Clerkships are the first immersive learning environments where medical students start transferring their classroom learning to the real world. Students have preclerkship clinical experiences with standardized patients or shadowing, but entering into clerkships is an exciting time for students because it marks the beginning of real-world learning to be a doctor. However, this transition requires them to undergo different learning experiences where they face considerable ambiguity and uncertainty.1,2 During this time students observe the practices, values, and norms of medical professionals in action. In addition, they are expected to “hit the ground running” by participating in low-risk tasks, taking initiative, and engaging in discussion about patient care. Successful adjustment to this real-place learning environment is not predicted by students’ preclinical knowledge and skills.3
Students’ learning in clerkship has been much studied to understand their professional identity formation and socialization.4,5Boys in White, the classic book on students’ socialization in medicine, depicts how medical students become socialized into the profession and the culture in medical training.6 Several recent studies shed additional light. Krupat and colleagues7 found that students tended to react positively to most clerkship events regardless of whether they were positive or negative. According to their findings, students perceived even negative events such as physicians’ poor behaviors as lessons learned, as those clerkship experiences also help them get a better sense of the system. O’Brien and colleagues8 reported that clerkship directors perceived students struggling with applying knowledge to clinical reasoning and engaging in self-directed learning, which students rarely recognized as struggles. Instead, they spent their energies struggling with uncertainty in their roles and responsibilities, expectations on their clinical performance, and the logistics of clinical settings.8 As those two studies indicated, students’ experiences in clerkships are characterized as socialization to get a better sense of the health care system and their roles as future doctors. These studies fit within the socialization literature, which focuses on students’ feelings and experiences in terms of professional identity formation. This avenue of study is less concerned with what students learn or expect to learn while on clerkships.
Thus, while students’ experiences in clerkships have been investigated, it is still not clear what students expect to learn, how they learn in clerkships, and what they actually learn. Therefore, the purpose of this study was to develop a more holistic understanding of medical students’ learning in clerkships by following students for the entire year of clerkship—specifically focusing on their learning expectations (what they expect to learn), learning process (how they learn), and learning outcomes (what they learn). To investigate these questions, we adopted the concept of legitimate peripheral participation in situated learning as an analytical lens to view students’ learning processes.9 In this view, students as newcomers learn through gradual participation in central tasks to become experienced members. Additionally, students’ social interactional processes of learning become the center of understanding of their learning experience rather than independent learning. Socialization, visualization, and imitation processes within the context of a community of practice help medical students to contextualize and apply the more abstract and decontextualized knowledge learned in previous years.
We used a longitudinal qualitative approach as the research design. A longitudinal approach is fundamental to investigate students’ entire experience of the clerkship year. We followed the study participants across their entire clerkship year (2011–2012), which entailed three in-depth interviews and one daylong observation for each participant. Given the students’ significant commitment to this study for one year, we provided the participants with compensation ($100) for their participation. The institutional review board at Southern Illinois University School of Medicine deemed this study exempt.
Setting and participants
The study setting was at the Southern Illinois University School of Medicine, which uses a problem-based learning curriculum in the first two years to teach basic sciences and clinical knowledge. Clinical faculty come from a school-based multispecialty practice, a community-based multispecialty practice, and various family medicine clinics in the area. The school is affiliated with two hospitals. In the third year, students have six clerkship rotations: internal medicine; surgery; psychiatry; pediatric; family and community medicine; and obstetrics–gynecology (OB/GYN). In the fourth year, students have additional clerkships including neurology, electives, and residency planning activities. We invited all 78 third-year medical students to participate, and 12 students voluntarily participated in this study. Since two of us have been involved in the curriculum at the school, we were confident that the participants represented the class appropriately in terms of high, mid, and low academic performance. Further, the participants were ethnically diverse, though in the interest of maintaining confidentiality we do not report the ethnicity of the participants.
