Developing and pilot testing competence cards in clinical rotations: medical students’ and supervisors’ perception

Developing and pilot testing competence cards in clinical rotations: medical students’ and supervisors’ perception | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Developing and pilot testing competence cards in clinical rotations: medical students’ and supervisors’ perception Doris Østergaard, Kristine Sarauw Lundsgaard, Astrid Elisabeth Bruun Boilesen, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4436923/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract BACKGROUND Several studies have shown that the medical students express uncertainty and a lack of preparedness in relation to being able to function as a doctor. The purpose of this project was to develop a portfolio with competence cards covering some of the seven medical roles, to introduce these in six departments and to evaluate the medical students´ and the clinical supervisors´ perception of this intervention. METHODS By using Kern’s six step a portfolio consisting of four competence cards was developed to be used in medical students 5-week clinical stay in the fourth year of their studies. Each competence card was intended to be used three times by peer-to-peer, by supervisor and by coordinators, respectively. At the end of the students´ clinical rotation interviews were conducted with students and supervisors. The project included three cohorts of medical students. An electronical version of the portfolio was available for the second and third cohort. RESULTS A total of 60 medical students used the competence cards. The students described easier access to supervision and systematic feedback. They appreciated the structure making the learning objectives clear. Both students and supervisors found the competence cards to reflect recognizable clinical situations and preferred the portfolio compared to the normal ‘logbook’. The electronic solution was easily accessible and was preferred. CONCLUSIONS Competence cards reflecting recognizable clinical situations are a functioning tool for supervision and feedback. The electronic portfolio is appreciated by students and supervision allows training in all sevens doctors roles. Clerkships Medical students Education Workplace based learning Evaluation of competence Figures Figure 1 INTRODUCTION The transition from the academic world at university, with a primary focus on the medical expert role (knowledge and skills), to work-based learning is complex and is in the literature described as difficult ( 1 ). Students often just memorize the curriculum and thereby only scratch the surface instead of reaching in depth learning ( 2 ). Several studies have shown that students express uncertainty and a lack of preparedness for the transition into doctor( 3 – 6 ). Despite profound theoretical knowledge the students do not feel prepared for the clinical tasks at hand. They find it difficult to apply their knowledge to a clinical context due to problems being less well-defined and situated in new situations( 7 , 8 ). The transition is easier, if students are introduced to topics including communication, teamwork, critical thinking, intellectual curiosity, emotional intelligence, resilience, and organizational skills( 9 ). Other studies have focused on patient safety, as one of the major problems is medication management, knowledge of e.g. incident reporting, being able to manage distractions and interruptions as well as difficulties in talking about mistakes( 10 – 12 ). Chen et al encourages analysing which tasks the candidates must be able to do and to develop a portfolio mindset already in medical school ( 13 ). This is supported by an article by Walton et al, which describes the implications of a postgraduate competence-based medical education for the undergraduate education( 14 ). Introducing a portfolio mindset from pre-graduate level will make the transition easier, as strengthened supervision and a greater focus on formative assessment supports student in making decisions about their learning( 15 ). Aarhus University, Denmark has recently introduced assessment of competence in clinical stays in all semesters and is gathering experience with this ( 16 ). The portfolio mindset might also help the students in forming their professional identities as doctors, forming the professional identity is important for becoming a doctor, as several newer studies, among them many Danish, have shed a light on ( 17 – 21 ). A structured training will lead to an assessment of competence, which means that the student can easily follow their own development and confidence in accomplished skills, and the supervisor becomes aware of where learning needs to be strengthened and the quality of patient treatment is thereby improved. The Canadian “seven roles of the doctor” has been adapted to Danish context in specialist training of doctors( 22 , 23 ). In addition, competence-based education was introduced. The clinical supervisors are often involved in both pre- and post-graduate education and will be able to facilitate the introduction of suitable tools for learning and competency assessment at the pre-graduate level. Formative assessment of competence is followed by feedback, which is essential for the student to develop, a recent Danish article describes this( 24 ). All in all, we speculate if the clinical rotations can be used to strengthen the medical students´ development of several of the seven doctor roles and if formative assessment of competence will help the students to develop a familiarity with patient-centred treatment ( 25 ). Aim The purpose of this project is 1) to develop a portfolio utilizing Kern’s 6-step approach encompassing competence cards covering some of the seven roles of the doctor for use in clinical rotations at medical and surgical departments in the fourth year of their studies, 2) to introduce these cards in six departments and 3) to evaluate the medical students´ and the clinical educators´ perception of this intervention. We expect this to strengthen learning during the clinical stay through a structured introduction of what is expected. We also expect the use of competence cards during the clinical stay will be of benefit to both the student and the supervisors, as progression can be followed. METHODS The study is an explorative study( 26 ). Context Faculty of Health and Medical Science, University of Copenhagen, Denmark. The medical school curriculum is six years, with clinical rotations starting from year four (Fig. 1). Figure one, titel: Distribuation of clerkships Figure 1: Showing the three years with clerkships, which subjects that are focused on and specialties. Red circle marks the clerkship for this project. The Heads of Departments of three gastro medical and three gastro surgical situated at three different hospitals agreed to be part of the project. At each of the six departments a consultant was appointed as the local project coordinator. During a semester, each department receives three cohorts of medical students. The students have a logbook describing the focus for their stay as well as the practical procedures they need to train and be assessed in. This is the students second semester with clinical rotations, prior to this they have had a five-week rotation in either a medical or surgical department. Overall, the semester consists of internal medicine (five weeks)-, surgery (five weeks)- and anaesthesia (two weeks) (Fig. 1). A total of 78 students were planned for the semester in spring 2023. We followed them in either a medical or surgical rotation. The project was funded and approved by the Copenhagen University. Ethical approval was not needed as the project did not involve treatment of patients. Development The development was guided by Kern´s six step approach( 27 ). 1. Problem identification and general needs assessment A general needs assessment was conducted based on the curriculum for the semester and the literature ( 28 , 29 ). 2. Targeted needs assessment A workshop was conducted with the coordinators from the departments in December 2022. 3. Goals and objectives Based on this, we selected the learning objectives that we intended to include and evaluate at the gastro units after workshop in December 2022. 4. Educational strategies The portfolio and competence cards were drafted and tested for understanding in January 2023. We decided how to organise the assessments during the students’ stay, and who should assess and provide feedback to the individual student. We decided to use the same headings in the competence cards and the same assessment strategy as at Aarhus University, Denmark. The first assessment was to be conducted by a peer within the first week(s), the second in the middle of the rotation and the third in the last week both were planned to be conducted by a doctor. The departments chose different strategies for being responsible for the assessments. In two departments, each medical student was coupled with a junior doctor, who should perform the competence evaluations. In the remaining departments, it was a more flexible arrangement, and all doctors could do it. The six local project coordinators expressed that the staff were familiar with evaluation of trainees’ competence, and they did not see the need for training in evaluating medical students. 