Turner, Simon R. MD, MEd; White, Jonathan MD, PhD; Poth, Cheryl PhD; Rogers, W.Todd PhD
The transition from preclinical to clinical education is difficult for many medical students.1 Among the challenges they face are unfamiliar environments, new roles, and a lack of clinical knowledge and skills. This issue impacts, and is of concern to, the major stakeholders in undergraduate medical education, including students, educators, health care providers, and patients. Students entering clerkship may be uncertain as to how to behave and act, mainly because they (dont) know what (is) expected of them.2 Radcliffe and Lester1 found that 50% of students did not feel well prepared for clerkship, and 93% thought a good introduction would make the transition easier. Educators, too, find students unprepared to begin clinical duties; in a survey of 192 American clerkship directors, 30%50% reported that their students needed better training in history taking, physical examination, communication, professionalism, and care systems.3
Classroom programs intended to prepare students for clerkship often focus on knowledge and skills that are not directly relevant to clinical trainees.4 A clinical skills course that medical students at our institution, the University of Alberta, take just before beginning their clerkships insufficiently prepares them for clinical work because it is both too short and too focused on books and lectures. Programs that expose medical students to the clinical environment early on have shown promising results, which may be understood through the theories of situated learning5 and legitimate peripheral participation.6 The chance to observe, or even apply, new clinical knowledge and skills in a real-world setting reinforces students learning.5 Furthermore, early clinical experiences have been shown to decrease students anxiety about clerkships and increase their clarity regarding their roles.7
Yet, opportunities for early clinical experiences are often limited in both scope and approach. According to a recent review of experience-based preparatory courses, they tend to lack measurable objectives and the vast majority (83%) last only between one day and one week.8 It was this apparent lack of long-term experience-based programs with measurable objectives, as well as our witnessing successive cohorts of students struggle with their preparation for clerkship, that motivated us to develop, implement, and assess the program we describe in this article.
One way to enhance the effectiveness of preparatory programs is to use near-peers as tutors and mentors. Such programs have well-established benefits, including improved social and cognitive congruence between learner and teacher.9 One form of near-peer learning is shadowing, in which junior students follow senior students or residents in a clinical setting, observing and sometimes participating in clinical activities. When graduating British medical students shadowed house officers, they reported that they gained experience directly relevant to their needs, became familiar with their work environment, were oriented to their future role, and learned specific and relevant medical knowledge.10 Similarly, in a program where first-year students shadowed third-year students, they learned about the practice of medicine, the process of becoming a doctor, providers of healthcare, the nature of real patients and the procedures of medicine.11 These two programs revealed the possible benefits of senior medical students shadowing residents and junior medical students shadowing senior students, but our review of the literature did not identify any programs in which junior medical students shadowed residents.
Drawing on our own experiences as students and teachers of medicine, in 2009, we developed a program to prepare students for clerkship and to address some of the issues faced by other preparatory programs. Our program applied the benefits of near-peer, experience-based shadowing programs to preclinical students, capitalizing on the knowledge, skills and experience of residents. We hoped that, by exposing students to and having them participate in clinical activities, they would both better understand the clinical environment and the trainee’s role within it, and gain the knowledge and skills needed to perform that role. From a practical point of view, we also wished to develop a program with minimal financial cost and administrative effort.
The program allows a first-year medical student to shadow a volunteer first-year resident from any specialty on multiple occasions over an extended period. We chose first-year students because of the potential for the greatest impact on their education as well as the potential to optimize the amount of time for students to form a long-term relationship with their resident throughout their training. We chose first-year residents because of their wide variety of clinical rotations, their high level of clinical expertise relative to medical students, and their closeness to students in age and training. We hoped this proximity would foster near-peer interaction, a better understanding of student’s needs, and closer relationships between students and residents. Although the clinical abilities of first-year residents are not as developed as those of more senior residents, we felt that their knowledge and skills, relative to those of first-year students, were sufficient to allow effective teaching.
