Students’ perceptions of relationships between some educational variables in the out-patient setting D H J M Dolmans, 1 H A P Wolfhagen, 1 G G M Essed, 2 A J J A Scherpbier 3 & C P M van der Vleuten 1 Background Medical education uses the cognitive apprenticeship model of student learning extensively. Students rotate among different hospitals and out- patient clinics where they are exposed to a range of professionally relevant contexts. Here they learn to think and act in different domains under the supervi- sion of experts. Previous research has shown that these learning situations involve little teaching. Students see a narrow range of patient problems and feedback is lim- ited. The aim of this study is to investigate relationships among some educational variables in the out-patient clinic. Method This paper provides a theoretical model that specifies the factors influencing the effectiveness of student rotations at out-patient clinics. The model makes distinctions between input variables, such as organizational quality, number of students contem- poraneously involved and available space, and process variables, such as patient mix and supervision, and the output variable of the effectiveness of rotations in out- patient clinics. Results The model was tested against empirical data from evaluative surveys and showed a reasonable fit. The model offers suggestions for improving the learn- ing environment of clinical rotations. Discussion The strength of this study lies in its process evaluation perspective which investigates interactions between intervening variables rather than the influence of particular variables in isolation from other variables. Keywords education, medical, undergraduate ⁄ *methods; teaching ⁄ *standards; curriculum; clinical competence ⁄ *standards; hospitals, teaching ⁄ standards; ambulatory care facilities. Medical Education 2002;36:735–741 Introduction The cognitive apprenticeship model of student learn- ing, in which a student or novice learns a domain- specific way of thinking and acting from an expert while working in professional practice, is a very old instruc- tional model. 1 This model has been used extensively in medical education for many years. In current under- graduate medical education, this means that students rotate among different hospitals and out-patient clinics, where they are confronted with doctors who are experts in different domains. During these rotations, students learn to think and act under the supervision of experts. Exposing students to a professionally relevant con- text is generally assumed to be preferable to a learning environment that is not context-bound. 2 During rota- tions in hospitals, medical students are confronted with problems in a maximally authentic fashion. Clinical rotations should therefore provide a powerful environ- ment for student learning. They are not, however, without problems. The learning experiences of students during rotations in hospitals and out-patient clinics are characterized by variability, unpredictability, and lack of continuity. Irby’s extensive review study demonstra- ted that students see a narrow range of patient problems in a single clinic and relatively few cases are discussed with attending doctors. 3 When cases are discussed, this usually involves little teaching and virtually no feedback is provided. Schamroth and Haines concluded that students receive relatively little feedback and supervision when examining patients and that students are only passively involved. 4 This study 1 1 Department of Educational Development and Research, Maastricht University, Maastricht, The Netherlands 2 2 Department of Obstetrics Gynaecology, Maastricht University, Maastricht, The Netherlands 3 3 Institute for Medical Education, Faculty of Medicine, Maastricht University, Maastricht, The Netherlands Correspondence: Diana Dolmans, University of Maastricht, Department of Educational Development and Research, PO Box 616, 6200 MD Maastricht, The Netherlands. E-mail: d.dolmans@ educ.unimaas.nl Developing professional skills Ó Blackwell Science Ltd MEDICAL EDUCATION 2002;36:735–741 735