Clinical logbooks: recording clinical experiences may not be enough

What is the difference between clinical education and minestrone soup? One comes as lots of little bits, all chopped up, oating in a sea of indeterminate nutritional value, and the other comes in a can. This joke, which I tell at far too many medical education conferences and staff development events, is now becoming hackneyed but nevertheless remains true. The paper by Diana Dolmans and associates1 in this issue attempts to look at one method of reducing the complexity of medical education by providing students with a log book. This log, appropriately for an instrument developed at Maastricht, contains a large variety of patient problems rather than key objectives, skills or teaching experiences. A number of findings from the study echo those of previous work. Firstly, the authors report that differences between individual students in their degree of clinical exposure are very high. Secondly, the number of problems on which students received feedback, based on direct observation by a supervisor, was small and no greater than 10%. Thirdly, students felt that the log was not sufficiently robust to provide insight into essential learning activities, or to adjust these in relation to their perceived needs, or to provide useful feedback on performance. It is tempting to use this current study to support the view that logs of clinical activity are not as productive as was first thought. That logs can provide teaching coordinators with useful data on the experiences of their students is not in doubt. However, as Dolmans points out, it seems to be increasingly the case that instruments like clinical logs will not be used to their full potential, unless we also address important strengths and restrictions of the clinical situation that impact on teaching.
Constraints on clinical teaching

equipped temselves for the rigours of A-level or basic medical science studies, are ill prepared for learning in a work-based environment, especially one in which they are under-valued. Students therefore need to be empowered to grasp the opportunities available to them. These opportunities can be enhanced, for example, by establishing `teaching' wardrounds and outpatients in which students must play a significant clinical role. In the United States examples exist of `real' clinics run by students for disadvantaged and poor communities, such as homeless or itinerant populations, for whom, otherwise, very little health care would be available. Although most of these models have been applied previously to underprivileged environments, there is no reason why similar activities could not be applied to some extent in the day-to-day activities of the hospital and general practice environments.
Skill centres and `real' teaching

These constraints include the feeling of inadequacy and the problems experienced by students when coming into clinical situations. Stritter2 pointed out, many years ago, that what students do to inuence their experience may be more important than anything their teachers can effect. Many students, having

Correspondence: Professor Brian Jolly, Medical Education Unit, University of Shefeld, Shefeld S5 7AU

Theoretically, the provision of skills learning centres with adequate simulation and feedback should provide students with more condence to get involved in the day to day work of the wards. It is of note therefore, that in a curriculum thoroughly underpinned by the clinical skills learning centre concept, as at Maastricht, students should still have such difculty with structuring their clinical learning experiences. This strongly suggests that one problem is to enable students to converse with clinicians at an appropriate level. In the classic study of clinical teaching in action by Mattern et al.3, several important factors stand out. These are the need for an orientation to clinical teaching events by the senior clinician present, face to face feedback for students to gauge their actual level of performance that is both supportive and critical, and the establishment of an appropriate collegiate, non-confrontational atmosphere in clinical situations. Professor Peter Howdle and colleagues at Leeds Medical School4 are developing wardbased teaching assistants. These posts are designed to facilitate students' entry into and utilization of wardbased activities. The incumbents are, currently, experienced nurses. The notion is that the teaching assistant takes responsibility for a small number of students and organizes patients for them to see and people for them to observe, observes students' clinical activities and

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provides detailed feedback on their performance. One teaching assistant is usually attached to three or four different rms and operates with them on different days of the week, at other times being available for student consultation. Naturally this involves collaborating with senior clinicians, and specialist registrars and house ofcers where appropriate, to provide specic activities. If students have problems they know they have a designated, but clinically aware, person to go to see whose primary responsibility is the organization of their learning activities. Another feature is the need to ensure good design of clinical environments. Frequently, these are not conducive to teaching. However, one very old teaching hospital in east London, now demolished, had two examination rooms to every consulting room in outpatients so that two patients could prepare to be examined independently, by students if necessary, while the consultant was dealing with a third patient in the consulting room. Such care in design of facilities could be legitimately funded by the Service Increment for Teaching (SIFT) as it has a direct impact on clinical delivery as well as upon teaching facilities. Coles5 has developed a four phase model for outpatient clinical education comprising: 1 A clinician demonstrating some clinical practice which is observed by trainees and then discussed with the clinician. 2 The trainee reecting on these observations and discussions and doing further work through reading and writing. 3 The trainee practises under supervision and then receives constructive feedback. 4 The trainee performs unsupervized, though with continuing further support and has opportunities to discuss performance with the supervisor. Other constructive ideas for structuring clinical learning settings are reported elsewhere.610
Peer review and clinical management

write into these job descriptions an element of responsibility for teaching organization.
Questioning in clinical learning situations

