Third-year medical students' experiences with dying patients during the internal medicine clerkship: a qualitative study of the informal curriculum.

PURPOSE: To explore third-year medical students' experiences with death and dying patients during the first internal medicine clerkship. METHOD: In August 2002, through purposeful sampling, the authors targeted for open-ended interviews 32 third-year medical students at the University of California, San Francisco in the first core internal medicine clerkship. Interviews averaged 45 minutes in length and were audiotaped, transcribed, and analyzed using a grounded theory approach. RESULTS: Twenty-eight (87.5%) students participated in interviews. All students encountered death or dying patients, and most cared directly for at least one dying patient. Students' relationships with patients were characterized by attachment, empathy, and advocacy. Students valued preparation by preclinical end-of-life (EOL) courses, but assigned greater value to patient care experiences guided by teams that acknowledged deaths, role-modeled EOL care, and respected students' participation in patient care. Clerkship experiences in EOL care affected students' developing professional identities by affording opportunities to manage strong emotions, understand the challenges of transitioning to residency, and gain a sense of self-efficacy as future physicians providing EOL care. CONCLUSIONS: Third-year medical students' experiences with dying patients affect their skills and attitudes in EOL care, as well as the emergence of their professional identities. The behaviors and attitudes modeled by residents and attendings during the clerkships can strongly influence students' perceptions of and self-efficacy in EOL care. Further research and interventions into how residents and attendings model responses to death in the clinical clerkship may suggest strategies not only for EOL training, but also for mentoring professional development.     

What students value: learning outcomes in a required third-year ambulatory primary care clerkship.

PURPOSE: To determine learning outcomes from the students' perspective on the clinical portion of a third-year primary care ambulatory clerkship. METHOD: Over 18 months (December 1994 to June 1996), students at the Medical College of Wisconsin identified what they had learned during the clerkship in each of seven learning settings. Responses were transcribed and a coding dictionary developed. Response frequencies were compared by logistic regression analysis over time and between rural and urban sites. Course goals set by faculty were compared to learning outcomes reported by students. RESULTS: The authors coded 3,030 student outcomes into 48 categories. The top ten learning outcomes by frequency are reported. Logistic regression analysis revealed no significant difference by time of year or by rural versus urban clerkship experiences. Twenty-six of 29 original course goals were congruent with the student-generated outcomes. CONCLUSION: Basic professional knowledge, skills, and attitudes were the learning outcomes most valued throughout the year. Being alone with patients and working with their preceptors were the students' most valued learning settings.     

Learning to be a doctor: Medical students’ perception of their roles in longitudinal outpatient clerkships

Objective

To understand how medical students perceive their roles in early longitudinal primary care clerkships.

Multidimensional effects of the 80-hour work week at the University of Michigan Medical School.

PURPOSE: To examine the effects of the new resident work-hour restrictions on medical students, as measured by their perceptions of the quality of their experiences during the required clerkships. METHOD: Evaluations of four clerkships were compared for two student cohorts at the University of Michigan Medical School. The first cohort, from the class of 2002-03, completed their clinical clerkships the year before the work-hour restrictions were implemented, and the second cohort, from the class of 2003-04, completed their clerkships the same year the restrictions were implemented. RESULTS: There were significant and notable differences in the experiences of the two cohorts. Students' perceptions of the quality of their experiences in the surgery-oriented clerkships (obstetrics-gynecology and surgery) in particular were significantly lower (i.e., more negative) in the 2003-04 cohort than in the previous cohort for the same clerkships. The nonsurgery-oriented clerkships (internal medicine and pediatrics) hired hospitalists, who offset the residents' workload (internal medicine) and assumed teaching responsibilities (pediatrics). Between 2002-03 and 2003-04, students' perceptions of the quality of their experience in the internal medicine clerkship remained mostly stable, and increased in several areas for the students in the pediatrics clerkship. CONCLUSIONS: Implementation of resident work-hour restrictions had significant effects on the education of the medical students studied. These effects need to be carefully analyzed and considered to ensure quality education for medical students. The findings also highlight that the nature of students' perceptions was related to preparations made (or not) by specific clerkships as restricted work-hour regulations were adopted.     

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

PURPOSE: 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. METHOD: 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. RESULTS: 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. CONCLUSION: 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.     

The effects of patient characteristics and practice settings on students' participation in a primary care clerkship.

