Traditional Clerkship Research Articles

Burden, Responsibility, and Reward: Preceptor Experiences With the Continuity of Teaching in a Longitudinal Integrated Clerkship

To address challenges to clinical education, clerkships should be designed to promote continuity of educational experiences including continuity in teaching. Yet, little is known about how continuity in teaching impacts clinical teachers. Experiences of clinical teachers who precept students during a longitudinal integrated clerkship (LIC) must be examined. The authors interviewed 27 preceptors who could compare their LIC with traditional clerkship teaching experiences. Teaching during an LIC had a significant impact on preceptors' time, effort, and clinic responsibilities. Preceptors felt they bore sole responsibility for teaching a discipline and ensuring students' learning, and they experienced a deep sense of reward observing students' growth. To support and sustain the reward of LIC teaching for faculty, LIC developers should focus on targeted faculty development and resource allocation to clinical teaching.

Continuity in a longitudinal out-patient attachment for Year 3 medical students

Concerns about the quality of medical student learning experiences during traditional clerkships have prompted calls to restructure clinical education around continuity. Many US medical schools have added longitudinal out-patient attachments to enhance student continuity with patients and supervising doctors. However, continuity with patients can be difficult to achieve and little is known about the independent effect of continuity with a supervising doctor and setting. This study describes students' perceptions of the types of continuity experienced in longitudinal attachments and the learning associated with continuity. This is a qualitative study using a grounded theory approach. Interviews were conducted with 12 Year 3 medical students about their continuity experiences with patients, supervisors and settings during their attachment. The resulting data were subjected to thematic analysis. Continuity with supervising doctors provided students with career mentorship and personal support. Student autonomy varied and was most dependent on the supervisor and setting. Students with patient continuity were more likely to report learning about chronic illness and communication skills. Students described the longitudinal attachment as helping them to develop their clinical skills and gain self-confidence within their role as future doctors, and as influencing their career choice. There is much variation in student experiences of patient continuity during a longitudinal attachment. Continuity with patients, supervisors and settings affects student learning in different ways. Additional dimensions of the experience, such as the nature of the patient-doctor relationship, the pace of work and the patient population, impact learning outcomes and should be considered when continuity experiences are being designed.

An Integrated Model for Radiology Education: Development of a Year-long Curriculum in Imaging with Focus on Ambulatory and Multidisciplinary Medicine

In 2004, Harvard Medical School initiated a pilot program, the Cambridge Integrated Clerkship, in which students study the core third-year medical disciplines in a longitudinal year long experience. In this paper, the authors describe the design of the radiology portion of this program and compare outcomes to those of students in a traditional curriculum. Students in the integrated curriculum were compared to students in traditional clerkships on the basis of Objective Structured Clinical Examination cases, final exams, fourth-year comprehensive exam scores, and choice of specialty. Scores on Objective Structured Clinical Examination cases and imaging final exams were not statistically different between the two groups, but Integrated Clerkship students had statistically lower scores on final exams. Integrated Clerkship students scored higher on the fourth-year radiology comprehensive exam than traditional students, but differences were not statistically significant. Choice of radiology as a specialty was not statistically different between the two groups. Teaching radiology in an integrated year long curriculum is feasible, with a minimal drop in exam scores but no changes in other evaluative measures and no decrease in the choice of radiology as a specialty. The program may give students a better appreciation of the role of radiology in an ambulatory setting and in relationship to other specialties.

Longitudinal Integrated Clerkships for Medical Students: An Innovation Adopted by Medical Schools in Australia, Canada, South Africa, and the United States

Integrated clinical clerkships represent a relatively new and innovative approach to medical education that uses continuity as an organizing principle, thus increasing patient-centeredness and learner-centeredness. Medical schools are offering longitudinal integrated clinical clerkships in increasing numbers. This report collates the experiences of medical schools that use longitudinal integrated clerkships for medical student education in order to establish a clearer characterization of these experiences and summarize outcome data, when possible. The authors sent an e-mail survey with open text responses to 17 medical schools with known longitudinal integrated clerkships. Sixteen schools in four countries on three continents responded to the survey. Fifteen institutions have active longitudinal integrated clerkships in place. Two programs began before 1995, but the others are newer. More than 2,700 students completed longitudinal integrated clerkships in these schools. The median clerkship length is 40 weeks, and in 15 of the schools, the core clinical content was in medicine, surgery, pediatrics, and obstetrics-gynecology. Eleven schools reported supportive student responses to the programs. No differences were noted in nationally normed exam scores between program participants and those in the traditional clerkships. Limited outcomes data suggest that students who participate in these programs are more likely to enter primary care careers. This study documents the increasing use of longitudinal integrated clerkships and provides initial insights for institutions that may wish to develop similar clinical programs. Further study will be needed to assess the long-term impact of these programs on medical education and workforce initiatives.

