International Journal of Educational and Psychological Researches

: 2015  |  Volume : 1  |  Issue : 4  |  Page : 283--288

Investigation of educational interaction among instructors and students in an outpatient clinic

Nikoo Yamani, Mohammad Fakhari 
 Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Science, Isfahan, Iran

Correspondence Address:
Dr. Mohammad Fakhari
Department of Medical Education, Medical Education Research Center, Isfahan University of Medical Science, Isfahan


Introduction: One of the main educational fields in medical education is an outpatient clinic. To better understand the clinical teaching-learning process in outpatient education, the quality of interactions among instructors, students, and patients was investigated in this study.Methods: This was a qualitative study which was conducted in an educational hospital at the Department of Surgery. The researcher observed interactions for 5 months and analyzed the 5th month's data only. All observations were narrated and qualitative content analysis method was adopted to analyze the data. Result: A total of 68 codes are extracted. The classification of revealed codes led to the generation of 10 sub-themes and four main themes. The theme "the instructional interaction" consists of "variety in teaching methods, selective educational content, instructors coordination, and course content based on educational needs" sub-themes. The theme "instructional management" consists of educational supervision and time management sub-themes. The theme "interactive learning" consists of "learning through interaction with patients" and "learning through interaction with peer" sub-themes. The theme "instructor as a role model" consists of "respect to codes of conduct" and "respect to patient's right" sub-themes. Conclusion: To enhance teaching and learning effectiveness in outpatient setting, more attention should be paid regarding the main themes of this study. More studies are needed to explore the quality of educational interaction in other clinical setting.

How to cite this article:
Yamani N, Fakhari M. Investigation of educational interaction among instructors and students in an outpatient clinic.Int J Educ Psychol Res 2015;1:283-288

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Yamani N, Fakhari M. Investigation of educational interaction among instructors and students in an outpatient clinic. Int J Educ Psychol Res [serial online] 2015 [cited 2021 Jun 21 ];1:283-288
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Outpatient setting in educational hospital is one of the main situations of medical student training.[1] In recent decades, medical education faced the gradual transition in medical training that is from inpatient to outpatient clinical education. According to the regulations of Iran Ministry of Health and Medical Education, half of the education and training time of the medical students should be assigned to training in outpatient setting.[2] In the related literature, many advantages of outpatient education are mentioned. Outpatient clinic is the best learning situation for students to inspect normal patterns of disease and provide proper information on the true spectrum of disease prevalence in the community. Furthermore, students could follow-up effects of treatment on patient. In addition, the students' become familiar with the approaches in interacting with the emotional and social aspects of the patients.[3],[4]

The main point of medical education in outpatients is that the graduated medical students would have an overview of prevalent diseases in their community in order to serve their communities' needs, and become competent in patient management and treatment.[2]

Despite the importance of outpatient training in medical education, the available evidence indicates that the medical students and the graduated general physicians are not satisfied with outpatient clinic education.[5],[6] Most of the findings focused on environmental and facilities issues in outpatient clinics;[6],[7] but the results of some studies revealed that outpatient education suffers from inappropriate educational methods, lack of interaction among instructors-student and instructor-patient.[2],[5],[8] Evaluation of clinical course indicates that insufficient interaction between students and instructors. Furthermore, students as a passive learner.[9]

There is no convincing research on quality of instructor–learner interaction in clinical education. The previous studies used questionnaire or cross-sectional observation by a checklist to assess efficiency of assets in outpatient settings.[3],[10] We must consider that instructor-learner relationship, and their interaction could be investigated by Inductive content analysis of longitudinal observation of their behavior.[11] Hsieh and Shannon[12] believed that conventional content analysis is appropriate for content analysis of qualitative data when available research literature on a phenomenon is limited for analysis and categorization of data. This approach allows categories and their titles extracted from the data.[13] Since there are limited researches on the quality of interaction between teacher and students in outpatient clinics, in this study, the qualitative content analysis of observation was used in one outpatient clinic to describe the quality of interaction in one educational course.


This was a qualitative study which was conducted in the Surgical Department of an Educational Hospital in Iran. The researcher explained objectives of the study to hospital authority and instructors then permission for observing ambulatory setting obtained. The researcher guaranteed the confidentiality of all the aspects in his study.