PURPOSE: To explore the effects of practice, patient, and encounter variables on students' participation in a third-year primary care clerkship. METHOD: In 1995-96, 154 students, randomly assigned to ambulatory teaching sites, completed for each patient encounter a scannable card indicating the patient's age range, gender, and insurance type, the setting of care, the type of visit, whether it was a repeat or first visit to the student, and the student's level of participation. Conventional measures of students' satisfaction (post-clerkship survey) and performance (preceptor ratings, USMLE Step 2, standardized-patient examination scores) were examined. RESULTS: The students reported significantly higher levels of participation for patient encounters taking place in clinic and emergency room settings than for those in private offices; for repeat rather than for first visits; for patients over 12 years old than for those 12 years old or younger; and for sick visits rather than for follow-ups or checkups. Students' participation had a modestly positive correlation with students' satisfaction and performance. CONCLUSION: Several practice and patient variables influence the level of students' participation in the care of ambulatory patients. The strongest predictor of active student participation is the clinical setting of the encounter. Monitoring students' self-reported levels of participation is an important tool for tracking the impact of practice variability on the quality of the learning environment in ambulatory clerkships.     

Perceptions and attributions of third-year student struggles in clerkships: do students and clerkship directors agree?

PURPOSE: To explore the congruence between students' and clerkship directors' perceptions and attributions of students' struggles during the transition to clerkships. METHOD: Focus groups and interviews were conducted with third- and fourth-year medical students and clerkship directors at 10 U.S. medical schools in 2005 and 2006. Schools were selected to represent diverse locations, sizes, and missions. Interviews and focus groups were recorded, transcribed, and analyzed thematically. RESULTS: Students' struggles included understanding roles and responsibilities, adjusting to clinical cultures, performing clinical skills, learning the logistics of clinical settings, and encountering frequent changes in staff, settings, and content. Clerkship directors recognized students' struggles with roles and responsibilities, performing clinical skills, and adjusting to clinical cultures, but they also focused on students' difficulties applying knowledge to clinical reasoning and engaging in self-directed learning. CONCLUSIONS: Clerkship directors and students recognize many challenges associated with learning and performing in the clerkships. Students' perspectives suggest that these challenges may be more complex than clerkship directors and clinical teachers realize and/or are capable of addressing. The areas in which clerkship directors' and students' perspectives are not congruent point to directions for future research that can guide curricula and teaching strategies.     

A model of how students link problem-based learning with clinical experience through "elaboration".

PURPOSE: In 1994, the medical school at the University of Manchester introduced a new integrated course that uses problem-based learning (PBL) throughout the clinical clerkships as the major approach for delivery of the core curriculum. This study explored how students linked PBL and clinical experiences. METHOD: All third- and fourth-year students were asked to respond to an open-ended question on the end-of-module course evaluation. Their responses were analyzed and grouped into themes. The authors also conducted three focus groups of third-year students and a further three focus groups of fourth-year students to explore how students viewed the links between PBL and clinical experiences. The discussions were taped and subsequently analyzed by the researchers independently. RESULTS: The authors found that the students used clinical experience as a means of elaborating their knowledge either at the time of encountering an appropriate patient (outside the group) or by bringing their experiences back to the PBL group for discussion (inside the group). Major facilitators of elaboration were the match between the clinical clerkship and the content of the PBL case, the role of the tutor, and the self-directedness of the student. A theoretical model of how students linked PBL with their clinical experience was derived based on a cognitive psychological approach to learning. CONCLUSIONS: The model will be of benefit as the authors try to improve the course for those students who were unable to use their clinical experiences to achieve the goals of their PBL discussions.     

Sixteen years' experience with a required third-year family medicine clerkship at Jefferson Medical College.

Jefferson Medical College has developed a program to successfully meet the goal of teaching ambulatory care to all medical students, by providing each of its 223 third-year students with a required six-week clerkship in family medicine. The structured clerkship takes place at one of seven residency-based family practice centers, is supplemented by a formal curriculum, and is based on the active clinical involvement of caring for patients under full-time family medicine faculty supervision. This clerkship has been in existence for 16 years, and has added over 400,000 student-patient encounters to the clinical education of over 3,500 students. Student evaluations of the clerkship have rated it the highest of the six required core clerkships at Jefferson. In addition, over 16% of Jefferson graduates have entered family medicine residency training programs, a rate higher than that of any other school in the northeastern United States, and significantly higher than the average for all U.S. medical schools (12%). Jefferson's experience suggests that ambulatory care can be taught as a core component of the clinical education of all medical students. To be successful, however, strong institutional support, a structured curriculum, an adequate number of patients, a dedicated faculty, a sufficient number of training sites, an appropriate evaluation process, and significant financial support are all necessary.     

