Medical School Clerkship Research Articles

Learning to connect: Students’ reflections on doctor–patient interactions

Objective Reflective writing is an established method for teaching medical students empathetic interactions, though little is known about students’ reflections on connecting with patients during the clinical clerkship. The purpose of this study was to describe factors that medical students perceive contribute to or detract from making connections with patients and families, as identified in a writing assignment during the pediatric clinical clerkship. Methods Reflective essays submitted by third-year medical students about interacting with patients/families during their pediatric clerkship were qualitatively analyzed for thematic content. Results Major themes emerging in 44 essays analyzed included time, knowledge, language and culture, and actions. Barriers to connecting for some students were considered resources by others. Critical reflection was present in 31.8%. Conclusions Students’ perceptions of factors that influence their interactions with patients and families will enhance or detract their ability to make connections. Through reflection, medical students – amidst clinical responsibilities – can identify how, why, and whether or not connections with patients/families have occurred. Practice implications Recognizing what factors medical students perceive as enhancing and detracting from connecting with patients/families will help preceptors foster those connections and mitigate barriers. Future study could assess how to best provide specific individualized feedback to best enhance critical reflection. We recommend the inclusion of brief reflective writing exercises during clinical clerkships in medical school, as it may augment students’ ability to connect.

Financial and Educational Costs of the Residency Interview Process for Urology Applicants

To investigate the financial and educational costs of the urology residency interview process, we performed a survey of the applicants to the 2006 urology match. All applicants registered for the 2006 urology match were invited to participate. In January 2006 prior to the match, an anonymous online survey containing 8 questions on the financial and educational costs of the interview process was distributed via email. Survey response rate was 61% (287/468). The median educational debt of the applicants was $125,000 (IQR 65,000 to 160,000). Respondents reported having a median 12 interviews (IQR 8 to 15) with urology residencies and spending a median 20 days (IQR 14 to 30) on the interview trail. The total cost of the interview process was a median $4000 (IQR 2000 to 5200) with a median expense per interview of $330 (IQR 211 to 455). Applicants reported that travel expenses accounted for a median 60% of overall interview expenses, whereas the remainder of the expense was accounted for by lodging (25%), food (10%) and clothing (5%). The money to cover these interview-related expenses was obtained primarily by loans. Forty-six percent of the applicants reported that skipping medical school clerkships and classes for urology interviews was "not at all detrimental" to their medical education, whereas 1% reported that it was "greatly detrimental." The financial cost of the interview process for urology applicants is substantial, although the educational cost appears to be limited. Efforts to reduce the financial impact of the interview process should be initiated at both a regional and national level.

Grade Inflation and the Internal Medicine Subinternship: A National Survey of Clerkship Directors

Background: Grade inflation has been demonstrated in certain medical school clerkships but never studied in the internal medicine subinternship. Purposes: The purpose is to determine the existence, extent, and possible causes of subinternship grade inflation. Methods: We surveyed clerkship directors as part of the 2004 Clerkship Directors in Internal Medicine national member survey. Results: The majority of clerkship directors agree that subinternship grade inflation exists. Half of SI students receive Honors and one third receive High Pass. Eighteen percent admitted passing a student that they felt should have failed. Difficulty delivering negative feedback is the top explanation for grade inflation. Conclusion: Clerkship directors agree that grade inflation exists in the internal medicine subinternship. Faculty development and further analysis of our current subinternship evaluation and grading system may help to minimize this problem.

Students' personality and ratings of clinical competence in medical school clerkships: a longitudinal study

This study was designed to examine the associations between students' personality and assessments of their clinical competence in medical school. A set of questionnaires was completed by 1710 medical students to measure their self-esteem, sociability, loneliness, general anxiety, test anxiety, neuroticism (emotionality), perceptions of early relationships with parents, and general health. Students were divided into three groups of the low, moderate, and high competent based on the number of ‘Honours’ ratings they received in core clinical clerkships during the third year of medical school. Multivariate statistical analyses showed that the low competent students scored significantly lower on the self-esteem and sociability, but higher on the loneliness scale. The low competent students also perceived their early relationships with their parents as less satisfactory. Findings suggest that medical students' clinical competence assessments are associated with some aspects of their personality and with perceptions of early relationships with their parents. Findings have implications for the development of educational remedies and counseling strategies.

An internet-based tool for evaluating third-year medical student performance

Background Shortened non-primary care medical school clerkships have increased time pressures for accurate assessment of student knowledge, skills, and attitudes. Paper-based student evaluations suffer from low response rates, inefficient data acquisition and analysis, and difficulty obtaining input from multiple evaluators. This project describes the development of a Web-based model for evaluating third-year medical student performance, improving evaluation response rates, and including multiple evaluators’ input. Methods A secure Web-based system was designed to maintain evaluation data (11-item competency-based evaluations, oral examinations, National Board of Medical Examiners surgery test, and objective structured clinical examination) for the third-year surgery clerkship. Historical response rate, completion time, and administrative effort data were compared with data obtained using the Web-based model. Results Faculty response rates improved from 71.3% to 89.9%, with response times decreased from 28.0 ± 3.0 to 9.0 ± 0.7 days using the Web-based model. Administrative time requirements decreased from 5 days to 2 hours per rotation, and manual data entry, analysis, and reporting were eliminated through e-mail evaluator notification, direct data entry, and real-time analysis. Evaluator satisfaction was subjectively higher using the Web-based model. Conclusions The Web-based 360-degree evaluation model improves third-year medical student assessment by including residents, reducing time and cost, and by providing a faster, more inclusive, and efficient evaluation.

