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Clinical Education

Preparing Medical Students for Clerkships: A Descriptive Analysis of Transition Courses

Poncelet, Ann MD; O’Brien, Bridget PhD

Author Information
doi: 10.1097/ACM.0b013e31816be675

Abstract

The transition from preclerkship to clerkship education has been identified as a particularly stressful and anxiety-provoking experience for medical students.1–4 All medical schools have incorporated clinically oriented courses and experiences into the preclerkship curriculum in the effort to improve students’ preparation for clinical settings and, correspondingly, to reduce some of the stress and anxiety associated with the transition.5–8 Despite these changes, students continue to encounter difficulties such as understanding their role and responsibilities within clerkships, applying theoretical knowledge in practice, adjusting to clinical cultures, performing procedures, using technical and interpersonal skills, and learning the routines and logistics when they begin their clinical rotations.5–7 Students have also reported feeling unprepared for specific aspects of clinical practice such as writing orders and progress notes, starting an intravenous (IV) line, and identifying hospital equipment.9,10 Meanwhile, clerkship directors have reported that third-year medical students are not sufficiently competent in important domains such as communication skills, interviewing/physical exam skills, clinical epidemiology and probabilistic thinking, professionalism, and life cycle stages when they begin their clerkships.11

One reason why these challenges persist may be an inadequate appreciation by clinical faculty for the amount of support and guidance that students, as newcomers to clinical practice, need in order to feel sufficiently confident in and comfortable with their roles and responsibilities to effectively participate in clinical practice.12 Many of the challenges that students associate with the transition to clerkships highlight their need for specific knowledge and information that is directly relevant to clinical settings, opportunities to familiarize themselves with the settings in which they will be working, and opportunities to practice the kinds of tasks and activities that they will most likely be expected to perform in their first clerkships. Clerkship transition courses offer a way of meeting these needs by providing a focused block of time in which students can learn clinically relevant knowledge and information in close proximity to the time and place in which it will be used, practice clinical tasks with coaching and feedback, and ease their way into clinical settings with guidance and support.

Thus far, few studies have been conducted about the efficacy of transition courses beyond students’ self-reported satisfaction with courses13 and changes in pre- and postcourse self-assessed levels of preparation to perform specific clinical tasks and acquire skills.9 We found only three transition courses described in the literature, which were each notably different in approach. One course was two weeks long and focused on a set of 18 tasks and skills that were identified as activities commonly performed by clerkship students.9 Two other courses were developed as part of curricula in two European medical schools.13,14 These courses were relatively long in duration (4 and 12 weeks). One course focused on assisting students with the shift to experiential learning, particularly working on students’ comfort with more goal-oriented, active, and reflective learning processes.13 The other course focused on helping students collect information and interpret clinical findings in ways that facilitate diagnosis and management of patients (clinical reasoning).14 The differences represented by this small number of transition courses raise questions about the goals and objectives of transition courses and the optimal means of achieving these objectives.

In light of these questions, our purpose is to describe the content and educational approaches used in transition courses, to examine the extent to which the objectives and content of these courses are aligned with the challenges associated with the transition to clerkships, and to provide a framework that can assist educators who are involved in designing or directing transition courses.

Description of Transition Courses

The data we present on transition courses are based on the results of an open-ended survey, conducted in 2003, that was e-mailed to curriculum deans at the 125 U.S. medical schools that existed then. Two follow-up attempts were made with each nonrespondent. The survey asked deans to identify whether they offer a specific transition course and, if they do, to describe the course and attach a syllabus or other relevant information. Of the 56 deans who responded to the survey (45%), only 30* described transition courses that met our criteria: (1) the course was at least one day and no more than 12 weeks, (2) the course occurred immediately before clerkships, (3) course content focused specifically on transition to clerkships, and (4) sufficient information was provided to allow us to code the responses. Each course description was coded for course structure, content, and instructional approaches. Three main curricular themes were derived from post hoc analysis of the data. The study was approved by the University of California–San Francisco institutional review board.

We identified three curricular themes from our analysis of the courses: (1) presentation of new information and skills, (2) review and application of preclerkship knowledge, skills, and attitudes in a clinical setting, and (3) student well-being and stress reduction. These themes are used as an organizing framework for our description of course content and instructional approaches. Table 1 displays the distribution of these themes in courses of three different categories of length: one to four days, one week, and two to seven weeks.

