Chittenden, Eva H. MD; Henry, Duncan MD; Saxena, Varun MD; Loeser, Helen MD, MSc; O’Sullivan, Patricia S. EdD
Dr. Chittenden is assistant physician and director of education, Palliative Care Service, Massachusetts General Hospital, Boston, Massachusetts. When this article was written, she was associate professor and director of the transitional clerkship, University of California, San Francisco, San Francisco, California.
Dr. Henry is a resident, Boston Combined Residency Program in Pediatrics, Boston, Massachusetts. When this article was written, he was a medical student at University of California, San Francisco, San Francisco, California.
Dr. Saxena is a resident in medicine, University of California, San Francisco, San Francisco, California. When this article was written, he was a medical student at University of California, San Francisco, San Francisco, California.
Dr. Loeser is associate dean for curricular affairs and professor of pediatrics, University of California, San Francisco, San Francisco, California.
Dr. O’Sullivan is associate director for educational research and professor of medicine, University of California, San Francisco, San Francisco, California.
Correspondence should be addressed to Dr. Chittenden, Department of Medicine, MGH, 55 Fruit Street, Founders 600, Boston, MA 02114; telephone: (617) 724-9197; fax: (617) 724-8693; e-mail: (firstname.lastname@example.org).
Medical school is inherently stressful for students.1 The transition from primarily classroom-based learning to clerkships is a particularly difficult time.2,3 A 1994 study found that, during their core clerkship years, U.S. students experienced higher levels of anxiety and depression than students in the preclerkship and fourth years, and, in a 2007 study, 23% of third-year students experienced depression and 57% experienced somatic distress.4,5 The curricula that medical schools have created to bridge the preclerkship-to-clerkship transition, including clinical skills courses, problem-based learning, and preceptorships, have improved medical students’ comfort at the start of rotations.6–11 Schools offer large-group, classroom-based sessions between the preclerkship and clerkship years to ease this transition,12 but few studies have looked at their efficacy.13,14 Given the need for transitional courses that help students, it is important to establish from theory how to design these courses for maximum benefit. In this article, we describe the development of a theoretically grounded transitional course and its effects as perceived by the participants.
Transitional curricula often fail to address students’ struggles such as (1) understanding roles, responsibilities, and expectations, (2) adjusting to the culture of clinical environments, (3) performing clinical skills including taking histories, performing physical examinations, charting, and presenting, (4) adapting to the logistics and daily schedule on the wards, and (5) adjusting to frequent changes in staff and setting.10,15 Students note their difficulty in adapting to inpatient culture, an overwhelming workload, and the lack of a meaningful clinical role as they essentially shadow others doing clinical work.16–18 They perceive instructors as not valuing their individual contributions while expecting them to conform to a performance stereotype of a confident and outgoing student.15 In contrast, students who feel that they are a useful and authentic part of a clinical team perceive their transition as smoother.10
Workplace learning theory indicates that learners must participate in an authentic context and need to feel invited to participate and engage with the team. Dornan and colleagues19 elaborated the definition of participation as both observing and “acting,” which is performing tasks under supervision. Sheehan and colleagues20 found that new trainees required an initiation period in which they gained practical logistical information, role clarification, and a clear description of what others expected. Additionally, effective learning required appropriate context21 as well as increasing levels of responsibility associated with increased learner confidence.19
This paper describes a transitional clerkship (TC) based on workplace learning principles implemented just prior to clerkship education. We examine the effectiveness that this approach has had in clarifying role perception and fostering confidence in students in comparison with historic controls who did not have this type of transitional experience.
Description of the TC
The University of California, San Francisco (UCSF) School of Medicine first implemented the TC in the spring of 2007 for the class of 2009. The TC evolved from a successful class of 2008 pilot program for 15 students who practiced clinical skills in a hospital environment. All other class of 2008 students participated in a three-day, classroom-based Preparation for Clerkships program (Prep) that reviewed oral presentations, prescription writing, feedback, and evaluation. Prep contained one experiential component: a half-day procedural skills session.
The TC’s objectives are to
* describe the roles of and expectations for third-year clerks;
* describe the routines and logistics of inpatient wards and the functioning of ward teams;
* illustrate important principles in giving and receiving feedback during clerkships; and
* strengthen students’ basic proficiency in oral patient presentations and admission and SOAP notes; basic skills in phlebotomy, arterial blood gases, and suturing; and the ability to find patient-related information from the medical record.
