A total of 44 students participated in seven group interviews, lasting between 97 and 114 min. The number of participants varied from 5 to 8, the mean age of the participants was 24 years (range 22–39) and 82% was female. All the participants had completed at least five clerkships prior to the general practice clerkship, with an average of 10 clerkships. During the interviews, it became clear that the students were used to talking about learning experiences in terms of knowledge, skills and attitudes, but many appreciated being invited to talk about other aspects. Moreover, students often used their hospital experiences as frame of reference in reflecting on their general practice experiences. They expressed the quality of their experiences more often in terms of “fun” and “appreciation” than in terms of “instructive”. Nineteen students responded in the member checking procedure and four students made minor remarks, for example regarding details of the GP surgery or their personal take on a certain topic. In the following paragraphs we present the results of the analysis with illustrative quotes.
Developmental space
The students said they learned by doing. The fruitful effect of ‘doing’ (such as conducting a consultation relatively independently) depended on the amount of space students experienced to mind their professional development. The ‘available space’ that emerged from our data consisted of interconnected components and processes contributing to personal growth. Personal growth transcends the acquisition and application of knowledge, skills and attitudes required for a specific clerkship or by a specific physician, and relates to the development of a student’s professional identity. We use the term ‘developmental space’ to denote the explicit and implicit opportunities for identity development that is afforded to and created by students. This term captures students’ experiences as participating professionals, which some students summarised as “finally feeling what it’s like to be a doctor”, or “no longer feeling like a clerk”.
P7.6: Sometimes I even feel that it’s alright for me to just call and say: well, this patient presents with these complaints, I find this and that on physical examination and er, I am thinking of prescribing this. And then he [the GP] says, it’s okay, just write the prescription. So, er yes, this feels very good, because I finally begin to sense something like (…) you are finally beginning to do things yourself.
P5.1: In other clerkships I often see more growth in knowledge and for the rest you just do as you are taught. But here [in general practice] you are also looking at things more critically like… is this really how I want to work (…)? Or how patients accept it, so to say?
In the following paragraphs we first describe two components of developmental space: contextual space and socio-emotional space. We then describe, in terms of these different types of spaces, three groups of activities that we identified as central to the general practice clerkship: holding independent consultations, talking about consultations, and observing the GP. These so called participatory activities demonstrate students’ potential for growth through the concept of developmental space.
Contextual space
The possibility for students to mind their learning was influenced by the attributes of the working environment, such as material, organisational and educational elements. Contextual space, for example, was strongly determined by the presence or absence of a special room for students with a computer and access to patient records and by the scheduling of patient consultations for students. The organisational element is manifest in clerkship length, specialty, and its position within the curriculum. For example, prior (clerkship) learning expectations and experiences influenced students’ perceptions of the contextual space as was exemplified by students expressing the contrast with hospital clerkships as “being offered a lot more opportunities to learn”. Contextual space was also determined by the time available for supervision, mutual observation and feedback, and the patient mix seen by students. These elements were potential educational stimuli for students.
P3.3: I do not have my own surgery hour, but the way we do it is that we always look in the computer and then there are usually two patients in the waiting room and then he [the GP] says well which one would you like to take? Do you want the knee problem or the lung follow-up? And then I pick the one I can learn from the most.
Socio-emotional space
Socio-emotional space embodies how students’ state of mind, often originating from interactions with the social environment, influences possibilities for learning. Students’ relationships with their supervisor, other team members and patients influenced their social and professional position within the practice. The nature of these relationships was partly influenced by the local working climate and habits, partly by a personal ‘click’ with the supervisor and other personnel, and was further developed by participation in patient care. The strong impact of the student’s position was manifest in its effect on emotional outcomes such as enjoyment and feeling respected and confident. These positive emotions enabled learning by providing space for students to build their skills and experiences, to accept weaknesses and to feel free to ask questions. If these elements were unclear or disturbing, students were compelled to attend to these negative aspects and as a result effective use of the socio-emotional space would be impaired.