Although not an official university program in its inaugural year, the program would likely not have been possible without the support of the Offices of Undergraduate and Postgraduate Medical Education, which greatly helped us recruit participants by providing access to students and residents. We approached both offices early in the program’s development for approval and advice and to ensure that the program would not interfere with the training of students and residents.
At the beginning of the academic year, we present the program to students and residents at their respective orientations and invite them to participate. Recruitment continues with a series of e-mail invitations and follow-up question-and-answer sessions. Once all participants have been determined, each first-year medical student is randomly assigned to shadow one first-year resident during clinical activities for four to six hours, once per month, for eight months (32–48 hours direct contact per year). Sessions are scheduled during the residents regular work duties and when the student is free of other academic obligations. Students can, at their discretion, shadow at night or on the weekends; however, because our institution already allocates students one morning and one afternoon per week to study or pursue additional learning opportunities (such as shadowing), concerns over work-hour restrictions are mitigated. We encourage participants to select shadowing times and settings that are mutually convenient and that provide a variety of clinical experiences. We place no limitations on the setting of the shadowing experiences, as long as they are clinically based. Possible situations include morning rounds, outpatient clinics, the emergency room, the operating room, labor and delivery wards, and evenings when the resident is on call. A student’s observation of and participation in clinical activities must always be under the resident’s direct supervision, and the resident must inform their own supervising physician or team of the student’s presence at least a day in advance.
We have developed and distributed to the program’s various stakeholders a number of documents with differing purposes. To optimize their learning, the students (and participating residents) receive documents containing objectives related to clinical medicine, a description of the life and work of a clinical trainee, and the CanMEDS competency framework.12 To ensure a safe and educational atmosphere for students and patients, and to improve the fidelity of the intervention, they also receive a document (available to readers upon request from the author) that describes the program format, including recommended shadowing frequency, duration and settings, policies related to harassment and abuse, and rules regarding student roles and resident supervision. Included in these rules is the stipulation that students are not to be used solely for educationally worthless “scut work,” but should be exposed to all parts of the resident’s job so they can better understand the day-to-day work. Residents must carefully judge and monitor the amount of patient care responsibility they give to students, always keeping in mind the student’s very junior level and the fact that they are often interacting with patients for the very first time. In all settings, and especially with regards to procedural skills, writing orders, or providing medical advice, students must be closely supervised and never placed in a situation that compromises patient safety. The ultimate authority regarding a student’s activities rests with the patient’s attending physician. The documents also include suggestions to maximize the learning potential of the shadowing sessions. For example, we encourage participants to schedule sessions for times when the clinical setting is busy enough to be interesting and educational, but not so hectic as to make teaching and interaction difficult.
Aside from the initial development of the learning objectives and program description, the administrative effort required to run the program consists solely of the short recruitment process and answering occasional e-mails from participants. During the program, students and residents also receive monthly e-mail reminders to schedule shadowing sessions. These e-mails include responses to frequently asked questions and suggestions to deal with any problems encountered, and serve as a distribution mechanism of program documents. In the program’s inaugural year, the administrative duties were performed by one of the authors, at that time a graduate student. In the following years, these duties have been taken over by an administrative staff member within the Faculty of Medicine.
In 2009–10 the program’s inaugural year, 173 out of 183 first-year medical students asked to participate. The size of the program, however, was limited by the recruitment of residents; 83 of 167 first-year residents, representing over 20 different clinical specialties, volunteered. We therefore randomly selected 83 students to be partnered with residents. The remaining 90 students formed a control group for comparison.
Students in the intervention group reported a mean total shadowing time of 44.5 hours during their first year of medical school, significantly greater than any informal shadowing carried out independently by students in the control group (28.6 hours, P < 0.001). The mean reported length of a shadowing session was 4.13 hours (SD = 1.28 hours, range 1–8 hours). Students reported participating in a wide variety of clinical settings, including inpatient ward rounds, outpatient clinics, the emergency room, labor and delivery, scrubbing in the OR, and on call at night. The activities in which they spent the most time were (in descending order) history taking, charting, physical examination, and CanMEDS behaviors.
