Objective: To explore medical students’ experiences working with frequently rotating pediatric inpatient attending physicians.
Methods: We performed a qualitative study using focus groups and individual interviews of medical students who rotated on the general pediatric inpatient service at Children’s Hospital Colorado. The majority of inpatient pediatric attending physicians worked 1-week blocks. We used a semistructured interview guide and analyzed data using the constant comparative method. In accordance with the grounded theory method, codes were developed using an iterative approach, and major themes were identified. Analysis indicated theoretical saturation was achieved. We created a theory that arose from analysis of the data.
Results: Twenty-seven medical students participated. Data analysis yielded 6 themes: learning climate, continuity, student resilience, opportunity to progress, growth into a physician, and evaluation. In the learning climate, the emotional environment was often stressful, although students valued exposure to different patient care and teaching styles. Senior resident continuity promoted student function; lack of continuity with attending physicians inhibited relationship development. Students were resilient in adjusting to changing faculty with different expectations. In the context of frequently rotating faculty, students had difficulty showing improvement to a single attending physician after feedback, which limited students’ opportunities to progress. Students perceived summative evaluation as less meaningful in the absence of having a relationship with their attending physicians.
Conclusions: Medical students valued exposure to different patient care and teaching styles. However, frequently changing attending physicians caused students stress and limited students’ perceived ability to achieve and show professional growth.
Hospitalists, general pediatricians, and pediatric subspecialists are responsible for important aspects of medical student education in inpatient settings.1–3 The frequency with which these attending physicians change on the inpatient wards varies by institution. Academic pressures and concerns for physician burnout have led many institutions to adopt a 2-week attending block, whereas the previous standard was 4 weeks.4,5
Few studies, all comparing 2-week with 4-week attending blocks on internal medicine units, have examined the effects on residents and students of working with shorter attending physician rotations. These studies were inconclusive, although they suggested that shorter attending physician rotations may negatively affect medical education.4–7 Frequent switches may inhibit the development of a meaningful relationship between faculty teacher and learner and may lead to only superficial assessment and feedback.8 One study of internal medicine residents suggested that learning in an environment of frequent transitions negatively affected the educational process; residents learned flexibility and efficiency at the expense of important attributes such as teamwork, relationship building, ownership of patients, and deep system knowledge.9 No studies to date have looked at the impact of inpatient attending physician rotation length on students in pediatrics, analyzed blocks shorter than 2 weeks, or used qualitative methods to understand student experiences with frequently rotating attending physicians.
At our institution most inpatient attending physicians rotate every week. Therefore, in a 1-month rotation, medical students may work with up to 4 different attending physicians. The purpose of our study was to explore medical students’ experiences working with frequently rotating pediatric inpatient attending physicians to identify ways to improve medical education in this clinical environment.
Children’s Hospital Colorado is a 314-bed tertiary care academic children’s hospital in Aurora, Colorado. There are 3 inpatient medical teams led by pediatric hospitalists, general pediatricians, subspecialty physicians, and pediatric chief residents. All attend for 1-week blocks, with the exception of 2 hospitalists who attend for 2 weeks at a time. In addition to the attending physician, the inpatient teams consist of a senior resident, 2 or 3 interns, and 2 or 3 medical and physician assistant students. Medical students rotate on inpatient pediatrics for 2 to 4 weeks.
We performed a qualitative study using focus groups and individual interviews. Both methods of data collection were offered to help establish trustworthiness of findings through triangulation (obtaining data through >1 method of collection) and maximize the opportunity for student participation given student time constraints. These qualitative data collection methods enabled the investigators to explore individuals’ knowledge, experiences, and attitudes.10 Written consent was obtained from participants. The study protocol was approved by the institution’s review board.