P5.5: You have to be on your toes all the time [in the hospital]. I mean, with the GP I felt this was yes… much less so. That was good, for then you start to feel that you are not afraid to ask questions and also that you can say, well, I don’t know this, tell me some more about it, while if you say that in the hospital you always feel like… yes, I should really know that. And then they say like: alright, go and look it up in the textbooks. (…)
P5.3: Or you get the whole lecture like… Do you really not know that?!
P7.4: And when the atmosphere is not good (…) then you hold back. (…)
P7.6: Then you really always have to adjust to what a doctor expects and wants from you. And because of that you cannot really be yourself, for you have, you lose some self confidence anyway and then you, yes, you have to take a different attitude every time and…
P7.5: That takes energy.
P7.6: That takes an awful lot of energy.
Participatory activities
We will describe three types of participatory activities which embody the meaning of and interaction between contextual space and socio-emotional space. This approach allows us to elucidate how ‘learning by doing’ contributes to students’ personal development.
Independent consultations
The students’ main activity was patient contacts. After an introductory period varying from 1 h to several days, students became increasingly independent in taking a history, doing a physical examination, and making a management plan. The GPs had the final responsibility and used varying strategies to ensure patient safety. Further supervisory activities were partly formal (weekly observation-based evaluations) and partly depended on GPs’ routine approaches and students’ development over time. How students learned to become progressively more independent in conducting consultations and how these learning experiences contributed to the development of their professional identity can be explained when we study these processes through the lenses of contextual and socio-emotional spaces.
Contextual space
Clerkship length and the type of primary care tasks in general practice gave students ample opportunity to engage in patient encounters and see patients again at follow-up visits. This ability to engage in continuity of care gave students essential feedback on their medical decision making and enabled them to build doctor-patient relationships. The specific illnesses and complaints in primary health care stimulated students to develop a ‘new way of thinking and acting’, which they found both inspiring and instructive.
P3.2: In the hospital we are used to, when people come, that means something is wrong. (…) And especially in general practice you make that distinction. (…)
P3.4: And what to me is especially good, (…) they [GPs] allow you to say, like what would you do? And then you have to think for yourself. I think this should be referred, or not, or… and I think in this way you learn somehow. For when he just says, yes I’ll refer, then you think, oh yes, of course. But you haven’t really thought it through for yourself.
Having their own consultation room gave students a clear status and enabled them to further develop their independence. This room symbolised their position within the practice and supplied them with a safe, private space. The same applied for having access to a computer and a well organised and filled consultation schedule. The latter often developed over time, and was a sign of growth.
P2.3: Your own room that is really very important, isn’t it? (…) You feel much more at home, much more at ease, much more… it seems silly, but you feel much more respected when you can sit in your own room…
Which aspects provided valuable guidance and feedback to students depended on their stage of development. At first, GPs’ observations, feedback and explanations were the main stimuli, but later on students learned more from being confronted with the consequences of their own actions, which was more powerful than merely being told what they had or had not done well.
P5.1: Generally I have been able to see quite a few patients again at the following visit, and I have really learned a lot from that. (…) Things like that are just good for you, to receive feedback on what you have done. Not only er, as an opinion or as yes… as feedback from some GP, but just like… yes objective things: lab results, X-ray results, er… improvement of the complaints or indeed worsening.
If, in time, the GP remained observing the student’s consultations with patients, this considerably dampened the experienced instructiveness of this activity because it detracted from the student’s opportunities for self-development. Nevertheless, during the whole clerkship it remained crucial that the GP was available to answer questions or take part in the consultation, both for the sake of patient safety and learning.
P6.4: Mostly I see a lot of patients together with my GP because there aren’t that many. In itself that is very good, because he can give feedback immediately. (…) But on the other hand, it sometimes makes me feel uncertain because the GP is present and (…) then you sort of feel someone breathing down your neck, like how would he do this, and that inhibits you from speaking freely.
