Communities of clinical practice: understanding how to optimize medical student experience on a surgical rotation

The interface between the preclinical years and the clinical years is a particularly stressful time for the medical student. After the relatively familiar territory of the laboratories and lecture theatres of the preclinical years, the clinical environment is viewed as difficult for students. The importance of a positive experience on a surgical rotation goes beyond overcoming the difficulties of transition, however. In a study from Australia, it was shown that 98% of students who expressed an interest in training as a surgeon could identify a positive influence by a Senior Doctor, or Trainee, at some stage during their undergraduate surgical experience. The teaching hospital is the primary site of clinical learning for medical students. However, the primary function of the teaching hospital is health care provision, and only secondarily is it a learning environment. As a result, much clinical learning is opportunistic and dependent upon patient census. Similarly, the nature of service provision means that clinical teachers are often put in situations where they are obliged to prioritize patient care over the teaching of medical students. Within this working environment, medical students are required to apply and expand their medical knowledge, learn clinical skills and to think of themselves as emergent medical professionals. This process requires developing and internalizing professional values, attitudes and behaviours. While professional attributes may be formally taught through courses at the medical school, they are also informally learned through participation in clinical activities in the teaching hospital. Egan and Jaye have applied Wenger’s model of communities of practice to the process of learning that occurs as students negotiate their training in the teaching hospital. They use the term ‘communities of clinical practice’ (CoCP) to describe the specific clinical groups that form around the patient’s bedside with the uniting purpose of patient care. Because the bedside is also the site of student learning on the ward, this is where students encounter a CoCP during their clinical attachments. Two important features characterize student participation in a CoCP. In the first instance, they are transient members who will be on the ward for only a few weeks. Second, their participation is both legitimate and peripheral. One mechanism by which legitimate peripheral participation leads to full participation is alignment – the sense of fitting in or sense of belonging that members of a CoCP experience. Importantly for medical students in the teaching hospital, legitimacy allows exposure to actual practice, while students who remain only peripherally involved require close supervision and special assistance, thus limiting intensity, risk, and the potential for error and consequent learning. Furthermore, it is through their participation in a CoCP that medical students learn how to ‘be one of us’. Medical students begin by practicing on the periphery of a CoCP and only move towards full participation if the right conditions occur. This process may not be fully complete until after graduation. How far the student moves towards full participation is both a function of the CoCP and the individual, but the surgical team can make this easier by making sure that the student is well prepared and has knowledge and skills required for the surgical rotation, perhaps gained in tutorials or a formal orientation. Some students put themselves forward, but many are inhibited by a wide range of concerns such as getting in the way, hurting the patient or making a mistake. The more supported and legitimate they feel, the greater will be their appropriate and effective participation. Helpful suggestions and signs of approval from other members of the team will help, while feeling that they are in the way, that the patient has not consented to their participation, belittling or delegation of inappropriate responsibility will tend to drive them away to the library. Wenger describes boundaries to participation in communities of practice. In many cases, these boundaries are very clear, such as professional roles and tasks, but some are obscure such as where people stand around a bed on ward rounds. A number of objects can also be boundaries such as the patient chart and, indeed, patients themselves. Allowing medical students to participate in record keeping and basic clinical tasks help to break down these barriers and make them feel useful members of the team. Surgical Trainees are in a unique position to help in this process, having been in this position themselves only recently. With their own recent experience and their understanding of the clinical environment, the Trainee, as a near-peer role model (people ‘near’ to the learner professionally and also in proximity and in frequency of social contact), is able to help guide the medical student through the complex ecosystem that is the clinical learning environment, and to enable them to fit into the surgical team. If surgeons are serious about the training of the next generation, it is incumbent upon the surgical community to welcome medical students into their CoCP. Orientating students to the hospital and to the team, and providing opportunities for medical students to function within the team, are vital to their enjoyment of their surgical rotations. Encouraging and educating Surgical Trainees to help medical students to fit into surgical teams will make this much easier. PERSPECTIVES