"Making the grade:" noncognitive predictors of medical students' clinical clerkship grades

OBJECTIVES: Because clinical clerkship grades are associated with resident selection and performance and are largely based on residents'/attendings' subjective ratings, it is important to identify variables associated with clinical clerkship grades. METHODS: U.S. medical students who completed > or =1 of the following required clinical clerkships--internal medicine, surgery, obstetrics/gynecology, pediatrics, neurology and psychiatry--were invited to participate in an anonymous online survey, which inquired about demographics, degree program, perceived quality of clerkship experiences, assertiveness, reticence and clerkship grades. RESULTS: A total of 2395 medical students (55% women; 57% whites) from 105 schools responded. Multivariable logistic regression models identified factors independently associated with receiving lower clerkship grades (high pass/pass or B/C) compared with the highest grade (honors or A). Students reporting higher quality of clerkship experiences were less likely to report lower grades in all clerkships. Older students more likely reported lower grades in internal medicine (P = 0.02) and neurology (P < 0.001). Underrepresented minorities more likely reported lower grades in all clerkships (P < 0.001); Asians more likely reported lower grades in obstetrics/gynecology (P = 0.007), pediatrics (P = 0.01) and neurology (P = 0.01). Men more likely reported lower grades in obstetrics/gynecology (P < 0.001) and psychiatry (P = 0.004). Students reporting greater reticence more likely reported lower grades in internal medicine (P = 0.02), pediatrics (P = 0.02) and psychiatry (P < 0.05). Students reporting greater assertiveness less likely reported lower grades in all clerkships (P < 0.03) except IM. CONCLUSIONS: The independent associations between lower clerkship grades and nonwhite race, male gender, older age, lower quality of clerkship experiences, and being less assertive and more reticent are concerning and merit further investigation.     

Time allocation of students in basic clinical clerkships in a traditional curriculum.

The objective of this study was to determine the amounts of time spent in various activities by medical students enrolled in basic clinical clerkships. In the fall of 1989, 80 third-year students at the University of North Carolina at Chapel Hill School of Medicine recorded their time allocations in eight categories over 24 hours for three consecutive days. After personal time, the students spent the greatest amount of time in organized educational activities (rounds, conferences, lectures), followed in decreasing order by chartwork, patient contact, examination study, ancillary activities, procedures, and directed study. The students reported an average of 5.8 hours of sleep per night. The students reported that when they were on call, they had significant increases in patient contact, chartwork, and ancillary activities. The authors suggest that third-year students may spend too much of their time in organized educational activities, and may benefit educationally from increased amounts of patient contact and decreased amounts of ancillary activities. These data provide an opportunity for clerkship and curriculum organizers to analyze the efficacy of the basic clinical clerkships.     

Student attitudes about a clinical experience in abortion care during the obstetrics and gynecology clerkship.

PURPOSE: An optional half-day clinical experience in abortion care was offered to third-year medical students rotating through the core obstetrics and gynecology (Ob/Gyn) clerkship at the University of New Mexico to improve education about women's reproductive health. This study using survey methods was conducted to rate the acceptability of the clinical experience and to document any changes in students' attitudes toward women's access to abortion. METHOD: All 145 students who rotated through the Ob/Gyn clerkship between March 2000 and March 2002 were provided an 11-item, confidential questionnaire to complete. Students who did not participate in the abortion care experience were asked questions about their reasons for declining participation; students who did participate were asked questions about the value of the experience. RESULTS: Of the 145 students who rotated through the clerkship during the study period, 126 (87%) completed the questionnaire. Of these students, 86 (68%) participated in the clinical experience and 40 (32%) did not. The majority of students who participated in the clinical experience rated it very highly. Of the 86 students who participated in the clinical experience, 33 (38%) reported a change in their attitudes about abortion; 31 (94%) of these became more supportive of women's access to abortion services. CONCLUSION: Clinical experiences in abortion care are acceptable to and valued by a diverse group of medical students and should be offered at medical schools throughout the United States.     

Early clinical experience enhances third-year pediatrics clerkship performance.

