ABSTRACT
A few studies have analysed the experiences of junior residents during the initial stages of their clinical training at community-based medical institutions for gaining initial experience as doctors using an associated learning theory framework. In this study, we investigated this learning process using an experiential learning model. The survey was administered through interviews and a written questionnaire to 10 junior residents involved in the initial postgraduate clinical training at two clinics in Tokyo operated by family physicians. The interview data were analysed qualitatively, whereas the results of the questionnaire, which included an experiential learning scale, were analysed quantitatively.
In the qualitative analysis, 59 themes were identified and classified into reflective observation, abstract conceptualisation, and active experimentation, as featured in the experiential learning cycle. The average scores for experiential learning before and after training at a community-based medical institution, as measured based on the experiential learning scale, exhibited a significant increase after the training. Experiential learning of junior residents was observed in various situations during their training period at a community-based medical institution, where active experimentation was the most commonly observed form of experiential learning.
Introduction
Japan is faced by challenges of a rapidly aging population, one of which is the immediate need for community-based primary care providers to identify methods to provide comprehensive support for elderly patients, by collaborating with multiple healthcare professionals. It is becoming increasingly important for medical students and junior residents to be trained at community-based medical institutions. In Japan, the aim of the initial postgraduate clinical training is to foster the character of the junior residents and to effectively equip them with a range of clinical skills that are required mainly in primary care [Citation1]. Initial postgraduate clinical training is mainly conducted at training hospitals including university hospitals, large hospitals (500 beds or more), medium hospitals (200–499 beds), and small hospitals (less than 199 beds). The training lasts for two years. Junior residents take community-based medical training for one month at an external medical institution after rotating through internal medicine, surgery, and the emergency department at their main hospital [Citation2]. In Japanese medical schools, 77 out of 80 schools introduced a community-based education and a primary care-oriented education within community clinics [Citation3]. Although many trainees have opportunities to see community patients and families in primary care settings during their undergraduate education, they mainly see patients in the setting of secondary or tertiary hospitals after medical qualification. Community-based medical training is valuable for residents to interact with local patients and families at primary care institutions after they become doctors. During the community-based medical training, junior residents often experience cases with complicated social backgrounds that are rarely seen in large hospitals. In addition, during their community-based training at an outpatient clinic or in home-based care, junior residents encounter patients from a diverse range of backgrounds who do not normally seek care from university hospitals.
One of the theories used for explaining the cognitive processes involved in learning from such new experiences is the Kolb’s experiential learning model [Citation4]. This experiential learning model comprises four stages: 1) concrete experience; 2) reflective observation; 3) abstract conceptualisation; and 4) active experimentation. This model indicates that one can generalise an experience into a schema or theory through reflective observation and then proceed to take action. Concrete experience refers to the stage where one gains on-site experience, whereas reflective observation refers to the stage where one reflects upon experiences gained from different perspectives. Abstract conceptualisation refers to the stage at which one extracts a personal schema or theory from reflective observation, whereas active experimentation refers to the stage at which the said schema or theory is put into practice during the next relevant opportunity.
Recent examples of research in the field of experiential learning include studies on the learning styles of junior residents involved in surgery and orthopedics [Citation5,Citation6]; one study was based on the process of gaining expertise as a public health physician [Citation7] and another on the process of gaining expertise as an emergency physician [Citation8]. A previous study aimed to clarify the process of experiential learning of nurses with more than 10 years of experience [Citation9] and another study investigated the learning process of radiological technologists [Citation10]. In terms of what is being learned at community-based medical institutions, it was reported that student reflection on the practical experience in rural settings before graduation primarily comprises the four learning stages of the Kolb’s experiential learning model [Citation11]. However, only a few studies have analysed the process by which junior residents gain expertise in community-based medical institutions using the experiential learning model, and thus the process remains unknown.
This study analysed the learning process by which junior residents gain expertise in community-based medical institutions in Japan using the mixed methods research in accordance with the Kolb’s experiential learning model.
