Learning in Real-World Settings
Tim J. Parkinson
Institute of Veterinary, Animal & Biomedical Sciences, Massey University, New Zealand
Informal schemes for veterinary students to undertake placements in the “real-world” settings of the clinical practice and government service branches of the veterinary profession are long-standing components of veterinary education. However, recent years have seen an unprecedented emphasis on such placements as a formal, critical, and integral part of veterinary curricula. The main themes that have come together to bring real-world placements to the forefront of curricula are the recognition that there are significant areas of veterinary practice that cannot readily be taught within the confines of an academic institution; the need to provide students with a greater scale or scope of clinical opportunities than are available through a university hospital; and constraints on universities’ ability to provide a full spectrum of clinical experience to students.
There has also been a significant change in the pedagogical environment of medical (and hence veterinary) education over the past two or three decades that has helped to drive clinical teaching toward real-world settings. There has been a substantial shift from didactic instruction and apprenticeship models of clinical instruction toward student-centered, constructivist modes of delivery, and the systematizing of clinical instruction around the competencies required of the newly graduated veterinarian. Furthermore, the competencies that the practicing veterinary profession expects of its new graduates are no longer confined to the areas of declarative knowledge and technical skills, but are also increasingly in the affective domains of communication, professionalism, and interpersonal skills. The profession, in fact, expects that graduates will be able to perform the clinical and technical tasks that will enable them to be effective as revenue earners (e.g., Jaarsma et al., 2008). To meet these new expectations, veterinary schools have had to invest in teaching methods that place greater emphasis on these skills, and, as part of that investment, have had to develop means by which they can be taught in the context of students’ real-world aspiration to be clinical practitioners.
Concurrent with these developments has been the opening of a number of new veterinary schools. For the established schools, their veterinary teaching hospitals (VTH) have had a long history of existence and, hence, also have a well-defined place in the veterinary community for their referral services and their needs for case material for clinical teaching. For new schools, setting up clinical teaching facilities has been challenging, as they do not have that history in the veterinary community. Even where there has been a long period of advocacy for a new school, that school, once founded, has to struggle for its “place in the sun” of a share of the local primary or referral caseload. Sometimes the need can be met by the purchase of an existing practice, sometimes there might be a gap in the provision of local/regional veterinary services, and sometimes neither of these options is readily apparent. This is not only the situation for new schools: existing schools may not be able to sustain some components of the teaching practice. Food animals commonly fall into this category: locations that may have provided a broad agricultural hinterland when the school was founded are now covered with urban development, and the rural practice has disappeared (Klee, 2008). Moreover, the effectiveness of clinical learning is also affected by the nature of the clinical practices that universities operate, inasmuch as universities need a cadre of clinical specialists to maintain their impetus in clinical excellence and research. Specialists, who may be operating at the level of secondary or tertiary referral, are not necessarily enthralled by teaching students simple medical or surgical procedures, so tension can ensue between the need for clinical specialisms and the achievement of Day One Competencies.
The net result of all of these trends has been a dramatic evolution of the use of external real-world settings, from the informal arrangements of “seeing practice” into key, core, planned, contractually defined components of the modern veterinary curriculum. Consequently, most veterinary schools have moved some or all of their clinical teaching to some form of distributed teaching model. Development of the distributed model, and the means by which it could be accredited as a means of providing clinical education, was not without controversy (Nelson, 2012), but the outcome of that period of discussion has been a robust model for curriculum delivery beyond the bounds of the veterinary teaching hospital.
Harden, Sowden, and Dunn (1984), in their seminal review of educational strategies in medical curricula, argued for community-based medicine as a critical curriculum component to supply the needs of practitioners who would subsequently provide primary accession medical services to the community. They noted that the hospital-based approach of medicine “has fostered an ‘ivory tower’ approach to medicine in which students during their training have little contact, if any, with the community which they are being trained to serve” (p. 291), and that “in hospital-based curricula it is in the process of becoming a doctor that the trend towards specialization has been initiated, intensified and maintained” (pp. 291–292). The large number of veterinary students who take internships as their first postgraduation employment who made that choice during their clinical training (Barbur et al., 2011) and the remarkable growth in veterinary specialty practice (Albers, 2008) may be symptomatic of the same process occurring in veterinary education.
By contrast, community-based training helps students to understand the importance of primary healthcare, provides access to a wide range of clinical material that is seldom seen in a teaching hospital (Figure 13.1), and, if managed well, can provide an intensely active learning environment. Most veterinary schools have recognized the disconnect between the high-level referral practice that typically characterized a VTH and the expectations of Day One Competencies of graduates, and have sought either to diversify back into primary accession care themselves or to obtain real-world placements with private practices. For example, Ohio State University recently re-established an ambulatory large animal clinical facility (Masterson et al., 2004), the University of Florida partnered with a private practice to deliver a small animal emergency medicine rotation (Olson, 2008), and Colorado State University has developed a pet hospice program to teach students how to manage the human and animal aspects of terminal care (Bishop et al., 2008).
