Clinical externships within undergraduate studies in veterinary medicine.

The purpose of this study was to evaluate the benefits of checklists for clinical practical courses. Clinical externships are a component of the practical part of the veterinary medicine curriculum. The control is under the responsibility of the training centres. Guidelines and checklists for extramural clinical courses were developed in order to facilitate control mechanisms. The analysis of such checklists should give an overview over the actual situation to enable the setting of minimum standards for extramural courses. The guidelines list practical activities carried out by the students in the veterinary practices or clinics. Data of 360 checklists were assessed in this study to evaluate whether checklists constitute a useful tool to control extramural studies.The results show that checklists are useful to enhance the knowledge of the training centre about the training of students to be adapted. However, the advantage is not completely clear to students. The communication of the importance of the extramural training sessions has to be enhanced.

Introduction

The teaching of practical skills is an important aspect of veterinary education and is fixed as a learning target in the Veterinary Licensure Act (TAppV) [1]. Veterinary undergraduate studies in Germany are regulated through the TAppV. It lays out the individual subjects and to some extent, their implementation [1], [2]. Following 11 semesters, the regular duration, graduates should leave university as scientifically and clinically educated vets in order to perform veterinary work. Graduates have a range of career options [3], [4]. This includes work as a practicing vet, in food safety, in public veterinary services, the industry or in research and teaching. Developing practical skills is one of the elementary prerequisites that prepare students for this multitude of career options. Work experience is particularly important as they play an important role in connecting acquired knowledge and practical skills [5]. For this reason, a practical year was integrated into undergraduate studies at the University Foundation for Veterinary Medicine Hanover (TiHo) from the winter semester 2004/05 onwards [6], [2]. The practical year takes place during the 5th year of studies and includes clinical training at a clinic or studies at a para-clinical institution of TiHo [7]. It enables the students to integrate much more deeply into the clinical and scientific routine, allowing them to gain hands-on experience before their studies end [8]. The so called orientation phase exists to ease the transition between the tightly organised studies and the career development after graduation [7].

According to the TAppV, veterinary training contains a scientific-theoretical component of 4½ years with 3850 hours of compulsory lectures and electives and a practical component of 1170 hours [1]. As part of undergraduate studies the practical component contains internal work experience at university institutions and extramural work experience. Extramural work experience are part of the teaching that takes places outside the university [7]. Placements on extramural work experience are organised by the students themselves [8]. Control of work experience lies with the educational institutions. The European Association of Establishments for Veterinary Education (EAEVE), a European body whose role is support and development of veterinary education in all its aspects in Europe and which carries out the evaluation of European veterinary educational institutions, requires the veterinary universities to prescribe and control the conditions for extramural job training [9]. Regulating extramural work placements however is proving to be difficult. In contrast to intramural work experience at university controlled clinics of TiHo which have a compulsory catalogue of clinical training on various wards, educational institutions are only able to make suggestions for the design of extramural work placements. The total number of hours and areas of activity are clearly defined. Clinical training involves 850 hours at a private veterinary clinic or surgery or a veterinary educational institution. These are subdivided into a small work placement of 150 hours over 4 weeks and a large work placement of 700 hours over 16 weeks or two times 8 weeks. The small placement is planned for the period following the 5th semester up until the 8th semester. The large placement is completed between the 9th and 10th semester. These take place outside term-time or in rotation during the practical year [7]. To gain an insight into the activities of students during the external rotation, TiHo has developed a manual for clinical work placements which detail the activities of students on external veterinary surgeries or animal hospitals. The manual documents the order and content of the placements and provide guidance for on-site placement supervisors and the students in designing placements [6]. Additionally, the form lists the minimum requirements to ensure that students benefit from the work placements [8]. Progress can be commented upon both by the trainee and the supervisor [6]. This feedback ensures the learning process and progress of students is traceable and shows strengths and weaknesses of the various private educational institutions and clinics. These checklists give the university a comprehensive picture of the extent of the practical activities and has the opportunity to evaluate the quality of training and establish minimum standards.

An analysis of the value and effect of a work-related log at the Department of Internal Medicine at the University Hospital Heidelberg showed that students felt more integrated into the daily routines and achieved higher satisfaction levels [10]. Also, the log books allow students to actively request learning content [10]. The logs used in human medicine or so-called portfolios are broadly comparable with the mentioned checklists for extramural work placements at TiHo. These forms are used to ensure standardised and structured training [10]. This study’s evaluation of the questionnaires will consider if the introduction of checklists would be a sensible addition to undergraduate studies in veterinary medicine.

Materials and Methods

As part of the statistical analysis, the data of two year groups for the period 2005/06 was taken, with a total of 360 clinical work placement checklists. These checklists can be accessed online via a portal accessible to students of all year groups. The collected data was evaluated using the spreadsheet application Microsoft® Office Excel 2003. The graphic display of the data material is in the form of bar and pie charts. Establishing the effectiveness and the value of the checklists is a key aim of the evaluation. Using the data analysis, a comparison between the activities in extramural work placements and the teaching content at TiHo should become possible.

