Medical students’ experiences of guided reflection on early clinical exposure: A qualitative study

doi:10.21203/rs.3.rs-3239987/v1

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Medical students’ experiences of guided reflection on early clinical exposure: A qualitative study

https://doi.org/10.21203/rs.3.rs-3239987/v1

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Introduction: Early clinical exposure in medical curricula can help students understand the social context of medicine and facilitate their transition to the clinical environment. To investigate the experiences of medical students in this regard, a study was designed and implemented with a focus on guided reflection.

Methods: In this qualitative study, 2nd-semester medical students underwent guided reflection and were asked to respond to open-ended questions in written form after their initial clinical exposure in teaching hospitals. The written answers provided by the students were analyzed using open coding to extract semantic units, subcategories, categories, and themes.

Findings: The responses of 52 participating students were coded, resulting in the extraction and formation of 279 semantic units, 22 codes, nine subcategories, five categories, and two themes.

Conclusion: Guided reflection through early clinical exposure lays the foundation for developing core competencies, including communication skills, problem-solving and clinical reasoning abilities, personal development, and the cultivation of professional identity and professionalism among medical students.

Guided reflection

medical student

early clinical exposure

thematic content analysis

During the last decades, the education system, as a social institution, has undergone significant changes and transformations, alongside other institutions, with notable reforms being implemented. Among the most crucial changes are the emphasis on the accountability of higher education and the adoption of competence and competency-based education in medicine, with Harden's introduction of it being recognized as the most influential development in the last decade (1). The implementation of competency-based education requires the incorporation of core competencies into educational planning as longitudinal themes, starting from the entrance to medical school and continuing through appropriate strategies and methods. As a result, early clinical exposure for medical students becomes crucial in creating suitable opportunities for developing the expected competencies. It is believed that reflection can be effective in this process (2). Dornan and Bundy (2004) reported in their study that early clinical exposure may shift medical curricula towards the social context of medicine, thereby facilitating the smooth transition of medical students into the clinical environment. This exposure can also serve as a source of motivation, making students more confident and fostering self-awareness and awareness of others. Additionally, it has the potential to strengthen and deepen their theoretical knowledge in a contextual manner, enhancing their understanding of behavioral and social sciences, the healthcare system, and the roles of healthcare professionals (3). Reflection is an indispensable and essential component of health professions education. It is a controllable process, and various educational interventions, such as guided reflection, can be utilized to enhance it. Through reflection, rote learning is eliminated, and it paves the way for deep and meaningful learning (4).

One of the challenges of clinical education is the absence of a clear connection between basic sciences courses and clinical practice. To bridge this gap, junior students require more exposure to the clinical environment and opportunities to observe the practical application of knowledge. Therefore, early clinical exposure and the presence of medical students in hospitals during the initial years are vital components of medical education (5, 6). Medical core competencies develop gradually during early clinical exposure and subsequent exposures in clinical training (2). The process of reflection can occur before, during, or after learning, leading to meaningful learning experiences. Notably, medical students may not fully comprehend the importance of learning basic sciences before entering the clinical environment. Early clinical exposure offers a suitable platform for reflection, fostering meaningful learning and skill acquisition by combining theoretical knowledge with clinical experience. This approach enables students to identify and become familiar with the essential competencies required in future clinical situations (7). Studies have demonstrated that early clinical exposure and engagement in the real clinical environment can enhance active learning, increase learner participation, and foster empathy among students (8). Various assessment tools, such as self-report questionnaires, written statements, and students' learning logs, have been employed to evaluate students during medical education courses (9).

As expected, medical students need to be able to identify and comprehend the professional behaviors of both themselves and others. To promote critical thinking about these issues, we encouraged them to engage in guided reflection on the actions of healthcare professionals at work, their dress code, the professional context, and various observed interactions during early clinical exposure. Although reflection is a well-known process, little is known about its application in early clinical exposure and its role in developing professional identity and professionalism in this setting. The aim of this study was to explore medical students' perceptions and the educational impact of guided reflection in the context of their first exposure to the clinical environment and social care experiences.