Correlating selection criteria with subsequent performance as residents.

The objective of this study was to determine which criteria in the residency application had the highest correlation with subsequent performance of orthopaedic residents. Data collected from the application files of 58 residents included scores on standardized tests, number of honors grades in the basic and clinical years of medical school, election to Alpha Omega Alpha, numbers of research projects and publications, and numbers of extracurricular activities. Measures of performance included scores on the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery Part I Examination, and faculty evaluations of overall, cognitive, affective, and psychomotor performance. The number of honors grades on clinical rotations was the strongest predictor of performance, whereas election to Alpha Omega Alpha was second. The only other significant correlation was between the number of fine motor activities and psychomotor performance. None of the predictor variables had a significant correlation with Orthopaedic In-Training Examination or American Board of Orthopaedic Surgery Examination scores. Consistency between faculty rankings in each of the four categories was supported by regression analysis. From the results of this study, it appears that academic performance in clinical clerkships in medical school is the most predictive of resident performance. Range restriction in the data available for orthopaedic residency applicants, however, likely precludes the development of a reliable model to assist in the selection of orthopaedic residents.

Mockingbird Years: A Life In and Out of Therapy

Mockingbird Years: A Life In and Out of Therapy

Profile of medical student teaching in radiology: Teaching methods, staff participation, and rewards

The purpose of this study was to collect demographic information about radiology departments and rewards for teaching activities, as well as the impact of new digital imaging methods on teaching. Two surveys were conducted of directors of medical school clerkships in radiology. The initial survey focused on numbers of staff and students, courses taught, and perception of rewards for teaching. The follow-up survey more specifically addressed teaching methods. Sixty-nine (50%) of the initial surveys sent to 139 departments and 46 (39% of a total of 119) of the follow-up surveys were returned. Clerkship directors spent an average of 9 hours per week teaching and performing administrative tasks, with most given no additional time off. Eighty-four percent of departments provide either no or insignificant rewards for teaching. Many departments have integrated the use of computers in teaching, and most have computers that students use during the radiology course. At the same time, digital imaging and picture archiving and communication systems (PACS) are used, or will be used within 1 year, in most departments. Clerkship directors receive little compensation in terms of time and rewards for medical student teaching. Teaching methods are evolving in response to the increasing use of computers, digital imaging, and PACS for at least part of the workload in most radiology departments.

An Encounter-Based Analysis of the Nature of Teaching and Learning in a 3rd-Year Medical School Clerkship

Background: Much of medical education has shifted from the hospital to ambulatory settings where each student works with a preceptor. Purpose: Our objectives were to describe the nature of community-based learning and to explore how learning experiences vary by type of health care visit. Methods: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of 3rd-year medical students contributed data on 1 full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age, gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, and preceptor teaching content. Results: Sixty-three students contributed data on 4,083 patient encounters. The majority of visits concerned acute complaints (37.7%) or health maintenance (26.4%). Many encounters involved students conducting the cardiovascular and pulmonary exams (33.2% each); fewer encounters involved neurologic (6.9%), gynecological (4.5%), and genitourinary (2.2%) exams. Students reported being observed performing histories and physical exams in 4% and 6% of encounters respectively. The most common student experiences were performing histories and performing physical exams unobserved during acute visits, which accounted for 65.8% and 52.4% of encounters overall. Conclusions: This system is useful for determining educational content and processes that occur in ambulatory settings. Important differences were found in teaching and learning by type of health care visit. This factor can and should be used when considering how students meet educational objectives in community-based ambulatory settings.

Development and Multicenter Evaluation of Multistation Clinical Teaching Scenarios on Immunization: The ATPM-CDC Teaching Immunization for Medical-Education (TIME) Project

The objective of this project was to develop and evaluate case-based immunization education materials that use a new teaching method called Multistation Clinical Teaching Scenarios (MCTS) for use in medical school clerkships and primary care residencies. A multidisciplinary team developed objectives, abstracted clinical cases, and created MCTS modules, which use contextual learning, problem solving, and small-group interaction. Mean scores increased from the 10-item pretest to the posttest by 3.2 (95% confidence interval [CI] of 2.8 to 3.6) items for measles, 3.8 (CI = 3.4 to 4.1) for influenza, and 1.8 (CI = 1.4 to 2.1) for hepatitis B (P < .01 for each). To evaluate the materials, we administered questionnaires and conducted focus groups. Most (99%) of the students and residents rated the materials highly, as did most (89%) facilitators. This new method has been widely tested, increases content mastery, and is well received.

