1. Student approaches to learning: Comparison of
longitudinal integrated clerkships and rotation-based
clerkships
J Konkin, C Suddards, Division of Community Engagement
Faculty of Medicine & Dentistry

2. Faculty/Presenter Disclosure
Slide 1
• Faculty: Jill Konkin,
Carol Suddards
• Relationships with
commercial interests:
None

3. Disclosure of Commercial
Support
Slide 2
• This program has received financial
support from Health Workforce
Action Plan, Government of
Alberta in the form of Program
Grant including budget for
Program Evaluation
• There are no conflicts of interest

4. University of Alberta, Edmonton, Canada

5. • ICC
communities
(10) range in
size from 5000
to 13000
• Students
spend 42
weeks in their
communities
• Students meet
the same
objectives as
RBC students

6. Integrated Community Clerkship–University of Alberta
• 3rd year of a 4-year medical program
• Physician teachers are primarily family physicians,
many with enhanced skills, i.e. generalist
environment
• 110 students (2007-2014):
• 49% male; 51% female
• On survey, 44% report rural background
• 22 students in 10 communities in 2014-15

7. • 18 weeks of mandatory rotations
Year 4 – Rotation-Based Clerkship
• 6 weeks subspecialty internal medicine
• 6 weeks subspecialty surgery
• 4 weeks emergency medicine
• 2 weeks geriatrics
• Remainder of year is 2-3 week elective blocks, time
off for Canadian Residency Matching Service
(CaRMS) and review classes at the end of Year 4

8. Part of larger program of research
• Evaluating program outcomes -- standards-based
and responsive to interests of stakeholders &
research community (Stake, 2004)
• Exploring how students make sense of their
lived experience in the ICC
• Wanting to better understand what works (or
does not), why and for whom
Program of research

9. What do we mean by approach to learning?
• ways in which students go about their academic
tasks, thereby affecting the nature of their learning
outcomes (Biggs, 1994, p318)
• responses to a learning environment rather than
characteristics of the learner
Background

10. Approach to Learning
• Has both an affective and a cognitive component
• focus on the learner rather than the teacher:
learners may comprehend what they learn from the
teacher’s perspective, but they learn [emphasis in
original] only what they construct for themselves.
How they do this is their approach to learning.
(Biggs, 1994, p319)

11. The research question
What was the lived experience of students in the
UAlberta Integrated Community Clerkship (ICC)?
Further analysis led us to ask:
How do ICC students adapt their approach to learning
from the continuity environment of the rural ICC (LIC)
in response to the RBC learning environment?

12. • reflective conversations using an open-ended protocol
• interpretist frame: phenomenological and hermeneutic
• grounded theory analysis following principles of iteration,
constant comparison, and theoretical sampling [Kennedy & Lingard,
2006; Lingard, 2014]
• two researchers with distinct educational and experiential
backgrounds
Methodology

13. Longitudinal Clerkships Rotation based clerkships
Learning in LIC and RBC
Continuity of patient care: therapeutic
relationships with patients and families
Exposure to clinical cases: no meaningful role or
connection to the situation or the patient
Exposure to clinical cases: understanding of
concepts but not of patients; lower retention
Continuity of supervision: scaffolded learning
Constant change in focus; disrupted learning
trajectory
Continuity of supervision: trusting relationships;
entrustment
No consistent supervision: difficult to tailor
teaching to the learner
Continuity of learning environment: collegial
relationships within a community of clinical
practice
Hierarchical system
Learning environment changes frequently; no
consistent relationship with a teacher or mentor

14. The LIC student experience: what students say
[I]t’s pushing more beyond
yourself; you know that
somebody knows what you’re
capable of, and so they expect
you to be better than that next
month…[2013-03-09]

15. What Learners say about Rotation-based clerkship
In the city you have residents who are, are
certainly willing to teach and able to teach but you
know them for a shorter period of time and so the,
their um educational moments are um maybe not
as fine tuned towards what you as a student need
to learn or, or you know, um are lacking in, in
knowledge and need to flesh out.[2010-04-06]

16. Affective:
Affective and cognitive effects of learning in RBC
• demotivating: “easy to just let things happen”
• loss of agency: “I’m not changing myself…I’m
learning …to stay still for fourteen hours…I’m just
not interested, at all”
• disrupted/ delayed professional development
formation: “I want to be who I was last year…”

