Wimmers Paul F, Schmidt Henk G, Splinter Ted A W
Institute of Medical Education and Research, Erasmus MC (University Medical Center Rotterdam), Rotterdam, The Netherlands.
Med Educ. 2006 May;40(5):450-8. doi: 10.1111/j.1365-2929.2006.02447.x.
Clerkship experiences are considered crucial for the development of clinical competence. Yet whether there is a direct relationship between the nature and volume of patient encounters and learning outcomes is far from clear. Some evidence in the literature points towards the importance of clinical supervision on student learning, but the relationship between clinical supervision, patient encounters and student competence remains unclear.
This study aimed firstly to determine the variation in students' clinical experiences within and across sites; secondly, to identify the causes of this variation, and thirdly, to investigate the consequences of this variation on students' competence.
Clerkship students at 12 hospital sites recorded their patient encounters in logbooks. Site characteristics that might influence the variation in patient encounters were collected. Student competence was determined by 3 independent indicators: a practical end-of-clerkship examination; a theoretical end-of-clerkship examination, and an evaluation of professional performance. A model was developed to test the available clerkship data using structural equation modelling (SEM) software.
Analysis of the logbooks revealed a large variation in the number of patients encountered by students. The average length of patient stay, number of patients admitted, and quality of supervision accounted partly for this variation. An increased number of patient encounters did not directly lead to improved competence. Quality of supervision turned out to be crucially important because it directly impacted student learning and also positively influenced the number of patient encounters.
Monitoring the effectiveness of clerkship by merely asking students to keep a tally of the problems and diseases they encounter, without paying attention to the quality of supervision, does not contribute towards improving student learning.
临床实习经历被认为对临床能力的培养至关重要。然而，患者接触的性质和数量与学习成果之间是否存在直接关系尚不清楚。文献中的一些证据表明临床督导对学生学习很重要，但临床督导、患者接触与学生能力之间的关系仍不明确。
本研究旨在首先确定不同地点以及跨地点的学生临床经历的差异；其次，找出这种差异的原因；第三，调查这种差异对学生能力的影响。
12个医院实习点的临床实习学生在日志中记录他们接触的患者情况。收集可能影响患者接触差异的地点特征。学生能力由3个独立指标确定：临床实习结束时的实践考试；临床实习结束时的理论考试，以及专业表现评估。开发了一个模型，使用结构方程模型（SEM）软件对现有的临床实习数据进行测试。
对日志的分析显示，学生接触的患者数量差异很大。患者平均住院时间、入院患者数量和督导质量部分解释了这种差异。患者接触数量的增加并没有直接导致能力的提高。结果表明，督导质量至关重要，因为它直接影响学生学习，也对患者接触数量产生积极影响。
仅要求学生记录他们遇到的问题和疾病来监测临床实习的效果，而不关注督导质量，无助于提高学生学习。
