Core Clerkship Research Articles

Pimping: Valuable Teaching Tool or Mistreatment? Perceptions of Medical Students and Faculty Differ.

ImportanceThe AAMC Graduate Questionnaire has drawn attention to medical student mistreatment. Pimping, a form of Socratic teaching often used in medical education where students are singled out by faculty for questioning, may be considered by some students and faculty as mistreatment. To date, minimal research has been performed on the viewpoints of students and faculty regarding pimping and its relation to mistreatment. ObjectiveThis study aims to formally define pimping and determine if there is a difference in the perception of students and faculty on its role in medical education.Design: Medical students and faculty of Michigan medical schools were surveyed via electronic questionnaire. Chi-squared and Fisher’s exact tests were performed.SettingMedical schools within the state of Michigan ParticipantsStudents who had completed their core clerkships and faculty with experience educating medical students in a clinical setting ResultsThe student response rate was 42%; the faculty response rate could not be determined. The majority of students agreed with our operational definition of pimping and 100% had experienced pimping. 54% of students reported a positive experience with pimping, 26% neutral, and 20% reported a negative experience. The majority of students reported it was challenging and educational and should be used regularly. Several differences were found between students and faculty as to why faculty use pimping. Students’ perception of their role on the clinical care team influenced their perception of pimping as mistreatment, and students reported pimping made them feel more a part of the team.Conclusion and relevanceThis study helps to define pimping and sheds more light on the perceptions of pimping from students and faculty and their differences. Most medical students report a benefit from pimping, even though it may be stressful, and suggest it should be used regularly, which is in contrast to faculty opinion. Pimping may make students feel more a part of the clinical care team, but their role on the team may not influence whether they perceive it as mistreatment.  Our data suggest medical schools should educate students and faculty on pimping and not move toward discouraging or banning it.

Residency Program Director Perceptions of Resident Performance Between Graduates of Medical Schools With Pass/Fail Versus Tiered Grading System for Clinical Clerkships: A Meta-Analysis.

Purpose: The variability and imprecision of clerkship grading raise concerns for program directors (PDs) during applicant selection. 1 Although the majority of medical schools have adopted pass/fail (P/F) preclinical grading, only 12 schools formally use P/F grading for clerkships. 2 Additionally, per Liaison Committee on Medical Education recommendations, events such as Hurricane Katrina and the COVID-19 pandemic have led additional schools to adopt P/F clerkship grading temporarily. 3 Moreover, the rise in studies describing student- and institutional-level disparities in clerkship grading has tasked medical education personnel with weighing the fairness and risk of disparities as well as the potential benefits of tiered grading. 1,4 With the continued paucity of literature examining P/F grading in core clerkships, 5 we conducted a meta-analysis of studies comparing PDs’ perceptions of residency performance among residents from schools using P/F versus tiered clerkship grading systems. Approach/Methods: Embase, PubMed, and Scopus were searched since inception through October 2020, and hand searches were performed of the retrieved reference lists. No study or language restrictions were applied. Studies exploring P/F clerkship in the context of a cohort of PD assessments were included, and the CLARITY risk of bias was used. Reviewers assessed study characteristics, overall resident performance, learning ability, work habits, work products, educational assessments, and PD’s personal evaluation (worse: 0 to best: 100), and were assessed using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. To account for different survey and grading metrics, adjusted standard difference in means were used. Main outcomes and measures were program director ratings of residents from U.S. medical schools using tiered versus P/F clerkship grading. Results/Outcomes: From 4,931 studies screened, we identified 6 eligible studies (3 cohort, 3 surveys; 6 low risk of bias) with 2,118 participants. From 31 accredited medical specialties, 7 specialties were represented with a median response rate of 81.0% (95% CI, 49.0–100.0). Reported as means, there was no difference in PD preference for residents from P/F or tiered grading system throughout residency training (37.0% Tiered; 95% CI, 0–100, P > .05). Adjusted scaled scores utilizing mean difference from an equal variance model from PDs showed overall performance (5.5; 95% CI, –1.9 to 12.9), learning ability (2.7; 95% CI, 0–5.4), work habits (2.9; 95% CI, 0–5.8), personal evaluations (–1.6; 95% CI, –3.8 to 0.6) and educational evaluation (1.7; 95% CI, –0.8 to 4.3) of residents from tiered clerkship grading systems were not statistically significant (P > .05) from P/F residents. However, there was a difference in work products produced (6.8; 95% CI, 1.4–12.2, P < .0001). Meta-regression standard difference in means revealed that there is no difference in tiered applicant’s overall performance in residency compared with P/F applicants (0.0001 fixed, P = .98; –0.0047 random, P = .81) Discussion: Clerkship performance has often been used as a metric to assess medical student preparedness for residency. 1,2 While PDs reported that residents from medical schools using P/F clerkship gradings tended to perform slightly lower on average, these results were not statistically significant. In addition, PDs did not generally prefer applicants from tiered medical schools. Given the continued expansion of P/F grading in medical school curricula, our findings allow for early discussion regarding the implications of P/F clerkship grading and its anticipated reception by stakeholders. Significance: In our cohort, there appears to be no perceived difference in resident performance based on clerkship grading system. This study provides further impetus for discussion of wider adoption of P/F grading in clinical clerkships.

