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Academic Medicine:
doi: 10.1097/ACM.0b013e3181a859d0
Clerkships

The Integrated Clerkship: An Innovative Model for Delivering Clinical Education at the Zhejiang University School of Medicine

Yu, Fang MD; Xu, Lingxiao MPA; Lu, Ding; Luo, Wei MD; Wang, Qingqing MD

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Author Information

Dr. Yu is a part-time doctoral candidate, Fourth Military Medical University, Xian, Shaanxi, China, and director, Office of Medical Education, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

Ms. Xu is vice-director, Office of Medical Education, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

Mr. Lu is director, Office of Medical Education, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

Dr. Luo is director, Office of Medical Education, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

Dr. Wang is director, Office of Medical Education, Sir Run Run Shaw Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

Correspondence should be sent to Dr. Yu, Office of Medical Education, Zhejiang University School of Medicine, 388 Yuhangtang Road, Hangzhou 310058, Zhejiang, China; telephone and fax: (86) 571-88208287; e-mail: (yufang@zjuem.zju.edu.cn).

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Abstract

The traditional curriculum of clinical science at the Zhejiang University School of Medicine (ZUSM) was dominated by lectures, and many critical factors in producing competent physicians (such as the development of skills and active learning) were largely neglected. During a four-year period ending in 2007, ZUSM developed and implemented a new model for delivering clinical science education—the integrated clerkship. The principal features of the model are the greater amount of time that students are exposed to and are working in the clinical environment as clerks and the great reduction in lecture hours. Unlike the U.S. model of clerkship, the integrated clerkship at ZUSM is characterized by a progressive process, with intensive preparatory lectures before the clerkship, which is divided into two levels, junior and senior. The junior clerkship is equally divided into didactic activities and clinical practice; the senior clerkship requires students to become an essential part of the work taking place on the wards. A preliminary program evaluation showed that the fundamental goals of the integrated clerkship had been largely attained, especially the mastery of basic clinical skills and retention of medical knowledge. Surveys showed that most of the integrated clerkship students and faculty members were satisfied with the new curriculum; the students felt better prepared to cope with the professional challenges of patient care, and they began to understand how social context affects their patients. As the pilot program in China, the integrated clerkship at ZUSM may serve as a template for medical schools at a similar level, in China and elsewhere.

Zhejiang University is situated in Hangzhou, the capital of Zhejiang Province, which is located on the east coast of China, 110 miles south of Shanghai. Founded in 1897, Zhejiang University is a leading research-intensive university, and it was ranked third among the universities of China in 2007.1 The Zhejiang College of Medicine was founded in 1912; it merged into Zhejiang University in 1998, was renamed Zhejiang University School of Medicine (ZUSM), and has since developed rapidly. ZUSM now ranks among the top 10 medical educational institutions in China,2 and its dynamism and strength in medical education, scientific research, and clinical practice are well recognized.

Currently, ZUSM provides four medical education programs that last from five to eleven years. The curriculum structures for medical education are similar. The medical component of the curriculum lasts four years: 1.5 years for basic medical science, 1.5 years for clinical science, and 1 year for internship (Table 1).

Table 1
Table 1
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The earlier, discipline-based learning format of the basic medical science curriculum was changed to a system-based learning format early in this decade. The two foundational clinical courses, Physical Diagnosis and General Introduction to Surgery, continue to be offered during the preclinical period. After the clinical science period, internship is the last year of clinical training in the medical school, and interns work as members of medical teams in the affiliated hospitals.

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The Challenge

Clinical science education is essential to the professional development of every medical student. But many factors critical to producing competent physicians, such as the acquisition and development of skills, independent learning, and responsiveness to the larger context, had been largely neglected in China. As at most other medical schools in China, the traditional clinical science curriculum at ZUSM was dominated by lectures, and the emphasis was on the retention of theoretical knowledge.3 Students were allowed to spend only one or two half-days each week in the hospitals to interact with patients, take histories and examine patients, practice write-ups, and discuss cases they saw on the wards.

The advantage of this lecture-dominated education was that it required fewer resources to produce more physicians. Thus, in the past half-century, China succeeded in greatly enlarging the medical workforce to deliver basic medical care to the population.4 But the disadvantages of this kind of training are serious. Because students have very little exposure to the clinical environment, they do not see patients through entire episodes of illness, from presentation to outcomes; therefore, students cannot participate actively in the full spectrum of diagnostic reasoning and therapeutic decision making. The result is that, when they become interns, their clinical abilities are far from adequate.

To make things worse, China does not have a systematically established residency training system after internship,5 and many medical graduates are expected to practice medicine largely independently. Thus, it is imperative that medical schools in China improve their clinical science education.