Methods
The study was conducted between March 2014 and March 2016 and involved 10 junior residents enrolled in initial postgraduate clinical training at two clinics specialising in family practice in Tokyo. Each resident rotated through the community-based training at community clinics for one month. Two clinics located at the suburban area of Tokyo, and family physicians, certified by the Japan Primary Care Association, were working as supervisors. Participants were selected by asking residents from the director of each clinic. The residents were informed about the purpose and procedure of the study and only those who consented were included in the study. Interviews were conducted in rooms where privacy was assured, and details regarding the study were explained in advance using an outline of the study protocol, for which written informed consent was obtained from all participants.
The principal author (KT) interviewed the junior residents individually and the interviews were recorded and transcribed. Interviews were conducted in a semi-structured format, and the collected data included information on their gender, the university they graduated from, their affiliated hospital for clinical training, the duration of their medical practice, and information regarding their experiences gained during their clinical training.
Questions asked were: ‘Have you encountered any difficult situations or cases you had never experienced before?’; ‘Have you had the opportunity to recall and review your experience from a new perspective?’; and ‘Have you had the chance to analyze your (unsuccessful) experience?’
Transcripts were analysed at the time of data collection simultaneously using the qualitative descriptive research method [Citation12]. The authors (KT and DS) consolidated the text data, identified the themes, and classified them into multiple categories and sub-categories. The questionnaire, which included an experiential learning scale (), was used to quantify the junior residents’ experiential learning. The experiential learning scale (10 items, 5-Likert scale) was formulated by Kimura et al. [Citation13] with the aim of measuring the degree of performance at each of the different levels involved in the experiential learning model. A paired t-test and a Wilcoxon signed-rank test were used to conduct a comparative analysis of the junior residents before and after training, and the significance level was set at p < 0.05. Data were analysed using IBM SPSS ver. 23. This study was conducted using a mixed methods research that combined the qualitative analysis of interviews and quantitative analysis of questionnaires.
Table 1. Experiential learning scale [Citation11].
Results
Of the 10 junior residents who were evaluated in this study, six were men and four were women. All junior residents were engaged in clinical practice for a period of one to two years, and all of them belonged to the same university hospital or its affiliated hospitals in Tokyo ().
Table 2. Subject background.
In the qualitative analysis, the 59 identified themes were divided into three main categories and nine subcategories (). The three main categories correspond to three stages in the experiential learning cycle, whereas the subcategories correspond to the core competencies of certified family physicians by the Japan Primary Care Association.
Table 3. Identified themes and categories.
Changes in the experiential learning scale scores before and after the training at community-based medical institutions are presented in . The mean overall scores changed from 37.0 to 41.8 (p = 0.005, Wilcoxon signed-rank test, Cohen’s d of 0.82), exhibiting a significant increase and satisfactory effect size. The change in scores for each junior resident increased in all cases.
Table 4. Changes in the experiential learning scores after community based medical training.
The typical examples of qualitative analysis results are described below for each of the three main categories shown in . The categories are indicated in < >, whereas the themes are indicated in [], with the text shown in italics.
Reflective observation
<Reflective Observation> comprised 20 different themes, including recognising [The importance of interviewing the family]; [Awareness of collaborating with caregivers when providing medical care to elderly individuals]; [Awareness of problems regarding inconvenient home environments]; [Acquiring awareness of providing a thorough explanation of conditions prior to discharging from hospital]; [The importance of time management in medical care]; [Difficulty in making policy decisions in settings that differ from hospitals]; [Awareness of the ill-effects of biomedical-centered medical care]; and [Recognition of patients who are easy/difficult to deal with].
These identified themes are merely at the stage of recognising the issues, and there is no suggestion regarding any of the detailed response. For example, in a situation in which a junior resident faced difficulty in deciding whether tests should be performed at the clinic or in a large hospital, the junior resident felt [Difficulty in making policy decisions in settings different from hospitals]. By caring for outpatients belonging to different sex and age, another junior resident gained ability in [Recognition of patients who are easy/difficult to deal with].