Table 1
Table 1:
Coverage of Three Course Themes, by Length of Transition to Clerkship Course, from 30 U.S. Medical Schools, 2003

Course length and design

Most courses (83%) were one week or less in duration, and the longest course was seven weeks. Although shorter courses might be expected to have covered fewer themes, this was not the case. Roughly half the courses in each category of course length covered all three themes. Courses were typically a mandatory, independent block or unit bridging the preclerkship curriculum and the clerkships. In a few cases, the course occurred in the final sessions of a yearlong introduction-to-patient-care course or as an initial clerkship block.

Content and themes

All courses included topics related to the theme of new information and skills. More than half of the courses (53%) covered topics related to all three major course themes. The array of content areas within each theme is described in Table 2.

Table 2
Table 2:
Curricular Content of Transition to Clerkship Courses, by Course Themes and Length of Course, from 30 U.S. Medical Schools, 2003

New information and skills

Transition courses covered a wide variety of information and skills that typically had not been covered in the preclerkship curriculum but that were perceived as important for students to have at the beginning of the clerkships.

One of the most common topics that appeared in course descriptions was new clinical skills. These skills covered a range of items such as writing orders, prescriptions, and notes in the chart; procedural skills such as suturing and resuscitation; and communication skills with other health care staff. Most courses provided information and practical experiences to familiarize students with different clinical settings such as the wards, the operating room (OR), and outpatient clinics. Information and training related to safety precautions were often covered to meet hospital policy requirements. The longer courses had the luxury of more time to incorporate clinical content knowledge in areas such as lab interpretation and ancillary disciplines (e.g., rehabilitation medicine, physical therapy, social work).

Review and application of knowledge, skills, and attitudes

Roughly half of the courses devoted time to reviewing clinical skills that were covered in preclerkship curricula such as history taking, physical exam, and oral presentations. Typically, the transition course curriculum provided instruction and/or opportunities for students to practice using these skills in ways appropriate to the demands and expectations of real clinical settings. For example, one course expected students to be able to perform a medical oral presentation and to be able to recognize specialty-specific SOAP notes. Similarly, several courses addressed professionalism, often highlighting key aspects relevant to clinical settings. For example, one course helped students think through approaches to potentially challenging ethical situations that might occur in clinic or on the wards. The course also expected students to be able to identify the components of medical professionalism. Review of knowledge topics such as basic medical topics, basic science topics, specialty topics, and knowledge about patient populations was not very common, particularly in the courses that were shorter in length.

Student well-being and stress reduction

Two thirds of the courses included content specifically related to student well-being and stress reduction. Topics and activities included tips or advice from current clerkship students, written guides such as a “surviving the wards” handbook, discussions of emotional issues and of the unique position of medical students, and student advocacy.

Instructional approaches

The transition courses we studied incorporated several different instructional approaches, as shown in Table 3. This is appropriate, given the diverse topics covered in each of these courses. As might be expected, the number of different approaches used in a course tended to be higher in longer courses as well as in courses addressing all three themes.

Table 3
Table 3:
Instructional Approaches Used in Transition to Clerkship Courses, by Course Themes, from 30 U.S. Medical Schools, 2003

Opportunities for hands-on practice were provided in most transition courses, and this was the most commonly used instructional approach among the courses. In some courses, students practiced procedures such as knot-tying, IV insertion, or nasogastric tube placement in a skills lab with an instructor. Students also practiced interviewing and/or conducting a focused physical exam with standardized patients. The feedback students received from these activities included self-assessment and checklists completed by standardized patients, videotaping and review with faculty and/or peers, and observation by a faculty member followed by formative feedback. Lastly, some courses provided opportunities to practice writing notes and orders, giving case presentations, and reviewing patient charts.

Large-group lectures and didactic sessions were used in more than two thirds of the courses and were the second-most-common instructional approach. This approach included panel discussions and presentations by clinical faculty and educational administrators on topics such as policies, expectations, professionalism, and safety precautions. Small-group discussions were included in some courses, particularly those that reviewed knowledge and skills for application in clinical settings. Often, these small-group sessions were used to work through cases or to discuss clinically relevant topics such as cultural sensitivity, health care disparities, or information search strategies and evidence-based medicine.

