When newcomers enter the workplace, they face a challenging process of learning how to participate in a new environment. This process involves detecting many implicit rules and norms of an established culture, navigating a complex web of interpersonal interactions, building relationships with key members of the community, and developing a working knowledge of the system and resources available to complete expected tasks. Medical students encounter this daunting task repeatedly as they move from clerkship to clerkship. Although some argue that the experience helps students develop adaptability and flexibility, the cognitive burden likely also results in a slower ramp-up and ability to focus on core knowledge and skills of the clerkship.1–3
A prior study has examined the struggles that students experience as they transition from the preclerkship realm to clerkships.4 Though medical schools and clerkship directors have become increasingly aware of the difficulties students face, even developing transitional clerkships and programs to address them,5–7 clerkship directors still may not have a complete understanding of the forces that influence students’ transitions onto their clerkships. Clerkship directors recognize that students struggle in developing ways of learning, adjusting to clinical culture, and acquiring clinical skills. Yet, clerkship directors know less about the effects of frequently changing rotations, logistics, and expectations that students experience.4 Formal efforts to transition from preclerkship activities to clerkships are difficult to capture in formal curricula.6,7 Most of the current literature explores the major transition between preclerkship and clerkship-based curricula, but students undergo transitions constantly, and those smaller transition points are less well characterized, even though learning environments differ between clerkships at the same medical school.8 In addition, not much is known about how students transmit information to each other.9
In an effort to better understand the processes that students undergo and the orientation elements that may help students transition and acculturate to individual clerkships, we examined the kinds of information students share with one another during formalized peer-to-peer handoff sessions. Similar in intention to patient handoffs,10 these sessions enable students just finishing a clerkship to share information and advice to orient students now entering that clerkship. Our aim was to characterize the transition process that students regularly experience between clerkships, and to compare how students’ perceptions of their experiences differ from clerkship to clerkship.
VALOR (Veterans Affairs Longitudinal Rotations) is a clerkship program at the University of California, San Francisco (UCSF), in which three cohorts of six third-year students rotate en masse between three Veterans Affairs–based clerkships.11 Surgery and medicine clerkships are eight weeks in length; in the blended neurology/psychiatry clerkship, students spend four contiguous weeks predominantly on the inpatient services of either neurology or psychiatry, have an eight-week psychiatry continuity outpatient experience, undergo shared didactics between the two departments throughout the clerkship, and receive a separate grade for each half-clerkship.
For four consecutive years, in the first week of the second VALOR-based clerkship, all VALOR students (71 students over the course of the study) met together once in a conference room with the explicit objective of sharing advice about the clerkship they had just completed. A faculty facilitator transcribed the students’ comments and remained silent except to keep time. Students in each cohort spent 15 minutes giving advice for the clerkship they had just left; the order in which clerkships were discussed rotated each year. At the close of VALOR, students evaluated the session on a five-point Likert scale (1 = not at all helpful, 5 = very helpful).
Each individual piece of advice (“comment”) spoken by a student served as a unit of analysis. The first author (D.M.) entered these 413 comments from four years of students’ comments (2008–2011) into separate cells of an Excel file, from which the authors conducted qualitative content analysis.12 All of us independently reviewed student comments and together developed coding categories and subcategories. To refine the initial coding scheme, we coded 69 comments; subsequently, two authors (D.M. and either B.O.B. or C.L.C.) coded the 344 remaining comments. We reconciled coding differences through discussion. We obtained UCSF institutional review board approval for the study, and all participants gave consent to participate.
We organized comments by coded categories and subcategories for each rotation. To provide a visual representation of the distribution of comments for different rotations, we calculated frequencies of students’ comments in the coding categories and subcategories for each clerkship. To compare subcategories across different categories and between clerkships, we also calculated frequencies of subcategory comments as a percentage of total comments within all categories for each clerkship.
Students rated the sessions very positively (4.6/5); each year, they rated these sessions as one of the most important aspects of the VALOR program.
We identified four major categories of advice: workplace culture, content learning, logistics, and work/life balance; we also identified subcategories for the first three categories. Table 1 shows representative examples of students’ comments in each of the categories and subcategories. Workplace culture encompassed expectations and norms of the clerkships, and interactions with patients and supervisors. We included patient interactions in this category because of the significant effect of the hidden curriculum, most often attributed to influences of workplace culture, on patient-centeredness.13 Content learning included optional experiential opportunities available to students, as well as learning strategies, resource materials, and advice related specifically to tests. Logistics referred to physical orientation, scheduling, and routine tasks. Work–life balance captured maintenance of well-being during the clerkship.
Overall, the categories of workplace culture, content learning, and logistics represented the vast majority of the comments, and comments in these three categories differed in frequency between each of the clerkships (see Figure 1). For medicine, students mentioned all three categories with similar frequency. In the neurology, psychiatry, and surgery clerkships, students commented on workplace culture more frequently than other categories. The five most frequently mentioned subcategories were expectations of the rotation, norms for the workplace, specific tasks to accomplish, available learning opportunities, and learning strategies.
