Discussion

Students found attending the clinics and operating theatre a less useful learning experience than they did the classroom-based sessions. One explanation for this may be the lack of exposure to otolaryngology as an undergraduate; with a poor level of baseline knowledge, students may struggle to follow a clinic consultation or the principles of a surgical procedure. Instead, the students found the examination skills session the most useful part of the placement, revising skills that were taught during the second and third years of medical school. Another potential explanation for this finding is that, within the classroom environment, the student is placed at the centre of the learning process, where the tutor's focus is on engaging the students. In contrast, during workplace-based learning, the primary focus is on the patient. Balancing the triadic relationship between clinician, patient and student in order to facilitate learning can be notoriously difficult.

Workplace-based learning is opportunistic and dependent on the clinical cases that present during a day. Therefore, the experience for the learners is inconsistent. In contrast, classroom sessions occur within a controlled learning environment, and consequently the learners’ experience is more reliable. Medical students’ focus is often on passing exams, rather than preparation for practice. Therefore, it may be expected that controlled learning experiences are more popular amongst students, as they usually have a higher educational yield in a given time period.

What the medical student may not recognise is the importance of workplace-based learning in their professional development. With clinical experience comes tactic knowledge; knowledge not easily transferred from one individual to another by means of didactic discourse. This encompasses areas such as non-technical skills, diagnostic reasoning and pattern recognition.^{Reference Heiberg Engel8} Furthermore, experiential learning in the workplace encourages reflective practice. Consider constructivist theorist David Kolb's learning cycle: the student's experience in the clinic or operating theatre provides a ‘concrete experience’ on which they can reflect, identify principles, form opinions and assimilate this into their existing knowledge. They are then ready to utilise this new knowledge in new experiences and the cycle continues. As such, this approach has another advantage in that learners gain applied rather than abstract knowledge.^{Reference Yardley, Teunissen and Dornan9} Additionally, spending time in the clinical environment allows students to appreciate the role of the otolaryngologist and provides an insight into what a career is like within the specialty.

Our teaching programme was organised and taught by an otolaryngology clinical teaching fellow. Clinical teaching fellows are junior doctors who are commonly undergoing a formal teaching qualification. They are relieved of some or all of their clinical commitments, allowing time for curriculum planning and placement organisation. Evidence suggests that students find teaching fellows more approachable, feel that content is pitched at the correct level and often prefer being taught by clinical teaching fellows rather than consultants.^{Reference Woodfield and O'Sullivan10} We noted a decrease in student satisfaction with lectures and placement organisation during the week in which consultants delivered the teaching programme rather than the otolaryngology clinical teaching fellow. Wider availability of clinical teaching fellow posts in otolaryngology could help ensure more consistent high-quality otolaryngology teaching for undergraduates.

The most frequent suggestion of how to improve the programme was to increase the length of the placement. A desire for increased otolaryngology placement time is common amongst medical students and medical graduates.^{Reference Ferguson, Bacila and Swamy2} In addition, the duration of undergraduate placement is often considered insufficient for making an informed career choice with regard to otolaryngology. A study by Doshi and Carrie showed that within a cohort of 30 surgically inclined final year medical students, only 6 felt they had enough undergraduate otolaryngology exposure to consider the specialty as a career.^{Reference Doshi and Carrie11} Furthermore, a study by Powell et al., of 444 foundation year one doctors, showed that only 8.7 per cent of respondents would consider otolaryngology as a career. A significant proportion of respondents felt they had not received adequate experience and information to make an informed career choice regarding otolaryngology.^{Reference Powell, Cooles, Carrie and Paleri12}

One aspect we found challenging was the number of students in our department each week. The number of students per week had increased from the previous year, from six to eight. Although a small increase, this posed a significant barrier toward certain teaching modalities such as bedside teaching. Moreover, with current efforts to increase the number of medical school places available, one may anticipate this becoming an increasing problem.^{Reference Rimmer13} This issue is compounded by the current working climate and the European Working Time Directive; junior doctors’ availability to teach medical students is limited.^{Reference Baker, Spence, Boohan, Dorman, Stevenson and Kirk14}

E-learning may help to provide a solution. E-learning can help alleviate the demands of teaching on staff time, and learners can have control over the content, pace, time and place in which learning occurs. ENT UK has produced a number of e-learning resources for this purpose, including: e-LefENT (an e-learning platform),¹⁵ Student and Foundation Doctors in Otolaryngology (‘SFO UK’) examination videos,^{Reference SFO16} and the recently developed ENT UK medical student and junior doctor handbook.^{Reference SFO17} More widespread use of alternative effective teaching modalities, such as e-learning, should be considered in light of the increasing numbers of medical students in the clinical workplace.