Purposeful Sampling Strategy
In accordance with rigorous qualitative research methods, we created a purposeful sampling strategy with explicit criteria to define the group of learners who could best inform our research question (ie, medical students who could best describe in detail their educational experience on a pediatric ward in which attending physicians rotated frequently). Medical students from the University of Colorado School of Medicine who had completed their third-year inpatient pediatric clerkship met these criteria. Students were recruited by e-mail in January 2012 from among those who completed their pediatric clerkship between April 2010 and November 2011. To ensure that students in our study sample were like the students in the group of medical students as a whole, the plan also specified sampling for maximum diversity, meaning the sample was examined for diversity in gender, length of inpatient rotation, time of rotation during the academic year, number of attending physicians during the rotation, and interest in pursuing a pediatric residency. At the time of the study, ~10% of medical students were from ethnic minority populations. To ensure that the perspectives expressed by students in the sample were representative of the perspectives of the larger group of students from which they were drawn, we continued to add students to the sample until qualitative data analysis indicated that themes in the students’ comments were repeating and no new themes emerged.
Two investigators conducted 3 focus groups sequentially, followed by 5 individual interviews over a 5-week period from March to April 2012 in a hospital conference room; students who participated in a focus group did not do individual interviews. Focus groups consisted of 7 or 8 students and were ~1 hour long; individual interviews varied from 16 to 43 minutes. Each participant received a $20 gift certificate. To facilitate focus groups and interviews, we used a semistructured interview guide (Table 1) that addressed teaching, feedback, evaluation, and students’ professional development. Student demographic characteristics were also collected. Focus groups and interviews were audiotaped and transcribed verbatim.
Three investigators immersed themselves in the data and analyzed them using the constant comparative method.11 Codes were built using an iterative approach; initial codes were modified and additional ones added to best reflect data content. At least 2 investigators individually reviewed coding on each transcript and coded data into relevant categories; as a group, 3 investigators then compared coding and resolved discrepancies by consensus. In accordance with grounded theory method, the 3 investigators grouped codes into themes and subthemes, returned to the data to verify relationships between the themes, and created a theory that arose from analysis of the data.11,12 Analysis included whether theoretical saturation had been achieved (ie, themes repeated and no new themes were emerging in the analysis). After analysis indicated that we had achieved theoretical saturation, we stopped sampling (ie, interviewing). As part of our iterative process, we modified our interview guide based on emerging themes to explore its content with limited investigator bias. In addition to triangulation by collecting data from both focus groups and individual interviews, trustworthiness of findings was assessed through sequential exploration of emerging hypotheses with subsequent study participants, reflexive team analysis in which investigators discussed and checked the data against the literature and their independent experiences,13 and member checking in which themes and their interpretation were discussed with a subset of study participants.14
Of 27 participating medical students, 48% were male (Table 2). The proportion of minority students in the sample was similar to that of the student body. The majority (78%) were in their fourth year of medical school at the time of the interviews. Five students (19%) also completed a 4-week pediatric subinternship at Children’s Hospital Colorado in which they each worked with 3 or 4 attending physicians. Data analysis showed that theoretical saturation was achieved.
Qualitative data analysis yielded 6 themes, several subthemes, and a grounded theory. No differences in themes emerged in the focus groups compared with the individual interview settings. Representative quotations are presented in Tables 3 and 4. Students often compared their experiences on other inpatient services, particularly those in which they worked with attending physicians for longer periods of time, with their experiences on the pediatric rotation. The themes, subthemes, and grounded theory are described later in this article.
The learning climate was shaped by the emotional environment, attending physicians’ varying styles of teaching and clinical care, the content of teaching, and the presence of physicians that the students could identify as role models. Students often felt stressed and anxious as a result of the frequent changes of inpatient attending physicians and the subsequent changing expectations. Still, many students valued the variety of teaching and patient care styles they observed among attending physicians. Because teaching activities were not coordinated between attending physicians, some students reported redundancy in teaching and complained about the lack of a standardized curriculum. The opportunity to identify and learn from positive role models was perceived as an important component of the learning climate.
Continuity and Relationships
Students lacked continuity with their attending physicians and often thought that their attending physicians did not get to know them. Students perceived that meaningful evaluation of their performance depended on the development of a relationship with their attending physicians, but meaningful relationships were established infrequently. However, students did experience continuity with residents, and they thought the residents made their role on the team more clear and meaningful. Continuity with residents also enabled students to develop meaningful relationships with the residents, which in turn facilitated student learning, assessment, and constructive feedback.