PURPOSE: To determine whether clinical experiences in the preclinical years improve medical students' performances in a third-year clerkship. METHOD: A cohort study reviewed the pediatrics clerkship performances of 400 Eastern Virginia Medical School students in the graduating classes of 1996 through 1999. The first two classes completed a traditional preclinical curriculum with limited clinical experience. The final two classes participated in a mentorship program that provided 18 months of early clinical experience, consisting of one-on-one half-day sessions every other week with a generalist community faculty. The authors compared the clinical clerkship performances of the groups using clinical skills (CS) scores, history and physical examination (H&P) scores, and scores on the NBME pediatrics shelf examination. They also looked at the mean MCAT and USMLE scores for each group. The authors also looked at the scores within each class, comparing students who completed one of the first two pediatrics clerkship rotations with their classmates who completed clerkships later in the academic year. RESULTS: The students' NBME scores rose significantly (p < .05, r2 = 0.95) over the four-year study, paralleling a significant rise in MCAT scores (p < .03, r2 = 0.73). The CS and H&P scores did not rise. Students who had the traditional preclinical curriculum and who completed their clerkships early in the year had significantly lower CS and H&P scores than did their classmates. In contrast, the scores of students who had the early clinical experiences did not differ significantly according to the timing of their rotation. CONCLUSION: Students who had participated in a mentorship program that provided early clinical experience demonstrated significantly improved clinical skills in the pediatrics clerkship early in the academic year.     

The longitudinal primary care clerkship at Harvard Medical School.

The primary care clerkship (PCC) at Harvard Medical School was established in 1997. The goals are to provide students with longitudinal experiences with patients and to include modern themes in the curriculum: managing illness and clinical relationships over time; finding the best available answers to clinical questions; preventing illness and promoting health; dealing with clinical uncertainty; getting the best outcomes with available resources; working in a health care team; and sharing decision making with patients. The PCC, a required course in the clinical years, meets one afternoon a week for nine months. Students spend three afternoons per month in primary care practices, where they see three to five patients per session and follow at least one patient ("longitudinal patient") over time. Classroom sessions, in both large- and small-group formats, promote a common educational philosophy and experience, and reinforce habits of problem-based learning established in the preclinical years. The students rated 74% of their preceptors excellent, especially praising their ability to facilitate and support good interpersonal relationships with patients, their ability to encourage students' independent evaluation of patients (as opposed to shadowing), and their enthusiasm for teaching. Students saw their longitudinal patients a mean of 4.8 times; 83% saw their patients at least three times. The PCC complements the curriculum of block clerkships in hospitals, and because the two are offered concurrently, students are required to come to terms with two substantially different cultures within medicine. Other medical schools are beginning to develop longitudinal clerkships to ensure that students have essential educational experiences that are difficult to achieve in block, hospital-based clerkships.     

A longitudinal, national study of the effect of implementing a required third-year family practice clerkship or a department of family medicine on the selection of family medicine by medical students.

PURPOSE: To conduct a longitudinal study of the effect of implementing a required third-year family practice clerkship or a department of family medicine on the proportion of graduating medical students choosing family practice as a specialty. METHOD: Using national data sets, the authors studied the proportion of students who chose family practice as a specialty at each medical school that implemented a required third-year family practice clerkship or a department of family medicine between 1984 and 1993. They compared the mean proportions of students choosing family practice for the three years before and three years after implementation of the required clerkship or the department. They controlled for national trends by comparing study schools with schools that did not have required family practice clerkships. RESULTS: The mean proportions of students who chose family practice increased 2.36% above control schools (95% CI = 1.06, 3.65) in public schools and 2.07% (95% CI = -2.58, 6.73) in private schools after a required third-year clerkship was implemented. The proportion of students choosing family practice declined by 0.84% (95% CI = -4.05, 2.47) after a department of family medicine was established. CONCLUSION: Implementing a required third-year family practice clerkship led to an immediate, significant increase in the proportion of students choosing family practice. Implementing a department of family medicine had no noticeable effect on the proportion of students choosing family practice in the first three years after implementation.     

Problem-based learning in the surgery clerkship: A change in philosophy

In the academic year 1989–1990, the Department of Surgery at the University of Kentucky College of Medicine introduced a modified third-year surgery clerkship. Its goals were to eliminate the lecture method of instruction, to involve students actively in the educational process, and to emphasize decision-making and problem-solving skills in the third year of medical school. Hands-on training in patient care procedures would be offered in a fourth-year acting internship after students had learned both problem-solving and life-long learning skills while concurrently developing a medical knowledge base. Students were removed from the traditional surgical service teams, since it was decided that team duties might be detrimental to educational goals. Problem-based tutorial sessions were designed, and a block of unscheduled time was provided for students to use in obtaining, exploring, and reflecting on medical information. Informal comparisons of students in the previous clerkships with those in the modified clerkship have noted positive changes in the students' intellectual maturity, motivation, enthusiasm, and time-management skills. Faculty and students have responded positively to the programs which are part of this innovative clerkship.     