The interviews were semistructured. We based interview protocols on the research questions and previous studies of the experiences of students transitioning from school to work.10 As seen in Appendix 1, preclerkship interviews investigated students’ prior health professional experiences, learning expectations, and concerns about clerkships. Midclerkship interviews covered four major areas: comparing actual experience with expectations, applying medical knowledge to practice, interpersonal interactions, and learning the norms of practice. Postclerkship interviews elaborated on the previous two interviews and captured the students’ reflections on their experiences in terms of learning outcomes. We conducted preclerkship interviews after the second year and before the first day of clerkships (June–July 2011). Midclerkship interviews were in middle of their third year (November 2011–January 2012); therefore, the students were in various clerkships when they had the midclerkship interview. As the students completed their third year, we invited them to the postclerkship interview (June–July 2012).
Generally, interviews were conducted by all three of us. One researcher followed the interview protocol, and the others asked questions to elaborate and probe students’ responses in-depth using the critical incidents technique.11–13 Using this interviewing technique, we asked students to recall a specific incident in which they described their experience in clerkships. For instance, students were asked to recall a specific time when they felt they were included in patient care activities. We recorded and transcribed all interviews for analysis. After each interview, we discussed new and reoccurring insights from the interview. Through the discussions, we agreed that the data collection was reaching the saturated level as no new information was appearing from the 11th or 12th interviews.14
Additionally, with permission from students and their clerkship at the time of the midclerkship interview, we observed all participants except one student through a full day of their clerkship experience and developed a set of field notes to augment the data sources. One of us followed a student from the start to the end of a clerkship day—for instance, from 6 AM to 5 PM. The observations were spread out throughout the clerkship year, from September 2011 to June 2012. All three of us collaboratively completed 11 observations since 1 observation did not happen because of a logistic issue. There was no standardized field note form; we recorded the key activities and interactions, along with contextual details by taking detailed notes.
We analyzed the transcriptions using grounded theory methods.15,16 Grounded theory is a qualitative research approach that aims to construct a substantive theory from the concepts and themes that emerge from data through an inductive procedure.17,18 This method emphasizes constant comparison of data, which entails testing emerging themes by comparing them with the original data across all interviews.16 With the research questions as a guide, all three of us carefully read the transcripts and attached initial, descriptive codes to statements; retrieved statements having the same descriptive codes and carefully reread the retrieved statements for open coding; and categorized the open codes to identify themes that emerged through a constant comparative process across the data.
The coding process started with two calibrating meetings to discuss coding rules and process to enhance interrater agreement in the coding process. In addition, we all coded seven transcripts together. These “calibration” meetings took place throughout the analysis, thus promoting a high level of agreement about how we coded and analyzed the transcripts. Each transcript took approximately two hours to code. Therefore, we spent approximately 14 hours improving our interrater agreement. The other 29 transcripts were divided and assigned to each researcher, who coded transcripts independently. We used a qualitative data analysis software, Atlas.ti version 7 (Berlin, Germany: ATLAS.ti GmbH) to help manage the coding and analysis processes. Open coding of all transcripts yielded 2,027 codes, which we analyzed and categorized into themes through density (number of times a code was used in analysis) and groundedness (degree to which the code is related to other codes). We also used the field notes to check the results during the constant comparative data analysis. In this way, the field notes were used as a way to triangulate the data analysis and interpretation of findings.
Of 78 eligible students, 12 voluntarily participated in this study. Seven students were female. Each participant completed all three interviews. Eleven observations were conducted since one observation did not happen because of a logistic issue. Table 1 summarizes our findings related to the research questions, including illustrative comments from students’ interviews.
Learning expectations (preclerkship)
Before students started their clerkship rotations, they were generally excited to learn in real-world settings, yet they seldom came up with specific learning expectations. In fact, most students wondered if they should have learning expectations. Participants generally seemed to feel that they would be passive recipients of an already-created curriculum. With more in-depth probing questions, they came up with what they would like to learn in clerkships and how they envisioned the clerkship learning. Below are several themes that emerged from our analyses of their preclerkship interviews.
