Background

The University of Auckland’s undergraduate medical programme is of six years duration. Years 4–6 are ‘clinical years’, with teaching and learning occurring predominantly in clinical attachments. The medical programme is based around a philosophical framework entitled ‘the Role of the Doctor’[2]. This framework expands on other international core competency frameworks such as the Canadian CanMEDS[3]. Graduate learning outcomes (GLOs) are structured in-line with this and are organised into five domains: Applied Science for Medicine, Clinical and Communication Skills, Personal and Professional Skills, Hauora Māori, and Population Health. These domains provide a structure to the curriculum, bolster integration vertically and horizontally, and describe the necessary scope of skills and experience expected of graduates. They underpin the competencies expected of students undertaking their clinical attachments, including their general practice (GP) attachments.

Other features of the curriculum are the clinical scenarios and progress tests. The clinical scenarios support and define the core curriculum of the programme[4]. They are linked to clinical disciplines and/or various organ systems, and each has learning points linked to the domains of the programme. About one third of the clinical scenarios are considered to be integral to general practice and primary care.

General practice training

General practice training occurs during GP clinical attachments in in all three clinical years. Each year level has specific learning outcomes and competencies which are expected to be largely met through these placements. These are structured according to the domains of the curriculum and reflect the GLOs.

Assessment for all years is linked to the curriculum domains. In Year 4 students undertaking a two week placement are required to attend, participate and be professional, and are marked as pass or fail on this basis. Assessments for Year 5 and 6 (where the attachment length is 4 weeks in Year 5 urban attachments and 5–10 weeks if a rural placement, and 6 weeks rural in Year 6) comprise an electronic Clinical Supervisor Report assessing competencies in the five domain areas; a mini-CEX[5], and online discussion forum and case based presentation both assessing critical reflection and use of literature[6].

To augment GP clinical learning, in 2019 the Department of General Practice & Primary Health Care developed ten e-learning interactive cases which can be completed asynchronously. Case topics were selected from the clinical scenarios[4].

The e-learning cases are presented as a mock appointment book (Figure 1). They are interactive with opportunities for students to input additional information such as history and examination (Figure 2). The cases include model answers, mind maps with links to key documents (Figure 3), podcasts, videos and other resources, and a final section for critical self-reflection and linkage back to the clinical scenarios.

Provision of e-learning programmes to replace undergraduate medical students’ clinical general practice attachments during COVID-19 stand-down

All authors

Rachel Roskvist , Kyle Eggleton & Felicity Goodyear-Smith

https://doi.org/10.1080/14739879.2020.1772123

Published online:

29 May 2020

Figure 1. Appointment book list of e-learning cases.

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Provision of e-learning programmes to replace undergraduate medical students’ clinical general practice attachments during COVID-19 stand-down

All authors

Rachel Roskvist , Kyle Eggleton & Felicity Goodyear-Smith

https://doi.org/10.1080/14739879.2020.1772123

Published online:

29 May 2020

Figure 2. Screenshot e-learning case history-taking page.

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Provision of e-learning programmes to replace undergraduate medical students’ clinical general practice attachments during COVID-19 stand-down

All authors

Rachel Roskvist , Kyle Eggleton & Felicity Goodyear-Smith

https://doi.org/10.1080/14739879.2020.1772123

Published online:

29 May 2020

Figure 3. Mind map of examination, differential diagnosis and management summary with links to resources.

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COVID-19

Novel coronavirus (COVID 19) emerged in China in late 2019 and spread throughout the world. In New Zealand we had our first case 28 February 2020. On 25 March, with rising numbers of cases, a Level 4 lockdown was instituted and universities closed. General practices moved to providing predominantly e-consultations (by phone or video), triaging patients before they consulted with them face-to-face. All University of Auckland staff faced the sudden challenge of delivering teaching remotely from their own homes. Year 6 medical students were considered to be essential workers, and could continue in their general practice placements. However Year 4 and 5 students were stood down from their attachments and required to study from home.

The level 4 lockdown created the imperative of having to develop a replacement programme for the clinical attachments. Department of General Practice & Primary Health Care academic staff had to rapidly develop an alternative online programme for these students to start in five days time.

The online learning programme

Online learning options are considered appropriate to meet the needs of adult learners[7], and there is evidence that online learning can be as effective as traditional teaching modes such as lectures [7–9]. There is some support in the literature for a ‘blended approach’ (face-to-face and online modalities) supporting clinical attachments [7,10–12]. However there is little guidance regarding the degree to which an online course can take the place of clinical learning, although it is unlikely to be wholly possible to replace clinical exposure [10,11,13–15].

It is thought that achieving many competencies traditionally met in clinical attachments is possible via online learning modalities, and this has been demonstrated in using online learning in teaching of clinical and communication skills [10,16,17]. These are generally to augment or supplement learning in the clinical attachment.

