Ambulatory education in clinics from the perspective of medical students in Iran , 2016

Introduction: Recent years have seen a growing attention to the function and position of ambulatory care and clinical education in medical education. The present study was conducted to investigate the current status of the quality of education in major clinics from the perspective of medical students. Method: This cross-sectional study was conducted in 2016 on 300 medical student from Lorestan University of Medical Sciences who selected through census method. Data were collected using a researcher-made questionnaire with a confirmed face and content validity and a reliability of 0.85. The data were analyzed in SPSS-21 using descriptive and analytical statistics. Results: The study participants included clerkship students (65.9%) and interns (34.1%) with a mean age of 22±2.1 and 24±3.5 years respectively. Statistically significant difference was observed between teachers’ quality of teaching and other domains from the perspective of the clerkship students. From the interns’ perspective, teachers’ quality of teaching and duration of attending clinics were the domains with significant statistical differences among clinics. (P<0.05). According to the assessments by the clerkship students and interns, the mean score in obstetrics clinics, was lower than other clinics. Conclusion: Given the results obtained, particularly on teachers’ quality of teaching, teachers are respectfully recommended to pay a special attention to clinical education, enthusiastically involve students in patient-associated issues and improve their skills using modern educational methods.


INTRODUCTION
Clinical education should be properly implemented as a foundation of medicine or will face problems in more advanced stages.Although inpatients' bedside teaching used to constitute the main part of clinical education, it failed to familiarize learners with publicly known health problems (1).Given the need for educational systems to train students according to future occupational requirements and graduates' achievements (2), new attitudes have been adopted towards outpatient treatment diagnostic, therapeutic and advisory services for outpatients, clinics provide the learning and teaching opportunity for the learners (5).Clinical education refers to any kind of learning achieved in clinics for prevention, diagnosis, treatment or follow-up during visiting and providing advice to outpatients (5,6).The function and position of outpatient care and clinical education in medical education has been stressed in recently conducted studies in both Iran and around the world (7)(8)(9)(10)(11)(12)(13)(14)(15).Jacobson found more positive attitudes in students towards clinical education compared to interdisciplinary education (16).The educational challenges reflected as suboptimal quality of clinical education in the literature (7)(8)(9) include patient diversity, an imbalance between the services provided for patients and the training offered to students and also between the number of students and the available clinical facilities and equipment.Irby described the clinical education performance as suboptimal by comparing it with interdisciplinary education (17).The studies conducted in Iran also revealed shortcomings in this educational area (7)(8)(9)(10)(11)(12)(13)(14)(15).Given that investigating the current status and the strengths and weaknesses of the program in learners' perspective plays a key role in improving the quality of education, the present study was conducted to investigate the quality of clinical education from the perspective of clerkship students and interns and to help those involved in education with making better educational decisions and plans for further educational improvement.andcommunity-based learning in most medical schools (3,4).In addition to providing.

Participants and Setting
The present descriptive cross-sectional study was conducted in 2016 academic year on 300 medical clerkship students and interns in Lorestan University of Medical Sciences.The census method was used to sample all eligible candidates including students passing at least one month of their program.The exclusion criteria comprised unwillingness to participate in the study and failure to complete or return the questionnaires.Ethical principles such as protecting the subjects' anonymity were also observed.

Data Collection Instrument
The data collection tools consisted of researcher-made questionnaires comprising demographic information and 23 items on five domains.These domains included teachers' quality of teaching (12 items), clinic's facilities and equipment (4 items), patient-associated issues (3 items), duration of attending clinics (2 items) and the number of students in each program (2 items).Of the 23 items, prescription-associated items addressed only the interns.The items were scored on a five-point scale including very poor (score 1) to very good (score 5).The overall score of the questionnaire thus ranged between 23 and 115.The content and face validity of the tool was confirmed by a review of literature and through a survey of medical education experts and university professors whose modifying and supplementary views helped compile the final questionnaire.The construct validity of the tool was assessed using an exploratory factor analysis, in which the items expressing similar concerns were taken as one dimension and the domains that covered most of the variance were put together in such a way that the domains had the lowest and their items the highest correlation A pilot study was conducted and the questionnaires were distributed among 45 students, including 30 clerkship students and 15 interns, to resolve the potential design problems before finalizing the questionnaires.After making the necessary modifications, a reliability coefficient of 0.85 obtained through the test-retest three weeks later confirmed the reliability of the questionnaire and a Cronbach's alpha calculated as 0.91 confirmed the internal consistency of the tool.

Statistical analysis
The data obtained were analyzed and explained in SPSS-22 using descriptive statistics, including mean, standard deviation and frequency, and analytical statistics including the t-test, the one-way ANOVA and followed by the Tukey's post-hoc test and the Chi-square.P<0.05 was set as the level of statistical significance.