A Program to Enhance Competence in Clinical Transaction Skills

The ability to take a comprehensive and accurate clinical history, perform a thorough and nuanced physical examination, engage in sequential clinical reasoning using all relevant clinical and laboratory data, and communicate clearly and compassionately with patients and other providers--the skills of the clinical transaction--are critical to a successful therapeutic outcome. Yet few medical schools' curricula include an explicit focus on developing these skills beyond the introductory level. Vanderbilt Medical School has developed a structured curriculum, integrated into the traditional clerkships of the third and fourth years, that ensures that each student receives specific instruction in clinical transaction skills. The clinical transaction curriculum is based on a set of 25 presenting problems, with learning objectives identified for each problem. Primary responsibility for instruction relating to each presenting problem is assigned to specific core clerkships, with the major portion of teaching provided by a nucleus of specially selected and compensated master clinical teachers. The Clinical Transaction Project at Vanderbilt was begun in 2004. Future development will focus on enhancing approaches to student assessment.

Early clerkships

Background: Early clinical experience is being introduced in innovative, vertically integrated undergraduate medical curricula. While in many cases, this early clinical experience is limited to the presence of patients during lectures, in Utrecht students gain ‘hands on’ experience of daily clinical practice during 6-week clerkships. We studied students’ and teachers’ opinions of these full clerkships in the third year of a medical course.Methods: All 238 clinical teachers and 89 students involved in the 2003/2004 third year clerkships of the new Utrecht medical curriculum were asked to fill in a 16-item questionnaire about background knowledge, clinical skills, communication skills, and readiness for clerkships. Answers were given on a 5-point Likert scale. Response was 61%.Results: Both students and clinical teachers answered all statements positively (score > 3.00), although some statements were awarded higher scores by students than teachers. In conclusion, students and teachers appear to appreciate clerkships early in the curriculum.Conclusions: Less background knowledge and a lower age than is usual for the more traditional (later) clerkships do not appear to hinder successful completion of an early clerkship. Indeed, early clerkships have several advantages, such as early observation of the future profession, increased motivation for further study, contextual learning, and improvement of clinical skills.

Using a Web-Based, Iterative Education Model to Enhance Clinical Clerkships

Although most clinical clerkship curricula are designed to provide all students consistent exposure to defined course objectives, it is clear that individual students are diverse in their backgrounds and baseline knowledge. Ideally, the learning process should be individualized towards the strengths and weakness of each student, but, until recently, this has proved prohibitively time-consuming. The authors describe a program to develop and evaluate an iterative, Web-based educational model assessing medical students' knowledge deficits and allowing targeted teaching shortly after their identification. Beginning in 2002, a new educational model was created, validated, and applied in a prospective fashion to medical students during an internal medicine clerkship at Harvard Medical School. Using a Web-based platform, five validated questions were delivered weekly and a specific knowledge deficiency identified. Teaching targeted to the deficiency was provided to an intervention cohort of five to seven students in each clerkship, though not to controls (the remaining 7-10 students). Effectiveness of this model was assessed by performance on the following week's posttest question. Specific deficiencies were readily identified weekly using this model. Throughout the year, however, deficiencies varied unpredictably. Teaching targeted to deficiencies resulted in significantly better performance on follow-up questioning compared to the performance of those who did not receive this intervention. This model was easily applied in an additive fashion to the current curriculum, and student acceptance was high. The authors conclude that a Web-based, iterative assessment model can effectively target specific curricular needs unique to each group; focus teaching in a rapid, formative, and highly efficient manner; and may improve the efficiency of traditional clerkship teaching.

