Medical students as teachers at CoSMO, Columbia University's student-run clinic: A pilot study and literature review

Abstract

Background: Although medical students are expected to teach as soon as they begin residency, medical schools have just recently begun adding teacher training to their curricula. Student-run clinics (SRCs) may provide opportunities in clinical teaching before residency.

Aim: The aim of this pilot study was to examine students’ experiences in clinical teaching at Columbia Student Medical Outreach (CoSMO), Columbia University's SRC, during the 2009–2010 school year.

Methods: A mixed-methods approach was used. Data included closed and open-ended surveys (n = 34), combined interviews with preclinical and clinical student pairs (n = 5), individual interviews (n = 10), and focus groups (n = 3). The transcripts were analyzed using the principles of grounded theory.

Results: Many students had their first clinical teaching experience while volunteering at CoSMO. Clinical students’ ability to teach affected the quality of the learning experience for their preclinical peers. Preclinical students who asked questions and engaged in patient care challenged their clinical peers to balance teaching with patient care. Clinical students began to see themselves as teachers while volunteering at CoSMO.

Conclusion: The practical experiences in clinical teaching that students have at SRCs can supplement classroom-based trainings. Medical schools might revisit their SRCs as places for exposure to clinical teaching.

Background

Teaching is an integral part of being a physician. Physicians teach patients, colleagues, residents, and medical students everyday. There is significant literature discussing the importance and effectiveness of teacher training for faculty and residents. Yet, the literature discussing the training of medical students as teachers is still growing.

Barrow (1966) first suggested in the 1960s that medical students are interested in teaching. He used surveys to show that medical students saw residents as teachers and looked forward to teaching in residency. Until the past decade, however, few formal students-as-teachers (SAT) programs have been described (Paiva et al. 1982; Craig & Page 1987; Greenberg & Jewett 1987). Medical schools are starting to recognize the importance of teaching students to teach (Moseley et al. 2002; Nestel & Kidd 2002; Pasquale & Pugnaire 2002; Bardach et al. 2003; Morrison et al. 2003; Haber et al. 2006; Blatt & Greenberg 2007; Dandavino et al. 2007; Pasquale & Cukor 2007; Smith et al. 2007; Ten Cate 2007; Pasquinelli & Greenberg 2008; Andreatta et al. 2009) and, according to a recent survey, almost half of US medical schools now offer some kind of SAT curriculum (Soriano et al. 2010).

Nearly all medical schools use their students as peer teachers (Soriano et al. 2010). Although many studies describe these peer teaching opportunities, few examine their effect on students’ development as teachers (Nestel & Kidd 2005; Buckley & Zamora 2007; Bulte et al. 2007; Ten Cate & Durning 2007; Harms Amorosa et al. 2011). Moreover, peer teaching experiences and SAT programs are classroom-based, and these skills may not translate directly to the clinical teaching of residency, much of which occurs at the bedside. We propose that student-run clinics (SRCs) can provide practical experiences in clinical teaching before residency.

The SRC literature acknowledges that students are teachers at SRCs, but does not describe this teaching in detail (Davenport 2000; Beck 2005; Simpson & Long 2007). The literature instead discusses other valuable learning experiences such as caring for the underserved, psychosocial medicine, systems-based practice, and access to care (Davenport 2000; Clark et al. 2003; Beck 2005; Hastings et al. 2007; Meah et al. 2009; Simmons et al. 2009; Sheu et al. 2011). It also discusses models for student-run health care delivery (Der et al. 2001; Bennard et al. 2004; Beck 2005; Moskowitz et al. 2006; Niescierenko et al. 2006; Simpson & Long 2007; Rosenbaum et al. 2008; Batra et al. 2009; Dvoracek et al. 2010; Strowd et al. 2011), the ethics of SRCs (Buchanan & Witlen 2006), and patient demographics, satisfaction, and outcome data (Cadzow et al. 2007; Ryskina et al. 2009; Ellett et al. 2010; Liberman et al. 2011; Zucker et al. 2011). We could identify no studies that describe SRCs as a place where medical students can learn how to teach.

