Relationships Matter: Enhancing Trainee Development with a (Simple) Clerkship Curriculum Reform

Problem: The traditional clerkship model of brief encounters between faculty and students results in reduced meaningful learning opportunities due to the lack of a relationship that enables repeated observation, supervisor feedback, trust formation, and growth. Intervention: Clinical clerkships at our institution were restructured to decrease fragmentation of supervision and foster an educational alliance between faculty and student. A mixed-methods approach was used to study the impact of this curriculum reform on the student experience in the obstetrics and gynecology clerkship. Student participation in patient care was assessed by comparing the number of common obstetric procedures performed before and after clerkship reform. Separate qualitative analyses of comments from student surveys and a faculty focus group revealed themes impacting student involvement. The supervisor–trainee relationship was further investigated by analysis of “rich picture” discussions with students and faculty. Context: Clerkships in the 3rd year of our 4-year undergraduate medical curriculum were converted from an experience fragmented by both didactic activities and multiple faculty supervisors to one with a single supervisor and the elimination of competing activities. Outcomes: Students in the revised clerkship performed twice the number of obstetric procedures. Objective measures (United States Medical Licensing Examination Step 1 scores, receiving clerkship honors, self-reported interest in obstetrics, and gender) did not correlate with the number of procedures performed by students. Qualitative analysis of student survey comments revealed that procedure numbers were influenced by being proactive, having a supervisor with a propensity to teach (trust), and contextual factors (busy service or competition with other learners). Themes identified by faculty that influenced student participation included relationship continuity; growth of patient care skills; and observed student engagement, interest, and confidence. The quality of the relationship was cited by both students and faculty as a factor influencing meaningful clinical participation. Discussions of “rich pictures” drawn by students and faculty revealed that relationships are influenced by continuity, early alignment of goals, and the engagement and attitude of both student and faculty. Lessons Learned: Clinical curricular reforms that strengthen the continuity of the supervisor–trainee relationship promote mutual trust and can result in a more meaningful training experience in less time. Reciprocal engagement and early alignment of goals between supervisor and trainee are critical for creating a positive relationship.     

Teaching Medical Students to Reflect More Deeply

Problem: Although many studies have examined the importance of reflective writing in medical education, there is a scarcity of evidence for any particular intervention to improve the quality of reflection among medical students. Historically, students on our Internal Medicine clerkship were given a written reflection assignment without explanation of critical reflection. To facilitate the development of deeper reflection, a new curriculum was introduced. Intervention: A 90-minute workshop on critical reflection was introduced at the start of the Internal Medicine rotation. Key components included a video clip stimulating reflection, small- and large-group exercises, and a faculty member's personal reflection. Students were then asked to write two reflection papers. To minimize bias, the names and dates were removed from each reflection paper and combined with reflection papers from a historical control group. Four faculty used a previously validated tool, the REFLECT rubric, to independently grade the written reflection papers as nonreflective (as a 1), thoughtful action (2), reflection (3), or critical reflection (4). The final grade of each paper was determined by consensus among the graders. Context: The 90-minute workshop was given once at the beginning of each 10-week requisite Internal Medicine clerkship to 3rd-year medical students. Outcome: One hundred fifty-five papers written after the workshop were compared to 155 papers from a preworkshop historical control group. The primary analysis showed the number of students writing “critical reflection” papers increased after the educational intervention, from 14% to 47% (p = .0002). The effect size using Cohen's d was 0.62. The kappa statistic used to measure interrater reliability among the four graders was 0.37. Lessons Learned: Through a 90-minute reflection workshop more 3rd-year students were able to demonstrate the potential for “critical reflection” compared to previous students not exposed to this teaching. Strengths include the large sample size of written reflection papers submitted throughout an entire academic year and blinded grading of papers that minimized bias. The low interrater reliability is a limitation. We believe this curriculum could readily be adapted to a clerkship seeking to enhance learner reflection.     

