Supporting medicalstudents’ workplacelearning:experience-basedlearning (ExBL)Tim Dornan, University of Manchester Medical School, Manchester, UKAlbert Scherpbier, Institute for Medical Education, Maastricht University, the NetherlandsHenny Boshuizen, Open University of the Netherlands

INTRODUCTION

Many health professionalscrave to know how toteach medical students,

and cannot find clear answers, letalone evidence-based ones, incontemporary publications. Thisarticle gives practical answers, yetit is evidence based because itderives from research into clinicalteaching and learning conducted

in the Universities of Manchesterand Maastricht.1 The clinicalteachers of today have to distancethemselves from their warmlyremembered days when studentswere few, in-patients were many,hospital stays were long andcardiac diagnoses were made withthe stethoscope.2 They mustlocate education in their clinicalwork by fostering a warm socialclimate in their practise. They

should focus their attention onindividual students’ learning,not on their teaching; situatestudents’ learning within theirinteractions with patients;support students, and challengethem in a way that makes themsupported participants inpractice at the highest level ofinvolvement that their abilityand the clinical situation permits,and adapt their behaviour

Many healthprofessionalscrave to knowhow to teachmedicalstudents andcannot findclear answers

Theory inpractice

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student-by-student and situation-by-situation. After defining someterms, we use the experience-based learning (ExBL) model(Figures 1 & 2) to give practicaladvice on how to be a facilitatorof students’ clinical learning(Box 1).

EXPERIENCE IN THEWORKPLACE

Despite their different surfacefeatures, out-patient clinics,hospital wards, general practicesurgeries, emergency depart-ments, day surgery units andoperating theatres are all placeswhere doctors work, studentslearn to work and where studentsmight later pursue their careers.So, clinical education is located inthe workplace, defined as a placewhere students, doctors andpatients come together in theconjoint pursuit of clinical care

and learning. Students learn fromexperience, which we define asauthentic (real as opposed tosimulated) human contact thathelps students learn about health,illness and disease, and how to bea doctor.

LEARNING RATHER THANTEACHING

There are good reasons for shiftingthe workplace educational focusfrom teaching to learning. Stu-dents are learning even when theirteacher’s mind is wholly focusedon providing clinical care. Thesubject matter learned fromclinical encounters goes far be-yond what students are explicitlytaught. A focus on learning re-solves any dichotomy between thetaught and learned curricula, andhelps students learn the hardestyet most important subject matterof all: how to be effective work-place learners. Focusing on learn-ing means paying at least as muchattention to the conditions forand processes of learningpresented in Figure 1 as to thesubject matter represented bypatients. It does not mean with-holding support and direction, assome clinicians seem to think.

FIRST, DO NO HARM

Students often say that they arelearning the profession ofmedicine in order to make adifference (to humanity). They

look on practitioners with envyand trepidation. They envy theirability to make a difference; atthe same time, students aspire tobe like their role models, but areafraid of doing more harm thangood when given responsibility.However, students can make adifference even before they areclinically competent: nine out of10 unselected patients find itbeneficial to contribute tostudents’ learning,3,4 so skilledteachers can conduct consulta-tions to both students’ andpatients’ mutual benefit. Bedsideteaching, in contrast, is a richsource of mutual harm, when allparties except an insensitiveteacher are embarrassed by thecollective invasion of a patient’sprivacy. Students learn best whenthey do not fear harming patientsand do feel they are helpingdoctors make a difference.

PARTICIPATION: THE CORECONDITION FOR LEARNING

Students learn by participating inactivities of the workplace,particularly ones that arechallenging. The exact definitionsof participation and challengevary according to the personalattributes and seniority ofindividual students, and dependon the case complexity. Box 1 andthe simplified schema in Figure 2explain the concept of partici-pation. There are three types ofactor in the workplace: patients,doctors and students. The type ofparticipation students are aimingtowards is making a difference topatients by interacting with themin the role of doctors.