Manuals for Clinical Work Placements

The checklists on activities carried out on clinical placements are filled in by the students and signed by the responsible vets. The checklist is clearly structured and contains three sections. The first section contains general information about the trainee, stating name, matriculation number and address. It also gives the name of the responsible supervisor and their medical practice or animal hospital and the length of the work placement. The type of practice (small animals, livestock etc) is to be filled in. The second section documents the activities carried out and in the last section the trainee and the supervising vet have the opportunity to comment on the work placement. Special attention will be paid to the following points in the evaluation:

Type of veterinary practice/animal clinic

Animal species presented

Patients examined by the students (passive, active)

Practical activities carried out

Participation in emergency services

Evaluation of the learning success by the students

Filling in the questionnaires was made compulsory to ensure a high response rate.

Results

In the following, the results will be presented in order of the checklist subject areas questioned. The basis of the study is the questioning of students of veterinary students in relation to their activities during an extramural work placement. In about 15% of the checklists evaluation was not possible due to incorrectly filled in forms. In such cases, forms were not filled in or unlikely activities stated or the number of activities or examined patients was exaggerated.

Distribution according to Type of Practice

The students can choose a type of practice for their extramural placement. The evaluation showed that the largest number of students, 39.4%, did their placement in a small animals practice, followed closely by mixed practices at 35.3%. Horse practices are at 12.2% and with 7.2%, livestock practices is only represent a small part of the total. Other placements, 5.8%, selected by students were in zoos or labs (see Figure 1 (Fig. 1)).

Figure 1

Types of practice chosen by the students for their work placements

The distribution between the different types of practice is shown according to gender in Figure 2 (Fig. 2). To ensure comparability between male and female students, the respective datasets were evaluated separately as with 89% of the total number of students, female students outnumber male students in this study. This is roughly equivalent to the distribution of students in veterinary education in general. The percentages thus relate to the specific gender groups, not the total number of students.

Figure 2

Types of practices chosen by students according to gender

Spectrum of Animals Presented

In the animal practices and clinics where students took their placements, various animal species were examined and treated. Small animals topped the list of presented animals with 23.7%, followed by pets with 19.5% and horses with 15.9%. In fourth place, with 13.8%, are birds and in fifth place cattle with 11.9%. Small cloven-hooved animals (7.7%) and pigs (7.4%) form the smallest group of animals presented (see Figure 3 (Fig. 3)).

Figure 3

Range of animals amongst patients presented

Specialist Fields of Illnesses

The illnesses examined by students can be grouped into different specialist fields. According to the trainees, a high number of gastro-intestinal cases (12.6 cases per week) is noticeable. In second place are other illnesses, with 8.8 cases per week, followed by orthopaedic patients with 5 cases per week and gynaecological cases which on average presented 4.7 times per week (see Figure 4 (Fig. 4)).

Figure 4

Medical domains of the illnesses presented

Activities Carried Out

Depending on the type of the practice, different types of activities were emphasises for the students. However, the types of activities carried out only varied numerically depending on the type of practice or animal.

An overview of all activities carries out shows which treatments can most frequently be taken on by students. Students are particularly frequently allowed to carry out injections. In first place are subcutaneous injections with 10.3 per week, closely followed by 9.5 weekly intra-muscular injections. At 7.0 there are imaging activities, taking blood was done 5.5 times per week on average. Students on average injected intravenously 5.2 times per week and carried out rectal palpitation 4.6 times per week. Lab activities and evaluation of blood tests were carried out approximately 3 times per week. Assisting in surgery and monitoring anaesthesia occurs twice weekly for most students. Activities such as evaluating urine tests, intubation, paracentesis, endoscopy, taking urine samples, birth-related examinations, obstetrics and placing tubes were carried out less than once a week. Other activities were listed as being carried out 5.1 times per week (see Figure 5 (Fig. 5)).

Figure 5

Distribution of activities carried out per week on average

Comments on the Number of Practical Activities Carried Out

The checklist on the external placements envisages an evaluation of students in relation to experience gained. The evaluation of the comments made by the trainees shows that sufficient experience was gained and that with 92.5%, the students judgement is very positive. In contrast, only 7.5% gave a negative evaluation (see Figure 6 (Fig. 6)).

Figure 6

Comments on the number of practical tasks carried out

Satisfaction with Guidance in Practical Activities

The positive evaluation of the students towards their placements is also reflected in their comments about guidance. The majority, 95.8%, judge the guidance on practical activities to have been good. In contrast, 4.2% of students were not satisfied.

Working Hours

Evaluation of the daily working hours of the students showed an average of 8.9 hours per day.

Participation in Emergency Services

Questions on participation in emergency services showed that 46.8% of students were involved in emergency services whereas 53.2% were excluded (see Figure 7 (Fig. 7)).