Columbia Student Medical Outreach (CoSMO), Columbia's free SRC, opened in March 2004 as a place where clinical and preclinical medical students could work together under the supervision of a volunteer attending to provide primary care to the uninsured in northern Manhattan. Although the primary goal of CoSMO is to provide needed healthcare services to the community, a secondary goal is to create a space where a unique type of medical education can occur. This pilot study is part of a larger effort to improve clinical teaching at CoSMO.

Table

Practice points

SRCs can provide students with practical experiences in clinical teaching. Optimal clinical teaching occurs when clinical students both challenge and support their preclinical peers. SRCs may improve the quality of students’ teaching and learning experiences by implementing a formal SAT program and feedback mechanism. Clinical students begin to see themselves as clinical teachers at SRCs.

Aims

While we also collected data on how preclinical students develop as clinicians, the purpose of this article is to examine the practical experiences in clinical teaching that clinical students may have while volunteering at an SRC.

Methods

Research design

We used a mixed-methods design, combining data from closed and open-ended surveys, focus groups and interviews to examine students’ experiences with clinical teaching at CoSMO (Figure 1). We conducted preliminary focus groups with preclinical and clinical students in May 2009 to inform the study, which was approved by the Columbia University Medical Center Institutional Review Board. We developed a preliminary conceptual framework similar to Daloz’ (1990) model of mentorship, which suggests that learning and mentoring relationships are most effective when students experience and teachers provide a balance of support and challenge. We used this framework to structure our survey instruments and topic guides.

Figure 1. Research design for mixed-methods study of student experiences in clinical teaching at an SRC, 2010. Notes: §Volunteers were eligible for interviews after having completed the survey, but were not eligible for the survey after participating in an interview. All learners participated in the interview during their first or only time at CoSMO. Four teachers participated in the interview during their first or only time at CoSMO. Three teachers participated after having previously volunteered and had been invited to complete the survey. ‡Two sets of combined and individual interviews were excluded because incorrect consent forms were signed.

From September 2009 to March 2010, we administered an online survey about teaching and learning experiences to all eligible clinical and preclinical student volunteers, respectively. To minimize recall bias, we sent an email with the link to the survey shortly after students’ Saturday shift in clinic (Figure 2). We also invited five preclinical and clinical student pairs to participate in semi-structured interviews. We interviewed the students individually and in teacher–learner dyads to gain insight into their relationship and how it facilitated or complicated learning and teaching while at CoSMO (Figure 3). Magni Hamso facilitated three focus groups at the end of data collection to allow students to reflect in small groups on their own experiences and on the data gathered from the surveys and the interviews. We recorded and transcribed all interviews and focus groups. Of note, no SAT program was implemented at CoSMO as part of this study; clinical students were simply asked to “teach” their preclinical peers, without any additional explanation, as had been done since the inception of CoSMO.

Figure 2. Teacher survey instrument (A) and learner survey instrument (B) used for study of student experiences in clinical teaching at an SRC, 2010.

Figure 3. Combined interview topic guide (A), teacher topic guide (B) and learner topic guide (C) used for study of student experiences in clinical teaching at an SRC, 2010.

Analytic technique

We analyzed our data using the principles of grounded theory (Strauss & Corbin 1998; Pope et al. 2000; Kennedy & Lingard 2006; Hanson et al. 2011). Magni Hamso and Amanda Ramsdell independently coded all interviews and one focus group. We compared codes and prepared a joint codebook (available upon request). Our inter-coder agreement rate increased from 63% to nearly 100% after we refined our codebook. Magni Hamso coded the remaining focus groups. We re-coded the transcripts to focus on the preclinical and clinical students’ perceptions of their experiences as clinicians and teachers, respectively, while at CoSMO. This re-coding helped us adapt our preliminary conceptual framework, which was informed by Daloz’ model of mentorship, to understand preclinical students’ development as clinicians if properly supported and challenged by their teachers, their clinical peers. We also wondered about the model's reciprocal application to the teachers, who are themselves learners (many engaging in clinical teaching for the first time), and how the teachers could grow as clinical teachers if supported and challenged by their learners, their preclinical peers. We used our conceptual framework to create a data display (available upon request) organized into three sections: (1) teacher perspective on own teaching, (2) learner perspective on teaching, and (3) proposed interventions for teaching. The “Results” section, organized in accordance with the data display, shows how clinical students serve as clinical teachers at CoSMO.

