During doctor of audiology graduate programs, students are expected to complete coursework and clinical training experiences across the breadth of the profession. Depending on the curriculum of the school and the clinical experiences available, the quality of their clinical training may vary, particularly in some of the specialty areas within audiology. With this in mind, the team of audiologists at the Intermountain Healthcare Hearing and Balance Center in Salt Lake City, Utah, has worked to create resources and use teaching methods to enhance the learning of our students during their semester-long internship. The goal is to provide a more structured, enriching clinical experience and expand upon what they have learned in the classroom.
Although this article is written from the perspective of a clinic specializing in vestibular assessment and management, readers will find that the ideas presented are easily transferable to various areas of clinical audiology education. This article describes the methods and resources regularly used in the training of graduate students at this clinic including: orientation, exams, grand rounds, reflection, and feedback. We discuss the rationale behind their implementation, as well as ideas for future direction.
On the first day of their internship, students are provided with a tour of the clinic, a folder containing orientation paperwork, and a discussion of expectations and goals. Establishing expectations is an important part of ensuring positive clinical education outcomes (Mormer et al, 2013). This is accomplished through the review of worksheets and checklists that describe expectations and assignments to be completed during the internship. For a list of the documents provided in the orientation packet, see FIGURE 1.
An entrance assessment, a 50-question exam, is administered during orientation. This will be addressed in the following section. Additionally, a list of references for texts and articles that our audiologists regularly use is provided to students. Many of these texts are owned by the audiologists and are available in our shared office space for students to review as needed. This provides students with information to reference, should a need for further clarification arise. Having a clearly organized orientation with accompanying paperwork provides time for the clarification of requirements and allows the program to move forward efficiently.
Testing: Exams and Quizzes
Our internship program uses exams and quizzes as a way to track progress and review necessary information. An entrance and an exit exam are completed on the first day of the rotation and again during the third-to-last week, respectively. Each exam consists of 50 questions concerning concepts essential to vestibular disorder evaluation and management. Questions are either fill-in-the-blank or multiple-choice and focus on topics such as normative data for vestibular diagnostics (e.g., caloric asymmetries, cVEMP thresholds, etc.). The entrance and exit exams enable supervisors to track students’ acquisition of knowledge during the semester and provide us with feedback on what topics may be underrepresented. The questions on the exams are a sample taken from a series of 10 quizzes.
These quizzes are administered throughout the semester in an online format and consist of 10 to 15 questions. Each quiz has a specific topic relevant to clinical practice. A list of these can be seen in the checklist in FIGURE 2. Quizzes allow students to determine what they have committed to memory and what they need to review, thereby using the learning strategies of retrieval practice and calibration (Brown et al, 2014, p. 201, 210). Testing provides a method for tracking student progress and conveying necessary information. An additional goal is to create a longer lasting and more durable knowledge base of the vestibular system for students.
Grand Rounds and Reflection Practice
Grand rounds are a common teaching practice in medical settings. These sessions remind audiology students of the importance of evidence-based practice (Hall, 2018) and provide an opportunity for reflection on clinical cases. The format used in this clinic is outlined on a checklist provided to students. It requires them to write a de-identified case report detailing history, findings, interpretation, recommendations, and a discussion of evidence used in their report, if applicable, along with a few sentences discussing their reflections on the appointment. During the first few weeks of the internship, cases are presented by preceptors to provide students with a better understanding of what is expected. After this period, weekly cases are agreed upon by the preceptor and student and then presented by the student at the following week’s grand rounds meeting.
Following this structure encourages students to generate a report on their own prior to receiving feedback from supervisors. It also provides students with the opportunity to reflect on what did and did not go well during the appointment, along with how they might improve. Practicing reflection and generation can have strong benefits for learning (Brown et al, 2014).
Feedback, Confidence Levels, and Goals
The role of feedback in contributing to positive clinical learning outcomes has been discussed in the previous work of Mormer and colleagues (2013). In this clinic, feedback is provided with the use of regular pre- and post-appointment discussions, along with formal skills assessments. The former is largely informal and completed before and after seeing patients to discuss what will be important in the appointment and to review what was covered. Skills assessments are completed by using a checklist to evaluate students on patient care, knowledge, efficiency, reliability, and clinical skills. Both of these provide the opportunity for preceptors and students to engage in constructive conversation and provide feedback to each other.
Confidence-level assessments are another useful resource that has been implemented. Students are asked to rate their confidence level in both performing and interpreting various procedures at the beginning, middle, and end of the semester. Responses are tracked on a spreadsheet (FIGURE 3) and are used to inform the team of specific procedures that may require further instruction. The assessment completed during the middle of the semester also includes a section for student feedback on what she or he personally would like to work on during the remainder of the semester. This presents the opportunity for interns to think critically about their strengths and weaknesses and provides them with the opportunity to steer learning toward their goals.
With busy schedules and fallible brains, having a document that is accessible to all preceptors that describes the goals and processes of the internship, outlines the assignments for students, and contains a centralized list of all documents has been crucial for staying organized. In addition to this document, we also use a number of checklists to outline the specific requirements for each assignment. A sample of the checklist we use for student assignments during the semester is shown in FIGURE 2. It has been very beneficial to display this checklist in an accessible area to facilitate the easy and efficient tracking of progress for both students and preceptors.
Ideas for Future Directions
Many discussions have occurred in our clinic about what resources and assignments will be most beneficial for students without overwhelming them or the preceptors. To accomplish this, we have worked to implement ideas from research in clinical audiology education and from research in learning processes. Although this article is not a comprehensive review, in our experience implementing the aforementioned ideas has led to increased student engagement and better learning outcomes.
Some ideas for future development include a more structured use of questions to promote higher level critical thinking and regular journal article reviews (Mormer et al, 2013; Hall, 2018). On a larger scale, researchers interested in clinical audiology education may investigate whether or not a highly structured clinical education experience can lead to better clinical abilities and knowledge acquisition.
This clinic’s objective is to develop our students’ knowledge base and clinical skill set in vestibular assessment and management. The ideas presented in this article, however, should be easily transferable to other areas of clinical education within audiology. Our hope is that, by developing the resources discussed here and standardizing our students’ experiences, all students are provided a well-rounded training experience.
Securing the time and support to develop a structured program may be a barrier at first. It has been our experience that, once resources are created, there is generally little time spent on maintaining the program. Our curriculum continues to evolve as new ideas are implemented and previous resources are updated. We hope that readers, preceptors and students alike, find the information presented in this article useful and seek to expand upon it.