Roles and Responsibilities of Medicine Subinternship Directors : Medicine Subinternship Director Roles.

The internal medicine (IM) subinternship (also referred to as acting internship) plays a crucial part in preparing medical students for residency. The roles, responsibilities, and support provided to subinternship directors have not been described. We sought to describe the current role of IM subinternship directors with respect to their responsibilities, salary support, and reporting structure. Nationally representative, annually recurring thematic survey of IM core clerkship directors with membership in an academic professional association as of September 2017. A total of 129 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited U.S./U.S.-territory-based medical schools. Responsibilities, salary support, and reporting structure of subinternship directors. The survey response rate was 83.0% (107/129 medical schools). Fifty-one percent (54/107) of respondents reported overseeing both core clerkship inpatient experiences and/or one or more subinternships. For oversight, 49.1% (28/53) of subinternship directors also reported that they were the clerkship director, 26.4% (14/53) that another faculty member directed all medicine subinternships, and 18.9% (10/53) that each subinternship had its own director. The most frequently reported responsibilities for the subinternship directors were administration, including scheduling, and logistics of student schedules (83.0%, 44/53), course evaluation (81.1%, 43/53), and setting grades 79.2% (42/53). The modal response for estimated FTE per course was 10-20% FTE, with 33.3% (16/48) reporting this level of support and 29.2% (14/54) reporting no FTE support. The role of the IM subinternship director has become increasingly complex. Since the IM subinternship is critical to preparing students for residency, IM subinternship directors require standard expectations and adequate support. Future studies are needed to determine the appropriate level of support for subinternship directors and to define essential roles and responsibilities.

What Does Honors Mean? National Analysis of Medical School Clinical Clerkship Grading

Medical Student Performance Evaluation (MSPE) letters provide critical comparative information about clerkship performance, and are a crucial part of the surgical residency application. The elimination of USMLE Step 1 numeric reporting increases the importance of transparency, standardization, and accessibility of comparative information reported on the MSPE. The objective of our study was to measure the variability in clerkship grade reporting on the MSPE from US medical schools, particularly focusing on the highest (honors) grades. We identified representative MSPE letters from US medical schools and recorded the percentage of honors for 5 core clerkships. We grouped medical schools according to medical school rankings, geographic region, and number of grading categories RESULTS: Of 122 medical schools, 106 schools (87%) reported their grading scheme and percent honors. The most commonly used grading scheme was a 4-tier system (51/122; 42%). The percentage of honors was highly variable (from 1-91%) and did not vary by region. However, schools in the top 20 research ranking were less likely to report grade comparisons (30% vs. 10%), and more likely to award more students honors in 4 of the 5 clerkships. Schools in the top 20 primary care ranking were more likely to award more honors in the medicine clerkship. There is significant variability in the number of grading tiers used and the percentage of students awarded honors across US medical schools. Factors that correlated to higher grades included schools with higher rankings, and higher ranked schools were less likely to report comparative information at all.

Teaching Telemedicine in the COVID-19 Era: a National Survey of Internal Medicine Clerkship Directors.