Box 1 lists four roles in whicha student may be a participant.A passive observer is a fly on thewall. A schoolchild visitinghospital for work experience, forexample, might experience goinginto theatre during an operationas participation, without eventalking to clinical staff or seeingthe patient. However, a third-year medical student would likely

Doctor

Som

eone who can m

ake a difference

Med

ical

sch

ool e

ntra

nt

Supportedparticipation

ProcessChallenge

ContextSupport

OutcomesEmotional and practical learning

grounded in experience

Affective

Pedagogic

Organisational

Realpatientlearning

Practicallearning

Emotionallearning

Figure 1. The experience-based learning (ExBL) model.

Doctor

Student Patient

Participation as:Passive observerActive observer

Actor in rehearsalActor in performance

Figure 2. Within the student-patient-doctor-

triad, the effective clinical teacher facilitates

interactions between student and patient.

Students arelearning even

when theirteacher’s mind

is whollyfocused on

providingclinical care

168 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 167–171

find that passive experience anon-participatory one. Observa-tion does not have to be passive,and the surgeon could turn thethird year’s experience into amore participatory one bydiscussing the operation withthem. A student told to go andtake a history from a patientwhose history has already beentaken by a doctor is an actor inrehearsal. Taking a history is theaction of a doctor, but replicat-ing an action purely for learningpurposes is rehearsal. Acting inrehearsal may be challengingenough to a junior student,particularly if the patient is veryill. A senior student wouldprobably not experience thatrehearsal as participation. On theother hand, taking the history onbehalf of a doctor – being anactor in performance – would bemore of a participatory experi-ence. In theatre, the seniorstudent would need to hold aretractor or go to the blood bankwhen the patient haemorrhagedin order to have a feeling ofparticipation. Students progressthrough the four levels ofparticipation and come progres-sively closer to making a differ-ence as they progress throughthe medical programme. Teacherscan accelerate progression bycreating conditions for studentsto participate at higher levels,and by being prepared to sharetheir expertise.

PROVIDING CHALLENGE INA SUPPORTIVEENVIRONMENT

Although modern-day students aresupposed to regulate their ownlearning, even the most motivatedand able of them do so best insupportive workplaces. Concen-trating on learning rather thanteaching does not mean leavingstudents to grope around inintellectual darkness. Theparadoxically simple way expertsaddress complex problems canprovide a good piece of intellec-tual scaffolding that is worth athousand of the factual bricks thatless expert teachers tend toimpart. Being supportive does notpreclude being challenging; onthe contrary, support makes itsafer for students to facechallenges. Good teachers allowuncomfortable silence to continueuntil a student volunteers ahalf-remembered fact; they do notridicule wrong answers; theychallenge students to attaingreater levels of participation(active rather than passiveobserver, or actor in performancerather than actor in rehearsal)whilst providing a safety net thatensures no harm is done topatients. In the out-patient clinic,this can by achieved by asking thestudent to conduct a consultationwhile the practitioner looks onsilently, available to be called onfor help when needed.

Engaging professionals-to-bein active learning calls for varioustypes of support. The ExBL model(Figure 1) recognizes three typesof support: affective, pedagogicand organisational. Whereasthe term organisational is a layone, the less familiar termsaffective and pedagogic canloosely be equated with heartand head, or emotions andintellect.

AFFECTIVE SUPPORT

Students are emotionally chal-lenged by feeling like little fish ina big pond, and by observingpatients’ negative experiencesand emotions, feeling helplessbecause a mere student is so farfrom being able to make adifference. Teachers can reducethe adverse effects of students’inevitable negative emotions bycreating a learning environmentthat has a warm climate, isrespectful and supportive ofpatients, makes studentswelcome, draws students into theteam, helps reticent onesparticipate, stops them feelinglike ‘spare wheels’, does notbelittle them and acknowledgesnegative emotions.