5. Implementation The competence cards were implemented in Spring 2023. One week before their rotations, the medical students were informed by mail about the project and received the portfolio. The local project coordinator introduced it again in the department. All three cohorts received a paper version of the portfolio, in the 2nd and 3rd cohort an electronic version was available. All doctors in the departments received information about the project, both written and verbal. The project was introduced by TB or DO in all departments. The project coordinators followed the implementation and were available to solve challenges and make sure that the portfolio was used as intended. We used a modified version of Laerdals Sim Capture™ developed for nursing students. SimCapture is, among other things, a rating tool. SimCapture is a closed system. When the electronic version was introduced, we provided a help link to an administrator, who could solve technical problems. 6. Evaluation The actual number of evaluations were calculated, and the content of the evaluation (pass/fail elements) was analysed. Group interviews of the medical students and doctors, respectively, were conducted by TB and DO at the end of their five-week rotation. The interview aimed to uncover their overall perception and experiences with the portfolio, thereby improving both content and organisation of the competence cards. In addition, we wanted their perspective on conducting evaluation of competence and providing feedback. Written notes were thematised according to Braun and Clarke( 30 ). A short questionnaire was sent to the project coordinators and supervisors, who had been involved in the formative assessment of the medical students. It contained seven questions and room for free text. In addition, we collected information from the project coordinators at meetings both during and at the end of the semester. RESULTS The portfolio and the competence cards The portfolio contained four competence cards. Each card covered 11 or 13 items (learning objectives) to be evaluated. The evaluators were asked to provide feedback using the free text areas. The four competence cards covered the following areas: 1. Taking the patient history and writing the primary record, 2. Ward round, 3. Pharmacology (internal medicine rotation), and 4. Operation/endoscopy (surgical rotation) Competence cards 1 and 2 were used in both medical and surgical rotations. The formative evaluation was planned to be structured observations followed by feedback (card 1–3) and case-based discussion (card 4). Appendix 1 shows the portfolio with the competence cards. After the first cohort had used the competence cards, a few minor changes were made. The medical students A total of 60 medical students were assessed using the competence cards. Table 1 shows the distribution of students according to departments as well as the number of assessments conducted by peers, supervisors, and coordinators. None of the students were assessed three times in all four competence cards. The total number of peer-to-peer evaluations was 90, the highest for the well-known tasks such as taking the patient history and ward round, and lowest for the new areas such as pharmacology and the operation/endoscopy (Table 1). The evaluation in the middle and the end of their clinical stay was conducted by either a junior or senior doctor. At the final evaluation the supervisor was asked to provide a pass/fail decision. A total of 88 final evaluations were conducted. Most of the students passed all items on the competence cards. Only a few items were impossible to rate because of the patient case chosen. Table 2 shows the number of final evaluations of competence conducted and the number of items on the card that the student passed. The medical students´ perception A total of 44 medical students participated in the interviews at the end of their stay. The duration of the interviews were 30–45 min and notes were taken by the leaders of the project (TB, DO). It provided valuable information about the students’ perception of the introduction of competence cards in their clinical rotation. Table 3 shows examples of themes based on citations. Their overall perception was that the competence cards worked well in the clinical work environment. The medical students valued well defined clinical tasks and being evaluated directly after a clinical task as it clearly reflected which competences the student has achieved or where to improve. The students mentioned that it made it easy to ask for supervision and feedback. They mentioned that the card “taking patient history” would be more useful in the previous semester. The competence cards were constructed with statements and without numbers to stimulate verbal feedback. The students suggested to change to a Likert scale, to make it easier to visualize improvement. An electronic version of the portfolio was introduced in round 2 and 3. The students preferred the electronic version to the paper version. They gave good suggestions on how to improve the electronic version such as easier access and improved layout. The students mentioned that peer-to-peer evaluation felt safe and helps overcome barriers and identify both strengths and weaknesses. In some situations, however, they mentioned that it did not make sense as they were novices as for example with the pharmacology and operation/endoscopy competence cards. They appreciated the clear description of learning objectives in the competence cards and found it helpful to be formatively assessed by doctors. Additionally, that it provided an opportunity for dialogue with the doctors, which their previous logbook did not. The students expressed that they felt more welcome as there is a plan for their stay and experienced that their learning was prioritised. The medical students appreciated the feedback both from junior and senior doctors and mentioned that they need to learn to provide feedback themselves. Some mentioned that the feedback from more senior doctors was more to the point than from junior doctors. Keeping the motivation for implementation was a challenge for all in a busy clinical environment and good ideas on how to facilitate this for next cohort of students were presented by the students. They appreciated being teamed up with a junior doctor, but doctors’ vacation and on calls could be a challenge and hence it should be clear that the task was then to be taken over by others. Many of the practical aspect could be introduced and evaluated by nurses such as the items on the pharmacology card. The project coordinators’ and the supervisors’ perception Overall, the project coordinators and the supervisors were positive and saw the value for the students and themselves. It became clear what the student could do and where there was room for improvement. It was mentioned that many of the students passed all items on the competence card, taking the patient history, at the first formative evaluation by a doctor, hence it felt as waste of time to repeat it at the end of their stay. That was also the case for the ward round card. In contrast, it was difficult to use the pharmacology and operation/endoscopy competence cards, because the content of these card items was new for the students. Table 4 shows examples of themes based on the citations and the questionnaire. Overall, it worked well to make a team of a student and a junior doctor. The benefit mentioned was the relationship with the medical student, where you felt responsible for the evaluations and ensured their clinical rotation was a good learning experience for them. In addition, that you saw the benefit of the feedback provided. DISCUSSION Main findings We successfully developed four competence cards covering the most important learning objectives and medical encounters to be used by medical students in fourth year. The portfolio system introduced systematic training and formative evaluation of competence. This was followed by constructive feedback in a few well-defined clinical areas of competence, which gave the students an opportunity to build an understanding of, and confidence in, the content of the roles. Overall, the medical students’ and the clinical supervisors’ reception were positive. The medical students’ and the clinical supervisors’ overall perception The medical students found the structured, formative evaluation helpful. It made it easy to ask for supervision and feedback. Overall, they preferred the portfolio from the existing logbook. Our study supports the benefit of introducing a portfolio mindset already in the pre-graduate education( 31 , 32 ). Medical students need to grow during their clinical rotations to be ready to perform tasks first with supervision and after training on their own ( 33 ). The interviews gave us valuable comments about the competence cards, both the content and the grading of the feedback. Overall, they found the content relevant, and representative of the learning objectives provided from the university. The content agrees with the undergraduate medical education literature( 33 ). Initially we used a Likert scale consisting of statements. This was changed to numbers after receiving feedback from the students, telling us, it was easier to visualize improvement this way, especially when entering a new rotation. The electronic version was favoured, but suggestions for how to improve were provided. The benefit of an electronic version is the registration of the competence evaluations. It is important to mention, that the medical students found peer-to peer evaluation valuable. They found it safe to ask a peer to do the evaluation, even though they did not know each other well. They perceived the learning environment