BackgroundPrior to the COVID-19 pandemic, telemedicine (TM) experiences in undergraduate medical education were uncommon. When students’ clinical experiences were interrupted due to the pandemic, TM education provided opportunities for students to participate in clinical care while adhering to social distancing guidelines.ObjectiveTo assess the prevalence of TM experiences in the internal medicine (IM) core clerkship experience prior to the COVID-19 pandemic, during interruption in clinical clerkships, and following the return to in-person activities at US medical schools.DesignThe Clerkship Directors in Internal Medicine (CDIM) survey is a national, annually recurring thematic survey of IM core clerkship directors. The 2020 survey focused on effects of the COVID-19 pandemic, including a section about TM. The survey was fielded online from August through October 2020.ParticipantsA total of 137 core clinical medicine clerkship directors at Liaison Committee on Medical Education fully accredited US/US territory–based medical schools.Main MeasuresA 10-item thematic survey section assessing student participation in TM and assessment of TM-related competencies.Key ResultsThe response rate was 73.7% (101/137 medical schools). No respondents reported TM curricular experiences prior to the pandemic. During clinical interruption, 39.3% of respondents reported TM experiences in the IM clerkship, whereas 24.7% reported such experiences occurring at the time they completed the survey. A higher percentage of clerkships with an ambulatory component reported TM to be an important competency compared to those without an ambulatory component.ConclusionsThe extent to which TM was used in the IM clinical clerkship, and across clinical clerkships, increased substantially when medical students were removed from in-person clinical duties as a response to COVID-19. When students returned to in-person clinical duties, experiences in TM continued, suggesting the continued value of TM as part of the formal education of students during the medicine clerkship. Curricula and faculty development will be needed to support TM education.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-07061-4.

Applying the Plan-Do-Study-Act cycle in medical education to refine an antibiotics therapy active learning session

BackgroundActive learning improves learner engagement and knowledge retention. The application of continuous quality improvement methodologies, such as the Plan-Do-Study-Act (PDSA) framework, may be useful for optimizing medical education, including active learning sessions. We aimed to enhance student satisfaction and achievement of learning outcomes by applying the PDSA framework to an antibiotic utilization curriculum for medical students.MethodsGuided by the Plan-Do-Study-Act framework, between February 2017 and July 2019, we developed, implemented, and revised an active learning session for medical students, focused on appropriate utilization of antibiotics during their Internal Medicine clerkship.ResultsAcross twelve sessions, 367 students (83.4%) completed the post-evaluation survey. Although baseline ratings were high (97% of respondents enjoyed the “active learning” format), constructive comments informed iterative improvements to the session, such as modifying session timing, handouts and organization of the gaming component. Intervention 3, the last improvement cycle, resulted in more favorable ratings for the active learning format (p = 0.015) improvement in understanding antibiotics and their clinical application (p = 0.001) compared to Baseline ratings.ConclusionsThis intervention suggests that active learning, with regular incorporation of student feedback vis-à-vis a PDSA cycle, was effective in achieving high student engagement in an Internal Medicine core clerkship session on antibiotic therapy. Iterative interventions based on student feedback, such as providing an antibiotic reference table and answer choices for each case, further improved student receptivity and perceived educational value. The study findings have potential implications for medical education and suggest that the application of the PDSA cycle can optimize active learning pedagogies and outcomes.

Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting.

IntroductionIncidents of bias and microaggressions are prevalent in the clinical setting and are disproportionately experienced by racial minorities, women, and medical students. These incidents contribute to burnout. Published efforts to address these incidents are growing, but gaps remain regarding the long-term efficacy of these curricular models. We developed and longitudinally evaluated a workshop that taught medical students a framework to respond to incidents of bias or microaggressions.MethodsIn October 2019, 102 Vanderbilt core clerkship medical students participated in an hour-long, interactive, case-based workshop centered around the 3 D's response behavior framework: (1) direct, (2) distract, and (3) delegate. Participants were surveyed before and after the training, and both qualitative and quantitative data were collected. A refresher workshop was offered 8 months later, which added two additional D's: delay and display discomfort.ResultsAfter the workshop, respondents’ knowledge of the assessed topics improved significantly, as did their confidence in addressing both personally experienced and witnessed incidents. Respondents initially indicated a high likelihood of using response behaviors to address incidents. The workshop did not consistently modify behavioral responses to experienced or witnessed incidents. Ninety-one percent of respondents agreed the workshop was effective.DiscussionThis workshop provided an effective curriculum to sustainably improve participant knowledge and confidence in responding to incidents of bias and microaggressions. This resource can be adopted by educators at other institutions.