More than half the programs that addressed all three themes included opportunities for students to interact with peers who had completed the clerkships. Often, these sessions provided a way for students entering the clerkships to ask questions and voice concerns about the experience and to receive advice and tips from peers. Lastly, a few courses scheduled time for students to experience a typical day in the hospital, OR, and/or clinic. Often, these experiences involved observing a ward team, shadowing a clerkship student, or going through an orientation to the OR.

Purpose or objectives

Only seven transition courses stated an explicit purpose or learning objectives. Goals and objectives included improving students’ comfort in clinical settings, improving students’ comfort and proficiency in performing specific clinical and/or procedural skills, providing opportunities for students to practice clinical skills and receive feedback, introducing new knowledge and skills that students will use in the clerkships, and facilitating the transition from student to professional.

Student assessment and course evaluation

Most courses included an evaluation of the course, primarily through students’ written course evaluations (53% of courses lasting one to four days, 90% of courses lasting one week, and 100% of courses lasting two to seven weeks). Few courses provided any evaluation of the students (13% of one- to four-day courses, 20% of one-week courses, and 40% of two- to seven-week courses). Evaluations of the students included self-perception surveys, written examinations, attendance, and formative feedback from standardized patients and faculty observers.

Course examples

Thus far, we have described the various components of transition courses without providing a sense of how these components might be organized in a course. In Appendix 1, we present three examples to illustrate the differences among transition courses with respect to curricular content, instructional approaches, and emphasis placed on each of the three major course themes.

Discussion

Students’ transition to the clinical clerkship year continue to be a challenge despite the addition of problem-based learning, clinical skills courses, and preceptorships in the preclerkship curriculum.5–8 One explanation may be that these efforts do not address the more immediate issues and concerns that are the sources of students’ anxieties during the transition to clerkship. Furthermore, a recent model of students’ learning in the clerkships shows that students develop practical competence, professional identity, and confidence primarily by participating in clinical activities.12 Factors such as fear, anxiety, lack of confidence in knowledge and skills, failure to understand roles and responsibilities, and difficulty understanding basic rules and routines clearly interfere with students’ ability to participate in patient-care activities and, thus, can inhibit the pace of their learning early on in the clerkships. Each of these factors has been identified in the literature as a challenge that students associate with the transition to clerkships.1–7 These findings signal a need for a clinically oriented and experientially based introductory period that can facilitate students’ entry into clinical practice, improve their ability to participate in clinical activities, and reduce the excessive anxiety and stress associated with the transition to clerkships. Transition courses can provide a way of satisfying this need, but so far there seems to be no framework or principles to guide the design and evaluation of these courses. At best, we know that students consider opportunities to participate in daily practice a beneficial part of transition courses13 and that they feel more prepared to perform some tasks and skills after participating in a transition course.9

The framework we propose as a guide for designing transition courses is based on three principles. First, the course must address aspects of the transition to clerkships that students have identified as particularly difficult or challenging and that clinical faculty or clerkship directors recognize as necessary for students to function in clinical settings and contribute to patient-care activities. Given that the courses are relatively short in duration, it is important to recognize that some needs are not appropriate to address in a transition course and, thus, to focus on those that can reasonably be addressed in a short period of time. Second, courses must have specific, measurable objectives that are consistent with the needs identified by students and clinical faculty and that are relevant to students’ performance and participation in the clerkships. Third, courses must use instructional approaches and include learning activities that match the needs and objectives. Using this framework, we can examine the transition courses in our study, highlighting some positive features and identifying some areas for improvement.

Principle One: Address aspects that students and faculty or clerkship directors recognize as problematic

All of the transition courses we studied used course time to introduce new information and skills that were perceived as important to students’ performance in the clerkships. Most often, this involved teaching students basic procedures, teaching safety precautions, and/or providing an orientation to clinical sites. These efforts are consistent with perceptions that students have inadequate technical and procedural skills when they enter the clerkships and have difficulty acclimating to clinical learning environments, given the complexity and pace of work in the clinical sites they rotate through.9–11,15

