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Fung, C., Relan. A., Wilkerson, L. Demystifying
"Learning" in Clinical Rotations: Do Immersive Patient Encounters Predict Achievement on the Clinical Performance Examination (CPX)?Academic Medicine 2007;82:S97-S100


Fung, C., Relan. A., Wilkerson, L. Demystifying
"Learning" in Clinical Rotations: Do Immersive Patient Encounters Predict Achievement on the Clinical Performance Examination (CPX)? Academic Medicine 2007;82:S97-S100

Reviewed by Catalina Kersten

What is the problem and what is known about it so far? Many medical schools have implemented logs to capture students' patient encounters. Thc data generated by schools have been successfully used to identify site differences, compare clerkships, and monitor students' exposure to patients. However, little infonnation exists regarding the relationship between process measures and outcome-assessment measures.

Wby did tbe researchers do this particular study?
The authors hypothesized that a comprehensive patient encounter regarding specific clinical problems would predict performance on similar cases assessed in an OSCE setting.

Who was studied?
The electronic 2004-2005 PDA patient encounter Jog data and Clinical Performance Examination (CPX) scores from 166 students rotating in three primary care core clerkships were analyzed retrospectively.

How was the study done?
All students entered data regarding patient encounters during their core clerkships on an institution developed PDA patient log. After completion of all core clerk.ships the students participated in an end ofthe year OSCE from which six clinical problems were assessed. In an attempt to closely match the learning experience with the CPX assessment criteria, only PDA data from patient encounters with no more than two complaints for the six clinical problems tested in the OSCE and encounters for which students had identified full responsibility (comprehensive patient encounter) were included for analysis. The CPX component scores from history, physical examination, and patient-physician interaction were used as the outcome variable in all analysis. Comprehensive patient encounters were compared with CPX component scores.

What did the authors find?
The range of reported number of exposures among students was wide. The subset of patients for which students identified fu ll responsibility represented roughly two thirds of the total patient encounters. The number ofcomprehensive patient encounters for a specific clinical problem did 'not predict students' perfonuance on the matching CPX case. In addition, the number of patient encounters from students in the lowest quanile of CPX case scores was no different than number of patient encounters from students in the highest quartile for CPX case scores.

What were the limitations of the study?
All patient data were self~reponed. with no monitoring system in place. By seuing a minimum requirement of entries the student's full exposure may not have been captured. The authors defined an immersive learning experience when the patient did not have more than two complains and the student had identified full responsibility for this encounter. Encounters that did not meet these criteria were therefore not included in analysis. The assumption that exposure to a patient with more than two complains may not represent an immersive learning experience may not be correct.

What are the implications of the study?
The leaming effect from patient exposure alone is not sufficient. Many variables such as supervision and feedback during these exposures most likely contribute significantly more than just patient volume.

Ed note: The study has face validity to me, which is my shorthand for saying that I am not surprised by the results. It would be nice if teaching and learning could be easily separated, but we know it's not that simple. We do know that stress re."lct"ions embed memories, and perhaps, despite the srudents' self~ reported "full responsibility for the encounter, they responsibility was not "full" enough to embed the right memories. On the other hand, perhaps the teaching did not drive the students to embed the concepts. Either way, we can get students to act as recorders of their experiences, but those records have been repeatedly shown not to correlate with student learning. Now, to conv ince the LCME. DZM

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