Credentials and Core Clerkships: Who's Training Our Physician Assistant Students (and Does It Matter)?

Evaluating the effectiveness of supervised clinical practice experiences (SCPEs) is a primary responsibility of the clinical education team. Physician assistant (PA) education is unique because preceptors are not confined to one professional credential. This study evaluated the relationship between students' perceptions of rotation experiences and the professional credentials of the preceptor of record. This retrospective data analysis evaluated data from 3 cohorts (2016-2018) across 4 PA programs. Preceptors of record were categorized as MDs/DOs or advanced practice providers (APPs). Analysis of 209 SCPEs found 91 APP preceptors (43%) and 119 MD/DO preceptors (57%). APP preceptors were most prevalent in family medicine/primary care (57%), internal medicine (50%), and emergency medicine (49%). Students' evaluation scores were higher for APP preceptors compared to MD/DO preceptors, but not statistically significant. This study showed that a considerable number of APPs are serving as preceptors and were found to have similar student evaluation scores to those of MD/DO preceptors.

Instilling Resiliency in Surgical Education: The Benefits of Longitudinal Medical Student Learning

The longitudinal clerkship has been recognized as an innovative, unique model in medical education that demonstrates significantly higher student and preceptor satisfaction with comparable long-term outcomes like performance on standardized examinations. At the center of this model is the student-preceptor relationship, which promotes effective student-directed learning and personal and professional relationships with established faculty mentors. The University of California, San Francisco (UCSF) has two clerkships models: a traditional or "block" model consisting of 2-month sequential clinical rotations in seven core clerkships, and a longitudinal model that integrates parallel out-patient clinical experiences over the entire year with one-on-one faculty preceptors from each core discipline with focused 2-week intensive inpatient rotations. In the setting of the Covid-19 pandemic beginning in Spring of 2020, this arrangement allowed for a natural experiment to evaluate the resiliency of the respective models in the face of unprecedented disruptions in education and healthcare delivery. As described in this perspective, both clerkships required rapid pivots; however, students enrolled in the longitudinal clerkship were more likely to develop stronger relationships with surgical faculty and felt more prepared for making career choices. Medical school curricula may benefit from incorporating longitudinal components, as this model provided flexibility and fostered greater faculty-student mentorship in the setting of disruption to medical education.

Correlation of Ophthalmology Residency Application Characteristics with Subsequent Performance in Residency.

Purpose Only from reviewing applications, it is difficult to identify which applicants will be successful ophthalmology residents. The change of the USMLE Step 1 scoring to "Pass/Fail" removes another quantitative metric. We aimed to identify application attributes correlated with successful residency performance. This study also used artificial intelligence (AI) to evaluate letters of recommendation (LOR), the Dean's letter (MSPE), and personal statement (PS). Design Retrospective analysis of application characteristics versus residency performance was conducted. Participants Residents who graduated from the Dean McGee Eye Institute/University of Oklahoma Ophthalmology residency from 2004 to 2019 were included in this study. Methods Thirty-four attributes were recorded from each application. Residents were subjectively ranked into tertiles and top and bottom deciles based on residency performance by faculty present during their training. The Ophthalmic Knowledge Assessment Program (OKAP) examination scores were used as an objective performance metric. Analysis was performed to identify associations between application attributes and tertile/decile ranking. Additional analysis used AI and natural language processing to evaluate applicant LORs, MSPE, and PS. Main Outcome Measures Characteristics from residency applications that correlate with resident performance were the primary outcome of this study. Results Fifty-five residents and 21 faculty members were included. A grade of "A" or "Honors" in the obstetrics/gynecology (OB/GYN) clerkship and the presence of a home ophthalmology department were associated with ranking in the top tertile but not the top decile. Mean core clerkship grades, medical school ranking in the top 25 U.S. News and World Report (USNWR) primary care rankings, and postgraduate year (PGY)-2 and PGY-3 OKAP scores were predictive of being ranked in both the top tertile and the top decile. USMLE scores, alpha-omega-alpha (AOA) status, and number of publications did not correlate with subjective resident performance. AI analysis of LORs, MSPE, and PS did not identify any text features that correlated with resident performance. Conclusions Many metrics traditionally felt to be predictive of residency success (USMLE scores, AOA status, and research) did not predict resident success in our study. We did confirm the importance of core clerkship grades and medical school ranking. Objective measures of success such as PGY-2 and PGY-3 OKAP scores were associated with high subjective ranking.