RESULTS
With a response rate of 92%, 22 partially-completed questionnaires were excluded in a total of 300 handed-out questionnaires.The students comprised 180 women and 98 men, including 183 (60.9%) clerkship students and 95 (34.1%) interns with a mean age of 24±4.2 and 24±3.5 years respectively.Table 1 presents the results associated with the interns and clerkship students' perspective on the current status of different dimensions of clinical education.The mean score of teachers' quality of teaching was the only dimension of clinical education with statistically significant differences in pediatric and surgery clinics compared to in obstetrics  2).
The comparison of the domain maen score of the questionnaire from the interns' perspective showed, teachers' quality of teaching and duration of attending clinics were the only domains with significant statistical differences among clinics.The mean score of teachers' quality of teaching was higher in the pediatric clinic and the mean score of duration of attending clinics was, lower in Obstetrics clinic,Other domains were not significantly different among clinics.Gender was also found not to be significantly different in the learners' view.
As seen in Table 3, which presents the frequency of variables that reflect the quality of education in all the study clinics from the perspective of the clerkship students and interns, the number of patients, patient diversity and cooperation ,teachers' commitment to training as well as adequacy of training were evaluated as poor, while cooperation of staff was rated as very good.

DISCUSSION
The present study was conducted to investigate the viewpoint of medical students enrolled in clerkship and internship programs about clinical education..
The results obtained revealed differences between clinics in some dimensions of the quality of education, particularly in teachers' quality of clinical teaching, in view of both clerkship students and interns.Amini reported no positive attitudes in clerkship students and interns towards teachers' performance as poor or moderate by the participants.Mortazavi et al. were the only authors reporting the greatest satisfaction with teachers' quality of teaching in clerkship students and interns working in outpatient departments (14).The present study however indicated little attention paid to this issue by the teachers, as reflected in the poor assessments made by the interns.Obtaining an accurate patient history with a focus on their problem as well as conducting short and thorough examinations is a basic responsibility of general practitioners, as emphasized by Masood et al. (18).Teaching how to communicate with patients to obtain their history therefore constitutes another domain of teachers' quality of teaching.This can be achieved if physicians can effectively communicate with patients, as suggested in the studies conducted by Zali et al. (19), Kalet et al. (20) and Sievers (21).Teachers' lack of interest in clinical education, probably as a result of inadequate motivation, was also rated poor by the clerkship students, which is consistent with similar studies (7,10,12).In order to improve teachers' performance and overcome their obstacles to ambulatory care education, proper measures and interventions should be adopted to improve the teachers' knowledge and attitude towards clinical education.To motivate teachers, Scott suggested that the annual promotion of teachers be based on regular and frequent evaluations of their educational performance (22).
Patient-associated issues, including the number and diversity of patients as well as patient cooperation during examinations and history taking, was rated as poor by the participants in all of the clinics, which is also consistent with the studies conducted by Khorasani et al. (12) and Avizhgan (10).Specific programs are therefore required to be designed as a model for future occupational environments to expand the range of educational clinic patients.
According to the interns, there are statistically significant differences between different clinics in terms of the mean score of duration of attending clinics, evaluated as inadequate particularly in obstetrics clinics, as was the case in the studies conducted by Shams et al., .
Amini et al. also identified inadequate time allocated by teachers and their failure to be present full-time as the main drawbacks of ambulatory clinics.Lesky et al. studied the educational challenges of medical students at outpatient centers and reported inadequate duration of training as an obstacle to ambulatory education (23).
Based on the results obtained, the ambulatory education program is recommended to be modified to maximize its applicability for learners.Teachers can help solve the inevitable problem of clinic overcrowding so as to both enable clinical ambulatory education and address patient-associated issues.
Cooperation of health staff was found to be a strength of educational clinics and evaluated as very good by the participants owing to having the score of work clearly defined for the personnel, which is however inconsistent with the poorly-rated cooperation of staff in the study of Anbari et al. (13).The present study interns identified excessively high number of clerkship students compared to the clinical capacity, which is consistent with the study conducted by Avizhgan et al. (10).As stated earlier, the number of students present in the clinic should be balanced by the improved physical environment of the clinic to enhance the quality of education and avoid education disruptions.From the view of the clerkship students and interns, the quality of clinical education received the lowest mean score in obstetrics clinics compared to in the other clinics, as the learners rated teachers' quality of teaching as poor, probably due to inadequate motivation or poor attitudes in teachers towards clinical education.All dimensions of the quality of clinical education were rated as poor or moderate by the learners except for a single item.Khorasani reported overall negative attitudes towards the current status of clinical education (12) and Alizadeh suggested that the present clinical education system does not meet the future requirements of physicians (24).Wolpaw reported partial satisfaction with ambulatory education (25), while Lubetkin reported a poor quality of education (26).
All this evidence suggests the lack of an integrated clinical education program for properly meeting the learners' needs.Teachers are respectfully recommended to pay a special attention to clinical education, enthusiastically involve students in patient-associated issues and improve their skills using modern educational methods.
Failing to investigate other types of clinics and teachers' comments was a limitation of the present study.

CONCLUSION
Education planners are required to observe the educational principle of making a balance between the number of students and the facilities available, to design comprehensive programs for expanding the number and diversity of patients in educational clinics and to do their best to turn the clinical setting to a model of the future occupational environment for physicians.To maximize the quality of education, teachers are recommended to involve the students in patient-associated issues while considering the learners' educational needs.

Table 1 :
The mean score of different dimensions of clinical education from the interns and clerkship students' perspective http://www.ejgm.co.uk 3 / 6 clinics (P<0.05); the highest mean score was found in surgery clinics and the lowest in obstetrics clinics (Table

Table 2 :
The mean score of different dimensions of clinical education from the interns' perspective

Table 3 :
The absolute and relative frequency of the variables reflecting the quality of clinical education from the perspective of the clerkship students and interns