University and Community Hospital Medical Student Emergency Medicine Clerkship Experiences

Objective : To determine whether there is a significant difference between educational opportunities for fourth-year medical students rotating at a university hospital (UH) compared with several community hospitals (CHs) during a mandatory emergency medicine (EM) clerkship.
Methods : A self-reported clinical tool was completed in real time by each student rotating for 2 weeks at the UH and 2 weeks at 1 of 4 CHs (3 affiliated and 1 unaffiliated). Students are required to document the number of patients seen and the number of procedures performed on each of 20 six-hour shifts. They rated the EM attending clinical teaching by site using a 5-point scale at the end of the clerkship.
Results : Most (95%) of the 87 students in the 7 clerkship blocks of the 1996–97 academic year rotated at the UH and a CH. Most (71%) students rated both the UH and the CH for the quality of teaching by attendings. There was a significant difference in the mean number of patients evaluated/shift (2.2 ± 0.10 vs 2.8 ± 0.10, UH vs CH; p < 0.001) and the mean number of procedures performed/shift (0.36 ± 0.04 vs 0.56 ± 0.05, UH vs CH; p < 0.001). Attending clinical teaching scores were significantly higher (p = 0.03) at the CHs.
Conclusions : The educational opportunities for students in an EM clerkship to evaluate patients and perform procedures were significantly greater at the community hospitals. Inclusion of community hospital settings in a medical student EM clerkship may optimize the clinical experience.     

Positive Outcomes of Optimizing Student–Preceptor Continuity in a Traditional Block Clerkship

Problem: Student–preceptor discontinuity during 3rd-year clerkships limits the quality and quantity of supervision, teaching, and feedback. Although longitudinal integrative clerkships increase continuity and are associated with improved student and preceptor experience, they require schoolwide curricular reform. Alternative innovations enhancing student–preceptor relationships within the constraints of a traditional block clerkship may demonstrate similar benefits. Intervention: We piloted a continuity-enhanced general pediatric ambulatory schedule during 2 consecutive clerkship blocks in 2013. Students in the continuity-enhanced model (n = 29) were assigned 1–3 primary clinic preceptors, whereas those in the traditional model (n = 30) worked with 5–8. Data were gathered from student assessments and anonymous student and preceptor surveys. We used t and Fisher's exact tests to compare the two groups and performed thematic analysis of free-text survey comments. Context: Our school utilizes a block clerkship model with approximately 30 students rotating through the pediatric clerkship every 8 weeks. During the 3-week ambulatory portion, students spend 8 half days in the general pediatric ambulatory clinic. At the conclusion of each clinic, attendings completed brief student evaluation cards. Traditionally, student and attending schedules were created independently, resulting in transient supervisory relationships and dissatisfaction with clinical engagement, feedback, and evaluation. Outcome: Seventy-three percent (43/59) of the students completed the survey. Ten general ambulatory attendings collectively completed 87.5% (35/40) of the monthly surveys. Continuity students received significantly more narrative evaluation comments (10.6 vs. 5.8, p <. 001) from general ambulatory clinic attendings and were more likely to have at least one general ambulatory clinic attending endorse being able to provide meaningful feedback and evaluation (n = 29, 100% vs. n = 20, 66.7%, p <. 001). Continuity students were also more likely to endorse being able to ask at least one of these attendings for a letter of recommendation (71.4% vs. 9.1%, p <. 001) and to have at least one general ambulatory clinic attending endorse being able to provide a meaningful letter of recommendation if asked (62.1% vs. 3.3%, p <. 001). Students (88.4%) and attendings (85.7%) preferred the continuity-enhanced schedule. The most frequent theme of both student and attending free-text survey remarks were relationships and assessment. Lessons Learned: Intentional scheduling of clerkship students to enhance preceptor continuity resulted in significant positive outcomes echoing the relationship-based educational benefits of longitudinal clerkships, particularly in regards to student assessment and feedback. Clerkship directors and other medical educators should consider implementing small changes within block clerkships to maximize student–preceptor continuity.     

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship

Background

Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear.

