Learning in practice Early practical experience and the social responsiveness of clinical education: systematic review

Objectives To find how early experience in clinical and community settings (“early experience”) affects medical education, and identify strengths and limitations of the available evidence. Design A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001. Data sources Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration. Selection of studies All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication. Results Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students’ confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations. Conclusion Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society’s needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums. Introduction The norm for the past century has been for medical students to learn theory for two to three years before seeing it applied in practice. Encouraged by professional bodies such as the UK General Medical Council, many medical schools are “vertically integrating” various types of practical experience into the early years, yet exponents of vertical integration have not clearly argued the case for it, let alone presented evidence in its favour. We developed a theory, grounded in consensus, that early practical experience (“early experience”) could orient medical curriculums towards the social context of practice, and strengthen students’ affective and cognitive learning. We have now extended this research by systematically reviewing publications on the topic under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration. This paper summarises the review and interprets its main findings in relation to contemporary trends in medical education.