Students found frequent changes of attending physicians challenging and stressful, particularly when different expectations were not communicated well. Students would learn these new expectations, although they often spent significant effort and time in doing so. Nevertheless, they felt that the ability to work with different people and adjust to different expectations was an important career skill.
Opportunity to Progress
Having an opportunity to progress was very important for students. Opportunities to show their clinical skills to the attending physician during a single week were limited because they might admit few or no new patients.
Because attending physicians switched each week, students could not build off the feedback from any single attending physician and then show him or her improvement. Feedback was also inconsistent between attending physicians and left students not knowing whether earlier deficiencies were resolved. Requesting feedback from the attending physician was uncomfortable because of the lack of a relationship, and students appreciated when their supervisors proactively gave feedback. Furthermore, each new attending physician needed time to identify a student’s current skill level, and the time spent repeating this step throughout the month limited the students’ progression.
Students found themselves having to prove themselves again to each new attending physician. However, continuity with residents counterbalanced the difficulty with establishing relationships with attending physicians. Development of relationships with residents enabled students to earn their trust, act with more autonomy, and have more opportunities to progress.
Growth Into a Physician
Challenges related to lack of continuity and inability to develop relationships with attending physicians appeared to limit students’ ability to make changes in response to formative feedback, thereby limiting their opportunities to progress.
However, many students showed resilience and adaptation, and if meaningful relationships were established, students did experience professional growth. When the learning climate and the relationships with teachers were such that this growth was possible, the rotation became a satisfying learning experience for them.
Students thought that meaningful evaluation of their performance by their attending physicians was hampered by their limited interaction and relationship development and by a lack of opportunities to show the attending physicians improvement in their skills. Because they had few opportunities to show their clinical skills, students worried that 1 suboptimal performance might have a significant negative impact on their evaluation.
Figure 1 depicts the theory that was created in the last phase of analysis when the investigators returned to the data to examine the relationships between themes and the students’ descriptions of positive learning experiences. The resulting theory posits that the learning environment comprises a dynamic interplay between the learning climate, continuity and relationships, and student resilience that, when optimized, provides students with an opportunity to progress. Students perceive summative evaluation of their performance as less important than meaningful growth; however, when their evaluators do have an opportunity to see students’ progress over time, students perceive their evaluations as more meaningful.
Our qualitative study offers additional insight into the perspectives of medical students who work with frequently rotating inpatient attending physicians. Our students viewed attending physicians as important figures who should play a critical role in their professional growth. However, the short amount of time students spent with an attending physician usually hampered their opportunity to progress and grow professionally. Residents on the team played an important role for many students because, in contrast to attending physicians, continuity existed with residents, particularly the senior resident, which provided an opportunity to develop relationships that facilitated student growth toward becoming a physician.
In our study the negative effects on students of frequent changes in their inpatient attending physicians clearly emerged: stress and effort related to adjusting to different styles and expectations, having to prove themselves again, lack of opportunity to build on assessment and feedback and demonstrate improvement in clinical skills, lack of coordinated teaching, and devaluing of summative assessment. There were also positive effects from working with multiple attending physicians. We found that students valued exposure to different patient care and teaching styles, and many students thought that the ability to adjust to different expectations and deal with different people, although stressful, was an important career skill.
Findings from the literature analyzing the impact of shorter inpatient attending blocks on learners have been inconclusive, although existing evidence raises concerns that medical student education is negatively affected. Learners’ evaluations of inpatient medicine faculty were lower when faculty rotated for 2 weeks rather than 4 weeks.5 One study found that medical students perceived worse teaching with a 2-week compared with a 4-week attending block.6 In contrast, another study reported that medical students found similar teaching effectiveness between shorter and longer faculty rotations.7 Previous studies have also found that learners think shorter faculty rotations reduce attending physicians’ ability to evaluate them.4,6 However, published research is limited by data derived from surveys and evaluation scores that do not well describe the reasons students prefer working with faculty for shorter or longer periods of time. Previous studies have not used qualitative research methods, an important strategy for exploring student perceptions. In addition to using a qualitative approach, our study is unique in that it analyzed even shorter (1 week) attending physician blocks and was conducted in pediatrics.