as safe and were open to feedback from peers. This is in alignment with studies showing the positive effect of peer-to-peer teaching( 34 ). The students were evaluated twice by a doctor, the first time in the middle of their stay and the second time at the end. Both students and clinical supervisors mentioned that it was unnecessary to repeat the evaluation if the student fulfilled the criteria in the middle of their stay. However, the students mentioned, that if they were interested in being evaluated again, for instance in a more challenging situation, it should be possible. The relative low total number of competence evaluations conducted in this study indicate that our portfolio was too big for a five-week rotation. Hence, either the number of competence cards or the number of repeated evaluations should be reduced. Building on the suggestions from the students and supervisors we intend to reduce the number of evaluations. This is in alignment with studies in postgraduate training, describing how programs need to adapt if the burden of assessment is too high( 35 ). The students mentioned differences in how feedback was provided. Some preferred feedback from junior doctors whereas others preferred feedback from senior doctors. One of the explanations might be that the juniors remembered what was difficult as a medical student and directed the feedback towards that, whereas the seniors provided more detailed feedback and were sometimes more critical. Concerns have been raised in the literature that formative assessment can be reduced to tick-box exercises( 35 ). Our study does not confirm this. Implementation The heads of department appointed coordinators, who found it easy to implement the portfolio for students, as they were familiar with evaluation of competence in specialist training of doctors. They were committed to introduce competence based medical education to pre-graduate education. A recent publication has shown that this can be difficult due to misaligned goals and in-adequate communication ( 36 ). To secure implementation of the project in a busy clinical department, it is necessary to visit the department regularly and support all participants to be sure that the evaluation of competence is done. One of the coordinator’s recommendations was to make the evaluation of competence simpler and more aligned with the evaluation of doctors, which means that the doctor in training prepare for the evaluation and ask for the evaluation when they find them-selves ready to pass. They thought that it would be more meaningful and at the same time simpler. The coordinators found that a train-the-trainers course was unnecessary, but based on the students’ feedback, we found that a train-the-trainers course was necessary. The supervisors and the coordinators mentioned that this initiative would not only be of help for medical students and supervisors but be of benefit for the patients. Discussion of the methods The study followed a well-recognised method, Kern’s six steps, for developing an educational activity. The portfolio was developed by clinicians and supported by professor and associate professors in medical education. After the first cohort, a few changes were made in some of the competence cards. They were in a generic format, which means that they can be used at all departments of internal medicine and surgery at this level of education. Hence the generalisability is high. We find it a strength that three cohorts of medical students from six different departments were included, as it has been possible to follow different implementation strategies. In addition, that each cohort of medical students were interviewed at the end of their stay, which made it possible to adapt for the next cohort. Future studies In conclusion, clinical rotations can be utilized better in strengthening the development of several of the seven doctor roles and develop a familiarity with patient-centred treatment. However, studies exploring the impact on learning and the benefit for the organisation are needed. In addition, new competence cards should be developed and tested in the specialties, i.e. psychiatry and neurology. CONCLUSION We successfully developed and implemented a portfolio encompassing four competence cards, that focused on training of the competencies needed as a doctor apart from the role as a medical expert. By this concept the students also trained important skills as communication, cooperation with colleagues and other hospital staff and the role as professional, which is known to be difficult to train. Both supervisors and medical students found the portfolio to be helpful and gave positive feedback. In addition, they mentioned challenges and gave input for how to overcome them. The use of the portfolio caused more systematic and structured supervision and feedback. The students became more aware of what their strengths and weaknesses are and how to improve their clinical skills. Thereby training with competence cards become a valuable step in medical training of competent future doctors, and ultimately for the benefit of patient safety. Declarations Ethical approval Danish law exempts this type of study from ethical approval as no patients are involved. The project is seen as a quality improvement project. The study protocol was approved by the Copenhagen University and the Heads of departments. All data is anonymised, and no data is person identifiable. Consent for publication Not applicable. Data availability The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests No competing interest. Funding We achieved a generous grant from the University of Copenhagen, which in addition guided us in identifying the Gastro Units involved in this study. Author contributions TB and DO conceived the project protocol. DO, KSL, AEBB, MLA, LTK, HK, TN, JR, AM, and TB contributed to the development of the portfolio. DO wrote the first draft of the manuscript. AM prepared figure 1. DO, KSL, AEBB, MLA, LTK, HK, TN, JR, AM, and TB commented and approved the final main manuscript. Acknowledgement We would like to thank our administrator, Jeppe Hartmann for taking care of all the practical challenges and Leif Henriksen from Laerdal (trademark) for giving us the possibility to use their platform and helping us to adjust to our needs. We would also like to thank all the departments involved in this project for their immense support. References Padley J, Boyd S, Jones A, Walters L. Transitioning from university to postgraduate medical training: A narrative review of work readiness of medical graduates. Health Sci Rep. 2021;4(2). Andersen S, Stentoft D, Emmersen J, Rasmussen S, Birkelund S, Nøhr S. Contention over undergraduate medical curriculum content. Int J Med Educ. 2019;10. Surmon L, Bialocerkowski A, Hu W. Perceptions of preparedness for the first medical clerkship: A systematic review and synthesis. BMC Med Educ. 2016;16(1):1–11. Kellett J, Papageorgiou A, Cavenagh P, Salter C, Miles S, Leinster SJ. The preparedness of newly qualified doctors - Views of Foundation doctors and supervisors. Med Teach. 2015;37(10). Hawkins N, Younan HC, Fyfe M, Parekh R, McKeown A. Exploring why medical students still feel underprepared for clinical practice: a qualitative analysis of an authentic on‐call simulation. BMC Med Educ. 2021;21(1). Burridge S, Shanmugalingam T, Nawrozzadeh F, Leedham-Green K, Sharif A. A qualitative analysis of junior doctors’ journeys to preparedness in acute care. BMC Med Educ. 2020;20(1). Berridge EJ, Freeth D, Sharpe J, Roberts CM. Bridging the gap: Supporting the transition from medical student to practising doctor - A two-week preparation programme after graduation. Med Teach. 2007;29(2–3):119–27. Sullivan PB, Gregg N, Adams E, Rodgers C, Hull J. How much of the paediatric core curriculum do medical students remember? Advances in Health Sciences Education. 2013;18(3). Wolf SJ, Lockspeiser TM, Gong J, Guiton G. Identification of foundational non-clinical attributes necessary for successful transition to residency: A modified Delphi study with experienced medical educators. BMC Med Educ. 2018;18(1):1–8. Shi W, Qin H, Vaughan B, Ng L. Educational Interventions for Medical Students to Improve Pharmacological Knowledge and Prescribing Skills: A Scoping Review. Perspect Med Educ. 2023;12(1):348–60. Klasen JM, Teunissen PW, Driessen E, Et al. Trainees’ perceptions of being allowed to fail in clinical training: a sense-making model. Med Educ. 2023;57(5):430–9. Krogh TB, Mielke-Christensen A, Madsen MD, Østergaard D, Dieckmann P. Medical students’ experiences, perceptions, and management of second victim: an interview study. BMC Med Educ [Internet]. 1. december 2023 [henvist 14. november 2023];23(1). Tilgængelig hos: https://pubmed.ncbi.nlm.nih.gov/37875909/ Chen HC, Van Den Broek WES, Ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Acad Med [Internet]. 1. april 2015 [henvist 14. november 2023];90(4):431–6. Tilgængelig hos: https://pubmed.ncbi.nlm.nih.gov/25470310/ Walton M, Harrison R, Burgess A, Foster K. Workplace training for senior trainees: A systematic review and narrative synthesis of current approaches to promote patient safety. Postgrad Med J. 2015;91(1080):579–87. Pinilla S, Lenouvel E, Cantisani A, Klöppel S, Strik W, Huwendiek S, m.fl. Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review. BMC Med Educ. 2021;21(1):1–10. Jungersen DR. Kandidatuddannelse målrettet generation Z: mindre udenadslære – mere feedback. Ugeskr Laeger [Internet]. [henvist 11. april 2024]; Tilgængelig hos: https://ugeskriftet.dk/nyhed/kandidatuddannelse-malrettet-generation-z-mindre-udenadslaere-mere-feedback Klitgaard TL, Stentoft D, Skipper M, Grønkjær M, Nøhr SB. Struggling to fit the white coat and the role of contextual factors within a hospital organisation - an ethnographic study on the first months as newly graduated doctors. BMC Med Educ. 2021;21(1). Jarvis-Selinger S, Macneil KA, Costello GRL, Lee K, Holmes CL. Understanding Professional Identity Formation in Early Clerkship: A Novel Framework. I: Academic Medicine. 2019. Johansson N, Nøhr SB, Stentoft D. A Scoping Review of the Relation Between Problem-based Learning and Professional Identity Development in Medical Education. Journal of Problem Based Learning in Higher Education. 2020;8(2). Johansson N, Nøhr S, Klitgaard TL, Stentoft D, Vardinghus-Nielsen H. Clinical problem-based medical education: A social identity perspective on learning. Dansk Universitetspædagogisk Tidsskrift [Internet]. 31. oktober 2022 [henvist 6. februar 2024];17(33):79–96. Tilgængelig hos: https://vbn.aau.dk/en/publications/clinical-problem-based-medical-education-a-social-identity-perspe De Lasson L, Just E, Stegeager N, Malling B. Professional identity formation in the transition from medical school to working life: A qualitative study of group-coaching courses for junior doctors. BMC Med Educ. 2016;16(1). Frank JR, Danoff D. The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29(7):642–7. Danish Health and Medicines Authority. Electronic ISBN: 978-87-7104-016-6, https://www.sst.dk/en/news/2013/~/media/39D3E216BCBF4A9096B286EE44F03691.ashx. 2014. s. 1–39 The seven roles of physicians. Chawes B, Johannesen J. Feedbackloop på medicinstudiets kliniske kurser. Ugeskr Laeger. 2020;182:1–10. McNair R, Griffiths L, Reid K, Sloan H. Medical students developing confidence and patient centredness in diverse clinical settings: A longitudinal survey study. Bd. 16, BMC Medical Education. 2016. Ringsted C, Hodges B, Scherpbier A. ‘The research compass’: An introduction to research in medical education: AMEE Guide No. 56. Med Teach [Internet]. september 2011 [henvist 19. december 2023];33(9):695–709. Tilgængelig hos: https://www.tandfonline.com/doi/abs/10.3109/0142159X.2011.595436 Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education - A Six-Step Approach. Johns Hopkins University Press, Baltimore. 2016;1:312–312. Klitgaard TL, Gjessing S, Skipper M, Nøhr SB. Becoming a doctor-The potential of a change laboratory intervention. Medical teacher. 2022. s. 1–9. Østergaard D, Nøhr SB. Overgang mellem medicinstudiet og Overgang mellem medicinstudiet og klinisk basisuddannelse i Danmark klinisk basisuddannelse i Danmark. Braun V, Clark V. BraunAndClarke_2006_ThematicAnalysis.pdf. Qual Res Psychol. 2006;3(2):77–101. Chen HC, Van Den Broek WES, Ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Academic Medicine. 2015;90(4):431–6. Encandela JA, Shaull L, Jayas A, Amiel JM, Brown DR, Obeso VT, m.fl. Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot. Bd. 28, Medical Education Online. 2023. Encandela JA, Shaull L, Jayas A, Amiel JM, Brown DR, Obeso VT, m.fl. Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot. Med Educ Online. 2023;28(1). Ross MT, Cameron HS. Peer assisted learning: A planning and implementation framework: AMEE Guide no. 30. Med Teach. 2007;29(6):527–45. Szulewski A, Braund H, Dagnone DJ, McEwen L, Dalgarno N, Schultz KW, m.fl. The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting. Academic Medicine. 2023;Publish Ah. Zetkulic M, Moriarty JP, Amin A, Angus S, Dalal B, Fazio S, m.fl. Exploring Competency-Based Medical Education Through the Lens of the UME-GME Transition: A Qualitative Study. Academic Medicine. 2024;99(1). Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Appendix1Portefolio.docx Appendix 1. The portfolio Appendix2Evaluationcoordinatorsspring2023.docx Appendix 2. The questionnaire used to explore supervisors´ perception of the introduction of competence cards Tables.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4436923","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":309368135,"identity":"13c29aa1-65ec-4f9d-a700-79b71dd7d2b3","order_by":0,"name":"Doris Østergaard","email":"data:image/png;base64,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","orcid":"","institution":"Copenhagen Academy for Medical Education and Simulation","correspondingAuthor":true,"prefix":"","firstName":"Doris","middleName":"","lastName":"Østergaard","suffix":""},{"id":309368136,"identity":"11474e97-c3f8-4fae-b7b8-f1256572eb2c","order_by":1,"name":"Kristine Sarauw Lundsgaard","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Kristine","middleName":"Sarauw","lastName":"Lundsgaard","suffix":""},{"id":309368137,"identity":"f6c1cf21-3b3b-4570-9cdf-fae45e7157ce","order_by":2,"name":"Astrid Elisabeth Bruun Boilesen","email":"","orcid":"","institution":"Copenhagen University Hospital Hvidovre","correspondingAuthor":false,"prefix":"","firstName":"Astrid","middleName":"Elisabeth Bruun","lastName":"Boilesen","suffix":""},{"id":309368138,"identity":"d83ece7f-43f3-4875-afe6-c4cfd08eb4cd","order_by":3,"name":"Mette Lehmann Andersen","email":"","orcid":"","institution":"Copenhagen University Hospital Herlev","correspondingAuthor":false,"prefix":"","firstName":"Mette","middleName":"Lehmann","lastName":"Andersen","suffix":""},{"id":309368139,"identity":"c29be071-66c7-4d2f-90fe-3be63e23bb8d","order_by":4,"name":"Lene Tschemerinsky Kirkeby","email":"","orcid":"","institution":"Zealand University Hospital Køge","correspondingAuthor":false,"prefix":"","firstName":"Lene","middleName":"Tschemerinsky","lastName":"Kirkeby","suffix":""},{"id":309368140,"identity":"5dc799f5-652e-4f33-aeca-8d498839705b","order_by":5,"name":"Helle Kristensen","email":"","orcid":"","institution":"Copenhagen University Hospital Hvidovre","correspondingAuthor":false,"prefix":"","firstName":"Helle","middleName":"","lastName":"Kristensen","suffix":""},{"id":309368141,"identity":"15e1680b-ad0f-493c-a532-2d8e4d4c6d87","order_by":6,"name":"Tine Nordal","email":"","orcid":"","institution":"Copenhagen University Hospital Herlev","correspondingAuthor":false,"prefix":"","firstName":"Tine","middleName":"","lastName":"Nordal","suffix":""},{"id":309368142,"identity":"c4b202cc-bf2d-4bbd-8870-206c5f04816c","order_by":7,"name":"Julie Rasmussen","email":"","orcid":"","institution":"Zealand University Hospital Køge","correspondingAuthor":false,"prefix":"","firstName":"Julie","middleName":"","lastName":"Rasmussen","suffix":""},{"id":309368144,"identity":"dd5aaa61-f009-4d2f-b37a-af1cc53f2444","order_by":8,"name":"Anne Mielke-Christensen","email":"","orcid":"","institution":"Copenhagen Academy for Medical Education and Simulation","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"","lastName":"Mielke-Christensen","suffix":""},{"id":309368146,"identity":"00859701-1b3e-4295-b7cd-57e0acc617e9","order_by":9,"name":"Trine Boysen","email":"","orcid":"","institution":"University of Copenhagen","correspondingAuthor":false,"prefix":"","firstName":"Trine","middleName":"","lastName":"Boysen","suffix":""}],"badges":[],"createdAt":"2024-05-17 13:06:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4436923/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4436923/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57841885,"identity":"eb2b077c-cca9-42fa-b109-3f4268df03ca","added_by":"auto","created_at":"2024-06-06 10:06:27","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45984,"visible":true,"origin":"","legend":"\u003cp\u003eShowing the three years with clerkships, which subjects that are focused on and specialties. Red circle marks the clerkship for this project.\u003c/p\u003e","description":"","filename":"Slide1.png","url":"https://assets-eu.researchsquare.com/files/rs-4436923/v1/479ae029fc2c28adfbf260dd.png"},{"id":81768917,"identity":"1db3200f-8737-47bc-9555-1a2dc748d840","added_by":"auto","created_at":"2025-05-01 13:51:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":536743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4436923/v1/108e2589-97c4-4871-8440-f9ace4a88a50.pdf"},{"id":57841883,"identity":"7e193824-5dbc-4bef-82f7-b4a547efa6fa","added_by":"auto","created_at":"2024-06-06 10:06:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":47858,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAppendix 1. \u003c/em\u003eThe portfolio\u003c/p\u003e","description":"","filename":"Appendix1Portefolio.docx","url":"https://assets-eu.researchsquare.com/files/rs-4436923/v1/0caaa78e515606fb2f195d39.docx"},{"id":57841884,"identity":"11c288e5-ca22-40fc-9689-20af4c132e08","added_by":"auto","created_at":"2024-06-06 10:06:27","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14720,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAppendix 2. \u003c/em\u003eThe questionnaire used to explore supervisors´ perception of the introduction of competence cards\u003c/p\u003e","description":"","filename":"Appendix2Evaluationcoordinatorsspring2023.docx","url":"https://assets-eu.researchsquare.com/files/rs-4436923/v1/25d6ef4c6e1a053a5bf68c42.docx"},{"id":57841886,"identity":"df8dad9d-f7a1-4847-9aa1-d2ce1f2aa5cd","added_by":"auto","created_at":"2024-06-06 10:06:27","extension":"xlsx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":20167,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-4436923/v1/6ada4024330c41c7aa202b4e.