The Challenges of Medical Students in Their First Times in Primary Care Outpatient Clinics: an Analysis of 4th Year Medical Students’ Reflective Log Books

Main Article Content

Autchara Angkanapiwat
Ruankwan Kanhasing
Kanokporn Sukhato


Background: The importance of learning experiences in outpatient setting for medical students has been emphasized in the past few decades.

Objective: To identify the 4th year medical students’ challenges during their first encounters with the real patients in primary care outpatient clinic. 

Methods: After the learning in OPD of primary care medicine clerkship, all 4th year medical students of Faculty of Medicine, Ramathibodi Hospital, were invited to write a log book pertaining the reflections on “What is the most challenging issue during your first experiences with patients in OPD?”. A content analysis of total 180 log books was done.  

Results: All students encountered problems in their first-time primary care clinic. The content analysis found four major challenges; 1. Taking patients’ history (taking personal history, taking notes in medical record during the history taking, capturing patient’s concerns, dealing with the third person during the history taking) 2. Doing physical examination (differentiating between the normal and abnormal signs, doing physical examination in the unfamiliar parts) 3. Giving advice and counseling (behaving professionally during the counseling time) 4. Managing their own uncomfortable feelings (creating trust, consideration, excitation, anxiety). The main themes and sub-themes are explained by using participants' direct quotations.

Conclusion: Most students struggled and required support.  The common core challenges that affected to the student’s confidence and their achievement of educational goals were identified. This provided new insights for medical teachers into what they should support for students and how to help students deal with this challenges. 


Article Details

How to Cite
Angkanapiwat, A., Kanhasing, R., & Sukhato, K. (2017). The Challenges of Medical Students in Their First Times in Primary Care Outpatient Clinics: an Analysis of 4th Year Medical Students’ Reflective Log Books. Ramathibodi Medical Journal, 40(1), 40–50. Retrieved from
Original Articles


Faculty of Medicine Ramathibodi Hospital, Mahidol University. Doctor of Medicine (M.D.) program. Faculty of Medicine Ramathibodi Hospital, Mahidol University. Published 2015. Accessed September 23, 2016.

Salama HM, Nour-Eldein H. Final year medical students’ satisfaction with clinical education and family medicine module. Suez Canal University. Egypt. J Contemp Med Edu. 2016;4(3):113-119. doi:10.5455/jcme.20160614032416.

Behmanesh F, Ahanchian H, Vakili R, Ahanchian N, Bagheri S. Teaching final-year medical students in a paediatric ambulatory care unit. Clin Teach. 2014;11(5):361-4. doi:10.1111/tct.12150.

Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70(10):898-931.

Jackson JL, O'Malley PG, Salerno SM, Kroenke K. The Teacher and Learner Interactive Analysis System (TeLIAS): A new tool to assess teaching behaviors in the ambulatory setting. Teach Learn Med. 2002;14(4):249-56. doi:10.1207/S15328015TLM1404_9.

Heidenreich C, Lye P, Simpson D, Lourich M. Educating child health professionals. The search for effective and efficient ambulatory teaching methods through the literature. Pediatrics. 2000;105(1):231-7.

Sakcharoen P. Adult Learning Theory and Self-Directed Learning Concept: Learning Process for Promoting Lifelong Learning. Journal of the Royal Thai Army Nurses. 2015;16(1):8-13.

Laidley TL, Braddock III CH. Role of adult learning theory in evaluating and designing strategies for teaching residents in ambulatory settings. Adv Health Sci Educ Theory Pract. 2000;5(1):43-54. doi:10.1023/A:1009863211233.

Limthongkul M, Aree-Ue S. Sources of Stress, Coping Strategies, and Outcomes among Nursing Students during their Initial Practice. Ramathibodi Nursing Journal. 2009;15(2):192-205.

Peters AS, Feins A, Rubin R, Seward S, Schnaidt K, Fletcher RH. The longitudinal primary care clerkship at Harvard Medical School. Acad Med. 2001;76(5):484-8. doi:10.1097/00001888-200105000-00023.

Vatcharavongvan P. Transformative learning and medical teaching. Thammasat Medical Journal. 2014;14(3):449-59.

Prajankett O. Transformative Learning: Nursing Education Perspective. Journal of the Royal Thai Army Nurses. 2014;15(3):179-184.