Goldberg, Charles MD; Insel, Paul A. MD
Dr. Goldberg is professor of medicine, University of California, San Diego School of Medicine, La Jolla, California, and staff physician, San Diego VA Healthcare System, San Diego, California.
Dr. Insel is director, Medical Scientist Training Program, vice chair/distinguished professor of pharmacology, and distinguished professor of medicine, University of California, San Diego School of Medicine, La Jolla, California.
Correspondence should be addressed to Dr. Goldberg, San Diego VA Healthcare System, Department of GIM, 111N, 3350 La Jolla Village Dr., San Diego, CA 92161; telephone: (858) 552-8585 ext. 2811; fax: (858) 642-6273; e-mail: firstname.lastname@example.org.
Many aspects of MD-PhD training are not optimally designed to prepare students for their future roles as translational clinician–scientists. The transition between PhD research efforts and clinical rotations is one hurdle that must be overcome. MD-PhD students have deficits in clinical skills compared with those of their MD-only colleagues at the time of this transition. Reimmersion programs (RPs) targeted to MD-PhD students have the potential to help them navigate this transition.
The authors draw on their experience creating and implementing an RP that incorporates multiple types of activities (clinical exam review, objective structured clinical examination, and supervised practice in patient care settings) designed to enhance the participants’ skills and readiness for clinical efforts. On the basis of this experience, they note that MD-PhD students’ time away from the clinical environment negatively affects their clinical skills, causing them to feel underprepared for clinical rotations. The authors argue that participation in an RP can help students feel more comfortable speaking with and examining patients and decrease their anxiety regarding clinical encounters. The authors propose that RPs can have positive outcomes for improving the transition from PhD to clinical MD training in dual-degree programs. Identifying and addressing this and other transitions need to be considered to improve the educational experience of MD-PhD students.
Medical schools devote substantial resources to training preclinical students in the art and science of interacting with and evaluating patients so that students are prepared to work in the clinical environment during their third and fourth years. The requisite skills are built in a gradual, multimodal fashion during the preclinical years, typically combining small-group sessions, lectures, standardized patient encounters, and patient care settings. Despite these efforts, many medical students are anxious about the transition to full-time clinical efforts.1–7
MD-PhD students typically take part in the same preclinical curriculum as their non-PhD-track colleagues. Then, instead of transitioning immediately into the clinical environment, they participate in an average of four years of didactic work and thesis research required for the PhD. By the time these trainees return to complete the clinical portion of medical school, most have not participated in patient care activities for several years. This gap in clinical exposure is emblematic of most training programs for physician–scientists, in which the students tend to move between the “siloed” domains of medical school and graduate school training. The transition into the clinical curriculum following the completion of requirements for the PhD degree may therefore represent a major chasm in dual-degree training programs—one that complicates the integration of educational efforts. When students navigate between academic venues that have quite different activities and requirements, they are exposed to unique stresses and challenges. As a result, trainees, especially MD-PhD students, can experience confusion (“living in different worlds”) and lose confidence with respect to their clinical skills.
We became interested in this transition period on the basis of our experiences interacting with MD-PhD students at the University of California, San Diego (UCSD). Our students routinely approached one of the authors (C.G.), asking to attend his clinic to brush up on basic patient-care-related skills immediately before beginning their clinical rotations. Reflecting on this situation, we realized that our MD-PhD program did not optimally assist students with the transition to clinical training. A needs assessment confirmed that they strongly favored establishment of a formal program to prepare them for this transition.
In this commentary, we draw on our experience identifying and addressing this transition for MD-PhD students at our own institution to call attention to this critical issue. First, we discuss the difference between MD-only students’ and MD-PhD students’ experiences with respect to the transition to clinical training. We then describe how we have approached this problem and close with recommendations for how others may wish to address these same issues.
Programs Designed to Assist MD-Only Students Transitioning to Clinical Training
Most U.S. medical schools offer programs to assist MD students as they transition from preclinical to clinical training.8–13 These efforts typically last about one week and occur immediately before the start of clinical rotations (i.e., between the second and third years). Such programs have grown out of the belief that preclinical curricula do not adequately prepare students for novel aspects of the clinical environment. The emphasis of these “transition efforts” is on providing students with pragmatic skills and experiences designed to improve their ability to function and learn within that environment. An array of educational modalities are used, focusing on the tasks (e.g., note writing, oral presentations), relationships (e.g., the student’s role on a patient care team), culture, and rules that govern patient care settings.13 Qualitative analyses of these efforts indicate that they are helpful.8–13 However, no data identify which aspects are most useful or whether these preparatory efforts are successful in either the short or long run. It was our opinion, supported by the views of transitioning UCSD MD-PhD students, that existing programs were not sufficient to address the deficits and concerns of dual-degree trainees. We thus developed a concise course of study, a reimmersion program (RP), that focused on skills related to typical patient encounters.