This qualitative study utilized content analysis and involved first-year medical students from the Mashhad Islamic Azad University of Medical Sciences in 2022. In this university, the early clinical exposure program is initiated in the 2nd semester and spans three days. During this program, students were grouped in tens and accompanied by a trained mentor in teaching hospitals affiliated with the university. Guided reflection was designed in the form of five open-ended questions to gather insights into the medical students' perceptions and feelings regarding their first professional attendance in the hospital, dress code, observations of health professionals' work, cultural and social aspects in the clinical environment, professional communication in the hospital, and critical thinking about both themselves and others. In this study, all satisfied students voluntarily participated. Adequate explanations were provided to the students regarding the optional nature of their participation, the confidentiality of their information, and the anonymous use of data. Students reflected their thoughts after giving informed consent. They were required to complete the forms and return them after three days. The received answers were carefully reviewed, and coding was performed for each interview. First, the answers were divided into semantic units, and in the next step, open coding was conducted. The initial codes were sent to the participants for approval. Different codes were compared based on their differences and similarities and then classified into subcategories and categories. This iterative process of refining categories continued, taking into account the unique characteristics of each category. During this stage of the coding process, the formation of categories and sub-categories, as well as the extraction of main themes, required considerable time and effort from the researchers to ensure the accuracy of the content. The findings were thoroughly discussed and reviewed multiple times by the researchers to enhance the study's rigor. To ensure trustworthiness, the researchers considered four criteria: credibility, confirmability, dependability, and transferability. Therefore, these criteria were met by dedicating ample time to collect and analyze data concurrently, establishing good communication with the participants, and obtaining their approval of the manuscripts. The researchers ensured a detailed description and sought feedback from other colleagues by re-reading the extracted codes to enhance accuracy. The conclusion and summary were reached with unanimous agreement among the researchers. Furthermore, to bolster the study's validity, an external expert in the field of qualitative research reviewed and confirmed the findings.

Like other qualitative research, this study is not devoid of potential errors, as the researcher's mentalities, thoughts, and opinions may inadvertently influence the research topic and data collection process. To mitigate this, we made a concerted effort to practice researcher bracketing during data collection and analysis to ensure an unbiased approach. Additionally, we provided assurance to all participants that their answers would be treated with utmost confidentiality by the researcher, aiming to minimize potential biases in respondents' responses. Furthermore, this study obtained ethical approval with the code IR.IAU.MSHD.REC.1401.181 from the Research Ethics Committees of Mashhad Medical Science Islamic Azad University.

In this study, a total of 52 students participated, with 29 being women and the rest men. The participants had an average age of 21.8 ± 0.8. Two reports were excluded from the study due to incompleteness. The findings of this research resulted in the extraction and formation of 279 semantic units, 22 codes, 9 subcategories, 5 categories, and two themes. The main themes identified were "Guiding and accelerating the development of professional identity and medical professionalism" and "Creating the basis for the development of medical core competencies." The extracted codes, classes, sub-classes, and themes are presented in Table 1.

Table 1

Initial codes, subcategories, categories and themes
Initial codes	Sub categories	Category	Theme
Good, positive and satisfying feeling of being in the hospital	Positive and motivating feelings	Experiencing Positive and motivating feelings	Guiding and accelerating the development of professional identity and medical professionalism
Affected by the professional and legal environment of the hospital	The role of environment in creating professional identity	Development of medical professional identity
Understanding the doctor's responsibility towards the patient
A deeper understanding of the future professional and career roles and responsibilities
Valuing and compliance with professional dress code	Valuing dress code
Increasing motivation for progress and effectiveness	Planning for personal development	Fostering the competency of critical thinking and improvement	Creating the basis for the establishment of core medical competencies
Increasing the sense of responsibility for improvement of their knowledge and skills	Planning for personal development
Feeling weak in initial communication with patients	Identifying individual weaknesses
Experiencing stress and lack of self-confidence
Identifying lack of knowledge and basic information
Identifying physical problems
Identifying practical skills problems
Ability to communicate with patients	Identifying positive personal traits for future roles
Identifying the appropriate personal characteristics of the medical profession in oneself	Identifying positive personal traits for future roles
Reporting adverse observations and experiences during the hospital stay	Observing some negative issues in the clinical environment
Observing non-compliance with professional rules in some cases	Observing some negative issues in the clinical environment
Observing respect and effective communication with patients and their companions as one of the basic principles of medicine	Communication skill with patients and colleagues	Fostering the competency of communication skills
Observing professional interpersonal relationships, mutual respect and teamwork
Creating a sense of empathy with patients
Understanding the importance of clinical reasoning in medicine	Understanding the importance of clinical reasoning and problem solving in medicine	Fostering the competency of clinical reasoning ability and problem solving
The challenge of history-taking and clinical reasoning
Realizing the importance of paying attention to the physical and mental symptoms and signs of patients in medicine

