A systematic review of the relationship between patient mix and learning in work-based clinical settings. A BEME systematic review: BEME Guide No. 24
In this BEME systemic review, the empirical evidence about the contribution of patient mix in work-based learning is addressed. A literature search was conducted across Medline, Embase, Web of Science, ERIC and the Cochrane Library. We included original, quantitative studies. After screening of 10,420 citations, 298 full-text articles were retrieved of which 22 were identified as relevant. Two reviewers assessed and extracted the data using a coding sheet and assessed the methodological quality of the studies. In the included studies encountered, patient mix is mostly presented without definition. Operationalizations of patient mix were fairly different, allowing very few inferences from the studies. Learning outcomes were divided into self-reported and formal assessment.
We found a positive relationship between patient mix and self-reported outcomes evaluating the progress in competence as experienced by the trainee, such as self-confidence and comfort level. Patient mix was also found to correlate positively with self-reported outcomes evaluating the quality of the learning period, such as self-reported learning benefit, experienced effectiveness of the rotation, or the instructional quality.
A relationship between patient mix and formal assessment was not clearly demonstrated, so increasing experience does not automatically lead to more competence. In addition, most formal assessments were not study specific and therefore probably not sensitive enough to ascertain how patient mix can affect learning outcome. We formulated six possible explanations that could explain why we found so little evidence for the relationship.
A secondary aim of this review was to address the influence of additional variables on the relationship between patient mix and learning. We found that especially supervision, but also learning style seemed to mediate this relationship.
At the end of the review a directions for future research are suggested. This systematic review emphasizes the problem with the description of ‘patient mix’ and a model for this description is therefore suggested. An inquiry into the detailed aspects of patient mix, and the contribution of these aspects to learning in a qualitative study is desirable.
Jip de Jong (lead reviewer), MD, GP, Department of General Practice/Family Medicine, AMC-University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
Mechteld Visser, MSc, PhD, Senior Researcher, Department of General Practice/Family Medicine, AMC-University of Amsterdam, Amsterdam, The Netherlands
Nynke van Dijk, MD, PhD, Senior Researcher, Department of General Practice/Family Medicine, AMC-University of Amsterdam, Amsterdam, The Netherlands
Cees van der Vleuten, MA, PhD, Professor of Medical Education, Department of Educational Development and Research, Faculty of Medicine, Maastricht University, Maastricht, The Netherlands
Margreet Wieringa-de Waard, MD, PhD, Professor of General Practice, Department of General Practice/Family Medicine, AMC-University of Amsterdam, Amsterdam, The Netherlands