Twenty-one out of 30 courses devoted time to reviewing material from the preclerkship curriculum and to helping students orient their knowledge, skills, and attitudes toward real clinical situations. Clinical skills such as oral and written presentations and focused history taking and physical exam were frequently included in transition courses, whereas fund-of-knowledge topics were rarely included in courses less than two weeks long. Each of these content areas is relevant to major challenges that students associate with the transition to clerkships, namely, restructuring their knowledge base to support clinical reasoning and practical judgment and applying their clinical skills.7,16 Within the short time frames that are typically available, practicing focused, specialty-specific oral and written presentations and history taking and physical exams is reasonable content for a transition course, particularly if aligned with the specialty of the student’s first clerkship. By contrast, the development of a well-structured knowledge base for clinical reasoning requires significant time and experience and, thus, is not an appropriate priority for transition courses. At best, a transition course might provide opportunities for students to practice using prior knowledge and experience to think through and respond to an authentic clinical situation.

Twenty out of 30 courses addressed student well-being and stress reduction, primarily by discussing topics such as stress management and self-care, identifying available resources, and providing opportunities for preclerkship students to talk with current clerkship students. These approaches might alleviate some of students’ anxieties, but many of the stresses that students have described in other studies seem to arise from the actual experience of being in a busy clinical setting and encountering uncertainty. Students have described feeling in the way, useless, or uncertain about their role,3,17,18 having difficulty finding time to read or study, adapting to more independent or self-directed learning,7,18,19 and adapting to new teaching styles, expectations, and forms of assessment.3,20 Few of the transition courses we studied explicitly covered these topics.

Principle Two: Articulate specific, measurable objectives

Only seven courses identified specific goals or objectives, revealing considerable room for improvement. Most of these objectives targeted students’ levels of comfort in clinical settings and with clinical and procedural skills. These objectives are consistent with transition challenges that have been reported by students. They are measurable through pre- and postcourse surveys and through students’ self-assessed levels of comfort early on in the clerkships. One course used self-perception surveys, though it was not clear whether this was a pre- and postcourse survey, and none of the courses collected information about students’ levels of comfort or confidence early on in the clerkships. Objectives such as improving students’ proficiency in particular skills are consistent with areas of need identified by both students and clerkship directors. None of the schools did this by measuring students’ pre- and postcourse levels of proficiency, and none assessed students’ proficiency in real clinical situations. Instead, faculty observers or standardized patients rated and/or provided feedback on students’ performance in simulated situations or tasks. Additional objectives such as introducing new knowledge and information and providing opportunities to practice skills and receive feedback are process-oriented goals rather than outcome-oriented objectives. These goals could be strengthened if they were linked to expected changes in students’ transition experience. Finally, although understanding their roles and responsibilities and learning the routines and logistics needed to function in clinical settings are significant challenges students have identified, none of the courses included specific objectives in these areas. Transition courses are strategically positioned to ease students more effectively into clinical environments, and they warrant explicit objectives and learning activities in this regard.

Principle Three: Use instructional approaches and learning activities that meet needs and objectives

Most of the challenges that students face are related to performance in clinical settings. For example, the new information and skills that students need are practical and will help them to function in clinical settings, to feel more confident or comfortable with the tasks and activities they are doing, and to participate in more patient-care activities earlier in the clerkships. In addition, students report difficulties connecting prior knowledge and skills to clinical situations. These needs suggest that opportunities to experience and familiarize themselves with clinical settings, particularly those in which their first clerkship will occur, are particularly important activities to include in transition courses.21 Surprisingly, only six courses actually included immersion experiences. Achieving objectives such as improved comfort, confidence, and proficiency with clinical skills also requires opportunities for authentic practice and feedback.21 Most courses did provide opportunities for active, hands-on experiences, but it is not clear how many of these experiences included observation and feedback. Without specific feedback, such opportunities to practice are less likely to improve students’ performance.22 Fewer than half of the courses used peer-to-peer teaching or mentoring, although this method is well suited to affective objectives such as improving students’ well-being and understanding of their role in a clinical setting. Furthermore, near peers (i.e., ending third-year students or fourth-year students) can provide valuable insights to beginning clerkship students because many of the transition problems and challenges may still be quite salient to them.23 Finally, a majority of the courses used large-group lectures and didactic sessions. These are appropriate methods for presenting new knowledge and information and for achieving some cognitive objectives,21 but, by and large, these are not the primary need served by transition courses. The proportion of time that students spend in lectures and didactic sessions should be minimal in a transition course.

