, an informal discussion was the primary teaching method used in clinical teaching; advance preparation by students enabled the preceptors to interact better with and improve teaching for students. Otherwise, the preceptors would ask students to study in advance to ensure that they had a basic understanding before discussions.
If you do not actively search for learning opportunities, and if the residents or interns do not actively teach you, you do not know what to do at the hospital. (R-03)
During ward rounds, we have a daily patient list. The attending would instruct me to take a look at a particular disease, stating that this case is very interesting, and ask me to study on it. They then discuss the background knowledge with us at the nursing station. (L-02)
The attending focuses on our cases for discussion and guides our thinking. Thus, they keep asking questions, and we must keep answering those questions until we cannot answer one. They then ask you to find the answer to that question through research. (L-01)
In the early stages of clerkships, both groups of students encountered the same problem of lack of awareness regarding how to apply the knowledge acquired during school to clinical care. All medical students stated that they memorized the teachings in the school and did not genuinely understand the acquired knowledge until after experiencing actual interactions with patients in hospitals.
I feel like the things I studied in the past cannot be practically applied to clinical work. (L-04)
During the fourth-year learning process, you are unable to grasp the key points or have a fuzzy concept. It is only in the fifth year that you realize, […] you now finally understand the concepts that were confusing before. (R-13)
LIC students stated that longitudinality provided them with a thorough understanding of diseases and treatments. TBR students generally encountered opportunistic learning content and thus learned through observation.
I think the advantage of LIC is that you acquire a thorough understanding of diseases and truly remember them. However, in the TBRs, you observe many common diseases in a short duration and thus may not remember each of them. (L-05)
Primarily, we share information with patients: [...] what we have seen in the operating room or the experiences of patients we have cared for, […] the general follow-up process, and the duration and approach of their treatments. (L-10)
In TBR [teaching methods], the diseases, types of cases, and patient symptoms you encounter influence what your preceptor teaches you. However, the acquired knowledge is scattered and unsystematic. (R-05)
Interactions with patients
In the early stages of clerkships, both groups of students were anxious during interactions with patients. Although students attended courses in school on history-taking, physical examinations, and communication skills, they were overwhelmed when encountering new patients on their own.
There was a time that my mind was completely blank when I faced a new patient; that is, I was very nervous and did not know what to say. (R-04)
Especially when we first entered the hospital, we really did not know what to say to the patient. We could only awkwardly say things like ‘Oh, how have you been? Have you gone out for a walk?’ Just saying the same things every day; we did not know what else to say. (L-10)
The descriptions of patient interactions by the students reveal differences between the two types of curriculum designs. During interactions with patients, most LIC students could completely describe patient and family backgrounds as well as physical and psychological changes before and after the occurrence of diseases; they could also describe their interactions with patients during follow-ups. LIC students conducted longitudinal follow-ups with patients. Under these circumstances, students could interact with the patients throughout the complete course of a disease, thoroughly understand the relationship between the disease and lifestyle of patients, and establish a meaningful relationship with them. Therefore, LIC students bridged the gap between physicians and patients and provided patients with attention and support.
I started to care for a patient with heart failure in the first week; […] over the course of 4 weeks, I was constantly observing this patient. […] I clearly observed the process of the attending physician modifying the treatment plan and thought it was very useful. (L-02)
In school, teachers only taught disease-related information. You learn about the development, treatment, and prognosis of a particular disease. However, teachers did not talk about the thoughts of patients with such diseases or the impact of the disease on patients’ families. Because they [patients] are willing to share, I realized that this disease actually caused different responses in different people. (L-09)
I think sometimes we play a kind of bridging role. For example, when making rounds, sometimes the patient is very nervous and forgets what they should ask. Afterward, they see us and say things like “Oh right, I wanted to ask you something.” Then, we ask the attending these questions on behalf of the patients. [...] In the past, you would never think that patients could actually be nervous, too or that they would just not think to ask these questions at the time. I only realized that during such interactions. (L-03)
TBR students had shorter interactions with patients. These interactions primarily occurred during hospitalization; students did not always have the opportunity to continue to provide care after discharge and thus rarely performed follow-ups. In their explanations of interactions with patients, most TBR students provided fragmented descriptions of communications between the attendings or resident doctors and patients, or they described patient disease processes. Few students attempted to understand patient backgrounds. Most interactions between TBR students and patients had a specific purpose, such as recording a patient history to accomplish an assigned task. Sometimes students could serve as companions and express care and sympathy.