Table 1 shows a sample schedule for the course; each student participated for 7 of 10 available days. We assigned students to inpatient wards, as they had participated in outpatient preceptorships throughout their preclerkship curriculum. Students spent three and a half days (50% of the course) at one of our three main teaching hospitals, usually the site of their first inpatient rotation. No assignments were made to pediatric wards or obstetrics units. Each student admitted a patient whom they followed into the next hospital day. To simulate rounding, students worked with a preceptor and five peers on a shadow team that existed solely for educational purposes; they neither provided patient care nor interacted with the inpatient teams caring for the patients. Preceptors set expectations for students, modeled professional behavior, and provided individualized feedback both after the initial admission presentation and during team rounds the following day. Peers also gave feedback. After two days of didactics, students repeated the clinical experience. Students worked with different preceptors for these two occasions and rarely for a two-day clinical experience. A total of 61 preceptors, including faculty, resident physicians, and fourth-year medical students, volunteered 338 hours to teach in the course.
Prior to the first patient encounter, students toured the ward and the hospital, met members of the interdisciplinary team (including nurses, social workers, and physical therapists), and learned logistics such as locating patients and their nurses and using the paging and electronic medical record systems. All students received computer access at their assigned hospital to facilitate review of relevant patient information.
The didactic portion was limited to 50% of the course time. Students heard lectures and panel discussions as highlighted in Table 1.
We compared the 147 students who took Prep in 2006 with the 155 students who participated in the TC in 2007 on a variety of measures described below. We analyzed data using SPSS Version 15.0 (Chicago, Illinois). We obtained approval from the institutional review board to report these evaluative data.
Perception of preparedness
We compared the TC and Prep students’ perceptions of preparedness in six skill sets. Students rated their perceived preparedness on a scale of 1 (“not true”) to 7 (“very true”). TC students gave higher ratings than did Prep students for five of six skills (Table 2). Using a conservative P value (<.008) to correct for multiple comparisons, TC students’ ratings were significantly higher on only two skills: “Understanding the roles of health care team members” and “Writing patient notes.” Neither group rated preparedness for “Using hospital services” very high, although Prep students rated this significantly higher than did the TC group.
Students rated their satisfaction on an end-of-course survey from 1 (poor) to 5 (excellent). TC students (n = 69) rated their satisfaction significantly higher than Prep students (n = 43) with means of 4.25 (SD = 0.96) versus 3.93 (SD = 0.80, P = .04). TC students rated the statement “I am clearer about the role of a third-year student than at the start of the course” as 4.42 (SD = 0.76) compared with Prep students at 3.77 (SD = 0.87, P < .0001). For the statement, “I feel more confident in my abilities to be a third-year clerk,” TC students averaged 4.01 (SD = 0.72), which was significantly higher (P < .0001) than the Prep students’ average of 3.40 (SD = 0.99).
Comments indicated that the TC clinical experiences increased confidence, dampened anxieties, and clarified expectations and roles. TC students mentioned the importance of preceptors providing feedback on oral presentation skills in a low-stakes environment. In contrast, Prep students gave fewer comments and expressed a desire for more practical information and more experiences in the clinical setting rather than the classroom.
We surveyed the TC students again after they had completed their first eight-week clerkship. They favorably rated both the TC as a whole and, specifically, the clinical experiences at 4.01 (SD = 0.85, n = 86) and 4.29 (SD = 0.75, n = 86), respectively. There was no statistical difference between student satisfaction with the course before and after the first clerkship. We did note an association between initial clerkship assignment and satisfaction with the TC. Specifically, students starting with pediatric and family medicine clerkships rated the TC lower than did students in other specialties. Statistical comparison was not done, because of the small sample size in some clerkships.
Performance in first clinical rotation
Residents and faculty evaluated students’ fund of knowledge, clinical skills, professional attributes, and interpersonal relationships and communication skills. No significant differences were found in the evaluations of Prep (2006) and TC (2007) students.