Evaluation of Undergraduate Clinical Training Based on Clinical Clerkships in Medical School

Evaluation of Undergraduate Clinical Training Based on Clinical Clerkships in Medical School

Beyond ‘Clinical’?: Four-Dimensional Medical Education

Medical education is in crisis. Undergraduates experience an excessive burden of information, develop attitudes to learning that are based on passive acquisition of knowledge than on curiosity and exploration, and suffer from progressive disenchantment with medicine. There is also a serious problem of providing adequate clinical experience for medical students at existing teaching sites, largely because of reduction in bed numbers, increased patient throughput and clinical specialization. This problem was identified over a decade ago in London but has not been solved by the merger of medical schools. A recent survey in one London teaching hospital showed underemployment of students and limited patient contact. A review of clinical clerkships in an Australian medical school revealed that one-third of teachers were perceived as unconcerned, discouraging, derogatory or hostile, and only one-half were rated as effective educators. One consequence has been the development of a wide-ranging debate on changing medical education. Traditionalists have diminishing room for manoeuvre in defence of existing educational practices, as cautious bodies like the General Medical Council (GMC) opt for fundamental reform.

Comparing clerkship sites in a community-based medical school by evaluating studentsʼ undergraduate and postgraduate performances

Studies have generally found clinical training sites within the same clerkship to be comparable regarding students' performances--by using undergraduate measures in individual clerkships at medical schools with university hospitals. The present study examined performance comparability among sites within two clerkships in a community-based medical school and used both undergraduate and postgraduate measures. The participants were the 349 graduates from the classes of 1988-1991 at Wright State University School of Medicine who took an internal medicine clerkship (332 of the graduates, in five principal combinations of sites) and a general surgery clerkship (349 at six sites). The undergraduate measures were final percent scores for the clerkships and subtest and total scores on the National Board of Medical Examiners (NBME) Part II examination. The postgraduate measures were supervisors' ratings from the first year of residency (210 graduates) and total score on the NBME Part III (212). Univariate analysis of variance and Tukey's multiple-range test were used for the comparisons. The only statistically significant difference among sites was for the medicine clerkship and involved only one undergraduate measure, the clerkship score (and the differences were slight, less than four percentage points). Virtually no differences in the students' performances on the undergraduate and postgraduate measures were found among sites for the two clerkships.

The effect of first clinical clerkship on medical students' specialty choices

Few studies of the effects of clinical clerkship sequence on specialty choice have been performed, and results of such studies have been conflicting. The effect of the first clinical rotation on specialty choice has not been examined. Transcripts of 569 graduates of Michigan State University College of Human Medicine were reviewed to determine the sequence of required clerkships and ultimate specialty choices. Actual residency choices for the five required specialties were compared to the predicted numbers of specialists for the cohorts of students taking each clerkship as a first rotation. No significant differences from the predicted values were found. Our data support the contention that the sequence of medical school clerkships has no effect on ultimate specialty choice.

The validity of clerkship performance evaluations.

The validity of narrative evaluations of clinical performance in medical school was investigated for three successive classes of medical school graduates. The criteria were ratings obtained from residency supervisors one year after entering the programme. Bivariate correlational analysis, multiple regression analysis and canonical redundancy analysis were performed to examine the associations between the evaluations by teachers of competence in medical school clerkships and the subsequent ratings by residency supervisors. The results, best summarized in the canonical analysis, showed two relationships between the two sets of measures (lambda 1 = 0.54 and lambda 2 = 0.47). The first relationship revealed an overall-competence-in-medicine dimension; the second suggested an interpersonal-skills/professional-maturity dimension. Overall, knowledge of clerkship performance accounted for 15% of the variance in residency ratings. The findings suggest the need to improve the assessment of professional maturity and behaviour during medical school.

Seeking A Residency Position: A Medical Student Perspective

Each year, students and residency programs alike invest time, money, and effort in negotiating residency positions. Despite the importance of students’ role in choosing a position, little has been done to understand their opinions of the desirable attributes of programs. The authors present their findings in a survey of 254 fourth-year medical students seeking a residency position in psychiatry who indicated their experiences with psychiatric clerkships in medical school, what they looked for in a residency position, and when they made their decision to enter psychiatry.

Computer scheduling of medical school clerkships

A significant problem faced by the administration of a medical school is the scheduling of students through a clerkship program. This paper describes a heuristic, random number based computer program developed and implemented at the University of Pittsburgh's School of Medicine to solve this linear scheduling problem.

Teacher-student interaction in a medical clerkship.

Seventeen randomly selected clinical teaching sessions in a medical school clerkship were videotaped during a one-month period, including teaching rounds, working rounds, morning report sessions, lectures, patient management conferences, grand rounds, and journal clubs. Using a verbal behavior classification schedule, the investigators analyzed the videotapes in terms of the proportion of talking done by clerkship instructors, medical students, residents, and others. The nature of the verbal interaction was examined by assessing the proportion of time devoted to giving information versus asking questions. The proportions on these dimensions were further analyzed according to the cognitive level of the verbal interaction. The data suggest that the teaching observed was not optimal for promoting problem-solving ability, since students were placed in a very passive role in which they received a preponderance of low-level, factual information.