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Developing and pilot testing competence cards in clinical rotations: medical students’ and supervisors’ perception","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eThe transition from the academic world at university, with a primary focus on the medical expert role (knowledge and skills), to work-based learning is complex and is in the literature described as difficult (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Students often just memorize the curriculum and thereby only scratch the surface instead of reaching in depth learning (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Several studies have shown that students express uncertainty and a lack of preparedness for the transition into doctor(\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Despite profound theoretical knowledge the students do not feel prepared for the clinical tasks at hand. They find it difficult to apply their knowledge to a clinical context due to problems being less well-defined and situated in new situations(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The transition is easier, if students are introduced to topics including communication, teamwork, critical thinking, intellectual curiosity, emotional intelligence, resilience, and organizational skills(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Other studies have focused on patient safety, as one of the major problems is medication management, knowledge of e.g. incident reporting, being able to manage distractions and interruptions as well as difficulties in talking about mistakes(\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eChen et al encourages analysing which tasks the candidates must be able to do and to develop a portfolio mindset already in medical school (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This is supported by an article by Walton et al, which describes the implications of a postgraduate competence-based medical education for the undergraduate education(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Introducing a portfolio mindset from pre-graduate level will make the transition easier, as strengthened supervision and a greater focus on formative assessment supports student in making decisions about their learning(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Aarhus University, Denmark has recently introduced assessment of competence in clinical stays in all semesters and is gathering experience with this (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe portfolio mindset might also help the students in forming their professional identities as doctors, forming the professional identity is important for becoming a doctor, as several newer studies, among them many Danish, have shed a light on (\u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA structured training will lead to an assessment of competence, which means that the student can easily follow their own development and confidence in accomplished skills, and the supervisor becomes aware of where learning needs to be strengthened and the quality of patient treatment is thereby improved.\u003c/p\u003e \u003cp\u003eThe Canadian \u0026ldquo;seven roles of the doctor\u0026rdquo; has been adapted to Danish context in specialist training of doctors(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In addition, competence-based education was introduced. The clinical supervisors are often involved in both pre- and post-graduate education and will be able to facilitate the introduction of suitable tools for learning and competency assessment at the pre-graduate level. Formative assessment of competence is followed by feedback, which is essential for the student to develop, a recent Danish article describes this(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). All in all, we speculate if the clinical rotations can be used to strengthen the medical students\u0026acute; development of several of the seven doctor roles and if formative assessment of competence will help the students to develop a familiarity with patient-centred treatment (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eAim\u003c/h3\u003e\n\u003cp\u003eThe purpose of this project is 1) to develop a portfolio utilizing Kern\u0026rsquo;s 6-step approach encompassing competence cards covering some of the seven roles of the doctor for use in clinical rotations at medical and surgical departments in the fourth year of their studies, 2) to introduce these cards in six departments and 3) to evaluate the medical students\u0026acute; and the clinical educators\u0026acute; perception of this intervention.\u003c/p\u003e \u003cp\u003eWe expect this to strengthen learning during the clinical stay through a structured introduction of what is expected. We also expect the use of competence cards during the clinical stay will be of benefit to both the student and the supervisors, as progression can be followed.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe study is an explorative study(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eContext\u003c/p\u003e \u003cp\u003eFaculty of Health and Medical Science, University of Copenhagen, Denmark. The medical school curriculum is six years, with clinical rotations starting from year four (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eFigure one, titel: Distribuation of clerkships\u003c/p\u003e \u003cp\u003e \u003cem\u003eFigure 1: Showing the three years with clerkships, which subjects that are focused on and specialties. Red circle marks the clerkship for this project.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe Heads of Departments of three gastro medical and three gastro surgical situated at three different hospitals agreed to be part of the project. At each of the six departments a consultant was appointed as the local project coordinator.\u003c/p\u003e \u003cp\u003eDuring a semester, each department receives three cohorts of medical students. The students have a logbook describing the focus for their stay as well as the practical procedures they need to train and be assessed in. This is the students second semester with clinical rotations, prior to this they have had a five-week rotation in either a medical or surgical department. Overall, the semester consists of internal medicine (five weeks)-, surgery (five weeks)- and anaesthesia (two weeks) (Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eA total of 78 students were planned for the semester in spring 2023. We followed them in either a medical or surgical rotation.\u003c/p\u003e \u003cp\u003eThe project was funded and approved by the Copenhagen University. Ethical approval was not needed as the project did not involve treatment of patients.\u003c/p\u003e \u003cp\u003eDevelopment\u003c/p\u003e \u003cp\u003eThe development was guided by Kern\u0026acute;s six step approach(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1. Problem identification and general needs assessment\u003c/h2\u003e \u003cp\u003eA general needs assessment was conducted based on the curriculum for the semester and the literature (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2. Targeted needs assessment\u003c/h2\u003e \u003cp\u003eA workshop was conducted with the coordinators from the departments in December 2022.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e3. Goals and objectives\u003c/h2\u003e \u003cp\u003eBased on this, we selected the learning objectives that we intended to include and evaluate at the gastro units after workshop in December 2022.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e4. Educational strategies\u003c/h2\u003e \u003cp\u003eThe portfolio and competence cards were drafted and tested for understanding in January 2023. We decided how to organise the assessments during the students\u0026rsquo; stay, and who should assess and provide feedback to the individual student. We decided to use the same headings in the competence cards and the same assessment strategy as at Aarhus University, Denmark. The first assessment was to be conducted by a peer within the first week(s), the second in the middle of the rotation and the third in the last week both were planned to be conducted by a doctor.\u003c/p\u003e \u003cp\u003eThe departments chose different strategies for being responsible for the assessments. In two departments, each medical student was coupled with a junior doctor, who should perform the competence evaluations. In the remaining departments, it was a more flexible arrangement, and all doctors could do it. The six local project coordinators expressed that the staff were familiar with evaluation of trainees\u0026rsquo; competence, and they did not see the need for training in evaluating medical students.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e5. Implementation\u003c/h2\u003e \u003cp\u003eThe competence cards were implemented in Spring 2023. One week before their rotations, the medical students were informed by mail about the project and received the portfolio. The local project coordinator introduced it again in the department. All three cohorts received a paper version of the portfolio, in the 2nd and 3rd cohort an electronic version was available. All doctors in the departments received information about the project, both written and verbal. The project was introduced by TB or DO in all departments.\u003c/p\u003e \u003cp\u003eThe project coordinators followed the implementation and were available to solve challenges and make sure that the portfolio was used as intended. We used a modified version of Laerdals Sim Capture\u0026trade; developed for nursing students. SimCapture is, among other things, a rating tool. SimCapture is a closed system. When the electronic version was introduced, we provided a help link to an administrator, who could solve technical problems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e6. Evaluation\u003c/h2\u003e \u003cp\u003eThe actual number of evaluations were calculated, and the content of the evaluation (pass/fail elements) was analysed.