The use of questioning in clinical teaching is historically well established. Yet researchers observe how frequently senior clinicians ask questions, wait a very short time for an answer and then end up answering themselves without really giving students a chance to think about the issues.11 Quite often questions are so trivial as to engender student wonderment. Students put more effort into thinking about why the question was being asked in the rst place than they do in answering the question itself. Frequently, of course, this is because in clinical teaching sessions students are penalized or humiliated for inappropriate responses.12,13 It is a principle of learning that if teachers wish students to be actively involved, they must nd positive ways of rewarding active involvement and reduce those that penalize it, no matter how inadequate the response may at rst appear. As Dolmans and colleagues reiterate in their article, in order to be effective `feedback should be provided frequently, under conditions that are stress free, should be nonjudgmental, should be complete and as rapid as possible and remediation should readily be available'.14 In all of these developments the student log should remain an important feature. As the reviewing and recording achievement project gains momentum in UK Universities, stimulated by the Dearing Report15 it is likely that students will become more responsible for both recording and charting their own clinical experiences.

Brian Jolly
References
1 Dolmans D, Schmidt A, van der Beek J, Beintema M, Gerver WJ. Does a student log provide a means to better structure clinical education. Med Educ 1999; 32:28597. 2 Stritter FT, Hain JD, Grimes MD, Clinical Teaching Re-examined. J Med Educ 1975; 50:87682. 3 Mattern WD, Weinholtz D, Friedman C. The attending physician as teacher. N Engl J Med 1983; 308:112932. 4 Stark P, Delmotte AE, Howdle PD. Teaching clinical skill using a ward-based teacher. Paper presented at ASME Conference, Southampton, UK. ASME 1998. 5 Coles C. Education in the outpatient clinic: purposes, content and methods. In: Peyton R, editor. Teaching and Learning in Medical Practice. Manticore Publications, Rickmansworth, 1998. pp 18192. 6 McLeod PJ, Harden RM. Clinical teaching strategies for clinicians. Med Teacher 1985; 7:17389.

One activity useful in the structuring the learning environment will be the peer review of clinical teaching now being introduced by a number of medical schools. Such activity has an advantage over feedback delivered by educationalists. In peer review another clinician can act almost as a simulated student, but with status equal to that of the teacher. An essential attribute of a good learning environment is the involvement of clinical managers in the provision of quality teaching and learning activities. Hence Trusts with clinical directors and medical managers need to

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Clinical logbooks: recording clinical experiences may not be enough 7 DaRosa DA, Dunnington GL, Stearns J, Ferenchick G, Bowen JL, Simpson DE. Ambulatory teaching `lite': less clinic time, more educationally fullling. Acad Med 1997; 72 (5):35861. 8 Wilkerson L, Irby DM. Strategies for improving teaching practices: a comprehensive approach to faculty development. Acad Med 1998; 73:38796. 9 Dent JA, Davis MH. Role of ambulatory care for student patient interaction: the EPITOME model. Med Educ 1995; 29 (1):5860. 10 Murdoch Eaton D, Cottrell D. Maximising the effectiveness of undergraduate teaching in the clinical setting. Arch Dis Childhood 1998; 79:3657. 11 Walker M. Small group teaching in the medical context. In: Peyton R, editor. Teaching and Learning in Medical

B Jolly Practice. Manticore Publications, Rickmansworth, 1998. pp 13954. Wolf TM, Randall HM, Von Almen K, Tynes LL. Perceived mistreatment and attitude change by graduating medical students: a retrospective study. Med Educ 1991; 25:18290. Harth SC, Bavanandan S, Thomas KE, Lai MY, Thing YH. The quality of studenttutor interactions in the clinical learning environment. Med Educ 1992; 26 (4): 3216. Rolfe I, McPherson J. Formative assessment: How am I doing? Lancet 1995; 345:8379. Department for Education Employment. Report of the National Committee of Inquiry Into Higher Education. (The Dearing Report) DfEE, London. 1997.

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