Figure 7

Participation in emergency work

Rating the Placement

The vast majority of students rated their placement as “good” (97.2%) and only a very small percentage (2.8%) rated it as “not satisfactory”.

Discussion

The goal of this study is the determine the effectiveness and value of checklists for extramural placements. The results show that using these forms, an enormous amount of information can be gained for the university about the activities of the students during their extramural rotation. As part of the evaluation, the educational centre gains an insight into how students experience their extramural placement and which teaching content is offered to them.

The students resonance about the placements they took was consistently positive and demonstrates the important role the extramural placements place in relation to the entire degree course in veterinary medicine. The experiences made and the practical skills learned represent an indispensable knowledge gain for each individual and are an important step in personal development and the route to independent activity. These characteristics in particular are of relevance in the highly and well structured degree course that is veterinary medicine. Work placements are often crucial in deciding on individual career paths and an important help in deciding on future areas of work for the students.

The graphics show that students most frequently choose small animal practice as a location. The percentage of livestock lies far behind small animals. This is supported by the statement regarding the range of animal species presented or examined by the students, where small animals and pets together represent more than 43% of the total. The trend towards small animal practice has been discernible for a few zears and since 2003 small animal practice is the most common form of practice in Germany [3]. In contrast the share of large animal and mixed animal practices is stagnating or shrinking [3]. The change in the spectrum of animal species presented has developed over the last 200 years. At the start of the 19th century horses formed the vast majority of patients at over 90% whereas recently, a reversal towards small animals has been visible [11]. When observing the growth of small animal practices, it should also be noted that the number of small animals and pets is also continually growing [3]. This picture fits with some people recently warning about changes in veterinary medicine in favour of small animals and against livestock the and who attribute this to the increase of the percentage of female students overall in veterinary courses. The increase of female students and the decrease of male students is conformed by a study which has investigate the new generation of veterinary students in Germany between 1991 and 2001 [3], [11]. However, Figure 2 (Fig. 2) shows that a similarly high percentage of male and female students choose small animal practices for their work placements. Reasons other than the gender imbalance must be looked at to explain the reasons for avoiding livestock practice. Aspects that should be debated are income opportunities, distance to work and workplace features. However, there is a notable tendency for male students to prefer alternative placement locations compared to female students.

No single reason for the changes in the gender balance amongst veterinary students can be determined and the situation is judged variously. There are theories suggest animals as patients in particular have made this career so attractive for women who bring certain emotional dispositions to the job [11].

Other studies also show that in addition to technical knowledge, an increasing amount of interpersonal skills such as compassion, care and understanding are asked for in veterinary medicine [4]. Other parties speculate that the reduction of male veterinary students is down to a loss of attractiveness of this career option [3]. Long-term studies have yet to show if the type of practice for future work coincides with the rotation at the place of education during the practical year or the extramural work placement.

The average practical activities of students, about 9 hours per day, is still below the average net working time of 9 hours 45 minutes determined by Friedrich [3]] for practice assistants and shows that even while in training, demands on students are similar to those of their future workplace.

This study shows how frequently patients with various illnesses of the organ system are presented and which practical activities can be learned in extramural placements. To deal with this issue and to prepare future vets for their working life in the best possible way, discussions between educational institutions and professionals can be conducted accordingly. The new TAppV offers educational institutions more freedom in designing the curriculum and enables the creation of new approaches to future design of undergraduate studies in veterinary medicine [12]. Information about the learning content of the extramural placements can be built into the future designs of the curricula.

A study conducted by Kraus et al [10] amongst students of human medicine showed that in some cases required clinical activities were deliberately or accidentally not carried our although they were documented in the forms. In addition, the way in which these are filled in leaves both the placement supervisors and the students with the impression that carrying out the activities and the feedback might not be taken that seriously and that documenting work only constitutes an annoying duty. For this reason, 15% of the checklists in this study could not be evaluated. Although checklists for some students have a negative controlling character, they permit better integration into the daily routing and an increasing number of clinical activities that can be carried out independently. For the successful use of checklists it is vital that their importance is communicated to allow students to see this type of documentation as an opportunity to actively request certain training contents [10].

In summary it can be stated that the use of checklists for extramural placements can be sensible and useful but that their potential in reality is often not fully realised. One positive aspect is that the evaluation allows an overview over the current situation and that using the results further research into training can be carried out. A disadvantage that should me mentioned is the additional time requirement caused by the need to fill in the forms for students and in particular placement supervisors. As many people questioned see recording activities as a time-consuming duty, in future designs of the checklist care should be taken to simplify the way in which they are filled in, in particular for recording individual activities carried out. As no severe individual consequences were drawn from these results to date, some users do not see the use of the questionnaires. This is a factor which quickly leads to frustration and sloppiness in filling out the forms. For this reason it is all the more important to continuously optimise the checklists to ensure enduring and sensible use.

Acknowledgement

Mrs Börchers and Mr Teke have equally contributed in the making of this study.

Competing interests

The authors declare that they have no competing interests.