To assess the program’s effectiveness, we compared the students in the program with those in the control group. We collected quantitative data by administering pre- and post-intervention questionnaires, which included an 18-item preparedness scale, to both groups of students and participating residents. The scale, validated by 17 experts in clinical undergraduate medical education from our institution, asked students to assess their preparedness to perform certain tasks that are part of the clinical student’s activities, such as performing physical examinations and taking histories. The Health Research Ethics Board of the University of Alberta approved the study.
The demographics of the intervention and control groups were statistically equivalent, as were their scores on the pre-encounter questionnaire preparedness scale. The response rates for all groups were 70% or higher, and estimates of reliability using Cronbach’s alpha were 0.78 or higher.
Of the 63 students in the program who responded to the questionnaire, 59 (93.6%) stated they enjoyed participating, 58 (92.1%) would recommend the program to a colleague, and 57 (90.5%) would participate again. When asked if the program should be available again the following year, all but one (98.4%) of the responding intervention group students, all 57 (100%) of the responding control group students, and 66 of the 70 (94.3%) responding residents agreed.
The intervention group had a significantly larger increase in their mean score on the preparedness scale (SD = 0.85) from pre- to post-intervention than did the control group (SD = 0.11, P = 0.005). Fifty (79.3%) of the responding intervention group students and 52 (74.3%) of the responding residents thought that participation in the program had better prepared the students for third-year clinical rotations. The majority of students and residents thought that participation in the program improved the student’s medical knowledge, the quality of their interactions with other health professionals and with patients, and their ability to perform physical examinations and take medical histories.
Our experience developing and implementing this program (with great assistance and cooperation from our institution’s administration) demonstrates that a student–resident shadowing program is both feasible and can help students prepare for learning in the clinical environment. The program, now in its third year (its second as an official part of the University of Alberta medical school curriculum), is still in demand by students and, much to our pleasant surprise, is enthusiastically supported by the residents and their supervising physicians. Such a program could be easily, and at little cost, adapted for use in most medical schools.
The major limitation of our evaluation was a lack of direct evidence that students in the program actually performed better than they otherwise would have upon reaching their clerkships. We intend to conduct a longitudinal study involving the cohort of students from this study, following their progression through clerkship, to assess the program’s long-term impact.
Despite its successes, our program did face some challenges. The most obvious challenge was recruiting enough residents to match one to each interested student. Our institution responded to the high demand from students by allowing unmatched students to enroll in the program the following academic year (as second-year students). Other means of increasing the pool of residents could be explored, such as offering incentives and allowing more senior residents to participate. The residents interviewed as part of our larger evaluation stated that participation required even less time and effort than they had expected, and that more residents would have signed up had they known how little work was required. They also reported benefits for themselves from participating, including the cementing of basic clinical knowledge, a deeper understanding of professionalism, and the opportunity to practice teaching in a low pressure setting. These benefits should be emphasized when recruiting residents to participate.
Other challenges included the rare resident who volunteered but then lost interest in mentoring their student and the occasional difficulty that students and residents had coordinating their schedules, especially around holidays.
Overall, however, our experience demonstrates that a program in which first-year medical students shadow first-year residents is easy to implement, costs little, and generates much demand. Most importantly, our assessment suggests that such a program can introduce students to the clinical environment, help them understand their role within that environment, and expose them to the knowledge and skills they need to succeed in that role. It can also increase student’s confidence and self-perception of being prepared for clinical training, valuable assets when they transition from medical school to clerkship. Future research will investigate the educational impact of this program on students as they enter clerkship.
Other disclosures: None
Ethical approval: Granted by the Health Research Ethics Board of the University of Alberta.
Previous presentations: Material related to this manuscript was presented at the following meetings: American Educational Research Association, 2011; International Conference of Residency Education, 2010; Association for Medical Education in Europe, 2010; and Canadian Society for the Study of Education, 2010.