Socio-emotional space
As a result of the one-to-one relationship with their supervisor, students felt there was room for the GP to monitor their development, to increasingly trust them as professionals and to give them progressively more independence in patient consultations. The same development of trust, albeit with a less pronounced impact, took place in the students’ relationships with other staff, such as receptionists and nurses. Independent patient consultations were significant in light of students’ social position in the practice, which varied from being an accepted member of the team that contributes to patient care to being ‘just the clerk/intern’. Providing continuity of care for a group of patients and establishing relationships with them contributed to the students feeling part of the team and created a firm basis for trying out new tasks or skills. The sense of being appreciated and being responsible resulting from feeling recognised as a team member was a strong motivator for students and strengthened their confidence. Moreover, taking responsibility increased students’ awareness of their own strengths and weaknesses thereby guiding them in when and how to ask for supervision or read up on a certain topic.
P7.5: Well, what I also like very much during this clerkship is that you are not so much seen as the clerk who is a nuisance and in the way. (…) You really have your own place there. You see patients, you feel you are really useful. (…) And because of that, you are more, simply part of the team and not someone placed below it.
The specific so-called minor illnesses and complaints which students ‘mastered’ in general practice contributed to their sense of professional identity as they became increasingly competent to answer the various questions patients asked them. Moreover, students also experienced personal growth as they became better able to deal with medical problems in their private life, for example when family members asked questions about their health.
Conversations about patient consultations
Student-patient encounters were framed in conversations with the GP during or after the consultations. These offered opportunities to both students and GPs. Together they could discuss patient management and elaborate on medical and behavioural issues, while the student could ask questions and the GP could provide feedback on student performance. Initially, these conversations would centre on practical feedback and on exploring and setting boundaries of independence based on the student’s performance and the GP’s customary approach. In time, once student and GP had established a feasible and safe working mode, students could develop a certain level of independence in deciding to what extent, when and how they wanted to contact their supervisor. Talking about patients was associated with the development of self-confidence, professionalism and medical knowledge.
Contextual space
The combination of clerkship length and one-to-one supervision offered a firm basis for providing, valuing and using appropriate feedback. Moreover, it provided room for the student to change and for the supervisor to notice that change. In most cases, students could consult the GP at any time, and transparency regarding how they could approach the GP reassured students.
P7.5: My room is next to the GP’s room. And er, we have arranged that when I am finished with a patient I leave the door ajar, and when he is finished with his patient and he sees my door is open he comes in. He sits down and then he says: well, tell me, er, what do we have here? And what are you going to do about it?
Whether or not the patient was present during a conversation between the GP and the student influenced if and how students asked questions or expressed doubt, since students thought this could interfere with the professional relationship they were trying to build with a patient. Knowledge and experiences obtained during previous clerkships made it easier for students to contribute to medical discussions and to value received feedback. Supervisors promoted fruitful discussions when they stimulated students’ thought processes in a challenging and non-judgemental manner, when they gave them a role in patient care and when they explained things when necessary.
P5.1: Especially with complaints of fatigue, yes, I often would think somatically, while yes… my supervisor’s experience naturally had taught that it is often not somatic. (…) And one time he said well, do you know what we’ll do? When you think it is somatic (…) then we’ll just do a blood test, you will see the patient again after a week and then you can see if you can find something… and I have never found anything.
Socio-emotional space
Students reported that the relatively friendly atmosphere and general interest that surrounded and coloured the conversations created room for them to ask questions and show weaknesses. Patient related conversations were most appreciated when student and supervisor were more or less equal conversation partners. Equality was apparent from the GP’s attitude and language and from the contribution the student was allowed to make to the diagnosis or treatment plan. This made students feel they were taken seriously and challenged them to be a really equal conversation partner and take responsibility. Students also derived a sense of equality from conversations when the GP showed that he/she was not omniscient. Interactions with receptionists and/or nurses who showed they regarded the student as a professional could foster a similar sense of professionalism.