An important aspect of online learning is developing an educational environment that supports learning. Building on previous work undertaken at the University of Auckland, we suggest that there are three broad domains of an educational environment in undergraduate medical education[18]. These domains relate to relational, organisational and personal goal aspects, and are consistent with broad social-constructivist educational environment theories proposed by van der Zwet [19] and Schönrock-Adema[20]. The relational aspect of the educational environment is suggested as a critical element in online learning[21], and reinforced by our previous work in developing online discussion forums[6]. Building on this prior work, we developed an online learning programme to replace the clinical teaching that Year 4 and Year 5 students are missing due to COVID-19.

Our online learning programme has three online components, reflecting the domains of educational environment theory: asynchronous discussion forums; a symposium facilitating social interactions and teacher presence, and a learning portfolio facilitating personal goal aspects and reflecting the organisational domain. The portfolio is in turn underpinned by a multi-theories model of adult learning, proposed by Taylor and Hamdy [22] and built upon the scaffolding framework that supports our entire medical curriculum.

Within this theory, five stages of learning are proposed: dissonance, in which the students’ knowledge is challenged; refinement, in which they complete research or tasks to refine new information; organisation, in which they restructure the information through reflection or the development of new schema; feedback, whereby they articulate their new knowledge with peers; and consolidation, where students reflect on the learning process and identify what they have learned. In Figure 4 the various elements of the online learning programme and their alignment with the multi-theories model of adult learning are presented, along with the student and programme roles that occur at each stage.

Provision of e-learning programmes to replace undergraduate medical students’ clinical general practice attachments during COVID-19 stand-down

All authors

Rachel Roskvist , Kyle Eggleton & Felicity Goodyear-Smith

https://doi.org/10.1080/14739879.2020.1772123

Published online:

29 May 2020

Figure 4. Elements of the online learning programme and their alignment with the multi-theories model of adult learning.

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The learning portfolio is mapped to the five domains of the medical programme and associated learning outcomes. We have developed a mind map providing online activities and possible resources to achieve the various competencies (Figure 5). Those on regional-rural programmes are provided with an additional mind map of extra resources mapped to their rural-specific learning outcomes[23]. Students are required to develop a learning plan documenting how they will achieve each learning outcome. They log their activities, recording why they chose each one, what they have learnt, and whether it leads to any further activities they could undertake. Key to this process is using the e-learning cases already available, which are underpinned by the curriculum domains, graduate learning outcomes and linked to the clinical scenarios. We are also able to use role-plays of general practice consults the students have previously practiced with actors as part of their 4^th year GP teaching week. Students are encouraged to practice these together over Zoom. The cases have instructions for the actor-patient, and debriefs with learning points.

Provision of e-learning programmes to replace undergraduate medical students’ clinical general practice attachments during COVID-19 stand-down

All authors

Rachel Roskvist , Kyle Eggleton & Felicity Goodyear-Smith

https://doi.org/10.1080/14739879.2020.1772123

Published online:

29 May 2020

Figure 5. Mind map of year 5 domains, learning outcomes and linked learning resources.

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Students are expected to do at least one activity per half day. Academic staff have prioritised production of more of the e-learning cases, with rural-specific ones added to the appointment list as rural ‘after-hours’ presentations. Other resources include podcasts, web-talks and videos on our Goodfellow Unit continuing professional development website (https://www.goodfellowunit.org/), selected BMJ Learning modules (available through our library site licence)[24], videos, guidelines, academic papers and other documents.

At the end of the attachment students submit their portfolios for assessment. The new learning portfolio replaces the mini-CEX and Clinical Supervisor Report in our clinically-based attachments, based on the premise that it is possible to meet competencies such as those assessed in the CSR via online mechanisms. Year 4 students receive a pass/fail mark based on the content of the portfolio and whether they have demonstrated that they had met all of the learning outcomes. Year 5 student portfolios are assessed in terms of their reflection on learning and use of literature to support this (similar to the online forum assessment in their clinical attachments).

Discussion

General practice is a diverse speciality, and an important part of training is wide exposure to the breadth of practice, with development and practice of communication skills. Although some of these needs can be met through online learning, it is not a full replacement of like with like. The importance of experiential learning is highlighted by the Royal New Zealand College of General Practitioners vocational training programme requirements for clinical practice as a major part of their training[25]. The challenge is defining how much learning can be undertaken online, and how much clinical exposure is still necessary.

There is limited evidence available for online learning replacing clinical experience. Our alternative online programme with links to the curriculum domains and GLOs, underpinned by educational theory, demonstrates a partial solution to the inability of students to attend their clinical placements. It allows students to focus on demonstrating competencies relevant and necessary for their progression, and hence enables them to continue their training. However, an authentic learning experience of interaction with patients is still integral to medical training, particularly in general practice, and they will still require this exposure.

Conclusion

The learnings from this experience contribute to the body of knowledge around online learning, particularly in meeting the needs of a clinical attachment traditionally grounded in experiential learning. It is hoped that the mechanisms described here to address this acute need might be useful to other educators facing similar challenges. Furthermore, this may not be the only time clinical students are stood down, and with increasing scarcity of placements this initiative may highlight an opportunity to reduce clinical time for students, but allow them to meet the competencies traditionally met in an immersive experience.