Windish, Donna M. MD; Paulman, Paul M. MD; Goroll, Allan H. MD; Bass, Eric B. MD, MPH
Over the past several years, U.S. organizations have recognized the need for curricular reform in all stages of medical training. At the undergraduate level, the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine have proposed guidelines for improving medical student education through the Medical School Objectives Project (MSOP)1 and Undergraduate Medical Education for the 21st Century.2 Within undergraduate medical education, the core clerkships of internal medicine, family medicine, pediatrics, surgery, and gynecology/obstetrics have introduced national guidelines to improve training in each of the respective disciplines.3–9 Similarly, the Accreditation Council for Graduate Medical Education (ACGME) recently addressed issues of competency in residency training.10
Although medical educators support many of these changes,11 implementation can be a challenge.12 To facilitate implementation of undergraduate educational reform in generalist specialties, the U.S. Health Resources and Services Administration has funded projects in internal medicine,13 pediatrics,14 and family medicine15 to develop curriculum resource guides for the core clerkships in these fields.
In the process of writing these curricular documents, collaborators have uniformly recognized the importance of preclerkship preparation to successful student learning in the core clerkships. Several competencies have been singled out for attention: communication skills, interviewing/physical examination, clinical epidemiology and probabilistic thinking, professionalism, systems of care, and attention to life-cycle stage.15 At issue is the appropriate level of preclerkship competence in these six areas and the adequacy of preparation for the core clerkships. To help inform curriculum planning at U.S. medical schools, we conducted a national survey of core clerkship directors to determine their views on the appropriate level of clerkship preparation and on the current state of student preparedness with regard to the six core competencies.
Study Design and Target Population
We conducted a national cross-sectional survey of clerkship directors at 32 U.S. medical schools. We targeted clerkship directors in six specialties: family medicine, internal medicine, obstetrics/gynecology, pediatrics, psychiatry, and surgery. The University of Nebraska College of Medicine institutional review board approved the study design.
Given the target population, we decided on a selection process that would ensure a broad representation of medical schools. We first stratified all medical schools by awards received from the National Institutes of Health (NIH) for the 2001 federal fiscal year.16 From this list, schools were divided into two groups: those in the top half of research funding dollars and those in the bottom half of research funding dollars. Schools were then separated into four geographic regions in the United States: Northeast, Southeast, Midwest, and West/Southwest. Using a random numbers table, we chose eight schools from each region (four schools with top 50% NIH funding, and four schools with bottom 50% NIH funding), giving a total of 32 schools.
We obtained clerkship director names for each selected school through the medical school’s admissions office or through clerkship society director lists for the specialty areas targeted. Names and addresses were confirmed during a phone conversation with a member of each clerkship director’s department. Because two schools did not have family medicine clerkships, we targeted 190 clerkship directors for inclusion in our study.
In 2000, the U.S. Health Resources and Services Administration funded the Family Medicine Curriculum Resource Project to help educators develop a resource document to address all four years of family medicine education, including the core family medicine clerkship. As part of the project, a Preclerkship Collaborative Workgroup (comprised of educators in pediatrics, internal medicine and family medicine) identified six competencies as high priorities in the first two years of medical school: communication skills, interviewing/physical examination, clinical epidemiology and probabilistic thinking, professionalism, understanding systems of care, and understanding a patient’s life-cycle stage. To inform this workgroup, we created a survey instrument that asked clerkship directors to rate the level of ability (none, minimal, intermediate, or advanced) in each of the six identified competencies that students should possess upon entering their core clinical clerkships. We also asked clerkship directors to estimate how prepared they feel their students are in each competency compared to the level of ability they felt is necessary upon entering the clerkships (much less prepared than necessary, less prepared than necessary, at the level they should be, more prepared than necessary, much more prepared than necessary).
We asked for information regarding each clerkship director’s academic rank, length of time involved in medical student teaching, years as a clerkship director, other teaching responsibilities in the first- or second-year curriculum, and the percent of their clerkship time in an outpatient setting. We also asked clerkship directors to indicate if their clerkship provides formal training in any of the six competencies because they feel students do not receive as much instruction as is needed in the preclerkship curriculum, and the most important competency that needs more attention in preclerkship training.
Members of the Preclerkship Collaborative Workgroup reviewed the instrument during a September 2002 meeting to assure that questions had reasonable face validity. The instrument was then pilot tested with the workgroup; with clerkship directors in psychiatry, obstetrics/gynecology, and surgery from three of the panel members’ medical schools; and with a group of academic physicians at the Johns Hopkins University Medical Institutions in specialty areas of internal medicine, pediatrics, family medicine, psychiatry, and neurology. From these sources, we considered suggestions regarding format and question clarity without changing the main content of the instrument.
We mailed questionnaires to each clerkship director in October 2002. Reminder letters were sent four weeks later. A final mailing was sent at eight weeks to those who did not respond to the first two mailings.