Effect of a required online graded curriculum in the clerkship years on medical student nationalstandardized examination performance.

Many medical schools have a distributed model for clinical clerkship education, challenging our ability to determine student gaps during clinical education. With the graduating class of 2017, A.T. Still University's School of Osteopathic Medicine in Arizona (ATSU-SOMA) began requiring additional online curricula for all clerkship courses. To determine whether third year and fourth year students receiving ATSU-SOMA's online curricula during core clerkships performed better overall on national standardized examinations than students from previous years who had not received the curricula, and whether scores from online coursework correlated with outcomes on standardized examinations as possible early predictors of success. This retrospective cohort study analyzed existing data (demographics and assessments) from ATSU-SOMA classes of 2017-2020 (curriculum group) and 2014-2016 (precurriculum group). The effect of the curriculum on national standardized examinations (Comprehensive OsteopathicMedical Achievement Test [COMAT] and Comprehensive Osteopathic Medical Licensing Examination of the United States [COMLEX-USA]) was estimated using augmented inverse probability weighting (AIPW). Correlations between assignment scores and national standardized examinations were estimated using linear regression models. The curriculum group had 405 students with a mean (standard deviation [SD]) age of 25.7 (±3.1) years. Two hundred and fifteen (53.1%) students in the curriculum group were female and 190 (46.9%) were male. The precurriculum group had 308 students (mean±SD age, 26.4±4.2 years; 157 [51.0%] male; 151 [49.0%] female). The online curriculum group had higher COMAT clinical subject exam scores in obstetrics and gynecology, osteopathic principles and practice (OPP), psychiatry, and surgery (all p≤0.04), as well as higher COMLEX-USA Level 2-Cognitive Evaluation (CE) family medicine and OPP subscores (both p≤0.03). The curriculum group had a 9.4 point increase in mean total COMLEX-USA Level 2-CE score (p=0.08). No effect was found for the curriculum overall on COMAT mean or COMLEX-USA Level 2-Performance Evaluation scores (all p≥0.11). Total coursework scores in each core clerkship, excluding pediatrics, were correlated with COMAT mean score (all adjusted p≤0.03). Mean scores for five of the seven assignment types in core clerkships, excluding evidence based medicine types, were positively correlated with COMAT mean scores (all adjusted p≤0.049). All assignment types correlated with COMLEX-USA Level 2-CE total score (alladjusted p≤0.04), except interprofessional education (IPE). Results from this study of 713 students from ATSU-SOMA suggested that our online curriculum supplemented clinic based learning during clerkship courses and improved student outcomes on national standardized examinations.

Moving toward Mastery: Changes in Student Perceptions of Clerkship Assessment with Pass/Fail Grading and Enhanced Feedback