The study period was from mid-January to mid-June 2014. Observer presence in the field was scheduled as 4 days in a week, 8–11 AM. The researcher observed interaction among five instructors, 11 residents and 22 interns in nine internship courses and 58 externs in 10 externship courses, in 5 months period, to best understand the educational setting and the individuals. To decrease the probability of the Hawthorne effect of observation on instructors and students' behavior, only the observations of the 5th month were narrated and analyzed in this study.

The researcher as a nonparticipant observer chose a point with a good view in the outpatient clinic room and listened to the conversation while watching the behavior of his study subjects. The researcher recorded his observation in narrative details. In the 5th month, he observed and narrated the interactions among 5 instructors, 11 residents, and 6 interns in two internship courses and 18 externs in three externship courses.

To analyze the narrative recorded contents of observation, first the manifest codes and then latent codes of interactions were extracted. Researcher combined the similar codes.[14],[15] The Elo and Kyngäs method was adopted to categorize codes that include open coding, creating categories, and abstraction in sub-themes, according to which the main themes obtained.[11] To increase the credibility of the content analysis, the researcher extracted codes under the supervision of an expert in qualitative researches. The themes and sub-themes were re-examined by that expert qualitative researcher to interpret the content of each theme, and to identify consistencies and incongruities.


The results of the qualitative content analysis of the 5th month observation of interactions were a total of 68 codes, 10 sub-themes, and 4 themes [Table 1]. In the following all themes and related sub-themes are explained in detail.{Table 1}

The instructional interactions

The instructional interaction theme is the first theme of this study. It was obtained due to the categorization of 26 codes into four sub-themes. In the following section, we continue to explain these sub-themes.

Variety in teaching methods

Variety in teaching methods is the first sub-theme in the instructional interaction themes. Observation of interaction revealed that instructors adopted different teaching methods. Mini lectures, case presentation and problem-solving are the most common teaching methods. In the case presentation method, each Student must select some patients and interview with them in the next room before attending the instructor in an outpatient clinic. At the presentation time, student must deliver the summarized and organized medical history, differential diagnosis, and treatment plan for each patient to the instructor. Two instructors used mini-lecture to teach diseases for them a suitable case for the presentation were not admitted to the clinic. In the problem solving method, instructor describes a case and asks students to offer differential diagnosis and treatment plans. Three instructors adopted each teaching methods according to educational opportunity. Two instructors adopted only problem-solving for teaching. One of them prepared some selected radiologic negatives of the previous patient as proper cases to teach radiologic test interpretation. One of the observations regarding case presentation teaching method is worded as below:

"A student told a summarized medical history and the listed medical problem of a patient. The instructor asked all students to list probable differential diagnosis. Three students told five differential diagnoses for this patient. Then the instructor explained the correct differential diagnosis and described how to treat this patient and other patients with the same disease. The instructor explained the proper physical examination and clinical tests in verifying the differential diagnosis and treatment for each determined diagnosis."

Selective educational content

This sub-theme is obtained from the codes that related to the consistency between predefined educational content and delivered content by the instructors. Observation of educational interaction revealed that every instructor selected some subjects as educational content based on his expertise with no regards to the students' needs. For example, one instructor who is an expert in abdominal tumors set most of educational content on how to diagnose and treat these diseases. He used case presentation for delivery of selected content. Sometimes he presented a short-mini lecture regarding the common illnesses as to complete the training content. As mentioned previously, one instructor, in general, concentrated on the interpretation of radiologic test and believed the interpretation of radiologic negatives was a necessary skill to be accomplished by every physician. One instructor focused on education of the history taking skills to externs and notified that these skills were the most essential skill to be accomplished by physicians. Another instructor emphasized that the patient education as the core treatment plan, thus, he described the proper techniques to educate patients.

Instructors coordination

This sub-theme is obtained from the codes that related to coordination among instructors as team members. Observation revealed the instructors do not follow the team-oriented approach. When an instructor was absent, there was no substitute for him. In this situation, a senior resident might deliver mini-lectures to externs. Interestingly, one of the instructors could not be present for a month due to an educational trip; the training session of this instructor was not resumed by other instructors.

Course content based on educational needs

In this outpatient clinic, three levels of learners such as resident, intern, and extern were taught simultaneously. Educational content was the same for all learners. No difference was observed in the content for students in the internship and externship training. Since interns had passed the course previously as externs, most content was reiterating for them. For example, one intern claimed that "during externship I heard the same discussion with same details. Instructors did not consider the interns educational needs. They focused only on the externs".

