| 2022 Journal of the Academy of Health Sciences: A Pre-Print Repository | Categories Paper

The Thruple of Self-Directed Learning: Marrying Student-led Community Outreach Clinics, Problem-Based Learning, and Professionalism Mentorship in Medical Education

by Teresa Marie Nufer, MD PhD ↓

As a student about to graduate from medical school who completed a graduate degree prior to entering medical school, I’ve developed opinions about various aspects of my medical education. I’ve had many profound and life-changing educational experiences, and I have also jumped through a lot of hoops. I’ve had excellent teachers and mentors guide me, and I can recount experiences where I felt demeaned or overlooked. I have been included and heard, but sometimes I’ve just had to put my head down and go with the flow. As I’ve had the opportunity to research medical education and reflect on my own experiences, I’ve come to believe that the best way forward in the medical education involves embracing every student’s ownership of their own learning1. While medical education has continued to develop and progress throughout the last few decades, there are still many opportunities for improvement to nurture and mold the kind of physicians that we want for the future2. Three important, interrelated tenets of self-directed learning include 1) early and longitudinal student-led community outreach clinic involvement, 2) problem-based learning (PBL), and 3) professionalism mentorship, ideally within houses (i.e., small learning communities) or a similar system.

Student-directed learning is often proverbially and colloquially discussed on many levels within medical education. However, few institutions truly have a curriculum that fosters student ownership of learning. As part of curriculum reinvention initiative entitled, MedEdMorphosis at the University of Utah, we are designing and workshopping specific aspects of a newly envisioned educational structure that will ultimately foster a greater ownership of learning and more impactful mentoring relationships between students and upper classmates, residents, and master clinician educators. While this has been a long term and complex process to imagine, design, workshop, and ultimately implement significant changes to our medical school structure and curriculum, I would like to focus this opinion piece on a few of the aspects of our plan that I am most passionate about and that I believe have the greatest opportunity to evolve medical education in Utah.

Student-Led Community Outreach Clinics

As a first- and second-year medical student, I had the opportunity to volunteer at a community clinic. I still vividly remember many of the experiences I had there, so many of which involved a moment in which something that I had learned in the lecture hall finally took real shape and form when I interviewed or examined a patient, or when I talked to my attending about a treatment plan. I remember my first time I observed costovertebral angle (CVA) tenderness in a patient with pyelonephritis. I remember doing a point of care (POC) glucose myself and explaining a diabetic diet to my patient in Spanish. My confidence as a budding physician first began to blossom in this community clinic. I could see for the first time how my classroom learning might apply, and how it couldn’t. Looking back, some of my clinical experiences during official clerkships comprised a more observatory, passive role, but in the student-run volunteer clinic, I got my first taste of what it felt like to help someone as a physician. It was a powerful and humbling role.

MedEdMorphosis hinges on our belief that early and consistent longitudinal exposure to hands-on patient care starts as early as the first week of medical school and leads to an exceptional learning environment where students take ownership of their knowledge and skills from the beginning. They can contextualize the knowledge they gain and build a framework for how to improve their skills and hone their understanding of scientific concepts. Nothing is learned in a vacuum. Students acquire knowledge and skills with the patient (and likely specific patients) in mind. Students will come to intimately understand the needs of underserved communities and develop greater empathy through actual experience rather than relying on vacuous lecture material. They will come to understand the roles of other healthcare professionals without having to take a separate course as they work closely with nurses, advanced practice providers such as nurse practitioners and physicians’ assistants, therapists, social workers, and medical assistants weekly and longitudinally4. Student involvement can also add significant value to patient care, the hospital system, and the educational system5,6.

While on the outset, this approach might appear to overwhelm the beginning student, the layered nature of student involvement in the student-led clinics will facilitate a stepwise approach to mastery of clinical skills, medical knowledge, and professionalism. In our current vision of how these student-led community outreach clinics will function, students in Phase 1 will apprentice and work closely with students in Phase 3 and beyond along with supportive faculty. These students within houses will develop long-term, and hopefully close and trusting, relationships with each other. These relationships will be cultivated and nourished within the house learning communities and in longitudinal clinical work.

Problem-Based Learning

Having completed a PhD before attending medical school, I will admit that starting medical school felt like joining a herd and was far removed from the self-directed learning guided by specific aims that I experienced as a graduate student. In some ways, medical school felt like a step backward in my education rather than a step forward towards my future career. As I progressed in my medical education and began to work with patients, my favorite learning moments in medical school were those where I was given a relevant clinical question to answer myself. The importance of asking the right question and finding an applicable answer cannot be overstated.  