\u003c/p\u003e \u003cp\u003eGroup interviews of the medical students and doctors, respectively, were conducted by TB and DO at the end of their five-week rotation. The interview aimed to uncover their overall perception and experiences with the portfolio, thereby improving both content and organisation of the competence cards. In addition, we wanted their perspective on conducting evaluation of competence and providing feedback. Written notes were thematised according to Braun and Clarke(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA short questionnaire was sent to the project coordinators and supervisors, who had been involved in the formative assessment of the medical students. It contained seven questions and room for free text. In addition, we collected information from the project coordinators at meetings both during and at the end of the semester.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe portfolio and the competence cards\u003c/p\u003e\n\u003cp\u003eThe portfolio contained four competence cards. Each card covered 11 or 13 items (learning objectives) to be evaluated. The evaluators were asked to provide feedback using the free text areas. The four competence cards covered the following areas: 1. Taking the patient history and writing the primary record, 2. Ward round, 3. Pharmacology (internal medicine rotation), and 4. Operation/endoscopy (surgical rotation)\u003c/p\u003e\n\u003cp\u003eCompetence cards 1 and 2 were used in both medical and surgical rotations. The formative evaluation was planned to be structured observations followed by feedback (card 1\u0026ndash;3) and case-based discussion (card 4). Appendix 1 shows the portfolio with the competence cards. After the first cohort had used the competence cards, a few minor changes were made.\u003c/p\u003e\n\u003cp\u003eThe medical students\u003c/p\u003e\n\u003cp\u003eA total of 60 medical students were assessed using the competence cards. Table\u0026nbsp;1 shows the distribution of students according to departments as well as the number of assessments conducted by peers, supervisors, and coordinators. None of the students were assessed three times in all four competence cards.\u003c/p\u003e\n\u003cp\u003eThe total number of peer-to-peer evaluations was 90, the highest for the well-known tasks such as taking the patient history and ward round, and lowest for the new areas such as pharmacology and the operation/endoscopy (Table 1). The evaluation in the middle and the end of their clinical stay was conducted by either a junior or senior doctor. At the final evaluation the supervisor was asked to provide a pass/fail decision. A total of 88 final evaluations were conducted. Most of the students passed all items on the competence cards. Only a few items were impossible to rate because of the patient case chosen.\u003c/p\u003e\n\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e shows the number of final evaluations of competence conducted and the number of items on the card that the student passed.\u003c/p\u003e\n\u003cp\u003eThe medical students\u0026acute; perception\u003c/p\u003e\n\u003cp\u003eA total of 44 medical students participated in the interviews at the end of their stay. The duration of the interviews were 30\u0026ndash;45 min and notes were taken by the leaders of the project (TB, DO). It provided valuable information about the students\u0026rsquo; perception of the introduction of competence cards in their clinical rotation. Table\u0026nbsp;3 shows examples of themes based on citations. Their overall perception was that the competence cards worked well in the clinical work environment. The medical students valued well defined clinical tasks and being evaluated directly after a clinical task as it clearly reflected which competences the student has achieved or where to improve. The students mentioned that it made it easy to ask for supervision and feedback. They mentioned that the card \u0026ldquo;taking patient history\u0026rdquo; would be more useful in the previous semester. The competence cards were constructed with statements and without numbers to stimulate verbal feedback. The students suggested to change to a Likert scale, to make it easier to visualize improvement. An electronic version of the portfolio was introduced in round 2 and 3. The students preferred the electronic version to the paper version. They gave good suggestions on how to improve the electronic version such as easier access and improved layout.\u003c/p\u003e\n\u003cp\u003eThe students mentioned that peer-to-peer evaluation felt safe and helps overcome barriers and identify both strengths and weaknesses. In some situations, however, they mentioned that it did not make sense as they were novices as for example with the pharmacology and operation/endoscopy competence cards. They appreciated the clear description of learning objectives in the competence cards and found it helpful to be formatively assessed by doctors. Additionally, that it provided an opportunity for dialogue with the doctors, which their previous logbook did not. The students expressed that they felt more welcome as there is a plan for their stay and experienced that their learning was prioritised. The medical students appreciated the feedback both from junior and senior doctors and mentioned that they need to learn to provide feedback themselves. Some mentioned that the feedback from more senior doctors was more to the point than from junior doctors.\u003c/p\u003e\n\u003cp\u003eKeeping the motivation for implementation was a challenge for all in a busy clinical environment and good ideas on how to facilitate this for next cohort of students were presented by the students. They appreciated being teamed up with a junior doctor, but doctors\u0026rsquo; vacation and on calls could be a challenge and hence it should be clear that the task was then to be taken over by others. Many of the practical aspect could be introduced and evaluated by nurses such as the items on the pharmacology card.\u003c/p\u003e\n\u003cp\u003eThe project coordinators\u0026rsquo; and the supervisors\u0026rsquo; perception\u003c/p\u003e\n\u003cp\u003eOverall, the project coordinators and the supervisors were positive and saw the value for the students and themselves. It became clear what the student could do and where there was room for improvement. It was mentioned that many of the students passed all items on the competence card, taking the patient history, at the first formative evaluation by a doctor, hence it felt as waste of time to repeat it at the end of their stay. That was also the case for the ward round card. In contrast, it was difficult to use the pharmacology and operation/endoscopy competence cards, because the content of these card items was new for the students. Table\u0026nbsp;4 shows examples of themes based on the citations and the questionnaire.\u003c/p\u003e\n\u003cp\u003eOverall, it worked well to make a team of a student and a junior doctor. The benefit mentioned was the relationship with the medical student, where you felt responsible for the evaluations and ensured their clinical rotation was a good learning experience for them. In addition, that you saw the benefit of the feedback provided.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eMain findings\u003c/p\u003e \u003cp\u003eWe successfully developed four competence cards covering the most important learning objectives and medical encounters to be used by medical students in fourth year. The portfolio system introduced systematic training and formative evaluation of competence. This was followed by constructive feedback in a few well-defined clinical areas of competence, which gave the students an opportunity to build an understanding of, and confidence in, the content of the roles. Overall, the medical students\u0026rsquo; and the clinical supervisors\u0026rsquo; reception were positive.\u003c/p\u003e \u003cp\u003eThe medical students\u0026rsquo; and the clinical supervisors\u0026rsquo; overall perception\u003c/p\u003e \u003cp\u003eThe medical students found the structured, formative evaluation helpful. It made it easy to ask for supervision and feedback. Overall, they preferred the portfolio from the existing logbook. Our study supports the benefit of introducing a portfolio mindset already in the pre-graduate education(\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Medical students need to grow during their clinical rotations to be ready to perform tasks first with supervision and after training on their own (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe interviews gave us valuable comments about the competence cards, both the content and the grading of the feedback. Overall, they found the content relevant, and representative of the learning objectives provided from the university. The content agrees with the undergraduate medical education literature(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInitially we used a Likert scale consisting of statements. This was changed to numbers after receiving feedback from the students, telling us, it was easier to visualize improvement this way, especially when entering a new rotation. The electronic version was favoured, but suggestions for how to improve were provided. The benefit of an electronic version is the registration of the competence evaluations.