Observation revealed that Instructors notified the student about the importance of educational experiences in preparation to serve the community needs. However, they presented issues that were not related to general physician educational needs directly. Instructors mentioned that these contents would not be so practical for students after graduation. They argued that these contents were delivered to inform students only. Once a student asked a specific question from an instructor, he told "there exist more than a thousand essential issues to learn, but you are asking this special question. You are neither a surgeon nor a specialist who takes care of the patient after surgery. A general physician must know the necessities in cancer such as screening and referral process, first learn the necessities and then look for non-compulsories".

Instructional management

The instructional management theme was the second theme of this study. It was obtained due to the categorization of 12 codes into two sub-themes. In the following section, we continue to explain these sub-themes.

Educational supervision

The instructors must supervise student's behaviors in the educational setting. Observations revealed that the course planner listed names of students for each course. In some days, the number of students decreased obviously. In these situations, instructors filled out attendance sheet. In most days, instructors did not control the students' presence. On the other hand, the instructors for each session were predetermined in the schedule. Sometimes two instructors worked in outpatient clinic simultaneously. In these days, students were confused to be present in which instructor educational room. Each student worked with either of the instructors on their will. For example, in 2 days that two instructors attended in outpatient clinic simultaneously, 1-day all student went in one room while six externs, three interns, and one resident attended in that room and all chair filled by students. In the next day, four externs and one intern were attended in another room and were supervised by another instructor. In these days, none of the instructors made any objection on this incident and did their work.

Time management

Educational time is limited for the instructors and time management must be exact and accurate to allow them to teach and perform their medical duties. To compensate for any shortening in time, they went through their training session in a rapid speech and manner. Most often them did not wait for the students to think and answer questions. They answered their own questions quickly. Their presentation was so fast that the students have difficulty in taking notes. But two instructors used most of time for teaching. They assigned their medical duties to their senior-residents and supervised them. These instructors spent more time on teaching and interacting with the students. They spoke slowly and waited for student to think and reply the questions.

Interactive learning

The interactive learning theme was the third theme of this study. It was obtained due to the categorization of 13 codes into two sub-themes. In the following section, we continue to explain these sub-themes.

Learning through interaction with patients

Student-patient educational interaction was the main learning experience in clinical education. Observations indicate that some students intended to interact with patient. All interns and some externs were not willing for these interactions. They sat on chairs and talked. Some students read their booklet. In almost days, some active students participated in the educational activity and tried to reply the instructor's questions. Sometimes instructor forced student to be active in the outpatient clinic. For instance, once a resident could not tolerate the situation and told all students:

"At the final exam, five grades must be given to the interns by the residents and inactivity in the clinic will reduce your final grade. You should know that we were very serious as the inactive students will not score the point. While the resident warned inactive students, an intern left the room to take a medical history from the patients. Furthermore, inactive externs became more active in their performance in this respect."

Learning through interaction with peer

Peer learning was the effective teaching-learning strategy. Observation revealed each rank of student has predetermined chair in the room. Resident and intern sat next to the instructor desk. Resident did not participate in instructional activities and most of time served as an assistant for instructor in visit and treatment of patients. Especially junior residents were less interested in training; they mostly interacted with their senior colleagues. When instructor was absent, the senior resident taught some educational issues. Interns sat next to one another and interacted less with the externs. The interns asked questions from the residents who sat next to instructors' desk. Externs intended to ask their question from other externs. For instance, during mini-lecture, an extern asked the extern next to him about the abbreviation used by the instructor, he did not know. The extern did not ask his question from the instructor. He waited and asked another extern and got the proper respond while the extern next to him listen the response as well".

Instructor as a role model

The instructor as a role model theme is the last theme of this study. It obtained due to the categorization of 18 codes into two sub-themes. In the following section, we continue to explain these sub-themes.

Respect to codes of conduct

Many specific codes of conduct are defined in the field of medicine. Respect to codes of conduct is worthless and is absorbed through observation of role model behavior. The students looked at their instructors as role models and learned the behavioral pattern with respect to the instructor's administrative esteem. Our observations indicated that instructors had different behaviors in the out-patient clinic. Some observed interactions revealed the professional standards. Two instructors attended in outpatient room on time, with their white cover and name tag on. They tried to behave in accordance with the defined codes of conduct. They notified the students' to respect professional behavior in medical profession. But two instructors did not respect the predefined rules. They entered in different times, sometimes with no white coat.

