Making the Most of Students’ “Down Time” in the Clinical Learning Environment

Pediatricians who teach medical students often cite the opportunity to demonstrate and share skills and knowledge with students as their motivation for precepting.1–4 The most significant barrier reported by non-preceptors in their decision not to teach students was lack of time.1–3 We suggest that teaching does not need to be solely the responsibility of the identified preceptor and that students can be encouraged to engage in self-directed learning in the clinical setting.5This article continues the Council on Medical Student Education in Pediatrics series about ways to enhance student learning in a clinical setting. We focus on how to assist a student in maximizing their learning by utilizing the unpredictable and often brief amounts of time that are available to them throughout a clinical day.Given their role as a learner, medical students do not have the same competing demands as preceptors. While students participate in patient care, they are not responsible for it; their primary role is to learn from the patients they see, under the guidance of their preceptors.Consider the following scenario: You arrive early at your community pediatrics office, a typical day. There is a full day of patients booked, and you already see that several emergency time slots have been added. You have Jaime, a third-year medical student joining you for their pediatrics rotation—this is their third day with you. The student seems to be capable of gathering core elements of the pediatric history, and you have had them start seeing select patients while you are finishing up with others. While you appreciate that they seem interested in learning, you find that they often appear bored when waiting for you, usually scrolling on their phone. You wonder how you can help them make the most of learning during their down time, when you are busy with additional clinical obligations.One often cited strategy to manage preceptor time pressure is to concurrently assign students independent patient-related tasks congruent with their level of skills and training while the preceptor is busy with other tasks. It may be unpredictable, however, as to how long a student will require to complete their assigned task; further, a well-intentioned preceptor may tell a student “I’ll be ready to review with you in 10 minutes,” but their own patient care work or other interruptions may result in delays. This leads to students having down time of unknown duration. While they may have earnest motivations to study while waiting, the unpredictability of how long they will have may deter students from accessing learning resources that require focus and attention, only to be interrupted when their preceptor arrives. One possible solution is to acknowledge the likelihood of down time and identify and recommend high-yield learning resources that can be used to consolidate the student’s in-the-moment learning regardless of whether the student has 1 or 10 minutes or longer. It is important for preceptors and students to recognize that multiple short study moments can add up to a significant amount of learning over the day.6When time available for self-directed learning is unpredictable, students need resources that provide the opportunity for high-yield learning in a short period of time. Essential characteristics of useful resources are that they are easy to access, free, require minimal time, and are relevant to the clinical setting to help anchor the students’ learning in the patients they are seeing; students can then apply the new information to other patients.Some resources may focus on key information on a specific topic or outline an approach to a clinical problem, and others, such as case-based self-assessment items, may focus on clinical reasoning and provide an opportunity to self-test and identify knowledge gaps. While many high-quality clinical learning resources exist, such as articles, podcasts, and web-based resources, many require a longer time commitment for learning and may provide details beyond what is essential for the medical student’s current need.Recognizing that in-the-moment learning is critical, we sought to identify specific high-yield learning resources for students that aligned with clinical learning.A survey of resources used by students at one institution suggests students find and access many asynchronous resources to varying degrees.7 We built upon these findings by seeking additional resources, looking to pediatric medical educators and pediatric medical education organizations, as well as searching for easily accessible online resources. A total 33 resources were reviewed for suitability based on our criteria of brevity, ability to derive benefit with unpredictable amounts of time, and being free and clinically based. Additional features that are desirable include self-assessment, feedback, and links to further references. A range of resource types are suggested to assist students at different stages and with different types of learning. From the reviewed resources, 6 met suitability for in-the-moment learning. Table 1 compares features of these suggested resources.PedsCases Notes8 offer succinct overviews of clinical topics or diagnoses in a visual infographic format that provides students with the background to approach a topic and build their knowledge. This is particularly useful when students only have a few moments to learn or review a topic or diagnosis. TeachMe Paediatrics9 also offers background information, but in a more in-depth format, and may be suitable when more time is available.Building upon this background knowledge, PaedsPortal10 and PedScripts11 present algorithms to approach clinical presentations and diagnoses. PaedsPortal also has links to articles, podcasts, and videos. The American Academy of Pediatrics Bright Futures Pocket Guide12 is a good overview for each age, from newborn to late adolescence, offering suggestions for history questions, physical exam tips, and anticipatory guidance.When students are ready to apply their knowledge, Cards13 is a formative learning resource based on clinical presentations and allows students to self-test and develop their clinical decision-making skills. Short clinical vignettes have questions about diagnosis, investigations, or management. Feedback, explanations, and additional resources are provided following the student’s response.We recommend the following process to engage students in making the most of their down time for their learning: (1) orient the student to the problem and a possible solution, (2) check in throughout the day, and (3) end with reflection and a learning plan.This may take place at the beginning of a student’s rotation with a preceptor or a reminder at the beginning of the clinical day. By acknowledging the problem of discrepancies between the time pressures of the preceptor and the student, the preceptor can focus on the solution as being an opportunity to use these moments in time to engage in high-yield, clinically focused learning. Provide the student with a list of resources, such as those listed in Table 1. Remind students that multiple short periods of time spent on this type of learning can add up over the course of the day.6 For example, “There will be moments of downtime throughout the day when I’ll be busy, and you can fill the time with resources to extend your learning. We’ll see a child this afternoon in follow-up for constipation. PedsCases Notes has a very helpful infographic that outlines the pathophysiology and management of this. When you have a few minutes, could you review it?”Give the learner the opportunity to ask questions throughout the day and focus your teaching and “clinical pearls” on reinforcing what they have learned and on filling gaps they have identified. Provide recommendations of topics based on the patients and cases encountered. For example, “Interestingly, we have just seen 2 patients, one who has asthma and one who has pneumonia. During your down time today, why don’t you use Cards and focus on respiratory distress to consolidate the differences between various conditions that present with respiratory distress in the pediatric population. Let’s talk about what you learned at the end of the day.”Ask the learner to tell you the 3 most important things they learned that day. These might be things learned from patients, from your discussions, or from resources. Have the learner identify 1 thing they want to learn about in greater depth, and make a plan to review it the next day. For example, “What is a learning goal you’d like to work on before clinic tomorrow?” or “We saw several patients of different ages today. Can you review the Bright Futures Pocket Guide guidance for well care visits with 15-month-old and early adolescent patients before clinic tomorrow?” Adding an opportunity to summarize the learning for the day and preview the next day may help the learner stay focused on the larger perspective of clinical care.Having a collection of recommended resources to help address different learning needs allows students to tailor learning to what may be needed in the moment based on the patients they are seeing. Providing students with guidance on how to use their “down time” can facilitate self-directed learning and foster a personal growth mindset, both essential to the practice of medicine and life-long learning.