[Difficulty in making policy decisions in settings different from hospitals]
‘Initially, I was not sure how far I could go with testing. In a hospital, it is routine to perform blood tests and X-rays, but I had to think about whether or not that person needed such a test or whether the test should be performed right away.’ (Dr. E)
[Recognition of patients who are easy/difficult to deal with]
‘Usually, an adult can be treated as an adult, and a child can be treated as a child. But if the patient seems to have a kind of self-awareness, but he or she depends on his or her mom, I wonder how to handle such a person.’ (Dr. C)
‘The most difficult time I had was while trying to communicate with young people around the age of upper elementary to middle school.’ (Dr. G)
Abstract conceptualisation
This category was comprised of 8 different themes, including [Acquisition of clinical skills considering the ill-effect of hospitalization on elderly individuals]; [The approach of considering medication adherence right from the time of prescription]; [Awareness of frailty being the reason for elderly individuals visiting the doctor]; [Awareness of the outpatient strategy for treating patients in a series of shorter sessions]; and [Creating an atmosphere in which the patients feel at ease to talk using ‘chime-in,’ ‘silence,’ and ‘smiles’].
The above themes reflect the stage in which junior residents think about taking specific actions based on the manifested issues but take no action later. For example, when a junior resident encountered a situation in which an elderly patient was not taking a prescribed medicine, the junior resident considered [The approach of considering medication adherence right from the time of prescription], which became the next task for training. When a junior resident encountered a patient for whom the consultation time tended to lengthen, the junior resident gained the [Awareness of the outpatient strategy for treating patients in a series of shorter sessions]; however, because there was no time during the training phase to achieve mastery of such a strategy, it also became a task for subsequent training.
[The approach of considering medication adherence right from the time of prescription]
‘I heard that one elderly patient could not swallow the pills, so I thought crushing them would make it easier to take them. However, it turned out that this patient did not like the terrible taste of the pills.’ (Dr. A)
‘Even before thinking about whether we can administer the right medical treatment for a patient, we need to think about whether the patient can actually ingest the medicine or if the patient cannot take it themselves, who is going to help them take it?’ (Dr. J)
[Awareness of the outpatient strategy for treating patients in a series of shorter sessions]
‘Well, I thought it would be better to combine treatment sessions if possible, but I think I could do that because I was a resident with lots of spare time. Now I think that it would be impossible in a real clinical situation. We can only treat them in several short sessions.’ (Dr. D)
Active experimentation
This third category comprised 30 themes, including [Proper use of differentiated communication with patients with dementia and their families]; [Awareness of narrowing down the focus when a patient has many complaints]; [Making an effort to create a personalised check-list]; [Making an effort to ask detailed questions regarding daily life when giving lifestyle guidance]; and [Starting with small talk to create an atmosphere where people are comfortable with sharing information].
These themes reflect the stage at which the junior residents took action to solve problems and gain mastery. For example, when a junior resident had a consultation with a patient with severe dementia, the junior resident used [Proper use of differentiated communication with patients with dementia and their families] and obtained detailed information from the family. The junior resident also practised [Awareness to narrow down the focus when a patient has many complaints] with an outpatient who had multiple complaints.
[Proper use of differentiated communication with patients with dementia and their families]
‘Yes, when I tried to proceed with something, the patient screamed, so I could do nothing. I can only tell if the patient is comfortable or not. I realised that I need to narrow down what I need to ask from the family and what to focus on during examination.’ (Dr. A)
‘As for the flow, the patient does not tell me anything, so I have to ask the family about how the patient is doing recently and try to find if there have been any changes. Then, I examine the patient, look for any changes, and decide on the prescription.’ (Dr. A)
[Awareness of narrowing down the focus when a patient has several complaints]
‘Let’s see, I have never heard of a condition called as orthostatic dysfunction. Therefore, I could not think of that because there were so many complaints when I first consulted with the patient … ’ (Dr. F)
Discussion
The results of this study revealed that community-based medical training provides junior residents with an opportunity to explore outpatient treatment strategies and communication skills, gain a deeper understanding of examining elderly patients, increase their awareness of collaborating with other professionals. It also helped them to gain an interest in and practise health promotion and preventive medicine and consider patient-centeredness and psychosocial perspectives. Of the four experiential learning categories, active experimentation had most themes. The experiential learning scores for all junior residents increased after training, and the quantitative analysis suggested the occurrence of experiential learning.