We calculated and displayed various characteristics of the respondents by percentage. For each competency, we also calculated the percentage of respondents reporting that students need at least intermediate ability, and the percentage reporting that students are less prepared than necessary. Bivariate analyses were done using the chi-square test to assess the significance of response differences by respondent characteristics. We performed all analyses using Intercooled Stata, Version 7.0 software (Stata Corporation, College Station, Texas).
Of the 190 clerkship directors surveyed, 140 (74%) returned the questionnaire. The response rate varied somewhat by clerkship type and geographic location (see Table 1). Nonrespondents were more likely to be from the West/Southwest of the United States (58%) and to be a clerkship director in surgery (62%).
Level of Ability Required and Preparation Needed in Each Competency
The majority of clerkship directors reported that students need at least intermediate ability in five of six competencies before entering their first core clerkship (see Figure 1). Over 95% of the clerkship directors surveyed felt students need intermediate to advanced level of ability in communication skills and professionalism. Comparatively, 73% felt that students need minimal or no ability in understanding systems of care.
Thirty to fifty percent of clerkship directors reported that students were less prepared than necessary in all six competencies upon entering the clerkships (see Figure 1). Fifty percent reported that students were less prepared than necessary in epidemiology/probabilistic thinking, whereas 30% reported that students were less prepared than necessary in communication skills. When we focused on the views of clerkship directors who reported that at least intermediate ability is needed in each of the six competencies, we found that the percentage reporting that students are less prepared than necessary was 28% for communication skills (95% confidence interval [CI], 21%–35%), 31% for professionalism (95% CI, 23%–39%), 43% for life-cycle stages (95% CI, 35%– 51%), 44% for interviewing/physical examination (95% CI, 36%–52%), 62% for epidemiology/probabilistic thinking (95% CI, 54%–70%), and 82% for systems of care (95% CI, 76%–88%).
Many clerkship directors indicated that their clerkship provides formal training in at least one of these six competencies because they believe students do not receive as much instruction as necessary in the preclerkship curriculum. Sixty percent of respondents stated they offer training in interviewing/physical examination, 35% in communications skills, 32% in epidemiology/probabilistic thinking, 27% in professionalism, 27% in life-cycle stages, and 14% in systems of care.
We reexamined responses to each question based on characteristics of the clerkship directors and their individual institutions. The views of clerkship directors in nonsurgical primary care disciplines (family medicine, internal medicine, and pediatrics) were compared to those in the surgical or non–primary care fields (obstetrics/gynecology, surgery, and psychiatry) (see Table 2). Clerkship directors in non–primary care specialties were more likely than those in primary care disciplines to report that students need at least intermediate ability in understanding systems of care (36% versus 19%; p < .05) and understanding a patient’s life-cycle stage (66% versus 49%; p < .05) upon entering the core clerkships. However, the two groups did not differ in their ratings of student preparedness in the six competencies.
Other analyses compared respondents’ ratings of ability needed and adequacy of preparation between groups defined by total years teaching, total years as clerkship director, and amount of NIH funding received by respondent’s school. No significant differences were seen for any of these variables in either the reported level of ability needed or in reported adequacy of preparation. (Data are available from the authors upon request.)
When asked to identify the most important competency that needs more attention in the preclerkship curriculum, 32% cited interviewing/physical examination, 21% communication skills, 16% professionalism, 16% epidemiology/probabilistic thinking, 8% understanding life-cycle stage, 6% understanding systems of care, and 2% listed other topics.
Some exceptions were noted, however, when we compared clerkship directors’ academic rank, number of teaching responsibilities in the preclerkship years, and amount of outpatient time offered in the clerkship. Clerkship directors with higher academic rank (associate professor or full professor) were more likely to report that students need greater ability in understanding life-cycle stages (63% versus 49%; p < .05) compared to clerkship directors who were instructors or assistant professors. Clerkship directors who had two or more teaching responsibilities in the preclinical years were more likely to report that students need intermediate or advanced ability in interviewing/physical examination skills (86% versus 73%; p < .05), and are less prepared than necessary in that competency (66% versus 47%; p < .05). Clerkship directors with greater than 50% outpatient time in their clerkship were more likely than other clerkship directors to report that students are less prepared than necessary in epidemiology/probabilistic thinking (79% versus 42%; p = .001).
In this report we present the results of a national survey assessing core clerkship directors’ views and observations regarding preclerkship preparation of U.S. medical students in six key competencies: communication skills, interviewing/physical examination, clinical epidemiology and probabilistic thinking, professionalism, understanding systems of care, and understanding a patient’s life-cycle stage. Approximately 80% or more of clerkship directors felt that high levels of ability are needed in communication skills, professionalism, and interviewing/physical examination before entering the clerkships. Thirty to fifty percent of respondents believed students are less prepared than they should be in all six competencies.