\u003c/p\u003e \u003cp\u003eIt is important to mention, that the medical students found peer-to peer evaluation valuable. They found it safe to ask a peer to do the evaluation, even though they did not know each other well. They perceived the learning environment as safe and were open to feedback from peers. This is in alignment with studies showing the positive effect of peer-to-peer teaching(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe students were evaluated twice by a doctor, the first time in the middle of their stay and the second time at the end. Both students and clinical supervisors mentioned that it was unnecessary to repeat the evaluation if the student fulfilled the criteria in the middle of their stay. However, the students mentioned, that if they were interested in being evaluated again, for instance in a more challenging situation, it should be possible. The relative low total number of competence evaluations conducted in this study indicate that our portfolio was too big for a five-week rotation. Hence, either the number of competence cards or the number of repeated evaluations should be reduced. Building on the suggestions from the students and supervisors we intend to reduce the number of evaluations. This is in alignment with studies in postgraduate training, describing how programs need to adapt if the burden of assessment is too high(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe students mentioned differences in how feedback was provided. Some preferred feedback from junior doctors whereas others preferred feedback from senior doctors. One of the explanations might be that the juniors remembered what was difficult as a medical student and directed the feedback towards that, whereas the seniors provided more detailed feedback and were sometimes more critical. Concerns have been raised in the literature that formative assessment can be reduced to tick-box exercises(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Our study does not confirm this.\u003c/p\u003e \u003cp\u003eImplementation\u003c/p\u003e \u003cp\u003eThe heads of department appointed coordinators, who found it easy to implement the portfolio for students, as they were familiar with evaluation of competence in specialist training of doctors. They were committed to introduce competence based medical education to pre-graduate education. A recent publication has shown that this can be difficult due to misaligned goals and in-adequate communication (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). To secure implementation of the project in a busy clinical department, it is necessary to visit the department regularly and support all participants to be sure that the evaluation of competence is done.\u003c/p\u003e \u003cp\u003eOne of the coordinator\u0026rsquo;s recommendations was to make the evaluation of competence simpler and more aligned with the evaluation of doctors, which means that the doctor in training prepare for the evaluation and ask for the evaluation when they find them-selves ready to pass. They thought that it would be more meaningful and at the same time simpler. The coordinators found that a train-the-trainers course was unnecessary, but based on the students\u0026rsquo; feedback, we found that a train-the-trainers course was necessary.\u003c/p\u003e \u003cp\u003eThe supervisors and the coordinators mentioned that this initiative would not only be of help for medical students and supervisors but be of benefit for the patients.\u003c/p\u003e \u003cp\u003eDiscussion of the methods\u003c/p\u003e \u003cp\u003eThe study followed a well-recognised method, Kern\u0026rsquo;s six steps, for developing an educational activity. The portfolio was developed by clinicians and supported by professor and associate professors in medical education. After the first cohort, a few changes were made in some of the competence cards. They were in a generic format, which means that they can be used at all departments of internal medicine and surgery at this level of education. Hence the generalisability is high. We find it a strength that three cohorts of medical students from six different departments were included, as it has been possible to follow different implementation strategies. In addition, that each cohort of medical students were interviewed at the end of their stay, which made it possible to adapt for the next cohort.\u003c/p\u003e \u003cp\u003eFuture studies\u003c/p\u003e \u003cp\u003eIn conclusion, clinical rotations can be utilized better in strengthening the development of several of the seven doctor roles and develop a familiarity with patient-centred treatment. However, studies exploring the impact on learning and the benefit for the organisation are needed. In addition, new competence cards should be developed and tested in the specialties, i.e. psychiatry and neurology.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe successfully developed and implemented a portfolio encompassing four competence cards, that focused on training of the competencies needed as a doctor apart from the role as a medical expert. By this concept the students also trained important skills as communication, cooperation with colleagues and other hospital staff and the role as professional, which is known to be difficult to train.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth supervisors and medical students found the portfolio to be helpful and gave positive feedback. In addition, they mentioned challenges and gave input for how to overcome them. The use of the portfolio caused more systematic and structured supervision and feedback. The students became more aware of what their strengths and weaknesses are and how to improve their clinical skills. Thereby training with competence cards become a valuable step in medical training of competent future doctors, and ultimately for the benefit of patient safety. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval\u003c/p\u003e\n\u003cp\u003eDanish law exempts this type of study from ethical approval as no patients are involved. The project is seen as a quality improvement project. The study protocol was approved by the Copenhagen University and the Heads of departments. All data is anonymised, and no data is person identifiable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eNo competing interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eWe achieved a generous grant from the University of Copenhagen, which in addition guided us in identifying the Gastro Units involved in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eTB and DO conceived the project protocol. DO, KSL, AEBB, MLA, LTK, HK, TN, JR, AM, and TB contributed to the development of the portfolio. DO wrote the first draft of the manuscript. AM prepared figure 1. DO, KSL, AEBB, MLA, LTK, HK, TN, JR, AM, and TB commented and approved the final main manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgement\u003c/p\u003e\n\u003cp\u003eWe would like to thank our administrator, Jeppe Hartmann for taking care of all the practical challenges and Leif Henriksen from Laerdal (trademark) for giving us the possibility to use their platform and helping us to adjust to our needs. We would also like to thank all the departments involved in this project for their immense support. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ePadley J, Boyd S, Jones A, Walters L. Transitioning from university to postgraduate medical training: A narrative review of work readiness of medical graduates. Health Sci Rep. 2021;4(2). \u003c/li\u003e\n\u003cli\u003eAndersen S, Stentoft D, Emmersen J, Rasmussen S, Birkelund S, N\u0026oslash;hr S. Contention over undergraduate medical curriculum content. Int J Med Educ. 2019;10. \u003c/li\u003e\n\u003cli\u003eSurmon L, Bialocerkowski A, Hu W. Perceptions of preparedness for the first medical clerkship: A systematic review and synthesis. BMC Med Educ. 2016;16(1):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eKellett J, Papageorgiou A, Cavenagh P, Salter C, Miles S, Leinster SJ. The preparedness of newly qualified doctors - Views of Foundation doctors and supervisors. Med Teach. 2015;37(10). \u003c/li\u003e\n\u003cli\u003eHawkins N, Younan HC, Fyfe M, Parekh R, McKeown A. Exploring why medical students still feel underprepared for clinical practice: a qualitative analysis of an authentic on‐call simulation. BMC Med Educ. 2021;21(1). \u003c/li\u003e\n\u003cli\u003eBurridge S, Shanmugalingam T, Nawrozzadeh F, Leedham-Green K, Sharif A. A qualitative analysis of junior doctors\u0026rsquo; journeys to preparedness in acute care. BMC Med Educ. 2020;20(1). \u003c/li\u003e\n\u003cli\u003eBerridge EJ, Freeth D, Sharpe J, Roberts CM. Bridging the gap: Supporting the transition from medical student to practising doctor - A two-week preparation programme after graduation. Med Teach. 2007;29(2\u0026ndash;3):119\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eSullivan PB, Gregg N, Adams E, Rodgers C, Hull J. How much of the paediatric core curriculum do medical students remember? Advances in Health Sciences Education. 