As one of the best universities in China, Zhejiang University aims to produce a medical elite, and therefore ZUSM has decreased its student enrollment over the years. In addition, ZUSM launched the Combined MD-PhD Degree Program in 2004 and the Doctor of Medicine Program in 2005, both of which are elite programs with a 4 + 4 structure. The initiation of top-level programs required a radical rethinking of the curriculum, especially the clinical science curriculum.

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Toward a New Model

What is the primary goal of medical education? What should we do to produce competent physicians? How can we make radical changes in our clinical science education? These questions were constantly on our minds as we developed and implemented the integrated clerkship model.

In 1871, the faculty of Harvard Medical School enacted what are called “the great reforms”—the first genuine improvements in medical education in the United States—which posited that the primary goal of medical education is not to provide students an encyclopedic knowledge of facts but to foster their ability to think critically, solve problems, acquire information, and keep up with changing times.6 Such training was better done in the laboratory and hospital than in the lecture hall. Thus, in 1893, when the Johns Hopkins University School of Medicine was founded, William Osler, physician-in-chief of the Johns Hopkins Hospital and professor of medicine at the school, made the hospital the focal point of the medical school. One of his innovations was that the students began to work and live in the hospital “as part of its machinery, as an essential part of the work of the wards.”6

This model is the clerkship, which has dominated the clinical education of medical students in the United States since the late 19th century.7 The clerkship structure allows the principle of “learning by doing” to be applied in clinical education. U.S. medical students learn from actual patients, and lectures and textbooks are regarded as useful adjuncts. Clerkship has been proven to be an effective clinical curriculum that provides medical students a unique opportunity to learn and practice clinical mastery across a wide variety of real patients.

The development of U.S. medical education gave us the answers to the questions we had on our minds. The clerkship model addressed our need to improve the clinical science curriculum. But many difficulties, such as social and cultural differences between China and the United States, faculty members’ understanding of the educational philosophy, and the time and commitment of faculty members to medical education, delayed adoption of the clerkship until 2003. At that time, a resident who had graduated from ZUSM and who was involved in teaching medical students in the clerkship at the Yale University School of Medicine strongly suggested that the clerkship model be adopted by China’s medical schools. Impressed by the arguments, the executive dean of ZUSM decided to begin work on adopting the clerkship at our university; he realized that a long period of preparation would be needed.

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Planning Process

In September 2003, the executive dean initiated the planning process for a clerkship. He appointed a task force that included faculty members in clinical disciplines, administrators, and senior students. To allow the envisioning of a new future and to ensure the active involvement of as many faculty members and students as possible, the planning process had four phases. During the first phase, the task force developed the goal and outcome objectives of the clerkship and created its planning guidelines. During the second phase, the task force explored alternatives to the models for the clerkship. In the third phase, the task force designed the clerkship, and, during the fourth phase, task force members trained the faculty members, administrators, and students involved in the clerkship.

After diverse opinions were expressed and considerable discussion took place, the task force reached the conclusion that the U.S. experience could not be exactly translated into the Chinese situation, because of the great differences between the historical and cultural backgrounds of the United States and China. This conclusion became the foundation for establishing the goals, objectives, guidelines, and curriculum for the clerkship. Thus, in establishing and designing an integrated clerkship, the differences between the United States and China were fully taken into consideration.

The first difference was in the students. For the students in the Master of Medicine Program, this was their first academic degree; because of their lack of background in college training, they were not as academically mature as U.S. medical students. Moreover, high school students in China are largely educated in a test-driven environment, with the ultimate goal of succeeding in the National Entrance Examination. Consequently, they have no experience of self-directed learning. The second difference was in the medical curriculum. Although courses in pathophysiology and physical diagnosis were included in the preclinical curriculum, exposure to clinical science and skill training was not sufficient during that period. The third difference was in the teaching philosophy. The philosophy and the concept of clerkship were not widely understood by our faculty and students, many of whom had not previously heard of clerkships. Therefore, it was difficult to follow the U.S. model of clerkship exactly; instead, the clerkship at ZUSM would have to be progressive and integrated. But the principles of the new clerkship, such as emphasizing fundamental principles and basic clinical skills, creating an environment in which the students will be extensively exposed to patients, preparing an interplay between the social and clinical sciences, providing students with the ability to access and integrate information electronically, and promoting and rewarding teaching excellence, would be very similar to the principles of the U.S. clerkship.

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General Description of the New Model

During a four-year period ending in 2007, ZUSM developed and implemented a new model for delivering clinical science education: the integrated clerkship. This was the first time that the clerkship model was introduced in a medical school in China. The integrated clerkship was first implemented from the spring of 2006 to the summer of 2007 for all 270 students in the Master of Medicine class of 2009 (the largest student body among the medical programs in ZUSM and the only one that has entered the clinical training stage so far); after some detailed modifications of the plan, it was continued for all students in the class of 2010 in the same program.