The effect on grades of the timing and site of third-year internal medicine clerkships

Two important factors affecting the performances of third-year medical students on their basic internal medicine clerkships were investigated: (1) the effect on their grades of when in the academic year they took the internal medicine clerkship, and (2) the effect on their grades of the site of the clerkship. During the academic years 1983-84, 1984-85, and 1985-86, the Department of Internal Medicine of the University of Illinois College of Medicine at Chicago conducted 12-week junior clerkships at six hospital sites. The study analyzed the 535 students' subjective grades, clerkship examination scores, final grades, and National Board of Medical Examiners Part I (NBME-I) scores. Although students' performances as characterized by subjective evaluations did not improve as the academic year progressed, mean scores on clerkship examinations improved steadily during the same period. The site of the clerkship, whether a community-affiliated hospital or a medical center hospital, affected neither subjective nor objective grades.     

Distributed radiology clerkship for the core clinical year of medical school.

OBJECTIVE: The central role that diagnostic radiology has in the modern practice of medicine has not always been reflected in radiology's place in the curriculum. We developed a new radiology clerkship for undergraduate medical students during their core clinical year that was supported by Web technology. The assumptions underlying the design of the clerkship were that radiology is best learned from radiologists and that students are most receptive to learning radiology when it is related to concurrent patient care experiences. DESCRIPTION: Beginning in May 2000, a required radiology clerkship experience was incorporated into the core clinical year at Wake Forest University School of Medicine. The core clinical year was organized into three 16-week blocks of clerkships. Two or four independent half-day radiology tutorial sessions were included with each clerkship block, and attended by all students in the block (approximately 35 students), regardless of their specific clerkship assignments. There were ten different radiology tutorials, each given three times during the year as students rotated through the clerkship blocks. Thus, each student attended a radiology tutorial session every four to eight weeks during the year. The topics covered during the tutorials were correlated with the content of the clerkship blocks and included adult and pediatric chest radiology, adult and pediatric abdominal radiology, body CT, neuroradiology, obstetric ultrasound, gynecologic ultrasound, osteoporosis, adult and pediatric fractures, mammography, and cervical spine trauma. The tutorials included pre- and post-test, lectures, case presentations, and sometimes tours of the radiology department. The educational emphasis was on pragmatic case-based learning exercises, development of verbal and visual vocabulary, and learning when and where to seek more information. To provide continuity and organization, Web-based curriculum materials were designed and implemented as a component of the clerkship. The home page of the Web site provided the schedule, faculty names, attendance and grading policies, course overview, and links to individual tutorials. The pages for individual tutorials included educational objectives, glossary of radiology terminology relevant to the subject, lecture slides and handouts, and teaching cases. All students had laptop computers and access to the academic network, but did not use them during the actual tutorial sessions. DISCUSSION: Implementation of the radiology clerkship required extensive negotiation with directors of other clerkships so that students could be released from their other responsibilities in order to attend the radiology tutorials. The radiology clerkship format has proven to be complex in its administration, with faculty and students on different schedules commuting to the radiology lecture hall from various locations. Extensive use of e-mail and communication via the Web site have been instrumental in reminding faculty and students of upcoming sessions. Preliminary evaluations have indicated that students liked the radiology sessions and learned a great deal, but disliked the scheduling and the lack of continuity. An evaluation of the curriculum and its components is ongoing.     

HEAL: an instructional design model applied to an online clerkship in family medicine.

