Patients and learners: time for a re‐evaluation of our goals in bringing them together

There is well-established evidence showing that learning to become a doctor is best mastered within the clinical environment itself.1 It is the authentic workplace in which knowledge, skills and attitudes can be integrated to achieve a level of competent behaviour fit for purpose.1 Not surprisingly, many medical training programmes have organised courses in which learning is located in the workplace, for instance by allowing undergraduate students to participate in providing aspects of health care. During these courses, students contribute under supervision to patient care, with gradually increasing independence and responsibilities. In this issue, Smith et al.2 report on a study in which pre-prescribing was used to understand how this supported participation in patient care influences students' workplace learning. As Smith et al.2 explain, learning processes, like making mistakes and needing help from doctors, are part of the challenging road along which a novice student must travel to become a professional, and eventually result in the ability to perform the task, maintain good relationships within the team, and develop a professional identity.2 Learning processes are part of the challenging road along which a novice student must travel to become a professional Helping trainees reflect upon their experiences is key to improving future performance.3 In their study, Smith et al.2 focus mainly on the effects of making mistakes on developmental outcomes. Trainees mention that they learn from their own and others' mistakes, which are afterwards discussed with peers, doctors and tutors.2 This illustrates the important role of feedback, as well as the active roles of trainees themselves in seeking information about their performance. Research in other domains, such as organisational and social psychology, has revealed valuable insights into the feedback-seeking behaviour of trainees.4 It emphasises the importance of creating teams that share responsibilities and of guaranteeing a safe learning climate in which trainees can be encouraged to seek feedback.4 Trainees seek feedback from their supervisors (i.e. doctors) and also from peers, nurses and patients.5 Every possible source can provide valuable information. It is important to guarantee a safe learning climate in which trainees can be encouraged to seek feedback Here too a preceptor may play a critical role in helping trainees recognise areas for improvement and find sources of valuable information. As Dornan et al.6 have observed: ‘…an effective teacher is someone who can simultaneously support students and challenge them in a way that builds practical competence and a positive state of mind.’6 As they participate in the clinical workplace, trainees become aware of their uncertainties and incompetences. This will influence their self-presentation and consequently their behaviour. The presence of a supportive supervisor who creates a safe learning environment and provides continuity in the process of feedback and reflection (i.e. establishes a good professional relationship) might reduce trainees' perceived costs and let them focus on the benefits of active participation in the clinical workplace.5, 7 As they participate in the clinical workplace, trainees become aware of their uncertainties and incompetences However, having trainees contribute to patient care will inherently influence patient safety. The discomfort this produces results in ‘a tension between [trainees’] feelings of empathy and the need to acculturate to their new professional identity’.6 Nonetheless, if society wants trainees to become competent professionals who add to patient safety in the long run, novice practitioners must be given opportunities to train and develop. This leads to a dilemma: how can we ensure an acceptable level of patient safety now and in the future, while creating opportunities for trainees to increasingly participate in the authentic clinical setting with increasing independence in preparation for their future work as doctors? In their paper, Smith et al.2 describe a method of pre-prescribing in which students act as part of the clinical team and are required to write instructions on in-patient drug charts that must be countersigned by a doctor. They created an environment in which students were able to make mistakes and to learn from mistakes, without any negative consequences for patient safety. Creating a clinical team turned out to be a crucial component within this process. The next challenge is to help these students perform more independently in daily practice. We believe that an open discussion of the actual risks and benefits of training to patients and the trade-off that is acceptable is required. If society wants trainees to become competent professionals who add to patient safety in the long run, they must be given opportunities to develop Another part of the solution must derive from a well-founded judgement of student capabilities and the level of independence it is appropriate to allow a student. Steps in the right direction, such as those of programmatic and team-based approaches to clinical training, are gaining ground.8, 9 When do we know the learner has reached a level of competence in which we can entrust the trainee with certain professional tasks? Cooke et al.10 have written: ‘It is now clear that for training in skills to be effective, learners at all levels must have the opportunity to compare their performance with a standard and to practise until an acceptable level of proficiency is attained.’ Hence, all members of the clinical team will be required to provide feedback to one another (i.e. it is not only trainees who require feedback) focusing on the attaining of appropriate standards of health care while guaranteeing patient safety. In their review, Cooke et al.10 state that if we want to develop competent professionals, ‘…our approaches to the evaluation of learners must reach beyond knowledge to rigorously assess procedural skills, judgement and commitment to patients’. An open discussion of the actual risks and benefits of training to patients and the trade-off that is acceptable is required Recently, scientific evidence in the medical domain has begun to encourage a programmatic approach towards learning and assessment in the clinical workplace.8, 11 On the one hand, assessment is used to facilitate learning through the provision of meaningful feedback after a trainee's performance has been observed. By contrast, information gathered from different observations and subsequent assessments, from different sources and at different time-points is used to make high-stakes judgements.8, 11 The combining of supervision, feedback and workplace-based assessment might facilitate the development of an educational programme which will allow the trainee to participate within a clinical team, build a professional identity and develop into a competent doctor without threatening patient safety.