In the new model, the curriculum has been radically revised. The principal features of the model are the greater amount of time that students are exposed to and are working in a clinical environment as clerks and their opportunity to see patients through whole episodes of illness and engage actively in patient care. Meanwhile, lecture hours are greatly reduced, and other forms of learning, such as case-based and problem-based learning (PBL) tutorials and Clinical Skills and Clinical Reasoning conferences, are widely used, with emphasis on self-directed and active learning. Among the various activities, “clerking” (working with medical teams) occupies the greatest part of the students’ time (about 50%); lectures take up 18%, case-based tutorials take 5%, PBL tutorials take 5%, Clinical Skills and Clinical Reasoning conferences take 7%, and other activities (such as orientation, examinations, and unscheduled activities) take 15% of the students’ time.

The goal of the clerkship is that the students demonstrate the following competencies before beginning an internship: mastery of the basic knowledge required, understanding of the scientific foundations of medicine and application of that understanding to the practice of medicine, mastery of the basic clinical skills needed to evaluate and care for their patients, development of the capacity for active and self-directed learning, awareness of and responsiveness to the larger context and the system of health care, and an ability to establish rapport with patients, their families, and other health professionals.

To make the integrated clerkship an experience of progressive learning, we arranged for intensive lectures and orientation before the clerkship and divided the clerkship itself into different levels. Thus, the integrated clerkship comprised three levels, scheduled in this order: lectures and orientation, junior clerkship, and senior clerkship.

In addition, because the residency training system in China is not as mature as that in the United States, we designed the clinical science education to include more disciplines as required courses than are included in the United States. Thus, our integrated clerkship included the following 12 disciplines, each of which is a required course: internal medicine, surgery, obstetrics and gynecology, pediatrics, radiology, psychiatry, neurology, infectious diseases, dermatology and sexually transmitted diseases, ophthalmology, otorhinolaryngology, and dental medicine. The internship that would follow the clerkship would include fewer required courses, and electives would be arranged.

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Curriculum Design and Organization

The integrated clerkship is divided into four units. The first is the lectures and orientation unit, which lasts 14 weeks. The second unit is the junior clerkship, and the third and fourth units are the senior clerkship. Each of the latter three units lasts 15 weeks. A two-week comprehensive clinical examination ends the clerkship. The total clerkship lasts 1.5 years (61 weeks of clinical science education).

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Lectures and orientation

This unit has two parts: intensive lectures and orientation. The goal of this unit is to prepare students to learn and work effectively in the clerkship.

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Intensive lectures.

The total number of lecture hours was reduced to 303, less than half the number in the traditional model. All 12 disciplines provide lectures. Among them, internal medicine provides the most, 66 hours of lectures, and dental medicine provides the least, 9 hours. Overall, this first unit provides up to 219 hours of lectures, and the remaining 84 hours of lectures are delivered in the second unit, the junior clerkship.

Intensive lectures focus on a general introduction and on several of the most common and important diseases for each discipline, with an emphasis on how the students should learn by themselves. Through these lectures, students are expected to construct a knowledge framework for each discipline, to master the basic concepts and principles of medicine, and to develop self-directed learning. The clerkship handbook specifies the minimum knowledge that the students are expected to gain during the integrated clerkship and emphasizes that less detailed information will be transmitted by faculty and that the students are expected to learn more on their own. To facilitate independent learning, the faculty recommends textbooks in both Chinese and English. Besides the clerkship handbook and the textbooks, the students can access the Zhejiang University Undergraduate Course Center, which makes all of the course materials available online. The Zhejiang University Undergraduate Course Center also facilitates communication between students and faculty through a variety of mechanisms, such as online assessments, online assignments, academic forums, and questionnaires. In addition, more than 10,000 electronic journals are offered on the intranet for all Zheijiang University students, so they can read the newest research reports in almost all disciplines.

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Orientation.

The orientation includes an introduction to the clerkship; information and training on giving oral presentations, clinical reasoning, and professionalism; and a special activity for understanding patients and societies, called “close patient care.”

Because Chinese medical students lack a clear understanding of the clerkship, an explanation of the development of medical education, particularly clinical education, in the United States is an important part of the orientation. The philosophy and teaching methods of U.S. medical education are discussed in detail.

In the preclinical years, Chinese medical students have little or no opportunity to come into close contact with patients. To provide students with a better understanding of the needs of patients and families, the ways in which social context affects patients, and the need to establish rapport with patients, their families, and other health professionals, we introduced “close patient care” into the orientation. In this component, each student is required to be with a patient on the wards for at least eight hours a day for one week. During that time, the student takes care of the patient in his or her daily activities, accompanies the patient during the processes of diagnosis and treatment, gives advice on health education and disease prevention, and performs some basic nursing procedures.