Analysis

The curricular themes identified among the transition courses are generally consistent with the kinds of difficulties and challenges students and clerkship directors associate with the transition to clerkships. Correspondingly, we conclude that it is appropriate for courses to address all three themes and to specify objectives within each. More specific decisions about appropriate course content necessarily depend on a combination of local needs and resources and topics most immediately relevant to transitions, first clerkship experiences, and efforts to facilitate participation in patient-care activities. Course duration is a key factor in the design of transition courses because it influences the objectives that a course can reasonably achieve, the amount of content a course can cover, and the instructional approaches that can be used. Given the importance of opportunities for authentic practice and clinical immersion experiences, we recommend that courses be a minimum of one week. Ideally, courses should dedicate a significant portion of time to opportunities for students to experience day-to-day activity in clinical settings. This time needs to be structured and guided by peers and/or clinicians so that students can efficiently gain a significant understanding of the workings of these settings. To the greatest extent possible, these experiences should occur at the site of students’ first clerkship. In addition, courses need to provide time for students to practice using existing skills in real or simulated clinical situations. This practice must be observed and include feedback. Other approaches and activities such as small-group discussion sessions and large-group lectures or didactic sessions can be used sparingly, when they are consistent with the content and objectives of the course.

To our knowledge, ours is the first attempt to describe the nature of transition courses in U.S. medical schools and to identify some of the unique purposes that these courses can serve in the curriculum. Until more information about the outcomes of transition courses is available, questions will remain about the possibility of accomplishing the same outcomes through better-designed “Introduction to Clinical Medicine” types of courses or through changes to the clerkships. There is some evidence suggesting that integrated, longitudinal courses spanning the first and second years can prepare students to transition more successfully to their clerkship year. For example, Whipple et al24 reported results from a recent evaluation of a yearlong, competency-based, clinical skills program for second-year students. The results indicate that students’ comfort with some clinical skills was significantly higher at the beginning of clerkships among students who went through the curriculum than among students who did not. Yet, these outcomes only address one of several dimensions of the challenges associated with the transition to clerkships.

Interestingly, all of the schools that had a transition course also had an “Introduction to Clinical Medicine” type of course, suggesting that transition courses are perceived as providing some added value. Data reported from a study of one transition course corroborate this perception. Chumley et al9 found that students felt more prepared performing 16 out of 18 specific tasks after participating in a two-week transition course than they did before the course. The students also felt more prepared performing 14 out of 18 tasks compared with a cohort of peers from a previous year that did not participate in the course. It may be that some of the challenges associated with early clerkship experiences are best addressed in a longitudinal fashion through the preclerkship curriculum, whereas others are better attended to through a focused transition experience immediately preceding the first clerkship. In either case, an explicit set of goals, learning activities, and assessment processes based on the three themes we have identified and the transition challenges highlighted through our review of the literature would enable a more evidence-based approach to identifying the most efficacious way to prepare medical students for their clerkships.

There are several limitations present in our effort to describe and evaluate transition courses. The information from our survey of U.S. medical schools is based on a limited number of respondents and on data that are five years old. There were no obvious demographic differences between the schools that responded to the survey and the schools that did not. Only eight schools responded that they did not have a transition course. Seventeen others considered their “Introduction to Clinical Medicine” course to be their transition course, but such courses were excluded from our analysis because they did not match the characteristics of a transition course as defined in our study. Admittedly, the descriptions presented in this paper do not necessarily represent the full spectrum of transition courses. In both the literature and in curricular databases, there is a paucity of information about the content and design of clerkship preparatory courses, so there was no reliable, expedient way for us to supplement or update the information collected through our survey. For this reason, we used multiple sources of information relevant to the transition to clerkships to develop a framework within which such courses can be reviewed and evaluated.

The open format of the survey used in our study has advantages and disadvantages. Respondents provided different degrees of detail about their courses and provided the information in a nonstandardized format. Consequently, important aspects of some courses may have been omitted. For example, only seven schools mentioned the purpose and objectives of their courses. Other schools may have had explicit goals and objectives for their transition courses, but they did not include them in their survey responses. The value of the open-ended qualitative approach is that it enabled us to capture the variety of approaches in an area that was very poorly documented. Future research can use the descriptive information and the framework we have developed to collect data in a more structured and systematic way.

