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Background: Recent global increases in medical student numbers and shifts in medical education from teaching hospitals to community settings call for effective strategies to meet the demand for general practice teaching placements. It has been proposed that "multi-level learning" (MLL), in which learning and teaching are shared across different levels of learners, may provide teaching efficiencies and valuable experiences for learners and teachers. Aims: To identify, evaluate and synthesize the evidence related to the types, benefits, challenges, and facilitators of MLL in community-based general practice, and the underlying mechanisms and associated contexts to explain the reported outcomes. Method: A realist synthesis approach guided the systematic review. Results: Fifteen papers were identified, providing primary evaluation data predominantly from interviews with or surveys of key stakeholders. Generally, all levels of learners reported overall satisfaction with their MLL experiences. Medical students appreciated learning from prevocational doctors and registrars due to social and cognitive congruence. Mechanisms and contexts that supported our hypotheses regarding successful MLL outcomes were identified, with "a strong teaching culture" being a major mechanism. Conclusions: The findings can help inform practices considering the implementation or enhancement of MLL initiatives in general practice. Further research should include measuring defined learning outcomes. [ABSTRACT FROM AUTHOR]

Background Despite a major research focus on clinical reasoning over the last several decades, a method of evaluating the clinical reasoning process that is both objective and comprehensive is yet to be developed. The aim of this study was to test whether a dual approach, using two measures of clinical reasoning, the Clinical Reasoning Problem (CRP) and the Script Concordance Test (SCT), provides a valid, reliable and targeted analysis of clinical reasoning characteristics to facilitate the development of diagnostic thinking in medical students. Methods Three groups of participants, general practitioners, and third and fourth (final) year medical students completed 20 on-line clinical scenarios -10 in CRP and 10 in SCT format. Scores for each format were analysed for reliability, correlation between the two formats and differences between subject-groups. Results Cronbach's alpha coefficient ranged from 0.36 for SCT 1 to 0.61 for CRP 2, Statistically significant correlations were found between the mean f-score of the CRP 2 and total SCT 2 score (0.69); and between the mean f-score for all CRPs and all mean SCT scores (0.57 and 0.47 respectively). The pass / fail rates of the SCT and CRP f-score are in keeping with the findings from the correlation analysis (i.e. 31% of students(11/35) passed both, 26% failed both, and 43% (15/35) of students passed one but not the other test), and suggest that the two formats measure overlapping but not identical characteristics. One-way ANOVA showed consistent differences in scores between levels of expertise with these differences being significant or approaching significance for the CRPs. Conclusion SCTs and CRPs are overlapping and complementary measures of clinical reasoning. Whilst SCTs are more efficient to administer, the use of both measures provides a more comprehensive appraisal of clinical skills than either single measure alone, and as such could potentially facilitate the customised teaching of clinical reasoning for individuals. The modest reliability of SCTs and CRPs in this study suggests the need for an increased number of items for testing. Further work is needed to determine the suitability of a combined approach for assessment purposes. [ABSTRACT FROM AUTHOR]

Background: Traditionally, clinical learning for medical students consists of short-term and opportunistic encounters with primarily acute-care patients, supervised by an array of clinician preceptors. In response to educational concerns, some medical schools have developed longitudinal placements rather than short-term rotations. Many of these longitudinal placements are also integrated across the core clinical disciplines, are commonly termed longitudinal integrated clerkships (LICs) and often situated in rural locations. This review aimed to explore, analyse and synthesise evidence relating to the effectiveness of longitudinal placements, for medical students in particular to determine which aspects are most critical to successful outcomes. Method: Extensive search of the literature resulted in 1679 papers and abstracts being considered, with 53 papers ultimately being included for review. The review group coded these 53 papers according to standard BEME review guidelines. Specific information extracted included: data relating to effectiveness, the location of the study, number of students involved, format, length and description of placement, the learning outcomes, research design, the impact level for evaluation and the main evaluation methods and findings. We applied a realist approach to consider what works well for whom and under what circumstances. Findings: The early LICs were all community-based immersion programs, situated in general practice and predominantly in rural settings. More recent LIC innovations were situated in tertiary-level specialist ambulatory care in urban settings. Not all placements were integrated across medical disciplines but were longitudinal in relation to location, patient base and/or supervision. Twenty-four papers focussed on one of four programs from different viewpoints. Most evaluations were student opinion (survey, interview, focus group) and/or student assessment results. Placements varied from one half day per week for six months through to full time immersion for more than 12 months. The predominant mechanism relating to factors influencing effectiveness was continuity of one or more of: patient care, supervision and mentorship, peer group and location. The success of LICs and participation satisfaction depended on the preparation of both students and clinical supervisors, and the level of support each received from their academic institutions. Conclusion: Longitudinal placements, including longitudinal integrated placements, are gaining in popularity as an alternative to traditional block rotations. Although relatively few established LICs currently exist, medical schools may look for ways to incorporate some of the principles of LICs more generally in their clinical education programmes. Further research is required to ascertain the optimum length of time for placements depending on the defined learning outcomes and timing within the programme, which students are most likely to benefit and the effects of context such as location and type of integration. [ABSTRACT FROM AUTHOR]