For example, the attending physicians tell me to ask the patients for their history, and I try to ask, but I am still new at this and do not know what to ask and thus can only follow the most basic standards from the textbook. When I ask, although I get an answer, there is a lack of… a human touch. Sort of like when a computer gives you a questionnaire to answer. I have only asked you where you feel uncomfortable and how uncomfortable you are. Although these things are necessary, I feel I should add some greetings and inquiries or have a chat with the patients, that is, consider them a friend. (R-06)
Interactions with preceptors and house staff
Curriculum arrangements for the two groups were different; thus, learning processes were different. In both groups, the attendings were the primary instructors at the hospital and the primary sources of clinical knowledge for students. In addition to small group lectures, teaching and learning majorly occurred in ward rounds or bedside teaching. During the teaching process, the attendings generally used the interactive discussion to direct student learning. However, considerable differences were observed in the interactions of TBR students with attendings of different disciplines; the level of the busyness of the attendings influenced teaching outcomes. By contrast, LIC students had continuous mentoring relationships with the attendings. The teaching roles of the residents for students were undefined, and their interactions were not close.
Basically, the attendings kindly respond to you. Because they know the goals of the clerkship curriculum, they will teach you. Of course, some [attendings] may actually be busy and have other things or research to do. They may not have much time [to teach]. (R-05)
Because you follow one preceptor for six months, you can better understand the job description of a physician in this department. Also, the preceptor better understands your learning situation, so they are more willing to let you do things independently. (L-09)
[LIC students] are more familiar with attendings. The attendings definitely remember your name and understand you more. Relatively speaking, you can ask them questions or ask for help, and they won’t refuse as much. [...] The advantage of LIC is that if you really want to learn something, the preceptors are generally happy to help you learn it. (L-07)
Interns and students interact frequently. This behavior is more evident in TBR students because they spend more time in wards, and the ages and nature of work of the interns and TBR students were similar. Therefore, TBR students generally learn ward work from interns. In the early stages of clerkships, TBR students experienced difficulty when assimilating into clinical teams because they were unfamiliar with the clinical workflow. Interpersonal relationships influenced this learning process. LIC students primarily learned from attendings; however, they learned ward work and basic clinical skills from interns.
The things we want to learn are mostly clinical work encountered during internships, and we learn that from interns. They also know more about what to teach us and what we will encounter in the next 1–2 years. (R-01)
Sometimes, I feel like I’m being left behind; […] much of the medical terms they use are abbreviations or codes, leaving me confused. I don’t know what I can do to keep myself from sitting on the sidelines, so that I can participate and learn because I am very afraid to bother the attendings since they are busy. (R-03)
Because I am familiar with some interns, I already know how to write admission notes and SOAP notes and enter orders. […] Some students may not be familiar with interns, or because the interns are very busy, they might not be bold enough to say “Please teach me!” I might know how to do something while my classmates still do not. (R-02)
Both groups of students demonstrated high levels of interest in doctor-patient interactions during their clerkships. Students observed the communication practices and modes of interaction between attendings and patients, and through these observations, they determined suitable communication methods accordingly.
Some attendings are very good at dealing with patients, thus helping you to learn how to handle patients in the future. (R-11)
I think the way that they [the attending] explains things to patients is very careful, quite detailed, and structured, so it is easier for patients to understand. I think this is a key area where we can learn from our preceptors; that is, how we should communicate our medical knowledge to patients in a way that they can understand. (L-03)
Table 3 details the academic performance of LIC and TBR students. LIC students had higher scores in clinical performance (94.79 ± 0.78) compared with TBR interviewees (91.29 ± 1.68, p < 0.001) and all TBR students (91.00 ± 1.32, p < 0.001). LIC students had higher scores in medical record writing (92.92 ± 2.90) than all TBR students (89.20 ± 2.90, p < 0.001); however, no significant difference was observed between the scores of LIC students and TBR interviewees (91.66 ± 2.88, p = 0.268). Furthermore, no difference was observed between LIC and TBR students in scores on written tests and the objective structured clinical examination. Higher final academic score was demonstrated in LIC students then sampled and all TBR students.