The Early Professional Contact course was the first early clinical introduction course at the Sahlgrenska Academy. According to evaluations of the EPC Course Questionnaire, both students and facilitators were satisfied with the course. The students found the course interesting and beneficial. They reported increased confidence when meeting patients and were inspired to their future work as doctors. Facilitators experienced a greater workload, less reasonable demands and less support than students. Thus, a discrepancy was observed.
Among students, participation rate was 70% and among facilitators 71%. This was regarded as acceptable for students but somewhat tenuous for facilitators as their total number was only 21.
Student representatives expressed worries about registering student views. Thus, we considered anonymity of the highest priority. Consequently, it was not possible to trace, record or analyse non-responders.
The Early Professional Contact Questionnaire was constructed as a combination of new questions with questions from the translation of the original CEQ and from Lander's new questions as described above. The aim was to create a questionnaire feasible and practical for this new course evaluation. However, deconstructing the original CEQ and Lander's questionnaire invalidates the prior validation of these methods. Discussing each item thoroughly with teachers, facilitators, and researchers at the university ensured face validity of the EPCQ. However, further research should investigate criterion validity of EPCQ by estimating its association with the outcome of similar questionnaires.
We have discussed the relevance of comparing results of items where students and facilitators estimated the same course aspect separately (the five items 3, 5, 6, 19, 23) However, these items concerned aspects of the course of interest to compare since course experiences associated with these central aspects contributed to the overall learning environment. An example of this is facilitator's workload versus student's workload. Yet, there was no relevance in comparing those items that reflected fundamentally different aspects of student and teacher tasks in education (items 14, 17, 18, 21 and 28).
The alpha-level of statistical significance was not adjusted for multiple testing. Thus, p-values between 0.01–0.05 should be interpreted with caution.
Cramer's V-index was used as a measure of effect size for items of class A. For class B variables ordered as categorical variables without equidistance we refrained from constructing a conventional measure of effect size. To avoid subtraction we prefer to present median values for each group (Table 4) without performing further mathematical procedures.
Comments on results
Results from the EPC questionnaire demonstrated that the aims of the course had been met from the students' point of view. Learning goals were to introduce medical students to clinical practice and physician's professional development. A major concern was to provide students with access to clinical experiences and participation in physician's clinical work in a safe and non-judging environment during the theoretical preclinical phase. When starting the EPC course, course leaders were familiar with learning goals and assessment conducted by colleagues in the Consultation skills course in term 5. Due to these circumstances, no summarizing assessment of learning goals in terms of student performance was arranged in the EPC course. However, EPC students' participation was mandatory and was registered by their facilitators. Over the years, a longitudinal learning progression was created as the EPC course was followed by the Consultation Skills course of term five (Figure 1).
The EPC course also increased student motivation for biomedical studies. This result is interesting since objections were raised that early professional contact would distract student attention from biomedical studies. On the contrary, it seems that EPC facilitated an interest in biomedical studies by connecting theory to clinical practice. Positive effects of integrating courses similar to EPC in the curriculum of undergraduate medical studies have been reported previously [3, 6, 12, 20–23]. Our results confirm the value of early clinical introduction as a means of integrating clinical experience in the preclinical basic science phase of a traditional medical curriculum.
Facilitators found the study guide useful but the students did not. One explanation for this may be that the preclinical students, who normally attended lectures and read large textbooks in basic sciences in the EPC course, were now focused on clinical and practical training. Another contributing factor is the lack of assessment, thus affecting student external motivation . Furthermore, it is possible that students were restricted from using the study guide by heavy workloads in parallel biomedical courses, thus lowering their internal motivation.
Consequently, main student expectation of facilitators was to arrange learning events during the EPC days. However, course leaders noticed a remarkably growing interest in the study guide during following courses. The study guide has been revised after discussions with course leaders, facilitators and students.