The students wanted to have hands-on experiences throughout their clerkship experiences. All participating students had had some prior health care experience including shadowing, volunteering in health care settings, medical mission trips, or social work prior to becoming a medical student. Some of them had family members who were doctors. They were familiar with the health care profession and environments at some level. Therefore, they believed that simple shadowing would be neither exciting nor helpful for their clerkship learning. While they understood that some level of shadowing and observation would occur, they expected to learn through actual hands-on experiences.
Realistic learning to become a real doctor.
Students expected their clerkship experiences to provide realistic learning. Students were excited about clerkships because they expected to be in real settings with real doctors. The students expected to learn by seeing real patients and being in real clinical settings. They had previously been in clinical settings through their shadowing or volunteering works before becoming a medical student; however, at that time their experience of being in a clinical setting was not necessarily as a doctor-in-training. During clerkships, they expected a more solid and professional role. They were no longer going to be “shadows” at the margins of the activity, but expected to be part of the care team. Anticipation of being an insider, of learning the inner workings of the hospitals and clinics, excited students as they looked forward to their clerkships.
Textbook learning translated into real-world practice.
The students expected their clerkship experiences to allow them to translate their book knowledge into actual clinical practice. The students wanted to see how diseases appeared in real patient cases. They acknowledged that there probably is a discrepancy between textbook learning and real-world practice. For example, they were told that a drug that they learned about in class would not be used in the clinical setting. The students wanted to learn what drugs physicians actually use and how diseases are treated in practice. Whereas they recently completed learning about diseases and health care more abstractly through textbooks and classroom learning, in clerkships they expected to learn more about how this knowledge was applied in practice.
Being more knowledgeable.
Students envisioned themselves becoming more knowledgeable through the opportunities to practice their clinical reasoning by applying their knowledge to real patient cases. Students wanted to have the opportunities to think through actual patient cases and arrive at diagnoses just like practicing doctors do.
Deciding on a specialty.
Given that all the students had prior health care experiences, some of them had an overall idea regarding what specialty they would pursue. However, they were still open to changing their minds because they had not been exposed to all specialties. They expected to learn more about a variety of specialties so that they could make a more informed choice about their careers.
Learning process (midclerkship)
With great excitement, students started their clerkship rotations. Some students started long clerkships (10 weeks) including surgery and internal medicine while the other students started short clerkships (6 weeks) including pediatrics, OB/GYN, psychiatry, and family community medicine. Below are students’ experiences gathered midway through their clerkships in relation to how they learn.
Students reported that during the clerkship they learned to navigate different clinical and social/professional environments. Students experienced a higher level of uncertainty and ambiguity in the hospitals and clinics than they expected, and therefore they often reported spending time figuring out what to do, how to do it, where to be, and why things were done the way they were. They found that the attendings created their learning environments. Different attendings had different styles of teaching, expectations, and evaluation criteria. These idiosyncrasies made the students’ learning processes highly uncertain and ambiguous. Many also believed that these idiosyncrasies made their evaluations more subjective than they expected. Therefore, it was a crucial process for students to figure out each attending physician’s expectations and preferences. Moreover, because students were assigned to different attendings almost every week in a clerkship, the navigation associated with determining expectations was a constant activity in their learning processes.
Learning by doing through impression management.
As they expected, students learned by doing. Typically, they were assigned patients to see in every rotation. By seeing patients or being allowed to do simple procedural tasks, students felt that they were recognized and invited to be part of the health care team. There were also moments where students took initiative to do things because invitations were sometimes unclear or not explicit.