Performance of Medical Students in a Nontraditional Rural Clinical Program, 1998???99 through 2003???04

To compare knowledge acquisition as measured by test scores for students in nontraditional clinical clerkships to scores for students in traditional urban hospital-based clerkships. Interdisciplinary and continuity-of-care clerkships in rural areas are the focus of the study. All the students' Medical College Admission Test (MCAT) scores, National Board of Medical Examiners (NBME) subject exam scores, and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores over a six-year period, 1998-99 to 2003-04, were compared for third-year students in nontraditional and traditional clerkships at the University of North Dakota School of Medicine and Health Sciences. Cohorts were 29 students in our Rural Opportunities in Medical Education (ROME) program and 296 students in traditional third-year clerkships. NBME subject exam scores were those in pediatrics, internal medicine, surgery, and obstetrics and gynecology. The exam used for family medicine is not standardized to national standards, but controlled within the Department of Family Medicine. MCAT and USMLE Step 1 scores were used as a means of controlling for prior academic achievement and ability. There were no significant differences (p > or = .05) in MCAT scores, Step 1 scores, subject exam scores, or Step 2 scores between the two groups. In contrast, students from ROME scored higher (p < or = .05) on the internal medicine clinical preceptor assessments than did students from the traditional track. These findings suggest that students in remote, rural, longitudinal, integrated learning environments can attain fund-of-knowledge scores comparable to the scores of students in traditional clerkships, and may, as in this study, receive higher ratings for clinical proficiency.

Comparing Rural-Trained Medical Students With Their Peers: Performance in a Primary Care OSCE

Background: Although it is well-established and considered successful, there is limited data on how the graduates of a Minnesota rural medical education program (Rural Physician Associate Program [RPAP]) compare with their peers.Purpose: To compare the performance of RPAP students with their peers on a primary care observed structured clinical examination (OSCE).Methods: The performances of RPAP students and a group of non-RPAP Year 4 medical students were compared on the same OSCE.Results: RPAP students performed at least as well as their peers on stations assessing performance on common primary care clinical scenarios but not as well on a small number of stations that assessed applied knowledge of specific content taught in the traditional clerkship curriculum.Conclusions: We provide evidence that rurally trained students at this institution performed at least as well as their peers on OSCE stations testing performance in common primary care scenarios. The broader implications of this study are that medical students may receive high-quality training in rural communities, as documented by their performance on an objective structured clinical examination.

The impact of multifaceted educational structuring on learning effectiveness in a surgical clerkship.

Various measures have been introduced to enhance learning experiences in clerkships, generally with limited success. This study evaluated the impact of a multifaceted approach on the effectiveness of learning in a surgical clerkship. In accordance with results obtained in continuing medical education, several interventions were introduced simultaneously. We compared students' evaluations of the traditional surgical clerkship with those of the restructured clerkship. Two consecutive cohorts of students were asked to complete a questionnaire about the quality and quantity of their learning experiences. Cohort 1 (n = 28) undertook the traditional clerkship and cohort 2 (n = 72) the restructured clerkship. A Mann-Whitney test was used to compare outcomes between the 2 cohorts. There were few statistically significant differences between cohorts 1 and 2. Overall, quality indicators did not differ between the 2 cohorts. A short-term multifaceted intervention led to a slight increase in the performance of clinical skills and a slight decrease in time spent on activities of limited educational value. The intervention may have been too brief to produce substantial effects. Future interventions should also target teachers, including trainees, in order to assess their opinions and address their educational needs.

Different Formats for a Neurology Clerkship Do Not Influence Written Examination Scores

Changes in health care delivery required substitution of a number of alternatives for the traditional inpatient clerkship used in the neurology education of fourth-year medical students at the Uniformed Services University of the Health Sciences and for third-year medical students from Georgetown University. We retrospectively analyzed grades on a locally generated multiple-choice examination based on a student objective list. Scores from students rotating on ambulatory neurology, neurosurgery, child neurology, neurorehabilitation, and rotations at other military hospitals over a 2-year period were compared with those achieved by students in a traditional clerkship at Walter Reed Army Medical Center. There were no significant differences in the grades between any of the groups. Student acquisition of factual material was not influenced by the type of clinical experience or by whether the student is in the third or fourth year of medical school.

Becoming a physician: students' creative projects in a third-year IM clerkship.

Medical educators have only limited understanding of how integrating humanities-based components into standard curricula contributes to the medical students' professionalism. This study qualitatively analyzed how students used a creative-project assignment during their third-year internal medicine clerkships to explore various aspects of their professional development. A total of 277 students from three consecutive classes (1999-2002) at the University of California, Irvine, College of Medicine each completed a creative project reflecting on a particularly problematic or meaningful illness-related incident. Process and content analyses of the 221 projects submitted for analysis were performed. Students' projects employed a wide range of formats, tones, and styles to examine the process of socialization into medicine. Within this framework, their work tended to explore issues such as the proper relationship of medical students to patients, coming to terms with death and dying, understanding the patient's experience of illness, and coping with professional and personal stress. A creative-projects course component can be a valuable adjunct to traditional clerkship activities in helping students to reflect on the process of becoming a physician.