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Clerkship

In the clerkship, most of the learning takes place in the clinical setting of our affiliated hospitals. Students rotate through 21 clinical disciplines, which are divided into three groups—A, B, and C. Each group lasts 15 weeks—14 weeks in the rotations and 1 exam week. The disciplines composing the three groups are detailed in Table 2; the duration of the rotation in each discipline is from 1 to 4 weeks.

Table 2
Table 2
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Accordingly, the students are divided into three groups (groups 1, 2, and 3), and they rotate through the disciplines. Thus, the disciplines experienced in the junior and senior clerkships differ for different groups of students. The common organizational feature is that the first 15 weeks of rotation constitute the junior clerkship, and the following 30 weeks constitute the senior clerkship. For example, a group 1 student may spend the junior clerkship on group A disciplines and the senior clerkship on group B and group C disciplines, whereas a group 2 student may spend the junior clerkship on the group B disciplines and the senior clerkship on group C and group A disciplines.

During the clerkship, two to three students are assigned to a medical team that is usually composed of one attending physician, one or two fellows, residents, and interns. Every member of the team can be a teacher of the students, but the attending physician is the team leader and is responsible for teaching.

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Junior clerkship.

The junior clerkship is equally divided into didactic activities and clinical practice. Students are on the wards in the mornings and spend their afternoons in didactic activities. In the mornings, students attend rounds with the medical team and observe its practices. In the afternoons, they attend lectures (two sessions), case-based tutorials (two sessions), and a Clinical Skills and Clinical Reasoning conference (one session).

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Senior clerkship.

The objectives of the senior clerkship differ greatly from those of the junior clerkship. In the senior clerkship, students are required to become an essential part of the work of the wards. Except for two afternoons every week (one for PBL tutorials and the other for a Clinical Skills and Clinical Reasoning conference), the students work on the wards or in the outpatient departments. Under appropriate supervision by a team member (usually a resident), the students take patients’ histories, perform physical examinations, practice write-ups, and carry out some basic procedures. Each student is also required to take on at least one new patient every week, to follow the patient’s daily progress until discharge, and to produce a complete write-up on the patient. During patient care, the development of abilities is emphasized, such as identifying, formulating, and solving problems; grasping and using basic concepts and principles; and gathering and then rigorously and critically assessing data. As the rotation progresses, students are also expected to assume increasing responsibilities in direct patient care.

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Support for students.

Because active learning is relatively new to Chinese medical students, it is important to ensure that they feel adequately supported during the clerkship. Student support is provided at different levels from ZUSM to each discipline through creating an educational environment, as explained below.

ZUSM provides the students with the clerkship handbook and logbook. The clerkship handbook includes complete information about the clerkship: goals and objectives; design and organization; minimum knowledge, skill, and attitude requirements; student assessment; and students’ evaluations of the clerkship, the affiliated hospitals, and the faculty. The students use the logbook to note what they have achieved in the areas of knowledge and skills. In addition, ZUSM provides students with access to the Internet and intranet, both in their dormitories and in each department of the affiliated hospitals.

In each discipline, students are welcomed by their teachers and get to know them. When the students first begin a new rotation, the head of that discipline gives a general account of the knowledge framework and the actual medical practice of the discipline, and the head of nursing emphasizes the rules and regulations and reminds students of anything that needs special attention. The attending team specifies the detailed knowledge, skills, and attitude required of the students and explains how the students are assessed in that discipline. In every discipline, the students can access the Internet and intranet in reading rooms.

Considering the growing emphasis on medical practice and research, many clinical academic staff cannot offer enough time and commitment to medical education.8 In every discipline, therefore, one faculty member or resident is appointed annually as the discipline tutor to facilitate the clerkship. The responsibilities of the discipline tutor are to coordinate the educational activities in his or her own discipline, to assist students in their self-directed learning, and, most important, to ensure that the students attain the clinical experience that they are expected to gain and that they are exposed to the range of clinical cases to be seen in the discipline according to the goals set out in the clerkship handbook. If a discipline tutor finds that a student is poor at independent learning, the tutor meets with the student to identify problems and to find ways to improve. The discipline tutors are more concerned when clinical cases in the wards do not cover the range of the training goals. On these occasions, discipline tutors try to find substitute means, such as standard patients, simulators, and sometimes lectures, to help the students achieve their goals.

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Other teaching activities.