17. Cognitive:
Cognitive consequences of RBC learning environment
• disrupted and discontinuous learning trajectory/
lower retention: “plenty of opportunities to forget
things that you’ve learned”
• absence of application and consolidation: “picking
up a little bit here and there”
• regression in thought patterns; dis-integrated
thinking: “I’m very much less impressed with myself
than I was last year [in the way that I approach a
problem]”

18. Adapting to the RBC learning environment
What are some of the adaptive behaviours that our
students told us about?
1. Watch and listen a lot:
• to gain clinical knowledge (most often disconnected bits as
opposed to approaches); and
• to get the lay of the land. They need to know the sub-culture;
what’s okay and what’s not okay, in each new situation.

19. 2. Connect back to their prior experience to
consolidate, formalize and refine their learning:
• What do I already know about this?
• What have I already learned/mastered that would allow me to
participate in the care of this patient?
Adaptations to the learning environment

20. 3. Take deliberate steps to establish a relationship of
trust with a resident or preceptor by:
• proving their knowledge,
• describing what they know, and
• undertaking sometimes meaningless tasks with intent to create a
positive impression.
Adaptations to the learning environment

21. 4. Self-advocate:
• ask targeted questions, seek clarifications, seize whatever
opportunities they can;
• make themselves known to preceptors (asking questions, offering
to do things);
• ask for more engaging learning opportunities;
• keep an open mind about what they might be able to gain from the
learning experience.
Adaptations to the learning environment

22. You kind of have to …toot your
own horn. …let them know if
you’re really comfortable doing
something.
I was …I think it was coming up on
my last shift [on emergency
rotation]… and I was with a
preceptor who had had me two or
three times …sometimes you have
on days and off days and it felt like
I had had a few on days with her. …
One student’s story
Self-advocate;
discernment
Recognize
the need for a
relationship

23. And there was a patient that came
up that uh needed a central line, uh
a subclavian line. And I had never
done one personally before but in, I
had done an ICU rotation where
there, like we had talked about it. I
had put one in a dummy and
watched other residents do it
One student’s story
Reflect on
past
experience

24. and I was kinda waiting for my
opportunity, which never came along.
And I was a little bit choked about it.
But uh then we had this patient in,
in emergency that needed one and
she was really hesitant uh to, to let
me do it. But I really insisted.
One student’s story
Determine
next learning
steps; look for
opportunity
Self-advocate

25. Like I know, I know how to do it and I
told her, like I went through the steps
with her. She was like OK, OK we’ll
do this.
So we went and did that … it was
really good …it’s I think one of the,
the ultimate in satisfaction in
medicine is when you, like having
been able to watch yourself make
that progression I think. [2010-04-05]
One student’s story
Establish
trust;
demonstrate
what you
know
Motivation to
learn and self-directedness
are
maintained.

26. Facilitating a “deep learning” approach allows students to maximize
their learning
• LICs encourage deep learning by connecting learning with patients
• In RBCs students are distracted from the core task of caring for
patients; opportunities are isolated
Why does it matter?

27. Most ICC students are not not willing to settle for
satisficing and adapt to the RBC environment by:
• continuing to focus on their learning needs and to seek out learning
opportunities
• utilizing the deep learning behaviours that were successful for them
in ICC
• sustaining their motivation for learning despite a largely de-motivating
learning environment with structural disincentives for
students to engage
Why does it matter?

28. Why does this matter?
What medical educators must do whatever the
setting:
• Be aware of the environment and its effect on
learning
• Be intentional about our teaching and support
learners in deep learning activity (at times in spite
of the environment)
• Advocate for and create, where possible, learning
environments that support learners in their
professional identity formation trajectory

29. Thank you!
???Questions???
Jill Konkin, MD jill.konkin@ualberta.ca
Carol Suddards, PhD suddards@telus.net
Contact

30. Why does it matter: The Learner’s Voice?
In order to care about what you’re learning about,
you have to care about the people that you’re
working with. In order to care about the people
that you’re working with, you need to spend time
to get to know them, right? You need to build
relationships. And building relationships in the
rotation-based clerkship is just a much more
difficult process to undertake than it is in a
community clerkship, where you have both time
and attitudes that seem to facilitate that. So I’d say
like personally it made a huge difference in how I
approached my learning on a day-to-day basis,
and how I reflect upon what the experience was
like.