Teaching in the medical setting: balancing teaching styles, learning styles and teaching methods

To assess the educational quality of a traditional clerkship, a questionnaire was administered to 28 students at the end of their 10-week surgical clerkship. The questionnaire contained 116 items on learning objectives, patient problems encountered by students, clinical skills performed, feedback received and amounts of time spent on various activities. The students indicated that they had adequate ability to correctly analyse and manage patient problems. However, the standard deviations and ranges show that individual students' exposure to various patient problems was insufficient. Students generally saw too few emergency patients. The frequencies of performance of diagnostic and therapeutic skills varied widely among students. Most of the feedback received by students was given by residents rather than faculty physicians. Students spent considerable time on activities of limited educational value. It appears that learning during a clerkship occurs rather haphazardly. There are indications that the 'educational exposure' varies substantially from student to student.

Clinical Competence Assessment in Radiology: Introduction of an Objective Structured Clinical Examination in the Medical School Curriculum

Rationale and Objectives Traditional oral and written examinations can be limited in predicting future clinical performance. Therefore Objective Structured Clinical Examinations (OSCEs) have been introduced in other specialties. The authors assessed their value in radiology. Materials and Methods The study includes 122 Harvard medical students who undertook 1-month compulsory clerkships at one of three hospitals (A, B, or C) in their 3rd and 4th year and a compulsory OSCE in their 4th year. The OSCE was constructed from five cases. Each had eight or nine standardized questions designed to test, within a set time, the perception of essential findings, their interpretation, and clinical judgment (maximum possible score, 100). Clerkship grades were high honors (score of 3), honors (score of 2), satisfactory (score of 1), and fail (score of 0). Predictors of OSCE scores—clerkship grade and affiliated hospital—were modeled as linear functions. Time elapsed between clerkship and OSCE was modeled as a nonlinear function. Results Although there was a positive relation between clerkship grade and OSCE grade, it accounted for an increase of only 5.7% in OSCE score per clerkship grade and did not predict performance of individual students. Students who trained in hospital B showed significantly higher OSCE grades. OSCE scores were highest when the examination was taken 8 months after the clerkship. Conclusion The OSCE may be useful to uncover deficits in individuals and groups beyond the ones detected with traditional clerkship evaluations and provide guidance for remediation. The improved performance after additional clinical exposure suggests that the OSCE may be well suited to test the integration of radiologic and clinical knowledge.

How effective is a clerkship as a learning environment?

To assess the educational quality of a traditional clerkship, a questionnaire was administered to 28 students at the end of their 10-week surgical clerkship. The questionnaire contained 116 items on learning objectives, patient problems encountered by students, clinical skills performed, feedback received and amounts of time spent on various activities. The students indicated that they had adequate ability to correctly analyse and manage patient problems. However, the standard deviations and ranges show that individual students' exposure to various patient problems was insufficient. Students generally saw too few emergency patients. The frequencies of performance of diagnostic and therapeutic skills varied widely among students. Most of the feedback received by students was given by residents rather than faculty physicians. Students spent considerable time on activities of limited educational value. It appears that learning during a clerkship occurs rather haphazardly. There are indications that the 'educational exposure' varies substantially from student to student.

Evaluation of students' learning in an interdisciplinary medicine--surgery clerkship.

To evaluate the impact of an interdisciplinary medicine-surgery clerkship (created to foster generalist education) on students' performances on National Board of Medical Examiners' (NBME) subject examinations. Test data for the 226 students who participated in the 16-week combined clerkship and for the 265 students who had completed the traditional clerkships (12 weeks of medicine, 12 weeks of surgery) were compiled and analyzed using t-tests for independent samples. Mean scores on the NBME subject examination in medicine increased significantly after the combined medicine-surgery clerkship (from 433 to 455, p < or = 0.5). Mean scores on the NBME subject examination in surgery were similar to those achieved in the traditional clerkship years. Since the medicine and surgery clerkships were combined into a single, interdisciplinary clerkship, students' scores have increased on the medicine NBME subject examination and have remained relatively unchanged on the surgery NBME subject examination, despite a substantial reduction in students' clinical experience in the combined clerkship from the traditional clerkships (16 vs 24 weeks).