Results

The data included 16 clinical student surveys, 18 preclinical student surveys, 5 combined interviews, 10 individual interviews, and 3 focus groups (Figure 1). Approximately 70% of the clinical students were third years and 30% were fourth years, a distribution typical of CoSMO's clinical volunteers. Approximately 75% of the preclinical students were first years and 25% were second years, similarly typical of CoSMO's preclinical volunteers.

The quantitative survey data (Table 1) suggested that both preclinical and clinical students appreciated their SRC experience, the majority rating it as “Good” or “Excellent.” Both clinical and preclinical students felt their preclinical and clinical peer, respectively, was supportive and instrumental to their experience, but few felt sufficiently challenged by their peer. The quantitative data were consistent with the qualitative survey data, which we describe below together with the individual and combined interview and focus group data. We conducted individual interviews after the combined interviews with teacher–learner dyads, to allow the respondents to privately address aspects of their relationship that they may not have felt comfortable discussing during the combined interview. However, we found that both teachers and learners were candid during the combined interviews and that the individual interviews allowed for further elaboration but did not contribute significantly different data. We thus do not distinguish between quotations from the combined and individual interviews. Unless otherwise indicated, the quotations come from the combined interviews, the individual interviews or the focus groups. For the remainder of “Results” section, we use the terms “clinical student” and “teacher” to refer to third and fourth year students and the terms “preclinical student” and “learner” to refer to first- and second-year students. We avoid using the term “peer” for the sake of clarity, although we do acknowledge that the learning and teaching that happens at CoSMO is between peers.

Table 1.  Frequency of ratings from teacher survey (n = 16) (A) and learner survey (n = 18) (B) for study of student experiences in clinical teaching at an SRC

A. Teacher survey		B. Learner survey
Overall rating of teaching experience		Overall rating of learning experience
Poor	0 (0)	Poor	0 (0)
Fair	2 (12.5)	Fair	2 (11.1)
Good	9 (56.3)	Good	7 (38.9)
Excellent	5 (31.3)	Excellent	9 (50)
Importance of learner		Importance of teacher
Not at all important	0 (0)	Not at all important	0 (0)
Somewhat important	2 (12.5)	Somewhat important	0 (0)
Important	10 (62.5)	Important	6 (33.3)
Very important	4 (25)	Very important	12 (66.7)
Supportiveness of learner		Supportiveness of teacher
Not at all supportive	0 (0)	Not at all supportive	1 (5.6)
Somewhat supportive	0 (0)	Somewhat supportive	1 (5.6)
Supportive	9 (56.3)	Supportive	6 (33.3)
Very supportive	7 (43.8)	Very supportive	10 (55.6)
Challenged by learner		Challenged by teacher
Not at all	1 (6.3)	Not at all	5 (27.8)
Somewhat	11 (68.8)	Somewhat	8 (44.4)
Quite a bit	4 (25)	Quite a bit	5 (27.8)
A great deal	0 (0)	A great deal	0 (0)

Note: Percentages are given within parentheses.

Teacher perspective on own teaching

Clinical students often had their first clinical teaching experience at CoSMO. Many found it challenging to teach while still developing as clinicians themselves. As explained by one teacher:

I felt challenged to do the things I felt had to be done and then have time or find time to then explain some of the things I had had to do.

Another teacher found it difficult to identify teaching moments while focusing on patient care:

It takes a lot of effort to work and teach at the same time. I have to stay on my toes to make sure I recognize teachable moments and take advantage of them (Teacher Survey).

The teachers acknowledged the importance and relevance of being able to simultaneously teach and provide patient care:

It's a really important challenge to be able to engage with your patient and take care of all of their needs … then at the same time being able to, either from example, umm, teaching the preclinical student or, umm, simply getting their reflections on something.