Students reported that an important part of their learning process required them to manage impressions. Students realized that how they were perceived by others (especially first impressions) directly affected their learning opportunities. One of the useful tips shared among students included the various preferences of different attendings, to which they needed to adapt. Students also realized that asking questions was an important way to demonstrate that they were interested, smart, and prepared for whatever the attending would ask them to do. However, students believed that asking a question perceived as “stupid” or demonstrating little knowledge or interest was perilous to their success because attendings would perceive them as neither smart nor prepared for some clinical work, which would affect subsequent evaluations. When asked a question, students felt that they needed to answer the question. Otherwise, they would create a poor impression. If seen in a positive way, students felt that attendings would trust and invite them to practice and allow them to be more involved in the patient care process. Students felt that they were being evaluated all the time and that, by managing impressions, students could receive better evaluations and earn more experiential learning opportunities.
Students’ awareness of impression management also governed their learning relationships when on a rotation in a specialty that did not interest them. On these clerkships, students had to balance the energy needed to appear to be interested with the energy they needed to study for board examinations and topics of more interest to them.
Balancing between clinical work and studying.
Students felt that they needed to be better at time management. They found that it is not easy to be present on the floor and still find time to study for the shelf examinations that culminated the clerkship. Students spoke of carrying review materials with them so that they could study during downtime. An important task was to find an appropriate place to study in each rotation where they could still be seen as available and not accused of “disappearing” and thus forced to the sidelines or assigned tasks of little importance. Some clerkships were structured to allow for time to study. In psychiatry, for example, students had relatively short days in hospitals and clinics. Students were relieved to have time allocated for studying because this was an important part of the program.
Learning outcomes (postclerkship)
After they finished their six clerkships, we asked participating students what they felt they had learned, if their confidence changed, and if so, in what ways. Further, the questions targeted their initial learning expectations to see if their expectations were met. Below are several themes that emerged from the postclerkship interviews.
Confidence increased in interactions.
Students reported that their overall confidence increased after the clerkship experiences. Specifically, students described far more confidence in interacting with patients, residents, attendings, and staff in hospitals and clinics than they had before their clerkships. They also felt more comfortable conducting real patient encounters. They felt that they had learned to manage their relationships with residents, attendings, and staff effectively. Further, they felt more comfortable with navigating the health care environment having developed a better understanding of how things work in hospitals and clinics, including a greater awareness of the norms that guide behaviors and work processes.
Limited opportunities to practice diagnostic thinking.
Whereas students had expected to become more skilled at applying medical knowledge to clinical work and coming up with differential diagnoses and plans for patient cases, they perceived that there were far too few opportunities for them to practice or observe comprehensive diagnostic thinking. Students could come up with their own diagnoses as they saw patients; however, their hypotheses and diagnostic thinking were neither heard nor coached by attendings or residents on a regular basis. Students perceived that their knowledge was still rather superficial. Students felt comfortable with simple cases yet not very confident in reasoning through the complex cases they encountered.
In the hospital setting, diagnoses and plans were often decided even before students saw the patients. For example, the surgical decision-making process was not easily visible to clerkship students because they were not necessarily in the clinic with the surgeon on the day the decision to operate was made. Students reported that learning diagnostic thinking did not happen as much as they hoped because of attendings’ busy work schedules and students’ limited responsibility in patient care.
Decisions about specialty.
Prior to the clerkship experiences, most participating students had some ideas regarding what specialty they would be interested in based on their prior experiences. After the clerkship year, students came to a better understanding about what specialty they would pursue. Several students described a type of “decision tree” to explain how they decided on their specialties. For example: “Do you like procedures? If yes, then Surgery or OB. If you like babies, OB. If not, some aspect of Surgery. If you don’t like procedures, do you like variety? If yes, then Family Medicine. Do you like puzzles and thinking? If yes, then Internal Medicine.” Students also found that having a good relationship with an attending who drew them into the practice was helpful in guiding their choice on a specialty.