Creating a contemporary clerkship curriculum: the flipped classroom model in emergency medicine

Background

The teaching modality of “flipping the classroom” has garnered recent attention in medical education. In this model, the lecture and homework components are reversed. The flipped classroom lends itself to more interaction in “class” and theoretically improved clinical decision-making. Data is lacking for this model for students in emergency medicine clerkships. We trialed the flipped classroom in our fourth-year student clerkship. Our aim was to learn student and faculty facilitator perceptions of the experience, as it has not been done previously in this setting. We evaluated this in two ways: (1) participant perception of the experience and (2) facilitator (EM physician educator) perception of student preparation, participation, and knowledge synthesis.

Methods

With permission from its creators, we utilized an online video series derived from the Clerkship Directors in Emergency Medicine. Students were provided the link to these 1 week prior to the classroom experience as the “homework.” We developed patient cases generated from the videos that we discussed during class in small-group format. Afterward, students were surveyed about the experience using four-point Likert items and free-text comments and also were evaluated by the facilitator on a nine-point scale.

Results

Forty-six clerkship students participated. Students deemed the online modules useful at 2.9 (95 % CI 2.7–3.2). Further, they reported the in-class discussion to be of high value at 3.9 (95 % CI 3.8–4.0), much preferred the flipped classroom to traditional lecturing at 3.8 (95 % CI 3.6–3.9), and rated the overall experience highly at 3.8 (95 % CI 3.7–3.9). Based on preparation, participation, and knowledge synthesis, the facilitator judged participants favorably at 7.4 (95 % CI 7.0–7.8). Students commented that the interactivity, discussion, and medical decision-making were advantages of this format.

Conclusions

Students found high value in the flipped classroom and prefer it to traditional lecturing, citing interactivity and discussion as the main reasons. The facilitator also viewed that the students were not only well prepared for the flipped classroom but that they also actively participated in and synthesized knowledge adequately during this experience. This study supports the use of the flipped classroom for EM clerkship students as a valuable, preferable teaching technique.

     

The Effect of Resident Duty-Hours Restrictions on Internal Medicine Clerkship Experiences: Surveys of Medical Students and Clerkship Directors

Phenomenon: Medical students receive much of their inpatient teaching from residents who now experience restructured teaching services to accommodate the 2011 duty-hour regulations (DHR). The effect of DHR on medical student educational experiences is unknown. We examined medical students’ and clerkship directors’ perceptions of the effects of the 2011 DHR on internal medicine clerkship students’ experiences with teaching, feedback and evaluation, and patient care. Approach: Students at 14 institutions responded to surveys after their medicine clerkship or subinternship. Students who completed their clerkship (n = 839) and subinternship (n = 228) March to June 2011 (pre-DHR historical controls) were compared to clerkship students (n = 895) and subinterns (n = 377) completing these rotations March to June 2012 (post-DHR). Z tests for proportions correcting for multiple comparisons were performed to assess attitude changes. The Clerkship Directors in Internal Medicine annual survey queried institutional members about the 2011 DHR just after implementation. Findings: Survey response rates were 64% and 50% for clerkship students and 60% and 48% for subinterns in 2011 and 2012 respectively, and 82% (99/121) for clerkship directors. Post-DHR, more clerkship students agreed that attendings (p =.011) and interns (p =.044) provided effective teaching. Clerkship students (p =.013) and subinterns (p =.001) believed patient care became more fragmented. The percentage of holdover patients clerkship students (p =.001) and subinterns (p =.012) admitted increased. Clerkship directors perceived negative effects of DHR for students on all survey items. Most disagreed that interns (63.1%), residents (67.8%), or attendings (71.1%) had more time to teach. Most disagreed that students received more feedback from interns (56.0%) or residents (58.2%). Fifty-nine percent felt that students participated in more patient handoffs. Insights: Students perceive few adverse consequences of the 2011 DHR on their internal medicine experiences, whereas their clerkship director educators have negative perceptions. Future research should explore the impact of fragmented patient care on the student–patient relationship and students’ clinical skills acquisition.     

