It’s all about the patients: a shift in medical students’ approach to learning during a novel distributed integrated clinical rotation
Authors: Couper Ian , van Schalkwyk Susan , Blitz Julia , Fish Therese , Viljoen Kobus , Smith Luné 
Published: October 2024

Abstract
Introduction
To ensure that pre-final year medical students at Stellenbosch University were able to resume clinical training during the COVID-19 pandemic, a 12-week integrated rotation was introduced, during which students were distributed across a widespread training platform in two provinces of South Africa, utilizing a range of health care facilities in both rural and urban areas, rather than the central academic hospital (CAH) in which they would have been doing clerkships. Called the Integrated Distributed Engagement to Advance Learning (IDEAL) rotation, this clerkship was based on supervised engagement in healthcare services, focusing on patient-based clinical training, self-regulated learning and student participation as integral members of clinical teams. The success of this emergency intervention has led to its formal incorporation into the medical curriculum. This study aimed to understand the factors that influenced learning among students undertaking the IDEAL rotation at multiple sites on a distributed training platform.

Methods
Using an interpretive paradigm, we sought to conduct focus group interviews with students who completed the first iteration of the IDEAL rotation in the year after they had undertaken it to understand their experiences. All 252 students who were eligible were invited to participate by email on several occasions. Ultimately three focus group discussions and two individual interviews were undertaken, based on volunteers. Using a semi-structured interview guide, these explored student perceptions of their learning and growth through the rotation. Inductive and deductive analysis was carried out to identify themes.

Findings
Student descriptions of their learning experiences coalesced in 6 themes. The rotation was an enabling learning experience, which was more practically focused and assisted students in developing confidence in their clinical skills. It was seen to be a humanizing learning experience with greater opportunities for the development of relationships with patients and families, as well as with health professionals, who made them feel part of the team, so it was also a more collegial learning experience. At the same time, it was a variable learning experience with a lack of standardization on a number of levels and challenges being experienced at particular sites regarding both logistics and the nature of the exposure. Students perceived it to be a very different learning experience from what they had encountered in the CAH in terms of relationships, the kinds of patients and problems they saw, and their active participation. Through this, they also learned more about themselves and their roles, making it a personal learning journey. The findings confirm the importance of the dimensions of person, participation and place for being and becoming a doctor in a clinical environment.

Conclusions
Student learning experiences in the IDEAL rotation emphasize the importance of context, reinforcing the value of a distributed training platform in developing health professionals who are responsive to their environment. They emphasize the vital role of active participation in learning and the centrality of relationships in medical training, helping to develop graduates who are human beings and not only human doings.