Case-based and PBL tutorials and Clinical Skills and Clinical Reasoning conferences make up the weekly structured didactic activities during the clerkship. Case-based tutorials, organized by the discipline tutors, are held twice a week in the junior clerkship; the class size is usually 10 to 20 students. Tutorial topics focus on diseases and syndromes reflecting both the most common issues and some difficult and complicated cases, selected in advance to ensure coverage of the range of clinical cases required in the clerkship handbook. Every student has at least two opportunities to give presentations about his or her actual patients. Case-based tutorials were designed to foster communication and presentation skills in our students, who are often somewhat shy. A PBL tutorial is held once a week during the senior clerkship; the class is usually small, seven to eight students. PBL tutorials are usually based on the patients cared for by the students. Each case is covered within two weeks. The PBL tutorial trains the students to contribute resources and explanations to the group discussion and to work cooperatively and respectfully with members of the group. Social, economic, and ethical problems are also discussed in both the case-based and PBL tutorials.

The development of clinical skills and clinical reasoning is an essential component of the education of a competent physician.9,10 Thus, once a week throughout the clerkship, every student is required to attend the Clinical Skills and Clinical Reasoning conference series. The contents of this course include basic clinical skills; interpretations of laboratory results, radiographs, and electrocardiograms; and critical thinking, such as applying the scientific method to the analysis, synthesis, and management of problems. Usually, these conference sessions include many students, sometimes up to 40.

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Assessment

In the integrated clerkship, assessment is based on the following basic principles: (1) assessment should include both formative and summative elements, (2) it should reflect the learning objectives of the clerkship, (3) it should cover each discipline in the clerkship, (3) it should be comprehensive and should include aspects of knowledge, skill, and attitude, (4) assessment of clinical skills should be based on the achievement of competence, (5) assessment methods should be valid, reliable, and realistic, and (6) assessment should be progressive, requiring sequentially increasing depth and complexity that build on preceding assessments. On the basis of these principles, students are assessed on different aspects throughout the clerkship. At the end of each discipline, they are assessed for their clinical performance, and they receive feedback. Clinical performance is evaluated as appropriate to the objectives of the discipline, from knowledge and skills to professional attitudes and behavior. Assessment of clinical skills mainly focuses on the medical interview, physical examination, procedures, problem solving, diagnostic reasoning, and case management. Assessments of attitudes and behavior mainly focus on honesty and integrity, maturity, responsibility, cooperation, altruism, and self-directedness during each rotation.

Each unit of the clerkship ends with a written exam, which is created at ZUSM, to evaluate knowledge retention. The contents of each exam are based on the expectations outlined in the clerkship handbook. In addition, in the middle of the senior clerkship, faculty members conduct a clinical skills and clinical reasoning assessment, which enables the faculty to recognize areas of underperformance and allows them to identify students who may need individual assistance.

The integrated clerkship concludes with a comprehensive exam that tests both knowledge and clinical skills. The final grade of the integrated clerkship is mainly based on the results of this exam, but other aspects of performance, such as a student’s performance in the case-based and PBL tutorials, in the Clinical Skills and Clinical Reasoning conference series, and in producing write-ups, are also taken into account. A percentage scoring system is used, in which the score on the written test accounts for 50% of the total grade, that on clinical skills accounts for 30%, that on write-ups and presentation accounts for 10%, and performance on the case-based tutorials, PBL tutorials, and the Clinical Skills and Clinical Reasoning conference series accounts for 10%.

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Early Program Assessment

Although formal assessment of the integrated clerkship is still in progress, we established an early assessment plan to focus on whether the program had achieved its fundamental goals and whether the program had been accepted by the students and the faculty. This preliminary assessment was comprehensive, consisting of a variety of methods and instruments that would provide both quantitative and qualitative data. The assessment investigated the domains of student and faculty attitudes and perceptions by using data derived from the end-of-clerkship questionnaires, measures of the clinical performance in each discipline, and exam results, including written and practical tests.

The end-of-clerkship questionnaires for the class of 2009 mainly focused on four aspects. The first aspect had to do with the students’ general perceptions of the new integrated clerkship with respect to its design and organization, the lectures, the clerkships, the case-based tutorials, the PBL tutorials, and the Clinical Skills and Clinical Reasoning conference series. The second aspect had to do with the perceptions of the educational environment provided by ZUSM, the affiliated hospitals, the disciplines, and the faculty. The third aspect specifically concerned the roles that students played on the wards during the junior and senior clerkships, and the fourth aspect concerned the students’ perceptions of the educational effects, mainly with regard to the abilities they attained in independent learning, clinical skills, communication, mastery of the principles of common diseases, and awareness of and responsiveness to the social context. The end-of-clerkship questionnaire for the faculty mainly dealt with the faculty’s perspective on the necessity of the new curriculum, its educational effects, and assessments of students, especially in the aspects of clinical skills and active learning.