Respect to patient right

Observations indicated that two instructors supervised the student-patient interactions closely. They constantly reminded the students on the importance of carefully listening to the patients complain and the importance of patient satisfaction in medical profession. Instructors did not allow re-examination of the patient for the training purpose. The student felt a limitation in learning the opportunity to carry out a physical examination. One day a student complained and the instructor told him "patient is a human with all his rights and we cannot allow him/her to be exposed to multiple physical examinations for the purpose of training. In addition to the resident, only one intern is allowed to check the patient".


This study was conducted to describe the quality of educational interaction in an outpatient clinic. The main themes introduced here were the Instructional interaction. In this educational outpatient clinic, instructors used multiple teaching methods and more emphasis on the selective educational content with respect to the externship educational needs. Donetto believes that the medical instructors adopt Banking Model in their patients training.[16] Another study showed that most instructors did not promote dialog and used one-way knowledge transfer to inform student.[17] In clinical education, instructional interaction and feedback is rare[18] their general approach of teaching is based on Banking Model of teaching as less emphasized on learning by doing or self-learning and active participation in teaching-learning process.

Instructor used variety of teaching methods in clinical education based on teaching situation. Nevertheless, this study indicates that instructors did not pay attention to defined teaching steps of each teaching method in the literature. Instructors did not prepare the requirements and prerequisites of their chosen teaching methods. In recent, SNAPPS model is the most recommended method to teaching in outpatient clinic.[4] But instructors did not use this model to teaching in this field. It should be mentioned the effectiveness of recommended teaching methods is not verified in previous studies.[19]

In clinical education, instructors are considered as an educational team. Coordination among the instructors in an educational team is of essential importance when it comes to training efficiency. They must cover all necessary content and pay attention to the difference in educational needs of students, this is while observations here indicate that the teaching content does not correspond to the interns' needs. In one study, Haphazard Teaching term was used to describe teaching process in clinical setting.[20] Recently, vertical integration of medical curriculum is praised in clinical education.[21] In the vertical integration of medical curriculum, through the students experience different clinical courses, as their levels increase, the complexities of the material increases as well.[22]

Instructional management is another theme in this study. In a study regarding instructors' roles and responsibility, course planning was the preteaching skills of the clinical teacher.[23] In clinical education, curriculum developers and course planner designed realistic training programs in regard to regional conditions in clinical education.[24] Accordingly, the instructors have enough authority to change the schedule if necessary. This study revealed those clinical instructors were not prepared to apply instructional management skills.

Interactive learning is another important theme in clinical education. Enthusiasm for teaching and learning is essential in interactive learning. It was observed in this study that the students were not motivated in participating in interactive learning, especially interns. According to the study conducted by Marshal, instructors and learners must have enthusiasm regarding their duties.[17] They must take attention to promote motivation for learning. Teaching based on the trainees' needs is a main factor to increase motivation.[25] According to Marshal Study, there is no correspondence between the students' needs and educational content in medical training.[17]

Interactions among junior and senior students were emphasized in Peer learning. Residents' participation in teaching process is considered as peer learning in medical education. The observations indicated a weakness in this respect. Peer learning is very important in externship course. The externs have learned the basic sciences and must try to integrate this knowledge to clinical experience. Studies regarding this issue indicate that basic sciences are forgotten when the students enter clinical training courses.[26] Some approaches used to increase integration of basic sciences in clinical training, Spencer et al. address new procedure where the basic sciences contribute to the clinical knowledge.[27]

Role modeling of clinical instructors are emphasized in the literature.[23] The instructors must be careful with their conduct and behavior since they represent Role-Model, part of the hidden teaching concept, for the students.[24] Results of a previous qualitative study by Yamani et al. revealed student learned professional manner through observation of their instructor's behavior.[28]

This study has some advantages such as decline the Hawthorne effect by longitudinal observation of interaction. Single nonparticipant observer, the 5th month analysis of observation and re-examination of codes extraction by expert qualitative researcher are others advantages that improve the credibility of findings. We must consider that findings of the qualitative study are not generalizable to other clinical situations. However, the findings may be transferable to same clinical settings.


Four main themes were extracted in this qualitative content analysis of teacher-student interactions. Instructional interaction and Instructional management as well as Instructor as a role model were three main themes which dealt with the concern of teacher interaction regarding students in clinical education. Interactive learning was a theme regarding interaction among student and patient. This study focused on educational interaction in an outpatient clinic. More studies are needed to deepen understanding of instructional and noninstructional interactions in outpatient and inpatient clinical education.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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