Our results indicated that junior residents learned significantly about communication. In a study on learning in nurses conducted by Matsuo et al. [Citation9], ‘learning communication through contact with patients and their families’ was one of the themes observed. It is believed that community-based medical institutions provide ideal settings for learning because junior residents have the opportunity of close contact with patients and their families. The findings bring hope to communication training in our setting, because Japanese undergraduate and postgraduate training offers limited opportunities on learning about communication. Undergraduate medical education in Japan typically provides less opportunity to interact and communicate with actual patients, compared to medical schools in the United States [Citation14]. Additionally, during the first year of residency training in Japan, the residents’ interpersonal skills including patient-centered attitudes seem to decline [Citation15], probably due to their substantial hard work while receiving little structured education and enduring sleep deprivation [Citation16].
There were several themes classified under the category of ‘approaching the elderly,’ and, according to Ishikawa et al. [Citation17], ‘medical students learn about chronic case management often involving elderly patients, and care for not only the patients but also their family during home visits. They experience holistic care in addition to focusing on the illness of patients during home visits.’ These facts suggest that community-based medical training offers better opportunities for junior residents to learn about holistic care, especially for elderly individuals.
According to Matsuo et al., the experiential learning cycle focuses on developmental challenges [Citation8]. Developmental challenges include themes such as ‘job transfer/unfamiliar responsibilities,’ ‘creating change,’ ‘high levels of responsibility,’ ‘working across boundaries,’ and ‘obstacles (i.e. business situations in adversity and unsupportive supervisors),’ which are known experiences that promote the personal growth [Citation8]. For example, in relation to [Proper use of differentiated communication with patients with dementia and their families], when Dr. A examined a patient with dementia, he found it difficult to confirm prescriptions and gain information directly from the patient and realised that the scope of the consultation needed to be expanded in terms of including the family in the same. Therefore, examining patients with dementia seemed like a developmental challenge for the junior residents and an encounter that contributed to the growth of the resident as a doctor.
Pearson et al. reported that meaningful encounter with a patient enhances clinical learning in primary care [Citation18]. In the case of Dr. D, who realised [The importance of time management in medical care], as a junior resident, she had trouble deciding how much time and effort to spend on one session of treatment for patients who tended to take longer sessions. Although no solution was reached during this particular training, it was conceivable that the encounter with that particular patient was a valuable experience that helped the junior resident to mature in his understanding of the process.
Our results can be categorized into three stages of experiential learning (i.e. reflective observation, abstract conceptualisation, and active experimentation). The fact that the largest number of themes was found in the active experimentation stage indicates the possibility for junior residents to complete the learning cycle even at the initial stages of their careers as doctors. For instance, Nakahara stated that ‘experiential learning is one of the central themes of human resource development [Citation19],’ and Kitagawa stated in his study on experiential learning for public health physicians that ‘the introduction of systematic experiential learning makes it possible to effectively secure and foster personnel [Citation7].’ These reports indicate that, to effectively foster junior residents, training at community-based medical institutions will require the introduction of a systematic education based on the experiential learning model. Furthermore, Leung et al. suggested that the use of different educational tools based on the theories of learning (e.g. experiential learning) and curriculum design for adults can improve the communication skills of junior residents [Citation20]. It is believed that the formulation of curricula that are focused on such learners will be useful for the clinical training at community-based medical institutions.
This study had limitations. It was restricted to Tokyo; the results may not be representative of community-based medical training for junior residents at other sites or in different cultures. Only a small number of junior residents were included in this study. It is possible that the interviewer influenced the junior residents’ responses as he was one of the doctors who provided guidance during the training.
Conclusions
Junior residents went through cycles of experiential learning during the early stages of clinical training at community-based medical institutions in this study. The results of this study demonstrated that several of their experiences were based on active experimentation. We believe that learning processes with ingenuity occurred while the residents handled diverse situations encountered during their practice of community-based medicine, for which they had no prior experience.
Ethics approval
This study was approved by the Ethics Review Committee of Tokyo-Hokuto Health Co-operative Association (reference number: 66).