Harden, Sowden, and Dunn (1984) also compared the modes of instruction during clinical rotations, contrasting the apprenticeship model that characterized traditional clinical curricula with a more systematic approach (see Box 13.2). The use of Day One Competencies to define the graduate outcomes of veterinary curricula has created a concurrent expectation that there will be planned and defined clinical learning experiences; and, since these are the competencies of a general practitioner, many of the competencies need to be learned in the context of primary accession, commercial, clinical practice.
One of the unique features of veterinary degrees that derive from the British (Royal College of Veterinary Surgeons, RCVS) model of veterinary education is the requirement for students to gain real-world experience of working with animals, particularly livestock, during the vacations of the junior years of their studies (Box 13.3).
The intent of these placements is to “provide the student with all the necessary handling skills and husbandry experience of common domestic species that they need to master before they progress to the clinical components of the course” and to “develop their animal handling skills across a range of common domestic species … and … their understanding of the practice and economics of animal management systems and animal industries” (RCVS, 2009, pp. 2–3). Using the model presented in Figure 13.1, these placements also engage students with the problems and practicalities of livestock management that they may never encounter in clinical veterinary practice.
The need for students to become familiar with livestock is the key foundational pillar of animal handling and husbandry (AH&H) placements, especially in the face of the decline in familiarity of working with livestock among entrants to veterinary school. The emphasis of AH&H placements has shifted with time: originally conceived as periods of “farm work,” these placements are now likely to have specific learning outcomes in terms of both the technical skills of familiarity/confidence with livestock, and gaining understanding of the management and economic factors that underpin livestock enterprises. Students generally have to produce a factual report on the placement, which may also require them to research and discuss in depth some aspect of the farm’s activity. Bristol University, for example, sets animal health-related tasks for students to research during their placements, with the expectation that each student will be able to lead a tutorial on that topic when they return to campus.
As with all real-world settings, students need to be adequately underpinned by university courses. Universities commonly provide junior-years courses in animal handling, but these may not be sufficient to meet either the requirements of health and safety authorities, or (perhaps more importantly!) the expectations of farmers. Some universities have therefore added intensive training around livestock/farm safety as a precursor to the AH&H placements. For example, Melbourne University (2015) requires that students undertake “an approved five day residential course in animal handling, environmental safety and management” as a prerequisite for its junior year courses in animal health, while Massey University (New Zealand) requires students to undertake a similar course at an agricultural training organization as the precursor to its AH&H placements.
There is, finally, an increasingly important, but deliberately understated, objective of such placements; namely, the recruitment of students into rural practice. Ensuring positive experiences of students in rural placements is seen as a key step in the development of an interest in a career in rural practice, as it is well documented that students who have had positive rural experiences are more likely to make initial career choices in this direction (Lenarduzzi, Sheppard, and Slater, 2009). In the realm of medical education, it is clear that recruitment into “difficult” areas can be enhanced by exposing students to a program-long, “longitudinal pipeline” of relevant, community-based placements (Quinn et al., 2011), and, in the veterinary context, pre-entry or early-program exposure to the rural sector is critical in orienting students toward future employment in that area (Schmitz et al., 2007). In North American universities, in which AH&H placements are not mandated by accreditation, the importance of high-quality farm exposure is nonetheless well recognized, and such programs have been developed in several universities that serve agricultural hinterlands (e.g., Smith, 2004; Karrier et al., 2008); these programs appear to be effective at recruiting students into food animal tracks.
In order to “have a realistic and appropriate perspective of the responsibilities of the veterinary profession” (University of California, Davis, 2015), prospective students are usually required to have completed a significant amount of veterinary experience before admission. After admission, regardless of whether a veterinary medical degree program adopts the traditional “preclinical, paraclinical, clinical” model or whether it has a more integrated structure, familiarization and enculturation with clinical practice are a key transition though which students have to progress. Johnson (2015) reviewed the programs of extramural study (EMS) placements in UK veterinary curricula, with the view that early clinical placements were primarily of value in learning the culture of veterinary clinical practice and observing the management of cases.