ProblemClerkship grades contribute to a summative assessment culture in clerkships and can therefore interfere with students’ learning. For example, by focusing on summative, tiered clerkship grades, students often discount accompanying feedback that could inform future learning. This case report seeks to explore whether an assessment system intervention which eliminated tiered grades and enhanced feedback was associated with changes in student perceptions of clerkship assessment and perceptions of the clinical learning environment. Intervention: In January 2019, our institution eliminated tiered clerkship grading (honors/pass/fail) for medical students during the core clerkship year and implemented pass/fail clerkship grading along with required twice weekly, work-based assessments for formative feedback. Context: In this single institution, cross-sectional survey study, we collected data from fourth-year medical students one year after an assessment system intervention. The intervention entailed changing from honors/pass/fail to pass/fail grading in all eight core clerkships and implementing an electronic system to record twice-weekly real-time formative work-based assessments. The survey queried student perceptions on the fairness and accuracy of grading and the clinical learning environment—including whether clerkships were mastery- or performance-oriented. We compared responses from students one year after the assessment intervention to those from the class one year before the intervention. Comparisons were made using unpaired, two-tailed t-tests or chi-squared tests as appropriate with Cohen’s d for effect size estimation for score differences. Content analysis was used to analyze responses from two open-ended questions about feedback and grading. Impact: Survey response rates were similar before and after intervention (76% (127/168) vs. 72% (118/163), respectively) with no between-group differences in demographics. The after-intervention group showed statistically significant increases in the following factors: “grades are transparent and fair” (Cohen’s d = 0.80), “students receive useful feedback” (d = 0.51), and “resident evaluation procedures are fair” (d = 0.40). After-intervention respondents perceived the clerkship learning environment to be more mastery-oriented (d = 0.52), less performance approach-oriented (d = 0.63), and less performance avoid-oriented (d = 0.49). There were no statistical differences in the factors “attending evaluation procedures are fair,” “evaluations are accurate,” “evaluations are biased,” or “perception of stereotype threat.” Open-ended questions revealed student recommendations to improve clerkship summary narratives, burden of work-based assessment, and in-person feedback. Lessons Learned: After an assessment system change to pass/fail grading with work-based assessments, we observed moderate to large improvements in student perceptions of clerkship grading and the mastery orientation of the learning environment. Our intervention did not improve perceptions around bias in assessment in clerkships. Other medical schools may consider similar interventions to begin to address student concerns with clerkship assessment and promote a more adaptive learning environment.

Supplementing the Subinternship: Effect of E-Learning Modules on Subintern Knowledge and Confidence

Supplementing the Subinternship: Effect of E-Learning Modules on Subintern Knowledge and Confidence

Workplace-based assessments of entrustable professional activities in a psychiatry core clerkship: an observational study

BackgroundEntrustable professional activities (EPAs) in competency-based, undergraduate medical education (UME) have led to new formative workplace-based assessments (WBA) using entrustment-supervision scales in clerkships. We conducted an observational, prospective cohort study to explore the usefulness of a WBA designed to assess core EPAs in a psychiatry clerkship.MethodsWe analyzed changes in self-entrustment ratings of students and the supervisors’ ratings per EPA. Timing and frequencies of learner-initiated WBAs based on a prospective entrustment-supervision scale and resultant narrative feedback were analyzed quantitatively and qualitatively. Predictors for indirect supervision levels were explored via regression analysis, and narrative feedback was coded using thematic content analysis. Students evaluated the WBA after each clerkship rotation.ResultsEPA 1 (“Take a patient’s history”), EPA 2 (“Assess physical & mental status”) and EPA 8 (“Document & present a clinical encounter”) were most frequently used for learner-initiated WBAs throughout the clerkship rotations in a sample of 83 students. Clinical residents signed off on the majority of the WBAs (71%). EPAs 1, 2, and 8 showed the largest increases in self-entrustment and received most of the indirect supervision level ratings. We found a moderate, positive correlation between self-entrusted supervision levels at the end of the clerkship and the number of documented entrustment-supervision ratings per EPA (p < 0.0001). The number of entrustment ratings explained 6.5% of the variance in the supervisors’ ratings for EPA 1. Narrative feedback was documented for 79% (n = 214) of the WBAs. Most narratives addressed the Medical Expert role (77%, n = 208) and used reinforcement (59%, n = 161) as a feedback strategy. Students perceived the feedback as beneficial.ConclusionsUsing formative WBAs with an entrustment-supervision scale and prompts for written feedback facilitated targeted, high-quality feedback and effectively supported students’ development toward self-entrusted, indirect supervision levels.

Integration of Point-of-Care Ultrasound Education Into the Internal Medicine Core Clerkship Experience.

Point-of-care ultrasound (POCUS) is becoming an essential skill for internists. To date, there are no professional guidelines for how POCUS skills should be taught to medical students. A panel of POCUS experts from seven academic medical centers in the United States was convened to describe the components of independently developed IM clerkship POCUS training programs, identify areas of similarity and difference, and propose recommendations for alignment.