Competing interests
The authors declare that they have no competing interests.
Acknowledgments
The authors express their heartfelt gratitude to Dr. Kei Takahashi and Dr. Takamasa Watanabe, Tokyo-Hokuto Health Co-operative Association, who provided invaluable support and assistance, Dr. Yuki Yonekura, St. Luke’s International University, who provided advice regarding statistical analysis, and Ms. Kayo Kondo, School of Politics, Philosophy, Language and Communication Studies, University of East Anglia, who assisted us in translating the manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
Additional information
Funding
References
- Ministry of Health, Labour and Welfare. New Initial Postgraduate Clinical Training (Draft) (22 Oct 2002) Attachment 1. (Japanese) http://www.mhlw.go.jp/topics/bukyoku/isei/rinsyo/keii/021022.html. Accessed 2017 Sep 26
- Saiki T, Imafuku R, Suzuki Y, et al. The truth lies somewhere in the middle: swinging between globalization and regionalization of medical education in Japan. Med Teach. 2017;39:1016–1022.
- Takamura A, Ie K, Takemura Y. Overcoming challenges in primary care education: a trial of a longitudinal integrated clerkship in a rural community hospital setting in Japan. Educ Prim Care. 2015;26:122–126.
- Kolb DA. Experiential learning: experience as the source of learning and development. 2nd ed. New Jersey: FT Press; 2014.
- Engels PT, de Gara C. Learning styles of medical students, general surgery residents, and general surgeons: implications for surgical education. BMC Med Educ. 2010;10:51.
- Richard RD, Deegan BF, Klena JC. The learning styles of orthopedic residents, faculty, and applicants at an academic program. J Surg Educ. 2014;71:110–118.
- Kitagawa S. Study of learning experiences of expert public health physicians. Med Educ. 2013;44:227–235.
- Matsuo M. Expertise and experiential learning of emergency doctors. Kokumin Keizai Zasshi. 2010;202:13–44. (Japanese)
- Matsuo M, Masaoka K, Yoshida M. The process of experiential learning in nursing: an empirical study using content analysis. Bull Sch Health Sci Sapporo Med Univ. 2008;11:11–19. (Japanese)
- Matsuo M, Muto H, Ogasawara K. The experiential learning process among radiological technologists. JART Jpn Assoc Radiol Technol. 2014;61:269–276. (Japanese)
- Dhital R, Subedi M, Prasai N, et al. Learning from Primary Health Care Centers in Nepal: reflective writings on experiential learning of third year Nepalese medical students. BMC Res Notes. 2015;8:741.
- Lambert VA, Lambert CE. Qualitative descriptive research: an acceptable design. Pac Rim Int J Nurs Res Thail. 2012;16:255–256.
- Kimura M, Tateno Y, Sekine M, et al. Development of the experiential learning inventory on the job. Res Rep JET Conf. 2011;4:147–152. (Japanese)
- Kuwabara N, Yamashita M, Yee K, et al. The evolution of the Japanese medical education system: a historical perspective. Hawaii J Med Public Health. 2015;74:96–100.
- Ishikawa H, Son D, Eto M, et al. Changes in patient-centered attitude and confidence in communicating with patients: a longitudinal study of resident physicians. BMC Med Educ. 2018;18:20.
- Deshpande GA, Soejima K, Ishida Y, et al. A global template for reforming residency without work-hours restrictions: decrease caseloads, increase education. Findings of the Japan resident workload study group. Med Teach. 2012;34:232–239.
- Ishikawa M, Maezawa M. The primary care program of undergraduate medical education. Igaku Kyoiku (Medical Education Japan). 2004;35:327–330. (Japanese)
- Pearson DJ, Lucas BJ. Engagement and opportunity in clinical learning: findings from a case study in primary care. Med Teach. 2011;33:e670–7.
- Nakahara J. Experiential learning: theoretical genealogies and research trends. JILPT Jpn Inst Labour Policy Training. 2013;639:4–14. (Japanese)
- Leung FH, Martin D, Batty H. A theory-based curriculum design for remediation of residents’ communication skills. Med Teach. 2009;31:e555–9.