This process is commonly started at the transition from the junior to the senior years of the program – often at the start of the final year. However, current thinking is that clinical activities need to be incorporated into the program at a very much earlier level, ideally as early as possible. In fact, this is the process that many veterinary schools operate. Early-years clinical experience is important, as it provides context and reality for preclinical studies and, even if brief, such placements are well received. For example, D’Amore et al. (2011) describe a one-week placement of first-year medical students in rural Australia as being enjoyable, but also as a vehicle for students to understand the clinical and technical learning that they would need to achieve to be successful in clinical practice. Kaye et al. (2010) had a similar experience of placement of first-year medical students in rural Uganda: “many of the students … were in favor of this being part of their medical training. Some of the reasons given … were that it enables students to understand the medical conditions in rural areas, to see a variety of medical conditions (some of which are not seen in the teaching hospital), and to learn about the management of the health care system.” In veterinary education, Stone et al. (2012) argued for exposure to companion animal primary care throughout the curriculum as a means of providing interest in primary practice per se and of creating context for concurrent studies. Interestingly, they “originally thought that the first-year students could serve as animal handlers, second-year students as receptionists, third-year students as veterinary technicians, and fourth-year students as clinicians. This proved to be fallacious thinking” (p. 212); rather, they found that “junior” students benefitted most when fully incorporated into the “inter-professional team.” Likewise, initiatives in the United States and Canada have aimed at stimulating the interest of first- and second-year doctor of veterinary medicine (DVM) students in food animal medicine by getting them involved in real-world problems at the farm, practice, or rural industry level (e.g., Iowa State University: Karrier et al., 2008; Michigan State University: Howard, Lloyd, and Grooms, 2009).
On the other hand, starting clinical practice can be stressful. One way to address this issue is the use of simulators to familiarize students with the clinical material and interpersonal interactions that they will encounter – a process that has been beneficial in nursing and midwifery (McNamara, 2015; Cummins et al., 2015). Likewise, nursing education has emphasized the importance of clear goals and expectations around early-year clinical placements (Andrew et al., 2009). Veterinary curricula similarly need to have clear expectations of students’ achievements in early clinical placements (Bell et al., 2010). For example, James Cook University, Queensland, Australia (2015a) has a series of preclinical courses in veterinary professional practice, which structure learning experiences across the early years of the program to create understanding of, and familiarity with, veterinary clinical practice as a precursor to the main block of clinical studies in the final year. Learning outcomes for the early stages of these placements are largely in the affective domain of communication, workplace ethics, and teamwork, with later placements having a greater emphasis on “clinical” skills such as client communication, history taking, record keeping, and clinical examination.
In order for veterinary schools to meet the expectations of Day One Competencies in companion animal practice, students need to be exposed to a broad range of primary accession and referral medicine, and (in the terms used in Figure 13.1) to the diseases and problems that are found in the “community,” but are not (or not commonly) seen in veterinary practice.
Most aspects of companion animal practice can be taught in external placements, and there are many examples in the literature of such placements. Emergency medicine and terminal care (Bishop et al., 2008) have already been mentioned; and private specialty clinics, wholly or partly owned subsidiaries, and private primary healthcare clinics (Bishop et al., 2008; Lloyd et al., 2008; Olson, 2008; Tyner et al., 2014) have all been used to good effect. There are common threads to the success of these placements, of which the most important appear to be:
- Structured expectations of students’ learning.
- The physical and professional resources of the practice.
- A collegial relationship between the university and the practice.
One of the most important aspect of students’ learning in the real world is that they are enabled to behave as though they actually are in the real world. In other words, students need to be active participants in the diagnostic workup, clinical procedures, and interactions with clients. However, the problems of prioritizing between the needs of the case (and demands of the animal’s owner) and the expectation of the student are well known (e.g., Magnier et al., 2011), and it is equally well known that real-world placements are of marginal value where students are merely observers. Hence, managing the expectations of both the students (“how much I want to do”) and the practices (“how much I am prepared to let you do”) is an important component in the success of real-world placements. Sometimes students’ learning is structured by the university, in terms of, for example, a cadre of technical and/or professional skills that the students are expected to achieve during their placement. Commonly this is managed through a structured logbook (Dale, Pierce, and May, 2013), a list of technical skills, or a series of learning objectives. Alternatively, the objectives for each placement can be negotiated between the student and the university or between the student and the practice. For example, the Royal Veterinary College (RVC, 2014) expects that students arrive with “a reasonable list of objectives for their time spent at that placement. It expects that their students will have a common sense approach to setting out this list of objectives, bearing in mind the stage of the course they have reached and their own level of competence.” This process of agreeing outcomes is valuable for all parties, since it allows the “I want to/you can do” discussion to be held at the start of the placement rather than leaving one or other party dissatisfied at its end; and it allows for objective assessment of the student’s achievements during the placement.