Of the 61 TC preceptors, 25 (41%) were faculty, 27 (44%) were residents, 7 (11%) were fourth-year medical students, and 2 were nurse practitioners. Broken down by specialty, 38 (62%) were from internal medicine, with the others from neurology (4), family medicine (4), psychiatry (3), orthopedics (2), surgery (2), and pediatrics (1). Forty-three (70%) responded to a short survey. The responders volunteered a median of five hours (range: 2–11 hours); 76% spent time with the students at the bedside. After excluding five preceptors who were relocating, 79% committed to precepting for the next year. Those who did not commit cited uncertainty in their schedules for the year. In their comments, preceptors spoke to the importance of a transitional course, a wish that they had had such a course in medical school, the enjoyment they derived from teaching this course, and the enthusiasm and eagerness of the students. Thirteen (36%) of the 36 responders who gave written comments used the word “fun” to describe the teaching experience. One attending noted, “I was hesitant to sign up because of my hectic schedule, but I’m so glad I did this. It was very refreshing to work with the new MS3s, they were so eager, endearing and hard-working. I wish I had this when I was a medical student!” Suggestions included better training for students on the use of the computerized medical record and a decrease in the number of students per preceptor group. Two preceptors commented that the two-day time commitment was challenging in the midst of their other commitments. Two fourth-year students commented that the experience provided excellent practice for the teaching they would do in internship.
When we asked students to rate their satisfaction with their preceptors by level of training (attending, resident, or medical student), 65 (42%) completed the online evaluation. All preceptor groups received ratings of 4.5 or higher (on a scale of 1–5) on the three measures of teaching effectiveness: enthusiasm, ability to provide feedback, and overall teaching excellence. Comments indicated that preceptors were encouraging and supportive, that attendings tended to focus feedback too specifically on their own field, and that fourth-year students did not give adequate constructive criticism. Whether students had one or two preceptors per clinical experience did not affect their satisfaction with the course.
UCSF’s TC successfully met its objectives in its inaugural year. In contrast to their peers in the prior, classroom-based course, TC students better understood their roles and responsibilities and had increased confidence. Both students and preceptors were satisfied with the course. We believe that the low-stakes, experiential model of the TC contributed to its success.
The TC’s curriculum was based on workplace learning theory. The course gave students more authentic inpatient practice opportunities than they had had in the first two years of medical school. In their Foundations of Patient Care course, they had taken histories from inpatients in groups of six students, worked with standardized patients and outpatients, and shadowed a team on the ward for two consecutive mornings. The TC, on the other hand, gave them a high-fidelity initiation to inpatient care, introducing them to the actual activities they would perform as third-year clerks in the inpatient setting. Importantly, they carried out these activities in a safe environment, in which they were given feedback but not evaluated. Researchers describe an inverted-U relationship between arousal and task performance, with performance being optimal at intermediate levels of arousal.21 Students who participate in a low-stakes transitional course may experience arousal to an appropriate level without being tipped into inappropriate (and perhaps maladaptive) anxiety.
Satisfaction with the TC was high among students and preceptors. Students felt that the course was important and should be continued into subsequent years. Preceptors noted that the absence of patient-care responsibilities allowed them to focus on teaching and to provide an educational experience that was meaningful to both them and the students. Satisfaction, although still high, was lower among students whose first rotations were pediatrics or family medicine. Both pediatrics and family medicine are substantially outpatient-based rotations and have cultures that differ from internal medicine, surgery, and neurology, where the majority of students were placed during the TC. We speculate that the lack of concordance between these students’ TC assignment and their first rotation may have contributed to the lower ratings. Course leadership should work to increase the fidelity between the TC experience and the first rotation specialty. An alternative solution would be to delay the TC experience to just prior to the first inpatient rotation for students starting with pediatrics or family medicine. Although we did not measure a difference in performance during the first rotation, there were anecdotal data from course directors that students were better prepared. Whether formal data will bear this out in future iterations of the course remains to be seen.
The curricular evaluation had limitations. Low student response rates were a threat to the validity of the results. We mainly examined the perceptions of learners and preceptors, rather than outcomes such as student well-being. Future studies should examine the lasting benefits of experiential transitional courses on confidence, integration into teams, satisfaction with learning, and mental health, including the prevalence of anxiety and depression. Additionally, studies should evaluate the immediate effect of transitional courses on students’ efficiency and productivity in such areas as charting and oral presentation. Finally, long-term effects should be examined further to determine whether some of these improved attitudes and skills persist through the clerkship year. It is possible that future curricular innovations without preclinical-to-clinical transitions, such as integrated longitudinal clerkships (in which students develop close relationships with faculty at the beginning of third year22) and integrated four-year curricula, may make transitional courses obsolete.