Third-Year Medical Student Attitudes Toward Internal Medicine

Student attitudes offer insight into career decisions and may suggest causes of the diminished interest in internal medicine. Students entering a salaried managed health care environment may have different attitudes about careers and potential income. Additionally, we evaluate the effect of an ambulatory experience on student attitudes and career selection. We surveyed 163 medical students from the Uniformed Services University of the Health Sciences, Bethesda, Md, at the successful completion of the third year to determine their attitudes regarding the work, lifestyle, prestige, patient type, and challenge of internal medicine, as well as primary care interest, and the importance of income in career selection. A subgroup of 107 volunteers was randomized to either the traditional internal medicine clerkship (n = 69), or to 6 weeks of ambulatory medicine and 6 weeks of ward medicine (n = 38). The selection rate was low for internal medicine (10%) and was high for family practice and transitional internships (37%). Although most students highly valued their internal medicine training, relatively few selected internal medicine as a career. Students saw chronic illness and type of work, but not lifestyle, as disincentives toward choosing an internal medicine career. Half of the students believed that income potential would be a major factor in attracting students into internal medicine, and that reimbursement should be shifted from procedural fields to primary care. The ambulatory clerkship did not affect student attitudes nor type of internship selected. Medicine clerkships, whether traditional or ambulatory, are highly valued educational experiences yet may be insufficient by themselves to attract students to an internal medicine career. Income potential remains an important concern in the setting of salaried managed care, even for students who lack financial debt.

Problem-based learning: An effective educational method for a surgery clerkship

Problem-based learning (PBL) has been implemented during the clinical years in a few medical schools. The purpose of this study is to determine whether PBL provides a better education than traditional methods. Students in the first and third rotations ( n = 42) went through the traditional clerkship, which utilized Socratic teaching (SI), while students in the second and fourth rotations ( n = 36) were taught by the PBL method. Two performance measures were used to assess clerkship effectiveness. One was a modified essay examination (MEE) administered as part of the departmental evaluation. The other was the NBME-II exam and its surgery subsection NBME-II-S. The MEE was designed to measure six dimensions of the problem-solving process. The NBME-II was utilized to measure knowledge. Unpaired t tests were used to identify statistically significant group differences. The PBL group performed significantly better on two MEE dimensions: (1) differential diagnosis formation (PBL, 92.5 ± 0.8; SI, 89.1 ± 0.5; P < 0.01) and (2) interpretation of clinical data (PBL, 93.3 ± 0.6; SI, 91.6 ± 0.4; P < 0.03). A third dimension, ordering appropriate lab and diagnostic studies, approached significance ( P = 0.057), and the PBL group performed better. On the NBME-II there was not a significant difference between the two groups. However, the trend ( P = 0.059) was for the PBL group to score higher on the NBME-II-S (PBL mean: 502 ± 15; SI mean: 468 ± 12). When overall achievement was controlled for, the PBL group performed significantly better than the SI group ( P = 0.046) on the NBME-II-S. This study suggests two conclusions: (1) PBL students performed significantly better on the surgery section of the NBME-II examination, and (2) some important clinical problem-solving skills may be better learned using the PBL method.

Commentary on “Problem-based learning in a surgery clerkship”

The Department of Surgery at the University of Kentucky College of Medicine is developing a modified third-year clerkship which stresses active student involvement in the educational process, the stimulation of life-long intellectual curiosity, and the development of problem-solving and time-management skills. The cornerstone of this program is problem-based learning (PBL). PBL places students in a situation in which they must identify, the major learning issues and solve the clinical problems presented in a series of paper cases. The students learn and practice a problem-solving method which rekindles their intellectual excitement for medical knowledge. After completing this program, the students are prepared and stimulated to be ‘immersed’ in the clinical setting through acting internships. The first students to complete the program have articulated concerns about the mixture of traditional clerkship clinical activities and PBL. These concerns are being addressed in subsequent modifications of the clerk...

The Effects of Teaching Medical Students Psychotherapy Skills in the Outpatient Department

A psychiatric clerkship which emphasizes a clinical exposure to the conduct of outpatient psychodynamic psychotherapy is described and evaluated. Compared to more traditional inpatient based clerkships, an outpatient psychotherapy-oriented clerkship attracts significantly greater numbers of students. In addition, medical students taking such a rotation rate its educational value on its completion significantly more positively compared to other clerkship sites. Finally, students taking the psychotherapy oriented clerkship opt for psychiatry as a specialty significantly more frequently than students taking the more traditional clerkships. The impact of such a learning experience on interpersonal skills with non-psychiatric, medical patients is also discussed.