How Do Clinical Electives during the Clerkship Year Influence Career Exploration? A Qualitative Study

Problem: Although many students begin medical school with some idea of their specialty interest, up to 80% of these students choose a different specialty by their final year. This pivot tends to happen in the clerkship year, when students are immersed in the clinical environment, gaining a practical understanding of the day-to-day work in different fields. Yet, in this year students have limited experiences with specialties. Clinical electives during the clerkship year may aid students in career development. The authors examined student career exploration through the lens of social cognitive career theory (SCCT). SCCT posits three variables that influence career development: personal goals, self-efficacy, and understanding outcome expectations. With this framework, the authors sought to understand how a program of clinical electives during the clerkship year influences students’ perceptions of their career exploration. We aimed to: (1) describe an innovative clerkship elective program designed for career exploration, and (2) explore how this influenced students’ career exploration using qualitative analysis. Intervention: Beginning in 2018, students at our institution were required to participate in three 2-week clinical electives during their clerkship year, called Clinical Immersive Experiences (CIExes). CIExes were categorized into four different types: apprenticeship, clinical skills building, integrative (multi-disciplinary), or subspecialty. Authors invited fourth year students to participate in interviews (January to March 2019) about how they selected electives and how these electives contributed to their career exploration. Interviews continued until reaching information sufficiency. Authors coded and analyzed transcripts using template analysis. Context: This curricular intervention took place in the context of large-scale curricular redesign. Students began clerkships partway into their second year of medical school. The family and community medicine clerkship, which was previously a 6-week core clerkship, was changed to a longitudinal format, thus freeing up 6 weeks for electives. Other core clerkships included anesthesia (2 weeks), medicine (8 weeks), neurology (4 weeks), obstetrics and gynecology (6 weeks), pediatrics (6 weeks), psychiatry (4 weeks), and surgery (8 weeks). Impact: From 15 student interviews, we identified three major themes. First, CIExes facilitated personalized career exploration. All students felt that at least one elective helped them solidify their decision about a specialty choice. Second, CIExes promoted focused learning and skills development that complemented core rotations. They noted the benefit of positive relationships with supervisors, particularly attendings, during these electives. Third, students highlighted how these electives fostered a positive learning environment and enhanced wellbeing. SCCT clarified how the CIEx program helped students advance their personal goals, self-efficacy, and outcome expectations during a pivotal time in medical school. Lessons Learned: We learned that from the student perspective, the inclusion of clinical electives in the clerkship year benefited students’ career exploration by helping them develop and refine their career goals, increase self-efficacy, and test outcome expectations in a meaningful way as anticipated from SCCT. In addition, we found that CIExes created a positive learning environment that allowed deep relationships to develop in fields of interest and that supported a strong sense of wellbeing. Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1891545

Clerkship Experiences During Medical School: Influence on Specialty Decision.

Clinical rotations during medical school are the time when most students select their specialty. Limited or lack of exposure could deter students from certain sub-specialties, and thus, insight into the selection process is essential. This study assesses the role of limited clinical rotations and perception of students on specialty selection. All graduating medical students were surveyed at our US-based institution for 2 years. The survey included both open- and close-ended questions related to influence of clerkship experience and other factors on specialty choice and suggestions for improvement. The data were analyzed descriptively and thematically. Majority of students (87%) had minimal exposure to their chosen residency specialty prior to the third-year clerkships. Role of a clerkship experience in selecting a specialty was significant for 70% students, especially interaction with attendings (92%) and residents (86.3%). The most influential reasons for specialty choice to change were clerkship experience (41%) and mentors (21%). Approximately 34% students chose a specialty that was not a part of third-year core clerkships, and the most significant factors influencing their choice were shadowing experience (21%) and lifestyle (18%). Further, thematic analysis suggested that earlier and more clinical exposure to various specialties and formal mentoring could make specialty selection process easier. Along with specialty content, the relationship of learners and teachers in the clinical setting plays a significant role in selecting and/or rejecting certain specialty by medical students. The study provides broader baseline data for medical schools and educators in preparation of curriculum and future physician workforce composition.

Designing and Implementing a Novel Virtual Rounds Curriculum for Medical Students' Internal Medicine Clerkship During the COVID-19 Pandemic.

