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Clinical work matters - a lot! Learning from clinical work: The roles of learning cues and credibility judgements. Watling C et al. Medical Education 2012;46:192-200.


Reviewed by Tricia McBurney

What was the study question?
What are the experiences that academic physicians view as being influential during their training?

How was the study done?
Twenty-two academic physicians, in practice for less than five years, at The University of Western Ontario, in Canada, were each interviewed for one hour. Participants reflected upon experiences during their training that influenced their clinical learning. Data were analyzed during and after data collection, using a grounded theory approach, to develop a model of clinical learning.

What were the results?
At the core of the authors' model of clinical learning is clinical work itself. As they participate in clinical work, trainees receive multiple "learning cues" that might influence their learning. These "cues" are feedback, role models, clinical outcomes, patient/family responses, and peer comparisons. Trainees do not respond to all of these cues equally. Rather, they make "credibility judgements" (how credible is this information?) on which of these cues to accept and integrate into their learning and which cues to reject. The cues most likely to be reflected upon and integrated into future practice, whether they are positive or negative, are clinical outcomes and feedback from patients and families. Feedback from preceptors, though, is not given the same regard. In contrast, it is subject to scrutiny and is often dismissed.

What are the implications of these findings?
Information related to the clinical work of being a physician - whether it is feedback from patients and families, clinical outcomes, or feedback about clinical work - is the most powerful influencer of trainee learning.

Editor's note: In this study, the physicians did not recall feedback from preceptors as being integral to their learning. Only rarely, they remarked, did feedback actually influence them. When it did, it shared three qualities: it was immediate, grounded in the clinical work, and aligned with the trainee's values and self-assessment. When we give feedback to trainees, we should attempt to anchor this feedback in clinical work so that it resonates well with our learners.

In an age where we rely on on-line cases to fulfill ED-2 requirements, this study reminds us that it is the clinical work that drives clinical learning. (SLB)

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