Six questions summarize the findings from the early program assessment, which was mainly composed of the end-of-clerkship questionnaires and exam results.

1. Was the new curriculum accepted by the students and faculty?

Feedback collected from students reflected their attitudes toward the clerkship. In the class of 2009 (213 of 270 students replied), 155 students (73%) were satisfied with the integrated clerkship, 49 (23%) had no opinion, and 9 (4%) were unsatisfied. The rate of satisfaction was much higher than that in the class of 2008 (204 of 272 students replied), of which 71 students (35%) were satisfied with their traditional model, 106 (52%) had no opinion, and 27 (13%) were unsatisfied. The statistics showed significant differences between the classes of 2009 and 2008 (χ2 = 336.94, P < .005). More than two thirds (n = 147; 69%) of the class of 2009 felt that, after the clerkship, they were better prepared than before to cope with the professional challenges of patient care.

Faculty members’ perceptions of the clerkship also were generally positive. In the survey at the end of the clerkship of the class of 2009, 180 faculty members were sent questionnaires; 121 responded. The data showed that 113 faculty members (93%) thought it was necessary to implement the integrated clerkship; 70 (58%) thought that the effect of the clerkship was good, 46 (38%) considered it mediocre, and only 5 (4%) said it was poor. But 82 faculty members (68%) felt that faculty contributions to this endeavor had not received appropriate recognition, such as consideration in promotions.

2. Did the students have more time to see patients, did they have the opportunity to meet patients before diagnosis and follow them through hospitalization, and could the students work on the wards as clerks and engage actively in patient care?

During the integrated clerkship, students spent about half of their time with patients and less than one fifth of their time in lectures. Thus, it was clear that the students had much more time to see patients than previously. In the senior clerkship, every student was required to take on at least one new patient every week and to follow him or her until discharge; thus, each student should have had at least 28 new patients whom he or she followed during the clerkship. Responses to the survey from the class of 2009 revealed that 204 students (96%) had taken on at least one new patient every week in the senior clerkship; 107 (50%) followed their patients until discharge, but only 62 (29%) thought that he or she had become an essential part of the work of the wards.

3. Did the students achieve mastery of theoretical knowledge?

In the new model, the lecture hours were reduced to less than half of the traditional load, and the students were required to learn independently. We were very concerned about the students’ capacity for independent learning, and we needed to ascertain the degree of knowledge mastery at the end of the new curriculum. Thus, at the end of the integrated clerkship, the class of 2009 was evaluated with the use of a traditional written exam. Their average score on this exam was two points higher than that of the class of 2008, which was not a statistically significant difference. This finding suggested that the class of 2009 retained knowledge at least as well as had the students learning under the traditional model.

4. Did the students master basic clinical skills and clinical reasoning?

Because retention of knowledge was the focus of the clinical education in the traditional classes, the mastery of basic clinical skills and clinical reasoning had not been formally assessed under that model, and thus no comparison group was available. But, according to a survey of the 63 faculty members who were involved in the clinical skills assessment part of the final exam for the class of 2009, 49 faculty members (78%) were satisfied with the performance of the students, 11 (17%) had no opinion, and only 3 (5%) were not satisfied.

The clinical competence of these students also was highly rated by experts from the National Undergraduate Medical Education Taskforce during a university evaluation by the Ministry of Education in November 2007, six months after these students finished the clerkship. Four patients, two medical and two surgical, were first selected by experts. In addition, four students were randomly selected by the experts, and these students were assigned to the four patients. All four students were first required to take each patient’s history, to perform a physical examination, and to write a medical record. Then, one of the students with a medical patient was asked to carry out thoracentesis, and the other was asked to perform a bone marrow puncture. The students with the surgical patients were tested on their basic procedural skills, such as skin preparation for the surgical procedure, incision, knot tying, and suturing. The results of the assessment were almost perfect, except that one student was very nervous when he took the history and the medical record that another wrote did not conform to the standard formulated by the National Ministry of Health.

5. Did the students develop active, independent, and self-directed learning?

The data from the questionnaire from the class of 2009 showed that 109 students (51%) believed that they were good at active and self-directed learning, and only 5 (2%) felt they were poor at it. The scores in the final written exam also indicated that active and self-directed learning had been developed. But the data from the faculty questionnaire did not show such a high evaluation of the students with respect to active learning. Only 47 faculty members (39%) thought that the students had a strong ability to learn actively; 65 faculty members (54%) considered the students mediocre active learners, and 8 (7%) felt they were poor active learners.

