On the job learning: the intern experience

Doctors in the first year of practice, (referred to as interns in Australia), identify the experience of caring for their patients and participating in the medical workplace as the most significant precipitator of learning. Curriculum frameworks provide detail about what is to be learned but do not define how the learning should take place. This study focuses on the ‘how and the why’ of intern learning on-the-job through phenomenographical research. Phenomenography allows us to hear the participants’ perspective on their learning experience and, through exploring variation in their experiences, come to better understand the nature of the phenomenon. Thirty-one interns were interviewed at three stages: pre internship, after their first rotation was completed and towards the end of the intern year, totalling 85 interviews (not all interns were available for all three interviews). Phenomenographic analysis indicated four qualitatively different approaches to intern learning on-the-job; Variation A Learning through the intern environment Variation B Learning through providing bedside patient care Variation C Learning through participation in collaborative patient care Variation D Learning through review and reflection on patient outcomes The study found that variations in the approaches to learning on-the-job taken by the intern were influenced by the context presented by each rotation. Each rotation provided a unique learning environment with its own set of relationships and working conditions. Four key elements that influenced the learning experience and promoted effective on-the-job learning were: the opportunities for bedside care; involvement in medical decision-making; the experience of responsibility for patient care; and the ability of the intern to reflect on their own performance, thereby assimilating the experience into their learning. The degree to which these elements were present in a particular rotation influenced the approach of the intern to on-the-job learning. The immediate supervisor or registrar provided critical assistance in negotiating these contextual elements, in particular maximising intern learning through collegial discussions about patient care. The intern-registrar discussions or ‘collegial moments’ are qualitatively different to ‘teaching moments’. The teaching moment focuses on the transference of knowledge and the training of the individual; in contrast, the collegial moment focuses on learning through collaborative decision-making whilst providing patient care.