When examining subcategories, we found more marked variations between clerkships in the kinds of information students shared with their peers (see Figure 2). Rather than attempting to depict our qualitative data as quantitative, we show Figure 2 mainly as a visual representation that highlights the differences in how students represent the clerkships in these handoffs. In medicine, students commented more frequently about tasks, including how to write notes and orders; content learning opportunities and strategies; and workplace culture expectations. Workplace culture expectations figured prominently in students’ tips about neurology, including what to expect on call and from supervisors. Neurology students also commented about schedules, specifically what activities occur when, but made no comments about physical orientation to the clerkship. Students just finishing the psychiatry clerkship spoke most about tasks, as in medicine, including the frequency and best timing to write notes. In surgery, students focused most on workplace culture norms, such as dress code and etiquette in the operating room, and how to maximize demonstrations of competence to faculty; comments about learning focused much more heavily on exam preparation and learning resources and less on tasks than any of the other clerkships. With the exception of psychiatry, students rarely shared advice about how to approach and care for patients. Patient comments on psychiatry pertained to managing threatening patients, developing rapport, and establishing continuity.
Our analysis provides a window onto the advice that third-year medical students deem important to hand off to other students. By examining transitions between individual clerkships and focusing on what students tell each other, rather than what they tell clerkship directors or researchers, our data extend findings from a prior study delineating struggles that students face when beginning the clerkship year.6 We do not intend this study to praise, condemn, or parse minutiae about these particular clerkships; instead, our findings exhibit a more detailed picture of students’ experiences and deepen prior observations that learning environments between clerkships at the same school differ.8
Of the five most frequently mentioned subcategories, only task-related comments fall squarely into material expected to appear in a standard clerkship orientation. To a degree, learning strategy advice also may be at the forefront of clerkship directors’ minds.4 Here we show that students believe it is also important to share advice concerning expectations of clerkships, norms students must follow, and learning opportunities. These items alert students to what was required to succeed in each clerkship, both in fulfilling clinical learning and maximizing performance on examinations, and likely represent important aspects of the “informal curriculum” with which students contend when transitioning between clerkships.9,14,15 For example, learning opportunities highlighted specific areas where proactive students could gain unique or high-yield learning; peer discussion may be the only forum for incoming students to be alerted to these hidden opportunities.
Prior descriptions of peer-assisted learning focus on how peers use “cognitive congruence” and “social congruence” to facilitate skill-building and understanding of challenging formal curricular concepts at an appropriate level.16,17 Our findings suggest that both of these kinds of congruence are also at play in students’ peer-to-peer handoffs. Learning opportunities and strategies address the best methods for students to gain the knowledge and skills they require from the rotation, drawing on cognitive congruence to know what entering students will find most challenging or rewarding. Advice on clerkship expectations, norms, and supervisors students will encounter is tailored via social congruence for the new students, who will fill a similar role as their peers, and have similar goals of maximizing clinical learning and performing well on examinations and in front of faculty members.
Students’ revelations to each other could represent a simple method for students to help resolve perceived paradoxes in the transitions between clerkships. Students transitioning between a less active experience to a more active one, or vice versa, undergo significant role dissonance. The differences visually depicted in Figure 2 further emphasize elements of the transition process that students may have experienced: Students moving from medicine to surgery must start thinking more about workplace culture norms and the end-of-clerkship exam, while deemphasizing tasks to which they may have become accustomed. Even students within our blended neurology and psychiatry clerkships must undergo significant differences in the way they act and perform. Our study supports the idea that students undergoing these miniature rites of passage between clerkships are willing to share information about upcoming clinical experiences and value the information they receive from others.18
Students rarely shared information related to patient care, except on the psychiatry clerkship, where one might expect more challenging patient interactions. This finding could be interpreted in several ways. Perhaps patient care is so clearly part of the everyday work that students do not need to give advice about it. An alternative and more disturbing possibility is that the informal curriculum on clerkships fosters an environment in which students prioritize advice about survival tips and strategies to succeed academically over advice related to patient-centered care.13 In prior work, residents have described a link between frequent transitions and devaluing interactions with patients.2 One recent study showed that students in a longitudinal integrated clerkship rated their experiences with patient-centered behaviors higher than students in VALOR or in traditional block clerkships.19 We believe that this is an important area for future study.
Advice related to work–life balance was also infrequent, even within the informal peer-to-peer structure of the VALOR handoff. Though there are several possible explanations for this finding, we have documented previously that the peer group continuity and weekly VALOR conferences frequently address themes of work–life balance11; therefore, this finding may not generalize to students in other settings without these opportunities.