Multiple sources of evidence suggest that problem-based learning (PBL) is superior to traditional lecture-based formats as evidenced by test scores as well as student preference7. PBL in its most traditional format would require students to bring problems and questions from their clinical experiences to a group of their peers and mentors, and then to discuss and research clinical approaches and solutions together. Though this may initially appear a haphazard and random approach, we envision a competency-based list of problems/subjects that should be covered in some way during Phase 1. An experienced, primary care-based highly experienced clinician educator would be present to guide student inquiries and supplement the PBL discussions with relevant clinical experience and materials. We also envision that a library of asynchronous resources would be made available to students to access in addition to sources such as UpToDate, Dynamed, and other databases. Traditional PBL may also be supplemented by team-based learning (TBL) and case-based learning (CBL) separately, or elements of these learning modalities may be incorporated into PBL group activities. Successful mentorship and teaching within PBL groups will require highly experienced clinician educators who are invested in the learning outcomes of their students. These leaders will be ethical and open-minded, and they will seek for genuine connection with their learners. They create an environment of curiosity, psychological safety, and passion for science and quality patient care.

Longitudinal Mentorship within Houses

We believe that trusting relationships with mentors and a strong sense of community within medicine will produce the best doctors8. We plan to achieve these outcomes through implementing a house system where we foster close professional communities of students from all levels, residents, highly experienced clinician educators, and staff within the school of medicine. Students will receive increased support to network and explore specialties. They will have close interactions with residents and be better prepared for clinical clerkships, residency, and ultimately successful careers as community-oriented physicians. Students will also have important leadership opportunities as mentors and participants in student-led boards that will prepare them for future leadership roles in medicine. We believe that students will achieve their highest potentials when adequately and longitudinally supported in close-knit groups that incorporate many levels of trainees and highly experienced clinician educators.

In recent years, there has been significant discussion about how professionalism is portrayed, exemplified, and taught to medical students. Professionalism is sometimes invoked as a suppressive mantle to encourage lecture attendance or discourage changes from the heteronormative superstructures of medicine9,10. Sometimes medical professionalism is talked about as part of the “hidden curriculum” of medicine that teaches hierarchically appropriate behaviors11. However, we believe that professionalism is best defined and taught within relationships—trusting relationships where students are treated as humans and capable, eager learners. Mistreatment has been another hot topic within the medical education literature12, but we further posit that mistreatment would require less attention if professionalism were taught compassionately within trusting mentorship relationships, such as those provided within houses. How can we encourage, teach, and measure the development of positive mentorship relationships within the house model? We hope to increase connection between students and mentors by training clinical educators who value and emphasize psychological safety13, appropriate feedback, empathy, and educational alliance14, as posited by the Connection Index (CI12) for measurement of connection between trainees and educators15. In a longitudinal study using a validated scoring system (the CI12), higher connection scores between educators and trainers were linearly associated with greater supervision attendance, higher personal achievement, and less negative emotional experience15.  We hope to implement the CI12 or a similar objective scoring system to identify faculty who require greater development while also prioritizing teaching to and reallocating resources for those educators who excel at connecting with their trainees. We hope that these core principles of psychological safety, appropriate feedback, empathy, and educational alliance can become core tenets of the house system, so that we accelerate learning and community building amongst medical students and their mentors/educators.

Conclusion

The University of Utah is passionate about upcoming changes proposed by MedEdMorphosis. As a graduating student, I am excited about rooting the educational experience of future students in longitudinal student-led community outreach clinicals, PBL, and mentoring relationships within houses. As we envision the future that we want for medicine, we believe that this “thruple” will produce the physicians that we need and hope for by increasing student ownership of learning. Future students will have the experiences to anchor and contextualize their medical knowledge at student-led community outreach clinics. They will have the skills to identify questions and find clinically relevant answers by participating in PBL. They will understand professionalism in a non-toxic, wholistic way through genuine connection and nurturing mentorship within their house relationships. We believe that medical education can and should be different and are boldly moving in the direction of the future that we want for our profession.

References

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The Thruple of Self-Directed Learning: Marrying Student-led Community Outreach Clinics, Problem-Based Learning, and Professionalism Mentorship in Medical Education by Teresa Marie Nufer, MD PhD