Enhancing Motivational Interviewing Training in a Family Medicine Clerkship

Problem: Despite the prevalence of unhealthy behaviors among patients in the healthcare system, traditional medical training involves little or no exposure to effective behavior change techniques such as Motivational Interviewing. Intervention: An online learning community for enhanced training in Motivational Interviewing was developed for 3rd-year medical students. The website included educational materials about Motivational Interviewing as well as problematic health behaviors, a repository of exemplar videos and student videos with feedback, and a discussion board. Student participants were given the opportunity to record an encounter with a patient and to receive feedback on their use of Motivational Interviewing from a faculty member. Context: Student volunteers in the Family Medicine Clerkship at Georgetown University School of Medicine were randomized to enhanced training, which included the online learning community, or training as usual. All student volunteers completed a questionnaire assessing self-efficacy initially and at the end of the clerkship. Students also participated in an Observed Structured Clinical Exam, which was subsequently coded by a blinded rater for behavioral counts of Motivational Interviewing techniques, key steps in Motivational Interviewing, and overall Motivational Interviewing style. Outcome: Students in the enhanced training arm were rated as having significantly higher scores in Motivational Interviewing style in the Observed Structured Clinical Exam than training as usual students. A significant increase in self-efficacy from pre- to posttest in the overall sample was observed but between-group differences were not significant. Student feedback was particularly positive regarding video recorded practice sessions with patients and individualized feedback. Lessons Learned: The results of this study as well as student feedback suggest that future work should include patient practice sessions and individualized feedback in developing Motivational Interviewing curricula.     

Core Practical Objectives: A Means to Standardize the 4th-Year Emergency Medicine Clerkship

Background: Core Practical Objectives (CPOs) are clinical emergency medicine (EM) experiences (including suggested number of patient encounters) that students use to self-direct clerkship progress. Purpose: This study investigates feasibility of implementing EM clerkship CPOs, describes characteristics of students fulfilling CPO guidelines, and relates CPO completion to outcome measures (exam scores and grades). Methods: Cross-sectional research was conducted comparing students completing and not completing CPOs by gender, month of rotation, total patients evaluated, clerkship exam score, and final grade. Results: Over 4 years, 117 students completed an EM clerkship utilizing CPO guidelines. Gender and clerkship month were not associated with fulfilling CPOs. Total CPOs completed correlated positively with percent score on written exam and grade for rotation. Completion of specific CPOs was associated with exam scores and final grade. Conclusions: CPOs were successfully integrated into an EM clerkship. Preliminary data suggest that CPO guidelines can be used to standardize EM clerkships.     

Use of Individualized Learning Plans to Facilitate Feedback Among Medical Students

Abstract

Theory

Self-regulated learning theory suggests that individualized learning plans can benefit medical trainees by providing a structured means of goal setting, self-monitoring, and self-evaluation. External feedback also plays an important role in affecting learner motivations, perceptions, and self-evaluations. Accordingly, having learners share individualized learning plans with preceptors might promote self-regulated learning by helping align the feedback they receive with their learning goals. Hypothesis: We hypothesized having medical students share individualized learning plans with attendings and residents would improve the quality of the feedback they received, increase the likelihood that feedback correlated to their learning goals, and improve their perceptions of feedback received. Method: In this multisite study, third-year medical students on their pediatric clerkship created individualized learning plans and shared them with residents and attendings by writing a learning goal on at least one of their required faculty feedback forms. The quality of feedback on forms with versus without a learning goal written on top was scored using a validated scoring tool and compared using a Wilcoxon signed-ranks test, and the frequency with which feedback directly correlated to a student learning goal on forms with versus without a learning goal written on top was compared using a chi-square test. Students completed a post-clerkship survey rating the quality of feedback and teaching they received, perceptions of the individualized learning plans, progress toward achieving learning goals, and whether or not they received teaching and/or feedback related to learning goals. Results: Thirty-six students completed a total of 108 learning goals and 181 feedback forms, of which 42 forms (23.2%) had a learning goal written on top. The mean (SD) feedback score between forms with [3.9 (0.9)] versus without [3.6 (0.6)] a learning goal written on top was not different (p = .113). Feedback on forms with a learning goal written on top was more likely to correlate to a student learning goal than feedback on forms without a learning goal (92.9% vs 23.0% respectively, p < .001). Student perceptions of the usefulness of learning goals did not differ between students who reported receiving teaching or feedback related to a learning goal and those who did not. Conclusions: Sharing individualized learning plans with preceptors helped align feedback with learning goals but did not affect the quality of feedback. Further research should examine the bidirectional relationship between individualized learning plans and feedback in light of other contextual and interpersonal factors.     