Conclusions

More that half of U.S. medical schools responding to our survey had specific transition courses before the clerkships. By using known challenges associated with the transition to clerkships and established principles of curriculum development and instructional approaches, we were able to develop a framework to evaluate the design, curricular content, and instructional approaches used in these courses. This framework can be used by medical schools to create or transform their own transition courses. We recommend that medical schools devote at least one week to a formal transition curriculum that is designed to improve students’ ability to participate effectively in patient-care activities in the clerkships. Three themes that are most appropriate for courses to focus on with respect to learning objectives and curricular content include acquisition of new clinical knowledge and skills; application of existing knowledge, skills, and attitudes in the clinical setting; and student well-being. Instructional methods should include specific activities in clinical settings, ideally the settings of the first clerkship. Each course must have clearly defined objectives that address specific transition challenges, include learning activities best tailored to accomplish the objectives, and have methods for evaluating student outcomes and course efficacy.

Acknowledgments

The authors gratefully acknowledge Lydia Segal, MD, for helping develop the survey and distributing and collecting the survey; Elizabeth Kaplan, MD, Omri Berger, MD, and Preetha Basaviah, MD, for coding the surveys; Christine Cofer, MD, for creating the database and entering data; and Arianne Teherani and Patricia O’Sullivan, for consultation on data analysis and critical review of the manuscript.

References

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*The 30 medical schools are located in all geographic regions of the United States: three (10%) are in the Southern region, six (20%) are in the Western region, 10 (33%) are in the central region, and 11 (37%) are in the Northeastern region. Schools with transitions courses include both publicly and privately funded medical schools: 11 (37%) are private, and 19 (63%) are public.
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Appendix 1

Program Examples, Transition to Clerkship Courses

The following three examples illustrate the differences among transition courses with respect to curricular content, instructional approaches, and emphasis placed on each of the three major course themes. The first example, similar to most of the longer courses that we studied, used an experientially oriented, hands-on approach and included direct observation of and feedback on students’ performance. This two-week course was made up of a combination of precepted clinical skills sessions, hospital ward experiences, and small- and large-group sessions. The first week included four half-day preceptor sessions in which students were observed doing two complete histories and physical exams. The students wrote admission and progress notes for each patient and practiced writing orders and presenting. Students also participated in bedside teaching and work rounds conducted by their preceptors. Students were required to create an appropriate differential diagnosis as part of the experience. In the second week, students spent two full days on a hospital ward. The course also included practical skills sessions on phlebotomy and order entry. Small-group sessions addressed radiology and electrocardiograms (EKG). Large-group sessions were held for orientation, a physical examination demonstration, and lectures on survival skills, ambulatory medicine, clinical lab medicine, infection control, risk management, ethics, radiology, and EKG, as well as a historical perspective of the institution. The students kept clinical evaluation logs during the two weeks and received formal evaluations from their preceptors. An additional inpatient session was available for students who needed more practice before starting the clerkships. The students were asked to evaluate the course at the end of the two weeks.

The second example is a one-week course that focused solely on students’ performance of new skills, particularly procedures. The program included skills sessions on nasogastric tube insertion, venipuncture, injections, intravenous line placement, urinary catheter placement, EKG techniques, suturing, spinal taps, isolation techniques, aseptic techniques, and tracheal suctioning. The sessions were taught by clinicians, nurses, physician assistant instructors, and staff from laboratory medicine. The students practiced on each other or on mannequins as appropriate. Suturing was practiced on pigs’ feet.

The third example is a two-day transition course. Although the course was short in duration, it covered all three course themes and used several different approaches to instruction. This course included large- and small-group sessions on the sociology of the wards and disparities in health care. There were also large-group sessions on adjusting to the wards, the Health Insurance Portability and Accountability Act, and universal precautions. Skills sessions included venipuncture and operating room etiquette. There was a session on use and interpretation of tools, including pulse oximeter, EKG, mask ventilation, end tidal carbon dioxide, and automatic blood pressure. Clinical skills such as chart orders and SOAP notes were reviewed and practiced for use in clinical settings in small-group sessions. The course concluded with a reception for faculty and students.

© 2008 Association of American Medical Colleges