On the basis of longitudinal interviews with 12 medical students across a year of clerkships, we found that participants’ learning in clerkships occurs within the context of dynamic social and reciprocal relationships between students and attendings or residents. Students earn learning opportunities through building trust, which is achieved through impression management. Impression management is an important yet unwritten norm in clerkships because attendings’ evaluation and teaching style are characterized by ambiguity and subjectivity.19,20 It is the learner’s responsibility to determine, on a person-by-person, place-by-place basis, what the parameters of acceptable performance are. Beagan21 found that medical students learn to not challenge clinicians, further suggesting that if students do not appear to be compliant they will have poor evaluations, which will affect their future careers. Consistent with Beagan’s findings,21 we found that the process of impression management explains the dynamic, reciprocal relationships enacted between students and attendings.22,23 When students represent themselves in positive ways (i.e., impression management), teachers including attendings and residents are more inclined to trust them, teach more, and evaluate them positively. A recent study reported that students had higher expectations of their own skill development than clinical faculty had.24 This finding may be related to students’ desire to impress faculty so that they “earn” learning opportunities.
A surprising finding of this study is that there exists a gap between students’ learning expectations and their actual learning experience in terms of learning clinical reasoning in clerkships. Being able to think through a patient case using medical knowledge to come up with a differential diagnosis, assessment, and plan is one of the core objectives of medical training. One of the overall objectives for the third-year clerkship curriculum in general is to prioritize patients’ problems, formulate appropriate differential diagnoses, and develop plans for diagnosis and management. However, most of our participating students reported that they did not learn clinical reasoning skills as expected in the clerkship environment. Expert physicians’ diagnostic thinking was not easily visible to students during clinical work in hospitals and clinics. Students reported few opportunities to practice comprehensive diagnostic thinking in their clerkships. Audétat and colleagues25 recently reported that clinical educators themselves had little training in clinical reasoning and perceived their role as role modeling rather than systematic teaching to developing clinical reasoning. The literature indicates that it is the learners’ responsibility to assimilate the experts’ clinical reasoning skills. However, as our findings support, the role modeling for clinical reasoning is marginally effective and not visible to medical students in clerkships.
This gap between expectations and actual outcomes of clerkship learning regarding clinical reasoning is surprising, yet it has been documented previously. Williams and colleagues26 reported that the clinical reasoning ability of students from five medical schools did not increase during third-year clerkships despite significant improvement in years one and two. As Prince and colleagues27 found, one may argue that students have difficulty in applying medical knowledge to real clinical practice because they do not have sufficient basic science knowledge. However, it is also reasonable to assume that medical students come to the third-year clerkships with an expectation to develop clinical reasoning skills and knowledge through guided practices and applications to clinical practice in real health care places. They expected to engage in legitimate peripheral participation, with their skills and abilities honed through the mentoring and coaching of experts. However, both the prior literature and our findings indicate that this expectation is not met in clerkships.
This study has two limitations. First, the study setting included only one medical school. Schools with different clerkship curricula or with a different student population may have different findings. Second, student participation was voluntary; therefore, the group may not represent the entire student population. However, the students who volunteered represented a wide range of achievement and were ethnically diverse.
Further studies are warranted to discern the barriers that prevent students from learning diagnostic thinking within the clerkship environment. While it is of pressing concern to clerkship directors and medical school faculty, the sources of the problem are likely multiple.8,25 For instance, there may be little focused time for teaching diagnosis and planning, or little direct contact between learner and teacher in environments where the expert can model his or her approach, and little time to allow the learner to practice with guidance. Given that coming up with diagnoses and plans is the real job of a physician and the objective of medical training, it is imperative to determine the environmental, professional, and social barriers to the modeling and explicit teaching that would convey these skills. Further, it will be important to assess to what degree the ambiguity and constant change (environment and teacher) interfere with students’ learning.
Acknowledgments: The authors are grateful to the students for their time and thoughtful contributions to this study. The authors also thank the clerkship directors, physicians, residents, staff, and others that allowed the observation of their work.
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