PEDAGOGIC SUPPORT

Teachers can help students partic-ipate in practice and learn fromparticipation by demonstratingfamiliarity with the curriculum,suggesting learning objectives andways of achieving them, helpingstudents apply theoreticalknowledge to authentic clinicalsituations, creating tasks thatallow them to participate, andinstructing them. Instruction, inthis context, means demonstratinghow to apply skills to real patientswith disease, supervising students’attempts to do so, and givingfeedback on their performance. Inan out-patient clinic, for example,pedagogic support includesorientating students to patientsand their diseases before theyenter the room, checking students’

Box 1. Four levels of participation

• Passive observer

Example: a young person tasting medical student life who is allowed toobserve an operation.

• Active observer

Example: a student attending an out-patient clinic who is drawn into athree-way conversation between doctor, patient and student.

• Actor in rehearsal

Example: a student previously taught to take a diagnostic history on astandardised patient, who practises history taking on a patient.

• Actor in performance

Example: a student who helps a casualty officer by taking blood and settingup a drip on an acutely ill patient.

Teachers canaccelerateprogression bycreatingconditions forstudents toparticipate athigher levels

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knowledge and learning needs,arranging for students to interviewpatients before the consultationproper, arranging the furniture sostudents and patients feelincluded, promoting three-waydiscourse and debriefing studentsafterwards. Role modelling isanother very important facet ofpedagogic support.

ORGANISATIONALSUPPORT

Another role of clinical teachers isto open up opportunities for par-ticipation. That may entail opti-mising the curriculum structure

and sequence, placement lengthor continuity of attachment toindividual teachers, and groupsizes. Within individual place-ments, organisational supportmeans optimising timetables, andotherwise creating opportunitiesfor supported participation.

WHAT STUDENTS LEARNFROM PARTICIPATION

Real patient learningInteracting with real patientsadds vital ingredients to students’learning: patients’ faces, storiesand perspectives. Real patientsillustrate the complexity and time

course of illness, and put therealities of clinical practice into awider and more holistic perspec-tive. Interaction with realpatients motivates students byshowing how much they have tolearn before they can truly make adifference, focuses their learningactivities, consolidates and linkslearning, and helps them remem-ber what they have learned. Realpatient learning leads to twomajor categories of outcome:practical and emotional.

Practical outcomes

Acquiring skillsPractical outcomes of workplaceexperience include the transfer ofskills to practice, and the acqui-sition of new skills that can onlybe learned, or are best learned, inpractise, particularly workplacecommunication skills.

Applying knowledgeLikewise, knowledge that a stu-dent has mastered in theory mustbe transferred and applied to thework setting, and can bestrengthened, deepened, broad-ened, contextualised and inte-grated as a result. Workplaceexperience helps students developthe intellectual skills of practise,and understand the social andpsychological determinants ofhealth and disease. There are alsotypes of knowledge known asimplicit and tacit knowledge(know-how) that can only beacquired in relation to authenticworkplace tasks.

Learning to learnAn important practical outcome ofworkplace experience that is veryeasy for clinical teachers to over-look is becoming better able tolearn. By participating in practise,students can learn immediatenecessities for workplace survival,such as how to behave, what toexpect from clinical staff, how tomake sensible choices, how tohandle difficult situations, howto manage time, and how to learnreflectively. In the longer term,

Another role ofclinical teachers

is to open upopportunities

for participation

Box 2. Behaviours displayed by skilled clinicalteachers and curriculum leaders

Skilled teachers:

1. Reconcile two competing pressures by locating student education withintheir delivery of patient care.

2. Mediate interactions between students and patients with considerationto both parties’ sensitivities: they take more than four learners to thebedside only with especial sensitivity.

3. Help students see how patients respond positively to them and theirlearning.

4. Mediate interactions with patients that make students feel likeparticipants in practice.

5. Help students participate by being supportive whilst challenging themto participate at the highest level their experience and the complexityof the clinical situation permits.