Expectations,Experiences, and Attitude Change During Medical School: Through the Eyes of Polish Medical Students

Background: Pressures related to medical training influence individual experiences in the course of study, which in turn can lead to changes in students’ professional attitudes. Purposes: The aim of this investigation was to explore expectations, experiences, and attitude changes among Polish students as they progressed through a medical university. Methods: The study used a longitudinal approach in which the same cohort of students was surveyed over time, with the same questionnaire administered, at the end of Year 1 and Year 6. Results: The results showed that the disparity between students’ expectations about studying medicine and the reality increased between Year 1 and Year 6 (p <.0001). The biggest gap concerned “technical support” and “contacts with faculty”—the observed effect size was medium with the respective Cohen's d values 0.507 and 0.368. Students in Year 1 were most disappointed by the “lack of support from faculty and their lack of interest in teaching,” whereas, in Year 6, students were most concerned about an approach to teaching that equipped them in theoretical knowledge at the expense of practical skills. Students in Year 6 noticed more changes in themselves and their perception of the world as a result of medical training than students in Year 1. However, the proportion of positive changes to negative ones was 5.4:1 for Year 1 and 1.4:1 for Year 6 students. Conclusions: Our findings show that medical training constitutes a strong socializing experience, which has positive and negative impacts. Negative changes perceived by students include an increase in distrust and cynicism, whereas positive changes consist of enhanced maturity, self-confidence, and empathy, which are likely to have an impact on future doctors’ professional practice.     

Length of Attending-Student and Resident-Student Interactions in the Inpatient Medicine Clerkship

Phenomenon: Changes in the medical education milieu have led away from the apprenticeship model resulting in shorter physician–student interactions. Faculty and student feedback suggests that supervisor/student interactions may now be more cursory with increasing numbers of supervisors per student, and shorter duration of interaction. This may affect both education and student assessment. Approach: We compared inpatient attending and resident daily schedules with those of 3rd- and 4th-year medical students rotating on medicine clerkships at Brigham and Women's Hospital during academic years 2009–11 to determine the number of days of overlap. We used evaluation forms to determine the extent of evaluator's self-reported knowledge of the student. Findings: We correlated the daily schedules of 199 students and 204 resident and 187 attending physicians, which resulted in 558 resident–student pairings and 680 attending–student pairings over 2 years. During a 4-week block, students averaged 3.7 attending physicians (M = 4, range = 2–7), with 49.7% supervised by 4 or more. Attending-student overlap averaged 9 days (M = 9, range = 2–23), though 40% were 7 days or less. Students overlapped with an average 3.4 residents (M = 3, range = 1–6). Resident-student overlap averaged 12 days (M = 11, range = 3–26). There were 824 student assessment forms analyzed. Resident and attending physician supervisors describing knowledge of their student as “good/average” overlapped with students for 14 and 11 days respectively compared to resident and physician supervisors who described their knowledge as “poor” (11 days, p < .01; 6 days, p < .01). Insights: On the inpatient medicine clerkship, students have multiple supervising physicians with wide variability in the period of overlap. This leads to a disrupted apprenticeship model with fragmentation of supervision and concomitant effects on assessment, feedback, role modeling, and clerkship education.