OBJECTIVE: The potential of distance learning technology to deliver educational programs in which instruction and evaluation are of a consistent and high standard across multiple settings is hampered by a lack of instructional design models. In response, we developed the HEAL (Heuristic for Electronic Asynchronous Learning) model for designing online curricula. DESCRIPTION: HEAL is based on the theories that learning is facilitated by independent problem solving, investigation, and discovery (heuristics); collaboration between students fosters learning; and the proven educational cycle of practice, feedback, and reflection is integral to the interrelated domains of skill development and personal awareness.(1) The HEAL model is defined by synergistic online learning activities integrated with real patient care. It is applicable to all medical education levels. We applied this innovative design template to an online curriculum that augments our conventional six-week third-year clerkship. Our students, who were placed in distant family physician offices, needed more interaction and learning from peers and faculty. The three elements of HEAL, and implementation in the "online clerkship," are: (1) Didactic modules teach and illustrate concepts. Students study modules (HTML pages) on management of diabetes (DM), and complete five modules on evidence-based medicine (EBM). They do EBM literature searches reviewed online by peers, faculty, and librarians, who provide feedback. (2) A problem-based case discussion promotes application of concepts from modules (horizontal curricular integration). Students view streamed video of a patient with a history suggestive of diabetes, review her medical chart online, and suggest evidence-based management in an asynchronous discussion group. The case progresses weekly to mimic 12 months of continuity of care. (3) A collaborative journal activity explores the results of applying elements one and two to real patients (vertical integration). Additional elements advance reflection, professionalism, and medical humanism. Participation in the journal discussion group, stimulated by online readings, enhances self-awareness, informs psychosocial aspects of element 2, and promotes generalization of learning objectives to real patients. We use BlackBoard software. Students log in two to three times per week. Faculty who are trained in online moderation facilitate the threaded discussion groups and provide feedback. DISCUSSION: Students in alternating clerkship blocks complete the online clerkship. Their performance is compared with that of students who complete a face-to-face diabetes curriculum, but no curriculum on EBM or medical humanism. After nearly a year (105 students), compared with the non-online group, students completing the online clerkship demonstrated greater gains in reported EBM skills from preto post-clerkship, larger increases in mean score (from pre to post) on a medical-humanism aptitude scale, and higher scores on a post-clerkship diabetes management assessment (all comparisons p <.05). The online clerkship will become a permanent part of our clerkship and we have begun to use HEAL to design other online courses, including continuing education courses.     

Communicating about sexuality: an initiative across the core clerkships.

OBJECTIVES: Recently there has been a renewed interest in teaching communication skills in U.S. medical schools. Yet a large number of physicians and medical students may be uncomfortable discussing matters of sexuality with their patients. We have developed a comprehensive, cross-clerkship curriculum for third-year medical students that strives to fill the educational gap concerning a variety of topics in sexuality. The objectives of this project are (1) to increase awareness among medical students that communication about sexuality is central to comprehensive health care; (2) to train faculty to teach students the knowledge, skills and attitudes necessary for communicating effectively with patients about issues of sexuality; and (3) to improve the level of student comfort in discussing sexual issues. DESCRIPTION: With support from the Josiah Macy, Jr. Foundation (part of the UMass Macy Initiative in Health Communication), and in consultation with clerkship directors, specific topics in sexuality were chosen for inclusion in four clerkships: internal medicine, family medicine, pediatrics, and psychiatry. The family medicine clerkship incorporated a fictional female adolescent into their case-based "standardized family." Faculty were trained to lead their small groups in a discussion of the potentially wide range of sexual behavior in this case study. Supplemental readings were provided and a PDA application is being developed. During the internal medicine clerkship a "difficult interview" session was held. Student volunteers interviewed three standardized patients with sexual issues: a sexually active young woman desiring contraception, a homosexual young man at risk for HIV, and a heterosexual male noncompliant with blood pressure medication due to sexual dysfunction. An HIV counselor was brought in as a discussant. The pediatric clerkship utilized a multimodal format to cover topics pertaining to gay and lesbian youth. Included were a didactic presentation, a videotaped panel discussion featuring two youths and a parent, and a modeled patient interview. The psychiatry clerkship included three relevant interventions: a didactic session around the topic of medication-related sexual dysfunction; a videotaped modeled interview of a sexually traumatized woman; and a session involving a standardized patient-a lesbian whose sexual orientation was not part of her psychopathology. Adjunct activities included a cross-clerkship faculty development session, evaluation components, and a module designed for the staff of a private office. The latter was piloted in the office of a community pediatrician. DISCUSSION: Medical students who experienced the curriculum found it valuable. Student self-evaluations, done at the end of each clerkship, indicate increased comfort in dealing with issues of sexuality. During the pediatric clerkships only, half the students received the curriculum while the other half served as a comparison group. The intervention group showed a slight decrease in homophobic attitudes; the lack of a larger effect is likely due to a high level of baseline acceptance and comfort around issues of sexual orientation in this particular medical school class. The pediatric segment will be modified to take this into account and present more advanced topics around sexual orientation and interviewing. The entire curriculum is being incorporated into ongoing clerkships using existing resources at the medical school.