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Acad Med. 2014 Mar;89(3):469-76. doi: 10.1097/ACM.0000000000000129.

How clerkship students learn from real patients in practice settings.

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Dr. Steven an academic fellow in general practice, the University of St. Andrews, St. Andrews, United Kingdom. Dr. Wenger is a social learning theorist and consultant, Grass Valley, California. Dr. Boshuizen is an education researcher, Open University, Heerlen, the Netherlands. Dr. Scherpbier is dean and education researcher, Maastricht University, Maastricht, the Netherlands. Dr. Dornan is an education researcher, Maastricht University, Maastricht, the Netherlands.



To explore how undergraduate medical students learn from real patients in practice settings, the factors that affect their learning, and how clerkship learning might be enhanced.


In 2009, 22 medical students in the three clerkship years of an undergraduate medical program in the United Kingdom made 119 near-contemporaneous audio diary entries reflecting how they learned from real patients. Nineteen attended focus groups; 18 were individually interviewed. The authors used a qualitative theory-building methodology with a conceptual orientation toward Communities of Practice theory. A learning theorist guided selective coding of a constant-comparative analysis.


Participants learned informally by participating in the communicative practices of workplaces. Two overlapping practices, patient care and education, were identified. Patient care created learning opportunities, which were enriched when practitioners intentionally supported participants' learning. Education, however, was not always coupled with patient care. So, talk positioned the boundaries of two practices in three configurations: education without patient care, education within patient care, and patient care without education. The nature and quality of participants' learning depended on how practitioners entered dialogue with them and linked the dialogue to authentic patient care.


Findings strongly suggest that medical students learn from real patients by participating in patient care within an educational practice. Their learning is affected by clinicians' willingness to engage in supportive dialogue. Promoting an informal, inclusive discourse of workplace learning might enhance clerkship education. This approach should take its place alongside-and perhaps ahead of-the currently dominant discourse of "clinical teaching."

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