Experience Based Learning (ExBL): Clinical teaching for the twenty-first century

Figures & data

Figure 1. Experience based learning model.

Table 1. Affective capabilities.

Subtype	Topics
Mood	Positive moods: Feeling …
	Happy Honored Inspired Proud	Reassured Rewarded Safe Satisfied
	Recognizing and responding appropriately to ambiguous or negative mood states such as feeling …
	Anxious Conflicted Depressed Frightened	Frustrated Sad Stressed Vulnerable
Motivation and confidence	Feeling: Accomplished Confident Motivated Self-efficacious
Other-directed emotions	Feeling: Empathic Compassionate Recognizing/responding to fear, dislike and other negative other-directed emotions.
Attitudes and values	Being: Caring Collaborative Nonjudgmental Recognizing: Boundaries Limits	Being: Respectful Responsible Self-aware Demonstrating: Personal values Positive attitudes

Figure 2. Support.

Table 2. Supporting participatory learning.

Relating to students The tips that follow emphasize clinicians’ social skills as their most important asset.

Get to know students, acknowledge them as individuals, make them feel invited and valued, and don’t allow them to feel uninvolved, in the way, or a burden. Reduce hierarchical distance between clinician, student, and patient. Use relationships with students to create a comfortable and relaxed climate for patients. Use language that students and patients understand and causes them minimal discomfort. Be generous with time: listen, explain, question, make suggestions, chat. Observe students: are they happy, sad, or anxious? Ask how they are feeling. Don’t be afraid to say how you are feeling. Model emotional awareness and openness. Relate intellectually as well as socially: think out loud; scaffold students’ understanding of what they are experiencing. Treat students as junior colleagues; inspire them with your enthusiasm and love of learning.

Briefing students

Find out their capability (often they will understate it) so you can meet their learning needs. Help them choose learning goals and ways of achieving these. Tell them what to expect of you and what you expect of them. Orientate them before participation begins.

Practising within the educational triad

Obtain patients’ consent for a student to be present and ensure the student knows you have done so. Handle sensitive consultations carefully so you involve students (if patients are willing) to patients’ benefit rather than harm. Be open, willing, friendly, kind, and helpful towards patients. Model the attributes of a good doctor: be clinically skilled, respectful and well mannered; demonstrate positive attitudes towards patients’ families and fellow staff. Empower students and patients to co-participate by, for example, giving a student a task and asking a patient to join you in giving constructive feedback. Use physical examination as an opportunity for students to come close to patients and overcome inhibitions. Ask students to present patients’ problems, propose and justify different explanations for and approaches to these, and choose between them; think out loud about your own approach. Seize “teachable moments.”

Managing the dynamics of observing, rehearsing, and contributing within the educational triad

Some general rules

Tailor your education to students’ capability and patients’ problems. Observing provides breadth; rehearsing provides depth; contributing confers legitimacy Use rehearsal for students to learn how to participate Whenever possible, turn observing to rehearsing, and rehearsing into contributing; involve students at the highest level their capability allows, given the situation at hand Respond flexibly to changes in clinical situations so students participate, throughout, at the appropriate level.

Managing interactions

Broker students’ interactions with patients and other clinicians Judge which rung of the ladder of participation gives the appropriate degree of challenge and agree this with patient and student. Match the challenge with the appropriate support. Encourage students to participate in pairs so they learn simultaneously and support each other’s learning.

Observing

Use observation to give students a breadth of learning. Encourage students to observe situations they are not yet ready to perform or are too complex for any students to rehearse or contribute. Consider giving students written guidance about what to observe, when, and how. Make it possible for the student to be present and comfortable about being there. Activate observation by engaging students in talk, scaffolding their learning, inviting them to think out loud, asking them questions, and probing their thoughts and feelings. Arrange the furniture so everyone can make eye contact and feel included. Ensure conversations are triadic, in which both patients and students speak and know they are listened to. Detail students to observe how you, residents, and other professionals practise; ask students to report on this. Promote active participation by, for example, asking a student to follow up a patient’s investigations and discuss their results with you.

Rehearsing and contributing

Task a student to, for example: Carry out part or all of a patient interview and/or physical examination. Conduct complete outpatient consultations or review inpatients then present provisional management plans for the patients. Provide opportunities for students to assist in operating theaters. Provide opportunities for students to summarize previous records and/or investigations of complex patients. Find opportunities for students to perform procedures they have been trained to do. Detail students to assemble information, organize aspects of care, and communicate with patients and professionals on your behalf. Manage time pressures by, for example, using students’ attentive communication with patients to buy yourself time to disengage, seek information, and make essential phone calls.

Debriefing students (See Table 3 for ways of encouraging reflection)

With due regard to patients’ sensitivities, stimulate students to reflect while participating in practice. Support students’ reflective learning by helping them verbalize RPL. Help students identify new capability and identity; reinforce this. Encourage students to put their thoughts and feelings into words so they turn partially formed impressions, questions, anxieties, and positive emotions into concrete and explicit thoughts and feelings on which they can continue to reflect. Ask students to interpret patients’ problems, propose and justify different approaches, and choose between them. Invite students to comment critically on your practice. Summarize your conversation and reinforce take-home messages. Advise students how to structure future experience and learn from it; suggest alternative ways of rehearsing tasks and transfer capability into authentic practice. Ask students about their study habits; suggest alternatives.

Table 3. Examples of RPL that turn experience into capability.

Experiences of:

Activities and events

Interactions with patients, their families, and health professionals.

Illness, disease, death.

Caring and clinical management.

People

Patients as whole people, not just diseases.

Patients’ and their families’ reactions to disease.

Relationships with patients and staff.

The temporal dimension of medicine

How diseases progress and/or respond to treatment.

How diagnoses unfold.

How doctors revise investigation and management plans over time.

Students’ states of mind:

Feeling involved in practice.

Being trusted.

Being confided in.

Being responsible.

Being useful.

Identifying with patients and professionals.

Rewards and challenges of caring for patients.

Consolidating and applying to real life:

Intellectual capability.

Affective capability.

The language of practice.

Self-reflective topics:

Oneself.

One’s reactions to others.

One’s professional identity.

One’s practical and affective capabilities.

One’s aspirations.

Figure 3. Supporting participation.

Table 4. Making placements supportive.

Provide leadership

Engender a supportive climate that prioritizes education and values students. Provide pedagogic expertise that optimizes students’ ExBL. Ensure students have space and learning resources (books, elearning, etc).

Organize students’ education

Integrate students into your clinical team so they can participate in its activities. Arrange individual and group learning activities to support students’ ExBL, for example: Group briefing and debriefing. Skills training. Seminars and tutorials. X-ray meetings and case conferences. Identify activities that provide participatory opportunities; particularly ones that allow students to contribute. Organize clinical schedules so they optimize learning opportunities. Ensure clinical staff are accessible to students; for example, list their contact details. Plan for students to socialize into your practice, including its language. Schedule students’ activities and ensure this is communicated. Arrange for students to attend clinical activities in numbers that optimize participation. Ensure students have ample, supported 1:1 interactions with patients. Attach students to clinicians with appropriate attitudes and skills. Encourage students to present patients on ward rounds or at clinical conferences, attend operations or other procedures, and participate as fully as is feasible.

Welcome students and orientate them to:

Clinical activities and the learning opportunities these provide. People who will support their learning and their roles. Intended learning outcomes and ways of achieving these. Sources of personal and pedagogic support and guidance (supervision and mentoring).

Figure 4. Patients’ and students’ involvement in ExBL.