Development of students’ nontechnical skills may, in fact, be one of the most valuable aspects of real-world placements in companion animal practice. Even though there are many useful ways of teaching communication skills in the “safe” setting of the university (e.g., Chun et al., 2009), real communication with clients remains a most demanding skill to learn, and transferring skills learned in the preclinical safe environment into the real-world workplace is critical to the professional development of fledgling clinicians. Consequently, providing opportunity for client interactions, with a focused, sympathetic critique (Adams and Kurtz, 2012), is an area of real-world placements that is undergoing rapid development. The second major nontechnical skill of which students have limited understanding is that of the business of veterinary practice (Bachynsky et al., 2013). Even though students do not necessarily take on board the commercial realities of practice during their clinical year (Rhind et al., 2011), those who are enabled to do so are better equipped for the commercial realities of their postgraduation work. Consequently, greater emphasis is being placed on students’ understanding of the business of commercial practice during their placements (particularly during the preclinical/clinical link placements). Interestingly, while early forays into improving students’ understanding of veterinary business were largely report based, tracking students’ earning potential through actual client charging plans (Roth, Poon, and Hofmeister, 2014) seems to be a way of moving business understanding from theory into students’ repertoire of skills.
Shelter medicine can be used to provide access to a wide range of clinical material: large numbers of animals for desexing surgery and other everyday procedures, along with the infectious diseases and “diseases of neglect” that are commonplace in the wider animal-owning community. Stevens and Gruen (2014) summed up the benefits of shelter medicine experience to students as providing “opportunities to practice zoonotic and species-specific infectious disease control, behavioral evaluation and management, primary care, animal welfare, ethics, and public policy issues” (p. 83); for this reason, many veterinary schools have incorporated local animal shelter resources into their clinical teaching. Indeed, for many schools, shelter medicine placements were their first foray into a distributed clinical teaching model. Desexing surgery is, of course, a critical skill for the graduate companion animal veterinarian, and the plentiful supply of animals requiring this surgery in animal shelters makes this a great environment in which students can learn that skill. Moreover, the students themselves can be a resource to the shelter by helping to manage the caseload of desexing surgery, so that there are useful outcomes for the school, the student, and the shelter itself. The mobile desexing service at Purdue University (Freeman et al., 2013), the collaboration between Texas A&M University and the Brazos Animal Shelter (Snowden et al., 2008), and the integration of the People’s Dispensary for Sick Animals (PDSA) into the clinical rotations of the RVC (Mahoney and Martin, 2011) are examples of such services. Developed countries may also assist developing countries in a similar way: Massey University sends groups of final-year students annually to the Pacific island nation of Samoa, where the students gain a great deal of experience in desexing surgery, while the country has the benefit of control of its feral dog population. The benefits of shelter medicine go far beyond desexing surgery, since students also have to manage animals with infectious diseases that are unusual in the population of owned, vaccinated animals; in managing these cases, students learn that epidemiological principles can be applied to managing infectious diseases beyond the boundaries of food animal practice.
Food Animal Practice
The use of real-world settings for teaching food animal practice has become an integral part of most universities’ food animal programs. Indeed, long before the notions of “distributed model” or “real-world setting” had entered the vocabulary of veterinary education, difficulties of maintaining an adequate caseload through the VTH were forcing schools into developing relationships with private or state-run practices.
The importance of industry exposure as a means of recruiting students’ interest in food animal practice is well recognized and so, interestingly, where the model of AH&H EMS is not mandated by accreditation, it may evolve anyway. For example, Michigan State University developed a “summer food systems fellowship program” (Howard, Lloyd, and Grooms, 2009) with the intent of interesting and challenging food animal students in order to “maintain populations of graduates who are willing to seek out job opportunities in the production animal arena” (p. 280). Immersion experience with the dairy industry is a strong pillar of this initiative. In Cornell University’s Summer Dairy Institute (Nydam et al., 2009), there is a strong emphasis on both the farm-level and herd health skills that dairy practitioners will need. Likewise, the University of Minnesota has a partnership with a large-scale dairy farm to provide students with hands-on experience in the management and disorders of cows in the pari-parturient period, as well as in the farm-level and clinician-level decision-making that surrounds such animals (Fetrow et al., 2004). A similar initiative in this arena is the Swine Medicine Education Center, a partnership between Iowa State University and AMVC Veterinary Services, which provides education and experience for veterinary students and graduates in various aspects of the pork industry (Iowa State University, 2015) in the real-world settings of pig farms and clinical practice. The importance of these initiatives is twofold. First, individual universities find it increasingly difficult to maintain faculty recruitment in specialized food animal areas, hence where such centers and immersion activities are managed on a regional or interinstitutional basis, better utilization of scarce faculty resources and stability of programs can be achieved (Moore, 2006). Second, such initiatives are of increasing importance in maintaining an adequate cadre of veterinary graduates entering food animal practice. This is partly due to the benefits of bringing like-minded students together: Nydam et al. (2009) recognized that the paucity of students who are interested in food animals in a typical veterinary class can leave those students feeling isolated, so a significant benefit is achieved by bringing students from various veterinary schools together into a situation in which they do not feel like a minority.