Our study adds evidence of both positive and negative educational effects resulting from shorter attending physician blocks. Despite significant negative consequences, it is unlikely that institutions will return to longer faculty rotations because of legitimate concerns about physician burnout.5,15 Yet the effectiveness of feedback and its subsequent impact on learning are thought to increase when learners and supervisors engage in meaningful relationships over time and when learners receive credible feedback, which is more likely to occur when learners have an opportunity to demonstrate improvement.16 This heightens the importance of developing strategies to provide students with opportunities to progress in the current inpatient environment. Some students in our study described experiences in which they thought they did grow as physicians, when attending physicians found ways to establish a relationship with them and provide meaningful feedback in the short period of time they spent together. Therefore, it may be possible for all attending physicians to learn how to overcome the problems associated with a fragmented inpatient schedule and create an environment that improves learning for students. As found in previous studies, successful relationships between students and attending physicians occur when supervisors know students’ names, include them in patient discussions, and display qualities such as enthusiasm, supportiveness, and encouragement.17–19 Perhaps more challenging in the setting of frequently changing attending physicians is creating a learning environment for students in which they perceive their feedback to be credible and have an opportunity to show improvement.
Our study’s findings offer clues about how to optimize the learning environment for all students in an inpatient setting with frequently changing attending physicians. Our grounded theory posits that an optimal learning environment should include a supportive emotional climate, coordinated teaching, the presence of positive role models, continuity with at least 1 teacher, and sufficient student resilience. Students, senior residents, and attending physicians together share the responsibility for learning. We propose the following framework (Table 5), the 5 Cs, for developing a positive learner–teacher relationship and partnership: Connect (build relationships), Communicate (explain expectations), Collaborate (use goals and practice, observe, and reflect), Convey (share descriptions of learner performance with the next teacher), and Constructive coping (help students become aware of their stress and provide support for student self-regulation of their cognitive, emotional, and somatic reactions).20 Furthermore, because students often have greater continuity with their senior residents, residents’ teaching curricula should be designed and implemented with material on these teaching skills.
Additional strategies might improve the student learning environment. Inpatient attending physicians could create a mechanism to track topics that have been covered either on rounds or in other teaching sessions to ensure that core topics are discussed and redundancies avoided. Continuity with students could be improved if attending physicians scheduled themselves in alternating 1-week blocks. For example, a student rotating for 1 month on the inpatient wards could work with 1 attending physician for weeks 1 and 3 and a second attending physician for weeks 2 and 4. In this model, attending physicians would have a week between blocks to reenergize and yet be able to assess student growth over time.
Our study has several limitations. Our study’s findings may not be representative of medical students at other institutions. Although we sampled for diversity and collected data until no new themes emerged, it is possible that aspects of the student inpatient experience were missed. Although it may be a limitation that the majority of our participants were fourth-year students reflecting on third-year experiences, we noticed that these students had more clinical experience to compare with their pediatric rotation, which seemed to add richness to the discussions. Students pursuing a career in pediatrics may have different perspectives compared with those pursuing other careers; we think both groups were well represented in our qualitative study. Finally, we did not address potential differences in student experiences working with hospitalists compared with other supervisors.
Medical students value exposure to different attending physicians’ patient care and teaching styles. However, frequently changing attending physicians caused students stress and limited students’ perceived ability to achieve and show professional growth. Residents who have continuity with students play an important role in facilitating student professional growth. We propose strategies to help faculty facilitate student learning in the inpatient environment. Because our theory was built from the perspectives of students, next steps could also explore the perspectives of other team members such as attending physicians, residents, and nurses on these transitions.
We thank Dorene Balmer, PhD, Baylor College of Medicine, and Karen Wilson, MD, University of Colorado School of Medicine and Children’s Hospital Colorado for their reviews of this manuscript. We also thank Sheryl Martinson for her transcription services.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by a University of Colorado Department of Medical Education grant.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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