Limitations of this study include its single-site design; because VALOR students rotate together as a cohort through their clerkships at one site, themes about physical orientation and logistics may be underrepresented in VALOR handoffs. In contrast, traditional clerkship students often arrive at a new rotation with diverse prior experiences of role, expectations, and norms. These differences in prior experience between peers who do not share the same third-year schedule might make traditional clerkship transitions even more jarring than VALOR transitions. Second, although VALOR faculty do not facilitate discussion in the peer handoff sessions, their presence could still affect what students choose to share with each other. Third, competition between students, though potentially lessened in VALOR because of its design, could still inhibit certain students from sharing secrets they uncovered that were especially beneficial during the rotation. Finally, we examined only the handoff between the first and second VALOR clerkships; different themes may arise as students further develop.
Rotating into a new clerkship is a challenging transition for third-year students. In addition to reintegrating into new medical teams, students face different workplace cultures, learning environments, and logistics with each rotation. Students must learn to navigate the nuances of their new clerkship, which may place greater emphasis on different elements of the clerkship environment than their previous clerkship, in order to successfully develop the clinical skills they require. Here we have shown that peer-to-peer handoff is a well-received method to transfer this information between students. We further suggest that leaving handoff communication about new rotations entirely to informal processes may grant an unfair advantage to students who are better connected with their peers or with upperclassmen. All students entering a clerkship may benefit from a more comprehensive preview of the factors that are important to their upcoming experiences, so as to diminish the heightened anxiety of the transition, to prepare for changing student roles, and to increase medical learning. Additionally, clerkship directors may wish to examine peer-to-peer handoffs to increase awareness of unintended consequences that expectations on their particular clerkship may raise. Greater awareness might prompt interventions that address characteristics inherent to that clerkship, such as to shift emphasis from a written exam towards clinical experience, or might trigger interventions that address more broadly applicable themes, such as to increase focus on patient care. Future work could explore differences between rotations by examining peer-to-peer handoffs in a more complete complement of third-year clerkships, at multiple rotation sites.
1. Holmboe E, Ginsburg S, Bernabeo E. The rotational approach to medical education: Time to confront our assumptions? Med Educ. 2011;45:69–80
2. Bernabeo EC, Holtman MC, Ginsburg S, Rosenbaum JR, Holmboe ES. Lost in transition: The experience and impact of frequent changes in the inpatient learning environment. Acad Med. 2011;86:591–598
3. van Hell EA, Kuks JB, Schönrock-Adema J, van Lohuizen MT, Cohen-Schotanus J. Transition to clinical training: Influence of pre-clinical knowledge and skills, and consequences for clinical performance. Med Educ. 2008;42:830–837
4. 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
5. 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
6. O’Brien BC, Poncelet AN. Transition to clerkship courses: Preparing students to enter the workplace. Acad Med. 2010;85:1862–1869
7. Turner SR, White J, Poth C, Rogers WT. Preparing students for clerkship: A resident shadowing program. Acad Med. 2012;87:1288–1291
8. Benbassat J. Undesirable features of the medical learning environment: A narrative review of the literature [published online July 4, 2012]. Adv Health Sci Educ. doi:10.1007/s10459-012-9389-5
9. Hafler JP, Ownby AR, Thompson BM, et al. Decoding the learning environment of medical education: A hidden curriculum perspective for faculty development. Acad Med. 2011;86:440–444
10. Foster S, Manser T. The effects of patient handoff characteristics on subsequent care: A systematic review and areas for future research. Acad Med. 2012;87:1105–1124
11. Chou CL, Johnston CB, Singh B, et al. A “safe space” for learning and reflection: One school’s design for continuity with a peer group across clinical clerkships. Acad Med. 2011;86:1560–1565
12. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qual Health Res. 2005;15:1277–1288
13. Haidet P, Kelly PA, Chou CCommunication, Curriculum, and Culture Study Group. . Characterizing the patient-centeredness of hidden curricula in medical schools: Development and validation of a new measure. Acad Med. 2005;80:44–50
14. Wear D, Skillicorn J. Hidden in plain sight: The formal, informal, and hidden curricula of a psychiatry clerkship. Acad Med. 2009;84:451–458
15. Hafferty FW. Beyond curriculum reform: Confronting medicine’s hidden curriculum. Acad Med. 1998;73:403–407
16. Lockspeiser TM, O’Sullivan P, Teherani A, Muller J. Understanding the experience of being taught by peers: The value of social and cognitive congruence. Adv Health Sci Educ Theory Pract. 2008;13:361–372
17. Ten Cate O, Durning S. Dimensions and psychology of peer teaching in medical education. Med Teach. 2007;29:546–552
18. Teunissen PW, Westerman M. Opportunity or threat: The ambiguity of the consequences of transitions in medical education. Med Educ. 2011;45:51–59
19. Teherani A, Irby DM, Loeser H. Outcomes of different clerkship models: Longitudinal integrated, hybrid, and block. Acad Med. 2013;88:35–43