Although our study was aimed at informing a project focused on improving curricula for family medicine clerkships, we saw a striking consensus of views in all of the clinical disciplines represented, not just in family medicine or the other primary care-oriented disciplines. A few exceptions were seen related to academic rank, number of teaching responsibilities in the preclerkship years, and amount of outpatient time offered in the clerkship; however, the majority of our comparisons between subgroups revealed no significant differences in opinions or perceptions about the preclerkship training of students in the six competencies.
Our study offers important insight into the views of clerkship directors across disciplines. The high concordance of opinions indicates that clerkship directors of many specialties share similar views and concerns regarding medical student preparation for the core clerkships, namely that preparation is important and that in the view of nearly half of respondents, preparation is inadequate. The survey instrument was carefully worded so that respondents would not mistakenly address ultimate level of competence expected rather than the appropriate level of preparation expected for medical students entering the clerkships.
Views about the appropriate level of preparation did vary by competency. There was strong agreement about the need for at least intermediate ability in communication skills, professionalism and interviewing/physical examination before entering the clerkships. Most clerkship directors also wanted students to have at least intermediate ability in epidemiology/probabilistic thinking and life-cycle stages before entering the clerkships. Only about one quarter of clerkship directors felt the same way about the level of ability students need to have in systems of care, but almost 40% still felt students do not receive enough preparation in systems of care before the clerkships.
The six competencies are recognized as important throughout the continuum of medical education. In 1999, the ACGME endorsed six competencies that residents should have proficiency in by the end of their training.10 Each of these competencies coincides with areas we assessed: communication skills (ACGME: interpersonal and communication skills), interviewing/physical examination skills (ACGME: patient care), professionalism (ACGME: professionalism), systems of care (ACGME: systems-based practice), epidemiology/probabilistic thinking (ACGME: medical knowledge and practice-based learning and improvement), and life-cycle stages (ACGME: patient care).
Our results suggest that students in many medical schools may receive inadequate preparation before entering the clerkship years. Since the Association of American Medical Colleges’ project panel on the General Professional Education of the Physician and College Preparation for Medicine report in 1984,17 many schools have responded to the call to integrate basic science teaching and clinical education, and to place a greater focus on problem-based learning. Most curricular changes have occurred in the first two years of training through multidisciplinary courses in clinical skills and sociobehavioral education.18 The effects of these changes in the first two years on students’ knowledge and skills are important to assess, because performance in these areas may be predictive of future achievement.19 Enhanced mastery of the key clinical competencies must be an essential educational priority deserving the attention of curriculum planners, because these areas are critical to competence as a physician.
Our study had several limitations. First, we had responses from only a sample of U.S. medical schools, but we attempted to diversify our sample through random selection after stratifying by geographic location and research emphasis of the schools. Second, we only had responses from six specialty areas. Our responses may not be representative of all clerkship directors, but we did have a high response rate across the six core disciplines surveyed. Third, although we did not directly observe students, we believe that clerkship directors are in the best position to assess student ability and preparation in these competencies. Fourth, although our survey focused on six competencies that were identified as high priority by an interdisciplinary group of medical educators, other competencies may also need more attention in preclerkship training. However, when we asked clerkship directors to identify the most important competency that needed attention in the preclerkship curriculum, only 2% identified a specific competency other than the six we focused on. Fifth, clerkship directors may have had a different understanding of what each competency meant despite the brief description in the questionnaire. Finally, we only had views of clerkship directors and not those of students. Physicians who have completed training may have different views about what is important to learn at this stage.
We conclude that many medical schools may need to give more attention to the clinical competency preparation of students for the core clerkships. Most clerkship directors in our survey believed students should have at least intermediate ability in five of six key competencies before beginning the core clerkships, but a sizable percentage of clerkship directors were concerned that students do not receive adequate preclerkship preparation in these areas. The results of our study should help inform and guide curriculum planners in designing and implementing curricula for the preclerkship training of students. The need is evident; the challenge will be implementation.
The authors wish to thank Jeffrey A. Stearns, MD, Project Director of the Family Medicine Curriculum Resource (FMCR) Project; Ardis Davis, MSW, the FMCR Project Manager; Christine C. Matson, MD, Chair of the FMCR Project Preclerkship Collaborative Workgroup; and the members of the Preclerkship Collaborative Workgroup: Rick E. Ricer, MD, John C. Rogers, MD, MPH, Scott A. Fields, MD, Thomas M. De Fer, MD, Mary Ann Kuzma, MD, Steve Miller, MD, William Raszka, MD, Larrie Greenberg, MD, William G. Wilson, MD; as well as Kent Sheets, PhD, the FMCR Curriculum Consultant, Roger Sherwood, CAE, Todd A. Dickinson, and Bradley Houseton for their support and feedback. In addition, we would like to thank Suellen Dashner at the University of Nebraska College of Medicine for her coordination of the survey administration.
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