In this study, 279 semantic units, 22 codes, nine subcategories, five categories, and two themes were identified. The five main categories include: "Experiencing Positive and Motivating Feelings," "Development of Medical Professional Identity," "Fostering the Competency of Reflection and Improvement," "Fostering the Competency of Communication Skills," and "Fostering the Competency of Clinical Reasoning Ability and Problem Solving." The two themes obtained are "Guiding and Accelerating the Development of Professional Identity and Medical Professionalism" and "Creating the Basis for the Establishment of Core Medical Competencies."

Category of "Experiencing Positive and Motivating Feelings"

In general, this experience created a satisfying and motivating feeling for the students. In this regard, the students expressed, "It was the first time I was in the hospital as a medical student. Despite not having slept for several days due to an exam that I had that day and feeling hungry, I didn't feel bored because I loved that environment, and it fascinated me every moment. I was eager to continue and explore the rest of the hospital." Another student shared, "It was a very exciting and interesting experience, and it provided me with a better and deeper understanding of the field I chose." In the qualitative study conducted by Lislot et al. (2007) on medical students, the participants expressed their enjoyment of clinical training and acknowledged the immense value of these experiences for their learning (10). The students' reflections highlighted that early clinical experiences offer valuable opportunities to learn professional practices encompassing mind, action, and attitude (11).

Category of "Development of Medical Professional Identity"

Early clinical exposure and presence in the clinical environment play a crucial role in the development of students' professional identity (12). Additionally, students' perception of the environment and adherence to essential principles, such as compliance with dress code, further strengthens this process. Examples of students' statements in this regard include:

"The type of dressing in the hospital is very important for a doctor. This opportunity allows us to apply what we have been taught in the university about how to dress, making us more organized, comfortable, and promoting harmony among everyone."

"Wearing a professional dress makes me feel comfortable as a student or doctor and allows me to focus on my work. It also gives the patient a sense of trust."

"The hospital environment fosters unconscious professional behavior among doctors and staff. For example, I observed sincere relationships with patients and respectful interactions among the staff, reflecting a culture of professionalism."

"The conditions in the hospital are different from the university, requiring a more professional approach. Despite the differences, the experience was pleasant and with more discipline."

Stark (2006) found that guided reflection is a valuable method for exploring professionalism in a real workplace, providing a rich learning experience (13).

Category of "Fostering the Competency of Reflection and Improvement"

Reflection is a metacognitive skill that empowers learners to enhance their understanding of past, present, and future experiences. Through experiential learning, reflection aids students in improving their future learning processes. The practice of reflection, incorporating self-awareness, self-monitoring, and self-regulation, leads to professional growth and improvement (9). In this study, all students mentioned their personal strengths and weaknesses through guided reflection. Analysis of the students' statements revealed that they expressed weaknesses in various areas, including communication with patients, experiencing stress and lack of self-confidence, deficiencies in basic knowledge and information, physical problems, and deficiencies in practical skills. One student shared their experience regarding the deficiency in basic knowledge: "Through this experience, I realized my weak point. I had not studied the lessons taught in the university in enough detail, and I paid more attention to generalities. Now I understand how these details are crucial in making accurate diagnoses of diseases. If we don't learn the subjects correctly and thoroughly in the university, we cannot provide proper care to patients as good doctors in the hospital, and the likelihood of error in disease diagnosis becomes very high."

Another student expressed, "Honestly, from a knowledge standpoint, I felt that I should study more than others, and I have a serious plan to improve my studying from the references." Some students reported physical problems, stating, "My problem was premature fatigue, and I was unable to stand for more than half an hour." In the area of skill deficiency, a student stated, "My weak point was taking blood pressure; I didn't know how to do it." Regarding stress and low self-confidence in initiating a relationship with the patient, a student shared, "At the patient's bedside, we were supposed to ask questions and take a history. I felt very stressed and unsure about how to communicate with the patient and ask the right questions. I hope this problem and my lack of self-confidence will be resolved in the future." Similar to many reports, including Sarikaya's study (2014), students in this research also experienced some degree of stress during their first clinical encounter with patients (9, 14).