Facilitators reported that they had stimulated students to contribute with individual experiences, thoughts and competence. These reports corresponded well to the results from students. Associations between students' and clinical facilitators' course experiences were also seen in items concerning student understanding of patient feelings. However, no association was displayed regarding the central aspect of giving feedback to students (item 13). This might indicate that feedback to students is a difficult task requiring practice . Moreover, feedback needs to be related to and supplemented by clear and attainable learning goals. The issue of feedback was often discussed during facilitator meetings and many expressed a need for more training in how to give feedback.
According to Biggs' concept of constructive alignment, the second main component in university education consists of teaching methods. The EPC small group model (four students led by one facilitator) appeared to function well (item 7, 26). According to students' opinion and facilitators' views, sharing experiences of the EPC day by reflection and discussion in small groups was helpful in student learning. However, no statistical associations were found between students' and facilitators' results in these two items.
It was interesting to see that facilitators reported that the workload and demands were high while students found course workloads low. Students still experienced that course goals were met.
The importance of being well prepared, when beginning as a facilitator, is well known . It is important that facilitators are adequately educated, given proper time and that aims, course content and students' own activities and facilitator tasks are well defined and clearly communicated . Overly high ambition among facilitators might widen their perception of main learning goals. Students can also develop a pattern of "consuming" practical learning events. The risk is then apparent that the facilitator might experience a heavy workload. If facilitator workload and demands continue to remain at too high a level, they might find their task overburdening and resign. To avoid this, facilitators should encourage their students to be active and share responsibility for the learning outcome of the EPC days. Students' opinion concerning the study guide might support this. Moreover, in this early phase of medical education, students may feel insecure and bewildered by all the new experiences in clinical practice . This may also result in a tendency to cling to their facilitators. Finding the right balance between challenge and support is a well-known dilemma in student-teacher relationships . Continuous contact between facilitators and course leaders is also important and regular facilitator meetings should be held. However, it must also be mentioned that in this study, facilitators found the course interesting and fruitful and reported EPC as having inspired them to continue their assignment.
There was a significant difference between students' and facilitators' experiences of support. The majority of students felt their EPC facilitator supported them. The facilitators, however, felt much less support from their heads of the clinics. This is a serious problem when accepting the role of facilitator and has been previously noted . It was also discussed during the regularly held facilitator meetings. Some facilitators reported problems with heads not supporting or accepting their task as facilitators. This problem could be illuminated by returning to Biggs' constructive alignment, in which institutional climate, rules and procedures represent the fifth main component in university education. It is vital that faculty working as clinical facilitators have acceptance and support for their task from their heads and colleagues. This is necessary in order to enable the doctor to engage in educating future physicians. Therefore, our result that the support from facilitators' heads of clinics was low should be taken very seriously. In many instances in health care today, short-term perspectives on economic effectiveness appear to have taken the upper hand. Thus, the individual facilitator is left to handle a conflict between "health care production" and the reproduction of professional knowledge and skills to future colleagues; medical students' need of an education in the clinical context. The central question of student access to clinical learning experiences and facilitators appears to have been neglected on a system level, at least in the Swedish context. Helping medical students to learn in practice should be recognized and included as an important long-term task for the health care system. Providing a positive learning environment for medical students demands much more attention in negotiations between the academy, the medical profession, and health authorities.
By studying the experiences of doctors as clinical facilitators we approach how doctors combine clinical work with their task as facilitators. Knowledge of the physician's perspective as a facilitator might provide the means to increase the positive experience of being a facilitator, thus assisting recruitment. The literature in this research area is growing and expanding [29–31]. Facilitator working conditions are likely to affect student learning. In this EPC course, the assignment as facilitator was voluntary, which likely resulted in motivated and interested facilitators. On the other hand, recruiting facilitators on a voluntary basis can be very time consuming and unpredictable. At many medical schools, the task of facilitator is compulsory and included in a physician's duties. Such a model might provide more stability but also addresses the need for further research on how to combine patients and students in daily medical work.