6. Do not hold back from showing personal warmth towards students.

7. Get all their staff to make the learning environment supportive.

8. Show they know what knowledge and skills are expected of students, andhelp them to apply those attributes to authentic clinical situations.

9. Organise the curriculum so that earlier stages support students’ learningin the later stages.

10. Organise the health care organisations that deliver the curriculum, andclinical units that provide placements, to optimise participation.

11. Regard real patient learning as an end in itself: something studentscannot get too much of.

12. Ensure students apply their knowledge to practical situations, apply theskills they have learned in simulation to authentic situations and learnhow to learn.

13. Are sensitive to the emotional dimension of students’ learning, which issometimes the most taxing one. Medical students are not just learningmedicine – they are becoming doctors.

14. Help students apply new practical learning to the benefit of theiremotional learning, and vice versa, and help them translate theirdeveloping competence into more complete participation in practice.

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students can become effectivelifelong learners by being able torecognise or seek out situationswith high learning potential. Theyset specific, measurable, achiev-able, realistic and time-boundlearning objectives, keep up withadvances in medical knowledgeand apply them at the point ofcare, and concentrate theirlearning efforts on activities withthe best returns.

Emotional outcomesThrough participation, studentsdevelop a sense of identity, buildconfidence, sustain motivation,and come to feel rewarded andsatisfied. Through experience,they can increase their self-awareness and develop empathicunderstanding of patients’situations. They can socialise inthe communities of practice towhich they will become fullmembers when they qualify.

LEARNING BEGETSLEARNING

The workplace is a great integra-tor of learning. Not only does it

help students become practicallycompetent and learn emotionally,but it does the two simulta-neously and in a mutuallyreinforcing way. Becomingpractically competent reinforcesstudents’ sense of identity,motivation and confidence, andvice versa, which in turn make iteasier to participate. Within thosefeedback loops lies the potentialfor virtuous or vicious spirals ofsuccess or failure to becomeestablished, which teachers canuse their relationships withstudents to identify and modulatefor the better.

CONCLUSION

ExBL places students’ participa-tion in practice at the centre oftheir progression from a medicalschool entrant to a qualifieddoctor, who can make a differenceto humanity. Participation meansinteraction with patients, more orless directly mediated by doctors.Students participate in rolesranging from passive observer toactor in performance. The rolethey adopt in any particular

situation is determined by theirseniority, the complexity of thesituation, the supportiveness ofthe learning environment and theindividual student’s responsive-ness to challenge. Participationleads to practical outcomes – theacquisition of skills, the applica-tion of knowledge and animproved ability to learn – andemotional outcomes, whichinclude the development of asense of professional identity,motivation and confidence.Practical and emotional learningare mutually reinforcing, andreinforce the ability of studentsto participate. Clinical teachershelp students to participate – andchallenge them – by supportingthem. Support can be categorisedas affective, pedagogic ororganisational. So the ExBL modelreframes clinical teaching assupporting participation.

REFERENCES

1. Dornan T, Boshuizen H, King N,

Scherpbier A. Experience-based

learning: a model linking the

processes and outcomes of medical

students’ workplace learning. Med

Educ 2007;41:84–91.

2. Markel H. The stethoscope and the art

of listening. N Engl J Med

2006;354:551–553.

3. Doshi M, Acharya S, Wall D. Mentally

ill inpatients’ experiences and

opinions on seeing medical students:

a questionnaire study. Med Teach

2006;28:568–570.

4. Mavis B, Vasilenko P, Schnuth R,

Marshall J, Jeffs MC. Medical

students’ involvement in outpatient

clinical encounters: a survey of

patients and their obstetricians-

gynaecologists. Acad Med

2006;81:290–296.

Practical andemotionallearning aremutuallyreinforcing, andreinforce theability ofstudents toparticipate

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