Of course, the students also highlighted their strengths. One student reported, "My strength is effective communication with patients. I believe I had a good rapport with them." Another student mentioned, "I consider my strength in this course to be clinical reasoning, and to further enhance it, I need to increase my knowledge as much as possible to excel in this aspect of my work." In addition to identifying their strengths and weaknesses, the students also mentioned strategies for improvement and development in their statements. For example, one student stated, "Since we are currently in the basic medical sciences stage and have limited exposure to bedside care, this experience allowed us to gain a better understanding of the courses by being in the hospital and interacting with internship students. It provided us with a broader perspective." Two students reported negative experiences, expressing: "As soon as I enter the hospital, I sense a heavy and gloomy atmosphere. Moreover, the prevailing silence creates a feeling of fear within me." Another student added, "The hospital experience does not align well with my mood." These cases warrant early attention and advice to address any potential challenges the students may face during their clinical training.

Category of "Fostering the Competency of Communication Skills"

The presence of students in the clinical environment and their observations of interactions that took place in the hospital highlighted the importance of communicating with colleagues, patients and empathy in medical practice. Some of the students' perceptions in this regard were as follows: "I found the respectful communication with patients fascinating. Despite the doctor's busy schedule, they demonstrated patience and treated the patients with respect." Another student remarked, "Professional relations were founded on mutual respect. It's not about someone with higher education having the right to dictate to others. The first rule for a doctor is to respect the patients, nurses, and other colleagues." Similarly, another student shared, "One of the best aspects of the hospital was the unity and mutual respect among all the staff, including doctors and nurses. Everyone showed great respect, helped and cooperated with each other, and strived to provide the best possible care for the patients. Each person in the department dedicated their best efforts to enhance the overall quality of work." Another student expressed, "I was truly impressed by the observation of a patient suffering from long COVID disease, who had sought treatment from various medical facilities and was visibly struggling with the illness, resulting in weight loss." Similarly, another student pointed out, "During several cases, I noticed that I was affected by the suffering and sadness of the patients, which I hadn't paid much attention to before. I believe I should learn clinical empathy and the appropriate way to respond to such situations. Additionally, I realized the significance of communication skills and the need for more practice, particularly in communicating with patients and taking their medical history."

A qualitative study conducted at the Mayo Clinic also revealed that early clinical experiences with hospitalized patients offered crucial opportunities for students' professional development. While some students experienced slight stress before each patient encounter session, they generally expressed enjoyment in the duties and roles of medicine. They expressed their fondness for interacting with patients in the hospital, engaging in effective communication, taking patient histories, conducting physical examinations, formulating differential diagnoses, and sharing knowledge (10).

Category of "Fostering the Competency of Clinical Reasoning Ability and Problem Solving"

The importance of clinical reasoning and problem-solving, as well as the significance of paying attention to the history, symptoms, and signs of the disease, was evident to the students, and they articulated their observations in their essays: "What really caught my attention is the mental pathways we must develop for ourselves. It's like a game or puzzle where we have to find the right answer, only much more serious!!" and "While studying the patient's records and their medical history, we tried to explain the reasons behind each symptom and determine which disease the symptoms might indicate. Finally, we summarized the information and arrived at the most probable options." Numerous other studies have also highlighted how students come to realize the importance of medical history and its findings in the process of diagnosis and treatment during early clinical exposure (14).

The findings of this study demonstrated that guided reflection during early clinical exposure lays the foundation for developing core competencies in medical students, including communication skills, problem-solving, clinical reasoning, personal development, and the establishment of professional identity and professionalism.

I. Ethical Approval and consent to participate

This study obtained ethical approval with the code IR.IAU.MSHD.REC.1401.181 from the Research Ethics Committees of Mashhad Medical Science Islamic Azad University.

ii. Consent to Publication

Not applicable

iii. Data Availability statement

All completed forms is available in Persian and kept confidential. Data are however available from the authors upon reasonable request and with permission.

The datasets generated and/or analysed during the current study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request.

iv. Conflict of interest

There is no conflict of interest.

v. Funding

Not applicable

vi. Author contribution

Arezou Farajpour, Armin Salehi and Rasam Mashoufi contributed to design, the acquisition, analysis, interpretation of data and drafting & revising manuscript and agree to be accountable for all aspects of the paper.

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No competing interests reported.

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Medical students’ experiences of guided reflection on early clinical exposure: A qualitative study

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