The UCSF TC is a low-stakes, high-fidelity clinical immersion experience that provides an important curricular transition for students at an anxiety-provoking time. Although developing and implementing such a course is time- and labor-intensive, our initial data support its continuation at UCSF. It has now been institutionalized into the curriculum, and we will even use lessons learned in the TC to inform and improve other transitions, such as those from undergraduate to graduate medical education, and from graduate medical education to independent practice.
1 Firth J. Levels and sources of stress in medical students. BMJ. 1986;292:1177–1180.
2 Radcliffe C, Lester H. Perceived stress during undergraduate medical training: A qualitative study. Med Educ. 2003;37:32–38.
3 Moss F, McManus IC. The anxieties of new clinical students. Med Educ. 1992;26:17–20.
4 Mosley TH Jr, Perrin SG, Neral SM, Dubbert PM, Grothues CA, Pinto BM. Stress, coping and well-being among third-year medical students. Acad Med. 1994;69:765–767.
5 Chandavarkar U, Azzam A, Mathews CA. Anxiety symptoms and perceived performance in medical students. Depress Anxiety. 2007;24:103–111.
6 Moss F, Cochrane JP, Yudkin JS. Introducing medicine to doctors. Lancet. 1987;329:203–205.
7 Whipple ME, Barlow CB, Smith S, Goldman EA. Early introduction of clinical skills improves medical student comfort at the start of third-year clerkships. Acad Med. 2006;81(10 suppl):S40–S43.
8 Remmen R, Scherpbier A, van der Vleuten C, et al. Effectiveness of basic clinical skills training programmes: A cross-sectional comparison of four medical schools. Med Educ. 2001;35:121–128.
9 White CB. Smoothing out transitions: How pedagogy influences medical students’ achievement of self-regulated learning goals. Adv Health Sci Educ Theory Pract. 2007;12:279–297.
10 Prince KJ, Van De Wiel M, Scherpbier AJ, Can Der Vleuten CP, Boshuizen HP. A qualitative analysis of the transition from theory to practice in undergraduate training in a PBL medical school. Adv Health Sci Educ Theory Pract. 2000;5:105–116.
11 Norman GR, Schmidt HG. The psychological basis of problem-based learning: A review of the evidence. Acad Med. 1992;67:557–565.
12 Poncelet A, O’Brien B. Preparing medical students for clerkships: A descriptive analysis of transition courses. Acad Med. 2008;83:444–551.
13 Chumley H, Olney C, Usatine R, Dobbie P. A short transitional course can help medical students prepare for clinical learning. Fam Med. 2005;37:496–501.
14 Van Gessel E, Nendaz MR, Vermeulen B, Junod A, Vu NV. Development of a clinical reasoning from the basic sciences to the clerkships: A longitudinal assessment of medical students’ needs and self-perception after a transitional learning unit. Med Educ. 2003;37:966–974.
15 O’Brien B, Cooke M, Irby DM. Perceptions and attributions of third-year student struggles in clerkships: Do students and clerkship directors agree? Acad Med. 2007;82:970–978.
16 Seabrook MA. Clinical students’ initial reports of the educational climate in a single medical school. Med Educ. 2004;38:659–669.
17 Hayes K, Feather A, Hall A, et al. Anxiety in medical students: Is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students? Med Educ. 2004;38:1154–1163.
18 Prince KJ, Boshuizen HP, van der Vleuten CP, Scherpbier AJ. Students’ opinions about their preparation for clinical practice. Med Educ. 2005;39:704–712.
19 Dornan T, Boshuizen HP, King N, Scherpbier AJ. Experience-based learning: A model linking the processes and outcomes of medical students’ workplace learning. Med Educ. 2007;41:84–91.
20 Sheehan D, Wilkinson TJ, Billett S. Interns’ participation and learning in clinical environments in a New Zealand hospital. Acad Med. 2005;80:302–308.
21 Koens F, Mann KV, Custers EJ, Ten Cate OT. Analysing the concept of context in medical education. Med Educ. 2005;39:1243–1249.
22 Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School–Cambridge integrated clerkship: An innovative model of clinical education. Acad Med. 2007;82:397–404.