Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, CA, USA.
Med Educ. 2012 Jul;46(7):698-710. doi: 10.1111/j.1365-2923.2012.04285.x.
Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design.
This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data.
Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care.
Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.
传统的分段式实习（BC）结构可能无法优化医学生在工作场所的参与度，而纵向综合实习（LIC）结构似乎更有利于学生随着时间的推移积极参与患者护理。了解这两种实习模式如何影响学生的角色和职责，可以为临床学习计划的设计提供信息。
这是一项多中心定性研究。我们在三个机构对 LIC 和 BC 医学生进行了半结构式访谈，在核心临床年的早期和晚期，以探讨他们与患者的互动经历以及他们所扮演的角色。利用“工作场所的促进因素”框架，对学生的角色和学习环境的质量进行定性编码，这些质量既可以邀请学生参与，也可以抑制学生参与。我们比较了早期和晚期访谈的转录本，以评估学生角色的变化，并进行差异案例分析，以确保编码与数据相符。
54 名学生参加了访谈。他们描述了在临床护理中担任三个主要角色，分别涉及：为患者提供支持；在医疗保健环境中共享患者信息；以及扮演类似医生的角色。LIC 和 BC 学生在临床年的早期和晚期都担任提供支持和传递信息的角色。相比之下，LIC 学生通常在管理患者护理方面扮演类似医生的角色，尤其是在临床年的后期，而 BC 学生很少扮演这种角色。环境和导师的连续性，以及导师对学生合法角色的认可，为学生积极参与患者护理提供了机会。
尽管 LIC 和 BC 学生都报告说在支持患者和分享患者护理信息方面发挥了重要作用，但只有 LIC 学生经常有机会成长为患者的医生角色。LIC 学生与护理系统的高度融合，以及他们与导师和患者的更深入关系，增强了他们提供以患者为中心的护理的动力和能力感。