6. Did the clerkship inculcate awareness of and responsiveness to the social context and system of health care in China?

Because awareness of and responsiveness to the social context and system of health care in China had been largely ignored in medical schools,11 we emphasized these factors throughout the integrated clerkship. In the orientation, we instituted the activity of close patient care for one week; for most students, this was the first time they were in such close contact with patients. In case-based and PBL tutorials, among the main topics of discussion were social, economic, and ethical problems. In the specially designed medical records for the new patients taken on by our students, each student was required to write at the end of the record about his or her personal experiences of the social, ethical, moral, legal, and economic issues encountered. Unexpectedly, we found mention in these records of many different issues covering a variety of topics, such as family policy, disease prevention, health promotion, first aid, proper communication, a patient’s need for consolation, medical costs, the medical delivery system, health insurance, and self-protection for physicians. Among these issues, the costs of medical care and the medical delivery system were of the greatest concern to our students. The survey results indicated that 151 students (71%) reported that they had begun to be interested in the issues around medicine and that they felt it was important for them to be concerned with these issues.

Thus, these initial data indicated that the new curriculum was basically successful in attaining the fundamental goals of having more time to see patients and follow them through hospitalization, working as clerks in patient care, attaining good mastery of basic knowledge and clinical skills, developing active and self-directed learning, and developing awareness of and responsiveness to the social context. More important, the new curriculum generally was well accepted by both the students and the faculty.

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Discussion

In recent years, innovation in the medical curriculum has developed quickly, but the radical innovations were mostly instituted in the preclinical years rather than the clinical years.12 Delivery of clinical science education in China needs improvement.13 As the first pilot program in China, the clerkship introduced in ZUSM may serve as a template for other medical schools, both in China and elsewhere.

The conduct of the integrated clerkship at ZUSM for two years has allowed our students to spend more time with patients, to meet them before diagnosis and follow them through hospitalization, and to engage actively in patient care by working on the wards as clerks. More important, it has provided an environment and impetus for active and self-directed learning. A preliminary program evaluation showed that the fundamental goals of the integrated clerkship were attained, especially in the mastery of basic clinical skills and retention of medical knowledge, and that the students had adapted to active, independent, and self-directed learning. This latter finding was encouraging because these students’ test-driven background had given us concern for their ability to change their style of learning.

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Obstacles encountered

Many obstacles were encountered during the implementation of the new curriculum, some of which were revealed in the results of the survey from the class of 2009.

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Time constraints and faculty members’ weakened commitment to medical education.

The university’s growing focus on success in research and the affiliated hospitals’ growing focus on improving medical practice have meant that many clinical faculty members can offer little time to medical education. Medical education often occupies the last place in the competition for their attention. But, in the integrated clerkship, faculty members are required to spend much more time with students than in the traditional model.

We believe that a commitment to education on the part of an attending physician greatly influences the behavior of the members of his or her medical team. By his or her attitudes and actions, the attending physician should elevate the status of education and should motivate team members to devote their time and energy to improvements in training. Thus, in the faculty development for the curriculum innovation, we paid more attention to the attending physicians. In addition, the end-of-clerkship survey included a form specifically designed to evaluate every attending physician on a team who had been responsible for the clerkship, and the statements on this form were given enough weight that they could influence a physician’s promotion and rewards.

We also devoted much time in our faculty development to the discipline tutors. If the medical team’s endeavor has been inadequate, the discipline tutor is responsible for reminding the attending physicians of their role in the clerkship and for reporting the problem to the education offices of the affiliated hospitals. At the end of the clerkship, the discipline tutors are evaluated by the students, and the results of these evaluations also influence the promotion and rewards of the discipline tutors.

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Teachers’ lack of understanding of reform in medical education.

Many teachers lacked a clear appreciation of the great importance that skills, attitudes, self-directed learning, and awareness of social context have in clinical education. Some believed that it was imperative for students to master basic factual knowledge, which they would use in clinical practice in the near future, and that it therefore was unreasonable to reduce the lecture hours so greatly. They also felt that Chinese medical schools had for many years successfully produced a medical workforce under the traditional model, and thus they asked whether it was truly necessary to radically change clinical education. An ongoing faculty development program is designed to nurture and develop faculty members’ concepts and teaching ability.

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The unfavorable effect of the current departmental structure on the clerkship.

There have never been general medicine and general internal medicine departments in our affiliated hospitals, and in some hospitals the general surgery departments have been divided into several sections, such as hepatopancreatobiliary surgery, gastrointestinal surgery, vascular surgery, and surgery of the mammary gland and thyroid gland. To enable a student to rotate through all of the main departments, we had to reduce the amount of time spent in each. For example, within the 12 weeks in internal medicine, students had to rotate through six subdepartments, which allowed only two weeks for each subdepartment. Many students complained that each rotation was too short for them to follow their patient from that rotation throughout the period of hospitalization. As yet, we have no solution to this problem.