P1.1: Or also when the GP doesn’t know something, or when he has the lab results then… At least with me they very often asked like well, what do you think? What would you do? Would you refer him or? Yes, I always liked that (…) and that way I felt they were taking me seriously.
Observing the general practitioner
Students observed their supervisors during patient consultations, in the running of the practice, in communicating with colleagues and in balancing their professional and private lives. Planned observations of patient encounters occurred mostly early in the clerkship and the extent of this activity depended on the level of independence the GP granted the student. In time, observations generally became context-related or occurred only when requested. The observations provided students with information about primary health care in general and with examples of how the GP fulfilled his/her tasks. In group practices, several GPs instead of one offered role models.
P6.1: I learn from the way my GP handles things, (…) how she deals with patients, how she deals with colleagues, how she deals with certain conditions, whether or not you should treat them, whether or not you should refer (…) Just a role model of someone with a lot of experience.
Contextual space
Clerkship length provided students with enough time to understand and value their observations of GPs’ behaviour, preventing them from passing early judgements and deepening their understanding of certain behaviour or idiosyncrasies. Students were used to view and judge primary care from a secondary care perspective. By observing how a GP communicated with colleagues in secondary care, students got the full picture and this was an important insight to guide them in their future professional practice. General practices were often located adjacent to or near the GP’s home and this gave students the opportunity to observe their GP in his/her private life and how this interacted with their professional identity. Sometimes these observations as well as conversations with the GP on this topic, prompted students to reflect on their future professional life in a different and more intense way than they had done during hospital based experiences.
P2.2: Now I see much more of the GP’s life style so to speak. And maybe I have just never thought about it so much.
P2.6: You often disconnect it. (…)
P2.2: During my clerkships (in the hospital) I did not really see this and now you do see it and that is another extra dimension that makes you think about what you want.
Variation in role models was very much appreciated. It made students feel they could develop their own style and use those elements they considered worthwhile. Moreover, variation in observations made students aware of how differences in working style affected patient encounters.
P3.3: Because I could observe two doctors, and one is really like, (…) he is really very open you know, there isn’t much distance. And the other is somehow, yes he is, he is more businesslike, more aloof. (…) And then you see, well yes, how I would want to be in the future (…) for you also see how patients respond, and also how you can get the most out of a conversation.
Observation in an instructional context, when a part task, such as a communication technique or knee examination, was demonstrated, was considered powerful when it was embedded in students’ authentic experiences or in questions derived from these experiences. Students learned the most when they could perform the observed task immediately afterwards.
Socio-emotional space
Especially early in the clerkship, observation enabled students to learn more about their supervising GP as a professional and as an individual. Some students said they partly adapted their own working style to that of their supervisor to make a good impression and, they hoped, to promote being accepted as a professional, even though they felt that this did not directly contribute to their own development. Comparing what they observed with their own views and behaviours could lead to both positive and negative identification. Students spoke of a need to have a positive role model. If they could identify with a GP, they sometimes interpreted this as confirmation of their own professional identity, and this provided room for further development. Negative identification could reinforce students’ own ideas about professionalism, but it could also make them feel insecure or uncomfortable if they were unable to do something about situations they considered undesirable.
P3.5: My GP is really someone who says, it is obviously not this, not, not. But patients just hear a jumble of a lot of terms and finally he says what it is. And I think; you see those people looking very anxious at first and then things just go horribly wrong (…) Then I just prefer to do things myself, rather than sitting there.
When GPs made themselves vulnerable, by being very open about their reflections on their feelings during patient encounters, for example, or by admitting to patients that they did not know it all, they set an example for students, who would then feel free to adopt similar behaviour.
P2.6: Then you see how he does it, how at the end of the patient contact he stops to think: Well, what has this done with me, and he tells you about it too. Even if it is quite… well quite deep and… that he makes himself vulnerable. And when he is not afraid to… then I will also not be afraid.