The UCSD MD-PhD RP
The RP requires 22 hours of effort from MD-PhD students preparing to transition to clinical training, and it occurs one half-day per week across a six-week period. It begins with a physical exam skills review session. During the first week, the students work in pairs to practice (and receive feedback on) key portions of the physical examination. The following week, they participate in an objective structured clinical examination (OSCE) that involves the interviewing and examination of standardized patients. The OSCE format is a well-established tool for evaluating and teaching clinical skills.14 The interactions with standardized patients last 15 minutes, followed by 10 minutes of feedback from a faculty observer.
The remaining RP activities take place with patients and faculty in clinical settings. Each student performs an observed history and physical examination (H&P) on a hospitalized patient. This gives the students an opportunity to practice the long-form H&P commonly used by third-year medical students and to receive feedback from a faculty observer. Each student then participates in three sessions in an outpatient environment (a family practice or internal medicine clinic). These sessions afford the students an opportunity for additional practice and feedback and give them a sense of the pace and intensity of real-world clinical efforts. The trainees are encouraged to further develop their skills by consulting recommended resources15,16 and by participating in other clinical activities, such as the UCSD student-run free medical clinic.
Over the past four years, 37 students have participated in the RP (8–12 students per year). Although the RP is a voluntary activity, all eligible students have opted to participate. Seventy-five percent reported no clinical encounters in the two years before taking part in the RP. We compared the OSCE scores of the transitioning MD-PhD students with those of MD-only students who completed the same OSCE at the end of their second year. We found that the MD-PhD trainees had significantly loweroverall scores (P = .01) than their MD-only counterparts. In addition, station-by-station comparison revealed that performance on the cardiovascular and pulmonary exams was lower (P=.05) for MD-PhD trainees than for MD-only students. At the conclusion of the RP, 95% of MD-PhD students reported that these efforts were a good use of their time, and all recommended that it be offered to future students. Each element of the program was viewed as helpful, with the OSCE and office-based sessions rated highest.
The Value of the RP
Our efforts in developing and initiating the RP provide insights regarding the perceived and actual levels of preparedness of MD-PhD students who are on the cusp of full-time clinical training. These trainees spent approximately four years away from clinical medicine, which had a negative impact on skills taught during the preclinical curriculum. Their feeling of being unprepared was manifested by high levels of anxiety regarding upcoming clinical rotations. Results from the OSCE show that their sense of unpreparedness was appropriate.
MD-PhD training is characterized by a series of transitions in which students move between the very different curricula and activities that occur during the medical school and graduate school educational experiences. Although such transitions are intrinsic to dual-degree training programs, we believe that not enough has been done to make them as smooth as possible. Difficult transitions, in turn, contribute to the growing gap between the clinical and research enterprises, further widening the “valley of death” that separates bench research from clinical application.17 A potential consequence is that physician–scientist graduates will be less inclined to bridge this gap as they craft their own careers.
The transition from PhD research to clinical rotations is one fraught with potentially negative consequences in the training of MD-PhD students. If students must devote efforts to relearn skills during early clinical rotations, they may be less able than their MD-only colleagues to maximize learning opportunities provided by these educationally rich environments. Because most graduates of MD-PhD programs plan careers that include clinical care,17 it is vital that early clinical rotations be positive and empowering experiences.
We believe, and our experience suggests, that these deficits can be corrected. An RP provides MD-PhD trainees with a means to relearn basic clinical skills and helps to normalize and validate individual students’ concerns and anxieties. In addition, a structured program for all MD-PhD students makes the process straightforward and accessible.
On the basis of discussions with those in other MD-PhD programs in the United States, we are aware that many either have or support the creation of reimmersion activities. In spite of these efforts and beliefs, an optimal RP has not been defined. Our experience identifies activities that are likely to be of use. However, additional study is needed to determine the best mix of activities for RPs. At UCSD, we plan to continue the RP and to obtain additional feedback from faculty and participants to help us improve it.
Establishing and refining RPs can be accomplished with a relatively modest amount of time, effort, and resources, and doing so meshes nicely with the current interest in reevaluating the physician–scientist training process.17–28 Improved connections between the clinical and research aspects of training should include identification of challenging transitions and implementation of programs that facilitate their successful negotiation. A closer integration of clinical and research training would likely help shift the focus away from the types of stark transitions that RPs seek to address. Unfortunately, physician–scientist trainees do not experience the optimal practical combination of clinical care and scientific research.28 Until this happens, we urge training programs to be proactive in identifying and addressing key transition periods when students navigate between the distinct and different environments that are inherent in MD and PhD training.