2013;18(3). \u003c/li\u003e\n\u003cli\u003eWolf SJ, Lockspeiser TM, Gong J, Guiton G. Identification of foundational non-clinical attributes necessary for successful transition to residency: A modified Delphi study with experienced medical educators. BMC Med Educ. 2018;18(1):1\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eShi W, Qin H, Vaughan B, Ng L. Educational Interventions for Medical Students to Improve Pharmacological Knowledge and Prescribing Skills: A Scoping Review. Perspect Med Educ. 2023;12(1):348\u0026ndash;60. \u003c/li\u003e\n\u003cli\u003eKlasen JM, Teunissen PW, Driessen E, Et al. Trainees\u0026rsquo; perceptions of being allowed to fail in clinical training: a sense-making model. Med Educ. 2023;57(5):430\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eKrogh TB, Mielke-Christensen A, Madsen MD, \u0026Oslash;stergaard D, Dieckmann P. Medical students\u0026rsquo; experiences, perceptions, and management of second victim: an interview study. BMC Med Educ [Internet]. 1. december 2023 [henvist 14. november 2023];23(1). Tilg\u0026aelig;ngelig hos: https://pubmed.ncbi.nlm.nih.gov/37875909/\u003c/li\u003e\n\u003cli\u003eChen HC, Van Den Broek WES, Ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Acad Med [Internet]. 1. april 2015 [henvist 14. november 2023];90(4):431\u0026ndash;6. Tilg\u0026aelig;ngelig hos: https://pubmed.ncbi.nlm.nih.gov/25470310/\u003c/li\u003e\n\u003cli\u003eWalton M, Harrison R, Burgess A, Foster K. Workplace training for senior trainees: A systematic review and narrative synthesis of current approaches to promote patient safety. Postgrad Med J. 2015;91(1080):579\u0026ndash;87. \u003c/li\u003e\n\u003cli\u003ePinilla S, Lenouvel E, Cantisani A, Kl\u0026ouml;ppel S, Strik W, Huwendiek S, m.fl. Working with entrustable professional activities in clinical education in undergraduate medical education: a scoping review. BMC Med Educ. 2021;21(1):1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eJungersen DR. Kandidatuddannelse m\u0026aring;lrettet generation Z: mindre udenadsl\u0026aelig;re \u0026ndash; mere feedback. Ugeskr Laeger [Internet]. [henvist 11. april 2024]; Tilg\u0026aelig;ngelig hos: https://ugeskriftet.dk/nyhed/kandidatuddannelse-malrettet-generation-z-mindre-udenadslaere-mere-feedback\u003c/li\u003e\n\u003cli\u003eKlitgaard TL, Stentoft D, Skipper M, Gr\u0026oslash;nkj\u0026aelig;r M, N\u0026oslash;hr SB. Struggling to fit the white coat and the role of contextual factors within a hospital organisation - an ethnographic study on the first months as newly graduated doctors. BMC Med Educ. 2021;21(1). \u003c/li\u003e\n\u003cli\u003eJarvis-Selinger S, Macneil KA, Costello GRL, Lee K, Holmes CL. Understanding Professional Identity Formation in Early Clerkship: A Novel Framework. I: Academic Medicine. 2019. \u003c/li\u003e\n\u003cli\u003eJohansson N, N\u0026oslash;hr SB, Stentoft D. A Scoping Review of the Relation Between Problem-based Learning and Professional Identity Development in Medical Education. Journal of Problem Based Learning in Higher Education. 2020;8(2). \u003c/li\u003e\n\u003cli\u003eJohansson N, N\u0026oslash;hr S, Klitgaard TL, Stentoft D, Vardinghus-Nielsen H. Clinical problem-based medical education: A social identity perspective on learning. Dansk Universitetsp\u0026aelig;dagogisk Tidsskrift [Internet]. 31. oktober 2022 [henvist 6. februar 2024];17(33):79\u0026ndash;96. Tilg\u0026aelig;ngelig hos: https://vbn.aau.dk/en/publications/clinical-problem-based-medical-education-a-social-identity-perspe\u003c/li\u003e\n\u003cli\u003eDe Lasson L, Just E, Stegeager N, Malling B. Professional identity formation in the transition from medical school to working life: A qualitative study of group-coaching courses for junior doctors. BMC Med Educ. 2016;16(1). \u003c/li\u003e\n\u003cli\u003eFrank JR, Danoff D. The CanMEDS initiative: Implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29(7):642\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eDanish Health and Medicines Authority. Electronic ISBN: 978-87-7104-016-6, https://www.sst.dk/en/news/2013/~/media/39D3E216BCBF4A9096B286EE44F03691.ashx. 2014. s. 1\u0026ndash;39 The seven roles of physicians. \u003c/li\u003e\n\u003cli\u003eChawes B, Johannesen J. Feedbackloop p\u0026aring; medicinstudiets kliniske kurser. Ugeskr Laeger. 2020;182:1\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eMcNair R, Griffiths L, Reid K, Sloan H. Medical students developing confidence and patient centredness in diverse clinical settings: A longitudinal survey study. Bd. 16, BMC Medical Education. 2016. \u003c/li\u003e\n\u003cli\u003eRingsted C, Hodges B, Scherpbier A. \u0026lsquo;The research compass\u0026rsquo;: An introduction to research in medical education: AMEE Guide No. 56. Med Teach [Internet]. september 2011 [henvist 19. december 2023];33(9):695\u0026ndash;709. Tilg\u0026aelig;ngelig hos: https://www.tandfonline.com/doi/abs/10.3109/0142159X.2011.595436\u003c/li\u003e\n\u003cli\u003eThomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education - A Six-Step Approach. Johns Hopkins University Press, Baltimore. 2016;1:312\u0026ndash;312. \u003c/li\u003e\n\u003cli\u003eKlitgaard TL, Gjessing S, Skipper M, N\u0026oslash;hr SB. Becoming a doctor-The potential of a change laboratory intervention. Medical teacher. 2022. s. 1\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003e\u0026Oslash;stergaard D, N\u0026oslash;hr SB. Overgang mellem medicinstudiet og Overgang mellem medicinstudiet og klinisk basisuddannelse i Danmark klinisk basisuddannelse i Danmark. \u003c/li\u003e\n\u003cli\u003eBraun V, Clark V. BraunAndClarke_2006_ThematicAnalysis.pdf. Qual Res Psychol. 2006;3(2):77\u0026ndash;101. \u003c/li\u003e\n\u003cli\u003eChen HC, Van Den Broek WES, Ten Cate O. The case for use of entrustable professional activities in undergraduate medical education. Academic Medicine. 2015;90(4):431\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eEncandela JA, Shaull L, Jayas A, Amiel JM, Brown DR, Obeso VT, m.fl. Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot. Bd. 28, Medical Education Online. 2023. \u003c/li\u003e\n\u003cli\u003eEncandela JA, Shaull L, Jayas A, Amiel JM, Brown DR, Obeso VT, m.fl. Entrustable professional activities as a training and assessment framework in undergraduate medical education: A case study of a multi-institutional pilot. Med Educ Online. 2023;28(1). \u003c/li\u003e\n\u003cli\u003eRoss MT, Cameron HS. Peer assisted learning: A planning and implementation framework: AMEE Guide no. 30. Med Teach. 2007;29(6):527\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eSzulewski A, Braund H, Dagnone DJ, McEwen L, Dalgarno N, Schultz KW, m.fl. The Assessment Burden in Competency-Based Medical Education: How Programs Are Adapting. Academic Medicine. 2023;Publish Ah. \u003c/li\u003e\n\u003cli\u003eZetkulic M, Moriarty JP, Amin A, Angus S, Dalal B, Fazio S, m.fl. Exploring Competency-Based Medical Education Through the Lens of the UME-GME Transition: A Qualitative Study. Academic Medicine. 2024;99(1). \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Clerkships, Medical students, Education, Workplace based learning, Evaluation of competence","lastPublishedDoi":"10.21203/rs.3.rs-4436923/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4436923/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBACKGROUND\u003c/h2\u003e \u003cp\u003eSeveral studies have shown that the medical students express uncertainty and a lack of preparedness in relation to being able to function as a doctor. The purpose of this project was to develop a portfolio with competence cards covering some of the seven medical roles, to introduce these in six departments and to evaluate the medical students\u0026acute; and the clinical supervisors\u0026acute; perception of this intervention.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003eBy using Kern\u0026rsquo;s six step a portfolio consisting of four competence cards was developed to be used in medical students 5-week clinical stay in the fourth year of their studies. Each competence card was intended to be used three times by peer-to-peer, by supervisor and by coordinators, respectively. At the end of the students\u0026acute; clinical rotation interviews were conducted with students and supervisors. The project included three cohorts of medical students. An electronical version of the portfolio was available for the second and third cohort.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eA total of 60 medical students used the competence cards. The students described easier access to supervision and systematic feedback. They appreciated the structure making the learning objectives clear. Both students and supervisors found the competence cards to reflect recognizable clinical situations and preferred the portfolio compared to the normal \u0026lsquo;logbook\u0026rsquo;. The electronic solution was easily accessible and was preferred.\u003c/p\u003e\u003ch2\u003eCONCLUSIONS\u003c/h2\u003e \u003cp\u003eCompetence cards reflecting recognizable clinical situations are a functioning tool for supervision and feedback. The electronic portfolio is appreciated by students and supervision allows training in all sevens doctors roles.\u003c/p\u003e","manuscriptTitle":"Developing and pilot testing competence cards in clinical rotations: medical students’ and supervisors’ perception","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 10:06:18","doi":"10.21203/rs.3.rs-4436923/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b5da99f-e868-4e3b-8c91-9d24036acb7a","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-01T13:43:51+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 10:06:18","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4436923","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4436923","identity":"rs-4436923","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}