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The problem of competition for patient resources.

In some departments, too many practitioners, including residents, postgraduates, interns, and physicians from other hospitals who are undergoing advanced studies, are in training. In such a situation, medical students face competition to become an essential part of the work of the wards, and the training opportunities for them decrease accordingly. To ensure that students attain the required clinical experience, attending physicians and discipline tutors must pay more attention to education and find other opportunities for student training, such as the use of standardized patients or simulators.

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The not-entirely-satisfactory design of the clerkship.

In the design of the clerkship, discipline groups A, B, and C covered different sets of material in different fashions during the junior and senior clerkships, which means that students did not all have the same experience in their two clerkship levels and could have experience at the senior clerkship level in only about two thirds of the disciplines. This design led to two difficulties. The first difficulty is that all students lack senior clerkship training in one third of the disciplines. The second difficulty is the possible inequity of the assessments, especially the comprehensive exam at the end of the clerkship, because all of the students have to take the same assessment even though their training is not all the same. The Clinical Education Committee concluded that such an arrangement does not affect the mastery of basic knowledge or clinical thinking for all students; such abilities can be taught through work on several typical cases, whether medical or surgical. Although the training in the clinical skills involved in the disciplines of the junior clerkship may be somewhat affected, the committee suggested that an incomplete training in these skills can be compensated for in the internship year, when the students can be encouraged to choose training in those disciplines in which they served as junior clerks. The committee also suggested that the comprehensive exam should focus on the basic skills that every student should acquire.

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Students’ discomfort with self-directed learning.

Although the data from the questionnaire completed by the class of 2009 showed that only 5 students (2%) felt they were poor at active and self-directed learning, we found that the scores of about 19 students (7%) on the final written exam were poor (i.e., a score below 50 out of 100); in the class of 2008, only 11 students (4%) had scores that low. Such findings indicate that some students are still uncomfortable with self-directed learning. This low comfort level has to do with the test-driven background of Chinese medical students. Even among these top students, some still face challenges with respect to self-directed learning because they are so used to depending on their teachers’ guidance. To avoid exam failures among the class of 2010, faculty members in some disciplines gave those students more lectures. But the Clinical Education Committee insisted that lectures should be limited and that discipline tutors should play a greater role in helping these students in their active learning; in addition, the medical teams should pay more attention to these special students, asking them more questions during morning rounds or on other occasions.

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Future directions for development

Although the integrated clerkship was implemented at ZUSM only two years ago, we and the medical school have experienced and learned a great deal from this innovative change. It has been a meaningful beginning. Although some people believe that students should be trained in active learning before they enter university and, therefore, that universities should not institute major educational reforms until reforms have begun in basic education, ZUSM could not wait for changes in secondary education. Despite these issues and other challenges, we believe that the efforts made so far to improve clinical science education have been worthwhile. We hope that this report will be useful to other universities that are considering changes in their approaches to clinical science education.

In the future, two issues will be worth our attention. The first issue focuses on the first of the above-mentioned obstacles—the constraints of time and the weak commitment of faculty members to medical education. In the new system of faculty management being discussed now, in which the faculty is to be divided into different tracks, such as teaching-oriented, teaching and research/medical practice in parallel, and research/medical-practice-oriented tracks, the different faculty tracks will be assessed in different ways. Thus, the faculty’s educational contributions are expected to be fully recognized. The second issue will be the last of the above-mentioned obstacles—some students’ discomfort with self-directed learning. Although the independent learning ability of our students has improved considerably, this aspect of their medical education remains a major challenge. The creation of an environment of promoting independent learning remains one of the focal points of our work. Along with the reduction in scheduled lecture hours in the clerkship, learning methods that emphasize active learning, such as small-group and PBL tutorials, will be used more extensively, and the approach to student assessment, which greatly influences the students’ learning methods, will also be a focus of more attention.

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Acknowledgments

The authors acknowledge the significant contribution of Dr. Jianhong Luo, the executive dean of Zhejiang University School of Medicine, for his mentorship and leadership in this project; without him, this work would not have been possible. The authors also thank Dr. He Huang, associate dean for medical education of Zhejiang University School of Medicine, for his managerial support in this project. Grateful acknowledgement is made for the thoughtful comments of Dr. I.C. Bruce, professor in the Physiology Department of Zhejiang University School of Medicine, who critically reviewed this article. Thanks are tendered to Drs. Hai Yu and Qiang Xia, professors of Zhejiang University School of Medicine, for their helpful comments and support.

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References

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2 Wu SL. The 50 Most Competitive Medical Schools in China, 2007 [in Chinese]. Available at: (http://edu.qq.com/a/20070330/000075.htm). Accessed February 10, 2008.

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© 2009 Association of American Medical Colleges

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