Teachers in general felt supported by their learners as they engaged in clinical teaching. Indeed, many teachers found it reassuring to collaborate with a preclinical student who could also think critically about their patient's care:

It's really nice to have someone watching you and asking you questions ‘cause it makes you think, “oh I didn’t think about that,” or “oh we should ask the patient that.”

As they taught, clinical students gained confidence in their own skills and knowledge:

It's almost nice going to the attending and you have no idea what you’re doing and, then you get it all wrong, and your diagnosis is totally wrong, and then you come back and walk out, “wow, so now that we’re thinking of diagnosis B, here's what I know about that.” And you can, you can talk about it with the [learner] … And it almost boosts your confidence up again.

Teachers, such as the one quoted above, received the support they needed from their learners to feel comfortable in their new role as clinical teachers.

Some teachers felt fairly comfortable as clinicians in the primary care setting, and were ready for the new challenge of teaching:

It's not really a novelty to me to see a patient by myself, but it is sort of novel to figure out how I’m going to rapidly convey a large quantity of information to someone else and let them, you know, still have some sort of autonomy when dealing with the patient.

Clinical students comfortable with patient care enjoyed figuring out how to teach in the clinical setting, something that for them was completely new. They appreciated their learners’ questions, which helped them connect clinical knowledge to the basic science of the preclinical years:

You really have to think through things and because everything is new to him, you know, he's going to ask the mechanism behind everything so I actually have to think about it, which I think definitely helps.

Teachers also enjoyed the challenge of trying to appropriately engage an active and eager learner:

I certainly felt challenged, umm, not only by, like, the types of questions but, like, here's someone who's very enthusiastic and wants to learn a lot of stuff and, “oh shoot, I need to, I need to be on the ball a little bit,” in terms of giving her what I know.

Many teachers realized that they enjoyed teaching at CoSMO and looked forward to teaching later on in their training and careers. As one teacher noted,

We’re going to be residents and then they’re going to be medical students or third year students, and some of our job is to teach, more as PGY2s than as interns, but … you always liked that intern that had a second to explain something to you.

However, clinical students also realized that teaching takes practice and that to be good teachers in residency, they needed to start training early. As one teacher wrote,

I’m not very good at teaching and need to practice more before I become an intern! (Teacher Survey).

Learner perspective on teaching

Preclinical students often had their first clinical experience at CoSMO. Many did not feel comfortable interacting with patients on their own and needed support:

I definitely felt like I was more passive the first time I went, because I didn’t really know what I was doing, I think it was like the first month of school and, umm, I just didn’t feel confident, umm, interviewing the patient by myself or anything.

Preclinical students described as effective those teachers who provided enough support for them to feel comfortable in the patient care setting. These teachers encouraged questions, prioritized their learners’ comfort, and engaged their learners in a manner appropriate for their level of training.

Supportive teachers were open to questions and were patient when learners struggled to understand:

[My teacher] was really receptive for me to go back on questions that I didn’t understand and to revisit things that he’d already explained but I’d forgotten.

These supportive teachers helped learners relax in the clinical setting:

[She] put me in a more relaxed state so I could absorb everything that she told me instead of being anxious about, you know, worrying about what they think of me.

Supportive teachers also prioritized their learners’ comfort and confidence. One learner described how his teacher took responsibility for his learner's mistakes when the learner presented the case to the attending:

When I presented the first case, if I didn’t know something or you know if I made a mistake and, at some points the attending could be, you know, a little hard, which is fine, but, umm, I think she did a good job with, like, also deferring some of the things … “Well, yeah, I could have told him that, sorry” … “I didn’t prep him on that,” or something like that … so it worked out well.

Not all clinical students were supportive teachers, however. These less effective teachers were not in tune with their learners’ need for help and guidance:

It wasn’t like, umm, “here why don’t you try the interview and I’ll jump in at times.” Umm, it was, like, “do you want to do it all, in Spanish.” So I was like, “ok, I’ll try,” so I tried it for a minute and then, and then I was hoping that, you know, I could keep doing it but ask questions to the [teacher] and she’d help me along. But as soon as I showed some fault, she just took over the rest of it.