Acknowledgments: The authors wish to thank the following individuals for their contributions to this study and publication: Lisa Madlensky, PhD, associate professor, Department of Family and Preventive Medicine, University of California, San Diego (UCSD) School of Medicine (SOM), provided statistical analysis. Mary Alice Kiisel, UCSD SOM, provided administrative support. Simerjot Jassal, MD, associate professor of medicine, UCSD SOM, provided detailed review and comments. The authors would also like to thank the UCSD clinicians who selflessly agreed to participate in the multiple activities that make up the RP. This program would not have been possible without their efforts. None of these individuals received financial support for their contributions. The Professional Development Center at UCSD SOM provided all of the support necessary to run the OSCE sessions.
Funding/Support: Funding to cover the cost of the OSCE activity was provided by Medical Scientist Training Program (MSTP) training grant T32 GM007198-37.
Other disclosures: None.
Ethical approval: This study was approved by the University of California, San Diego IRB.
1. 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
2. Chandavarkar U, Azzam A, Mathews CA. Anxiety symptoms and perceived performance in medical students. Depress Anxiety. 2007;24:103–111
3. Moss F, McManus IC. The anxieties of new clinical students. Med Educ. 1992;26:17–20
4. Prince KJ, Boshuizen HP, van der Vleuten CP, Scherpbier AJ. Students’ opinions about their preparation for clinical practice. Med Educ. 2005;39:704–712
5. Radcliffe C, Lester H. Perceived stress during undergraduate medical training: A qualitative study. Med Educ. 2003;37:32–38
6. Seabrook MA. Clinical students’ initial reports of the educational climate in a single medical school. Med Educ. 2004;38:659–669
7. Small RM, Soriano RP, Chietero M, Quintana J, Parkas V, Koestler J. Easing the transition: Medical students’ perceptions of critical skills required for the clerkships. Educ Health (Abingdon). 2008;21:192
8. Jacobs JC, Bolhuis S, Bulte JA, Laan R, Holdrinet RS. Starting learning in medical practice: An evaluation of a new introductory clerkship. Med Teach. 2005;27:408–414
9. Poncelet A, O’Brien B. Preparing medical students for clerkships: A descriptive analysis of transition courses. Acad Med. 2008;83:444–451
10. van Gessel E, Nendaz MR, Vermeulen B, Junod A, Vu NV. Development of 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
11. Chumley H, Olney C, Usatine R, Dobbie A. A short transitional course can help medical students prepare for clinical learning. Fam Med. 2005;37:496–501
12. Chittenden EH, Henry D, Saxena V, Loeser H, O’Sullivan PS. Transitional clerkship: An experiential course based on workplace learning theory. Acad Med. 2009;84:872–876
13. O’Brien BC, Poncelet AN. Transition to clerkship courses: Preparing students to enter the workplace. Acad Med. 2010;85:1862–1869
14. Epstein RM. Assessment in medical education. N Engl J Med. 2007;356:387–396
15. Bickley LS Bates’ Guide to Physical Exam and History Taking. 200910th ed Philadelphia, Pa Lippincott
17. Jeffe DB, Andriole DA. A national cohort study of MD-PhD graduates of medical schools with and without funding from the National Institute of General Medical Sciences’ Medical Scientist Training Program. Acad Med. 2011;86:953–961
18. Roberts S, Fischoff M, Sakowski S, Feldman E. Transforming science into medicine: How clinician–scientists can build bridges across research’s “Valley of Death.” Acad Med. 2012;87:266–270
19. Varki A, Rosenberg LE. Emerging opportunities and career paths for the young physician–scientist. Nat Med. 2002;8:437–439
20. Nagasako EM. Aligning academic medicine with the needs of the health care system by creating a cohort of physician–researchers in the social sciences. Acad Med. 2011;86:1346
21. Kanter S. 2011 question of the year. Acad Med. 2011;86:1
22. Skochelak S. A decade of reports calling for change in medical education: What do they say? Acad Med. 2010;85(9 suppl):S26–S33
23. Whitcomb ME. The need to restructure MD-PhD training. Acad Med. 2007;82:623–624
24. Ahn J, Watt CD, Man LX, Greeley SA, Shea JA. Educating future leaders of medical research: Analysis of student opinions and goals from the MD-PhD SAGE (Students’ Attitudes, Goals, and Education) survey. Acad Med. 2007;82:633–645
25. Andriole DA, Whelan AJ, Jeffe DB. Characteristics and career intentions of the emerging MD/PhD workforce. JAMA. 2008;300:1165–1173
26. Brass LF, Akabas MH, Burnley LD, Engman DM, Wiley CA, Andersen OS. Are MD-PhD programs meeting their goals? An analysis of career choices made by graduates of 24 MD-PhD programs. Acad Med. 2010;85:692–701
27. Ciampa EJ, Hunt AA, Arneson KO, et al. A workshop on leadership for MD/PhD students. Med Educ Online. August 10, 2011;16
28. Goldstein MJ, Kohrt HE. What happened to the concept of the physician–scientist? Acad Med. 2012;87:132–133