IntroductionDuring the COVID-19 pandemic, third-year medical students were temporarily unable to participate in onsite clinical activities. We identified the curricular components of an internal medicine (IM) clerkship that would be compromised if students learned solely from online didactics, case studies, and simulations (i.e., prerounding, oral presentations, diagnostic reasoning, and medical management discussions). Using these guiding principles, we created a virtual rounds (VR) curriculum to provide IM clerkship students with clinical exposure during a virtual learning period.MethodsHeld three times a week for 2 weeks, VR consisted of three curricular components. First, clerkship students prerounded on an assigned hospitalized patient by remotely accessing the electronic health record and calling into hospital rounds. Second, each student prepared an oral presentation on their assigned patient. Third, using videoconferencing, students delivered these oral presentations to telemedicine VR small groups consisting of three to four students and three tele-instructors. Tele-instructors then provided feedback on oral presentations and taught clinical concepts. We assessed the effectiveness of VR by anonymously surveying students and tele-instructors.ResultsTwenty-nine students and 34 volunteer tele-instructors participated in VR over four blocks. A majority of students felt VR improved their prerounding abilities (86%), oral presentation abilities (93%), and clinical reasoning skills (62%). All students found small group to be useful.DiscussionVR allowed students to practice rounding skills in a supportive team-based setting. The lessons learned from its implementation could facilitate education during future pandemics and could also supplement in-person clerkship education.

Are Clerks Proficient in the Basic Sciences? Assessment of Third-Year Medical Students' Basic Science Knowledge Prior to and at the Completion of Core Clerkship Rotations.

Basic sciences are a cornerstone of undergraduate medical education (UME), yet research indicates that students' basic science knowledge is not well retained. Many UME curricula are increasing the integration between the basic and clinical sciences with the goal of enhancing students' knowledge levels; however, the impact of clerkship training on students' basic science knowledge remains inconclusive. Thus, using clerkship directors' expectations as framework, we aimed to assess third-year medical students' basic science knowledge during clerkship training and evaluate the influence of clerkship training on their basic science knowledge. Using concepts deemed necessary by clerkship directors, we created a basic science assessment for each clerkship rotation. Assessments were distributed to third-year medical students as a pre- and post-test to assess their basic science knowledge prior to and at the completion of each rotation. On average, students retained ≥ 60% of relevant basic science knowledge from pre-clerkship, and neither clerkship rotation order, nor the basic science discipline being assessed, impacted students' basic science knowledge levels. Post-test data revealed that students, on average, reinforced fundamental concepts during clerkship. Interestingly, even though lower-performing students demonstrated the greatest post-test improvement, they still left each rotation with knowledge deficits compared with their highest-performing peers, suggesting that the clinical experience of clerkship appears to be particularly beneficial for lower-performing students, in regard to enhancing their basic science knowledge. Overall, results indicate that earlier exposure to clinical learning in UME, along with integration of basic science education into clerkship, could promote students' basic science knowledge acquisition and retention.

Capturing the Moments: An Autoethnographic Exploration of Self-Preservation in Clerkship

Phenomenon For most medical students, clerkship represents a transitional phase into the ‘real world’ of medicine. This transition is often accompanied by significant mental stressors, burnout, and empathy decline. Educator led resilience curricula designed to support students during this critical period often focus on teaching generalized strategies to promote wellness and lack the student input and perspective in their development. Thus, they may be of minimal value when learners are faced with acute moments of challenge and distress in their day-to-day work. The following project seeks to provide an insider view on the experience, interpretation, and response to these moments of challenge and distress from the frontline perspective of clinical clerks. Approach: Using collaborative autoethnography, two medical students documented 85 reflections on their emerging professional identity over the course of a core clerkship year. A narrative analysis was conducted iteratively in partnership with a staff internist and a medical education researcher experienced in autoethnography, allowing for robust multi-perspective input. Reflections were analyzed and coded thematically; disagreements were resolved by consensus discussion. Findings: A key theme of the reflections was self-preservation, conceptualized within two principal contexts: (i) Clerk-patient relationships, wherein we found ourselves in emotionally difficult situations; and (ii) Clerk-preceptor relationships, in which self-preservation manifested through a series of self-protective mechanisms. Insights: The practice of self-preservation is understood as the conscious act of boundary-setting and psychological defense in situations that pose a real (or perceived) threat to the clerk’s wellbeing. At best, self-preservation serves as a temporary compromise to the stressors and burnout of clerkship. We speculate, however, that, left unchecked, acts of self-preservation may lead to habitual selfishness and apathy, qualities that are in diametric opposition to those expected of future physicians, and may manifest later (when these learners progress through the hierarchy) as the unprofessional behaviors that perpetuate the cycle of the hidden curriculum.