The teacher in the quote wanted to give the learner the opportunity to interact with a patient with relative autonomy. However, in the end, the teacher prioritized her own need to manage the patient's care over her role to support the student's need to learn through patient care.

Some learners had prior clinical experiences and felt comfortable in the patient care setting. These learners described as effective the teachers who challenged their medical knowledge, engaged them in patient care, and pushed them beyond their comfort zone. One learner shared this about being challenged by his teacher:

Since she didn’t know necessarily exactly what I knew it was more of stretching what I had already learned into more of a clinical setting. And, and taking that, the knowledge that I might already have one step further even if I hadn’t like explicitly learned it in the classroom.

Another learner felt challenged when his teacher let him take the lead in patient care:

Having someone who is supportive of your developing and learning as a clinician, and giving you opportunities to, umm, take the lead on things even if you aren’t, you don’t have very much experience. So that's really important because I don’t have a ton of experience yet in all of these … I definitely need support but I also need to learn by doing.

One learner was pushed beyond her comfort zone while taking a patient's blood pressure for the first time. While the learner simply said that, “the technique he used while he made me take the blood pressure one more time … was really great,” her teacher described this technique in more detail:

Even though she’d sort of begun taking things off and you could sort of see her starting to abandon ship sort of thing, but I tried to really hold her in the spotlight a little bit. Because it's important for her to be able to deal with the emotions of a physical exam and with getting things wrong.

Although the above learners felt challenged, as the quantitative data also showed, not all learners felt challenged by their teachers. Their teachers seemed to prioritize working on their own clinical skills over teaching or were not aware of their teaching responsibilities at CoSMO. As one learner explained,

My interpretation was that each [teacher] kind of had different goals during the encounter. I mean, I think some wanted to take on more of that teaching role and kind of saw CoSMO as good for that. Some of them, you know, did see it as a way to work on their own skills and that the teaching was just, was more secondary.

Another learner reached a similar conclusion and in the survey wrote the following about his teacher:

Poorly organized, unclear that teaching was a part of the day, too busy staying afloat herself to pay attention to other students.

Proposed interventions for teaching

Both teachers and learners had recommendations for how to improve their experience at CoSMO. They suggested that formalizing the teacher's role, adding structure to the learner's role, and developing a feedback mechanism could significantly improve their experiences.

Both teachers and learners felt that formalizing the teacher's role could improve the learning environment. As one learner suggested, simply emphasizing the importance of their teaching role to the clinical students could reduce some of the variability in the learning experience for the preclinical students:

Some of them are, you know, are prepared and do consider it to be part of their role, but others … they’re focused on, you know, on their portion of it and you’re there, to, to kind of tag along, and, you know, just follow their lead. So, I think, just making it more, you know, a more definitive role as a teacher would certainly help.

Other learners thought that more clearly defining the preclinical students’ role could improve their learning experience:

I think it could be useful to provide the [preclinical students] with some scaffolding, especially since we don’t have much if any clinical experience. Maybe have a list of useful questions to ask when taking a patient's history would’ve helped me when I got stuck during the interview (Learner Survey).

Both teachers and learners felt that setting expectations for the learner could help engage them further. Moreover, empowering learners to ask their teacher to emphasize teaching could improve their learning experience:

I think it should be a part of your role as a [learner] to in a way call out your [teacher] if they weren’t teaching you and be, like, “Could you teach me more?”

Finally, both teachers and learners recommended developing a feedback mechanism. As one teacher commented,

I wish we got feedback. I understand you wouldn’t want them telling us directly, ‘cause we know who they are, but if we could filter the feedback through you. Because I’m sure there's things we could do better and differently, we just have to know about it.

One learner emphasized the importance of feedback for teachers, especially for those who did not prioritize teaching or did not know how to teach:

I don’t know how you would work something like that out, but I think, especially right after the clinic you have an idea of what worked well for you as a [learner] and what didn’t work that well, and maybe having that type of feedback for them to know what worked for them could potentially be something valuable for [teachers].

Both preclinical and clinical students suggested that through a formal feedback mechanism, the teachers might improve their teaching skills and the learners might benefit from supportive and challenging teachers dedicated to helping them learn about patient care and clinical medicine.

Conclusions

At the SRC that we studied, many medical students had their first experience in clinical teaching. They had the opportunity to practice and acquire teaching skills crucial in preparing for residency.

Both clinical students who were teachers and clinical students who were learners were able to reflect on their experiences at CoSMO and explain why their exposure to clinical teaching was positive or negative. The learners identified their differing needs for support and challenge and, in accordance with Daloz’ model for mentorship, they had highest regard for those teachers who were able to effectively tailor their teaching to their learner's level of comfort with patient care. The learners challenged their teachers, not only by asking them about the relevant basic science but also by compelling them to balance teaching with patient care, a challenge not unlike what they will face in residency. The teachers were perhaps most challenged by their situation of having to simultaneously teach and provide patient care. Although not completely consistent with Daloz’ model of mentorship and description of a mentor as the one who provides support and challenge, these constructs of support and challenge help us understand how students might learn to teach while volunteering at an SRC.

Consistent with the literature, our pilot study suggests that medical students are well aware of the qualities of a good clinical teacher, including being supportive and enthusiastic, being capable of adapting to different learning styles and levels, being open to feedback, and having a good fund of knowledge (Sutkin et al. 2008). SRCs such as CoSMO can expose students to clinical teaching and provide opportunities to learn and improve their clinical teaching skills. However, students may benefit from formal training and feedback to help them take advantage of these opportunities and develop the qualities of good clinical teachers.

Using the data from this pilot study, we hope to create an SAT curriculum that can help move students’ experiences in clinical teaching at CoSMO from simply exposure to practical training in clinical teaching. We also hope to expand our study to include more students and to examine how over time clinical students can develop as clinical teachers at an SRC.

Limitations

This study has several limitations. Both Magni Hamso and Amanda Ramsdell were involved in the CoSMO leadership at the time of this study. However, all data and analysis were reviewed by members of the university's Center for Education Research and Evaluation, objective outsiders with significant experience in qualitative research. We tried to limit bias by reassuring students that their comments were confidential and that all identifying information would be removed and recordings destroyed after they had been transcribed.

The survey sample was also smaller and the response rate (48% for teachers and 56% for learners) lower than expected. The study did reach saturation, with surveys, combined and individual interviews, and focus groups generating the same overarching themes of support and challenge, suggesting that we had collected sufficient data. However, our conclusions were based on the opinions of our respondents, who may not be representative of all CoSMO volunteers, let alone other SRC volunteers. Although the structures of many SRCs are similar, with clinical students teaching preclinical students while together providing patient care (Simpson & Long 2007), the findings of this study are not generalizable.

Recommendations

It is well-accepted that SRCs provide important clinical service-learning experiences. What has not yet been established is that SRCs provide opportunities for students to practice clinical teaching. Although the data from this study are unique to CoSMO, we believe that similar opportunities in clinical teaching exist at many SRCs.

Recent survey data show widespread use of medical students as peer teachers, yet fewer than half of medical schools endorse formal SAT programs (Soriano et al. 2010). We suggest that SRCs provide students with crucial experiences in teaching. Even as schools begin to offer SAT programs, we believe that SRCs may provide invaluable practical experiences in clinical teaching. Opportunities in classroom-based teaching are easy to organize and in most places already exist (Soriano et al. 2010); opportunities in clinical teaching, however, are more difficult to arrange. We encourage leaders of SRCs to evaluate their clinical students’ teaching experiences and provide instruction in the fundamentals of clinical teaching. We also encourage medical schools to revisit their SRCs not only as places for valuable experiences in service-learning, but also as places for practice in clinical teaching.

Acknowledgments

The authors would like to acknowledge Aubrie Swan Sein, PhD, Evaluation Specialist at the Center for Education Research and Evaluation at Columbia University Medical Center, for her contributions to this project.

Declaration of interest: The authors report no declarations of interest. This project received no outside funding.