Transition points in medical education can be abrupt, stressful, and disorienting for learners.1,2 Such transitions can affect learners’ professional identity formation and may lead to adverse patient care outcomes.3 After medical school matriculation, the first transition point for students is the move from the preclinical curriculum to clinical clerkships. During this transition, students experience a rapid shift in their responsibilities, methods of learning, and lifestyle while simultaneously having to learn how to cope with disease and death in practice.2
Academic performance also can pose a challenge during this transition. As novices, students typically perform worse on both knowledge-based and clinical assessments that take place early in their training compared with those that occur later.4 While this outcome may be anticipated, clerkship grades are a major driver of a successful residency match,5 and thus performance during this phase of training may have significant consequences for learners.
Proposed solutions to improve the transition from the preclinical curriculum to clinical clerkships include grading on a “curve”4 and offering a transition-to-clerkship course (TTCC).6 Grading on a curve provides a mathematical solution to accommodate learners’ deficits by adjusting expectations throughout the academic year. However, this practice does not improve learners’ actual performance and may limit educators’ ability to assess learners’ progression over time. By comparison, TTCCs are designed to promote learners’ development by explicitly providing them with educational resources to succeed in the clinical environment. While TTCCs have been well described, outcomes data are lacking. Poncelet and O’Brien suggested that medical schools evaluate students’ performance early in clerkships to gauge the impact of TTCCs.6
At the Virginia Commonwealth University School of Medicine (VCU-SOM), we developed a TTCC to improve the transition to the clinical phase of our curriculum. Here, we describe the development of this course and its impact on students’ clerkship performance.
Before 2013, between the preclinical (2 years) and clinical (2 years) phases of the curriculum, all students at VCU-SOM completed a 1-week clinical orientation. This orientation covered required hospital tasks, workshops related to procedures (e.g., scrubbing technique), and guidance on expectations (e.g., grading) for clerkships.
During the 2013–2014 academic year, a comprehensive curriculum reform effort resulted in a consolidated preclinical phase (18 months) and an opportunity for reforming the clinical phase. Following a general and targeted needs assessment, a work group of key stakeholders, including medical students, determined that an ideal approach to improving education transitions was to add intersessions for students as they moved from the preclinical curriculum to clerkships and from medical school to residency. The 2-week TTCC was developed to assist with the transition to clerkships.
We designed the TTCC using Kern and colleagues’ approach to curriculum development as a guiding framework.7 Leaders from the dean’s office (M.S.R.) and simulation center faculty (C.B., E.B., C.G.) coordinated its development and implementation. Members of the dean’s office (M.S.R.), simulation center (C.B., E.B., C.G.), clerkships, and medical student government collaborated to recruit faculty to participate. See Table 1 for a summary of the steps used to develop the TTCC.
During the preclinical phase of the curriculum, direct patient care training is focused on the primary care setting. By comparison, the clinical phase focuses on acute care provided in an inpatient setting. Therefore, the TTCC needed to bridge the gap between general doctoring concepts (e.g., history taking) and the knowledge, skills, and attitudes required to care for patients throughout a hospitalization.
We developed learning objectives and educational strategies using Bloom’s taxonomy8 and Kolb’s learning cycle9; foundational material would be introduced first in the TTCC, with experiential learning opportunities provided later. The resulting course incorporated elements from the existing clerkship orientation and added panel discussions, skills development sessions, and interactive case-based workshops. The TTCC leadership team added a simulation-based component the following year. See Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/A729 for a summary of the curricular elements of the TTCC. Further descriptions of the main components are provided below.
One faculty facilitator (M.S.R.) developed and led each of 2 case-based workshops. The goal of these workshops was to introduce students to concepts that they would need to apply during the subsequent simulation and during clerkships. Students were assigned to small groups of 6 for each workshop. The first workshop introduced students to methods for obtaining a focused history and physical examination, order entry, and disposition determination. The second workshop provided guidance on crafting oral presentations. The content was organized around a typical hospital course for a patient (i.e., presentation through discharge). Large-group facilitated discussions were integrated throughout the workshops.
This component took place in the simulation center. A large-group prebrief occurred before the first simulation. A 4-stage, 2-hour simulation followed. Each stage included two 15-minute components: a standardized patient (SP) encounter followed by a faculty-facilitated debrief session. A faculty facilitator provided students with instructions before each stage and led the group debrief. A faculty facilitator and SP were assigned to groups of 4 students for the entire session. Faculty were recruited from VCU-SOM and were given an orientation and a facilitator’s guide, which provided discussion questions for each stage.
Four simulation cases were developed, each spanning 4 stages of a hospitalization: (1) presentation to the emergency room, (2) admission to the hospital floor, (3) decompensation event, and (4) discharge. Students were assigned specific roles for each stage. See Figure 1 for a schematic of the key tasks in the simulation with an illustrative example and Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/A729 for further details.
Implementation and evaluation
We introduced the components of the TTCC over a 2-year period. The panel discussions, skills development sessions, and case-based workshops were implemented during the 2014–2015 academic year. The ward simulation was added during the 2015–2016 academic year. We assessed the feasibility of designing and implementing the TTCC and students’ reactions and clerkship performance to determine its impact. This work was deemed exempt from ethical review by the VCU institutional review board.
Overall, the TTCC provided a feasible, well-received, and effective method for improving the transition from the preclinical to the clinical phase of training. When compared with those who completed the standard curriculum, students who received the TTCC with the simulation performed nearly 2 points better on their first clerkship evaluations and significantly better across all clerkships.
The panel discussions and skills development sessions were led by students and developed with members of the medical student government. The costs for the simulation were approximately $3,500 for 162 SP hours including training and conduct of the cases. An estimated 100 faculty hours were required for the debriefing and training. The simulation center ran 4 to 5 cases at a time over 5 half days.
To measure students’ reactions, we administered 2 surveys: one immediately following the simulation and one 3 weeks after the start of clerkships. See Supplemental Digital Appendices 3 and 4 at https://links.lww.com/ACADMED/A729 for copies of the survey instruments. The postsimulation survey contained 17 items that assessed students’ perspectives on their preparedness for clerkships and the value/quality of the simulation. Overall, students reported that the simulation seemed realistic, provided opportunities to understand continuity of care and develop teamwork skills, and resulted in improved confidence.
The post-TTCC survey contained 1 item for each element of the course and used a 5-point Likert scale (1 = poor to 5 = excellent). The highest-rated elements were the interactive activities such as the ward simulation (mean = 4.7, SD = 0.63) and the case-based workshops (first workshop: mean = 4.5, SD = 0.74; second workshop: mean = 4.5, SD = 0.65) as well as the examination preparation (mean = 4.7, SD = 0.63) and grading (mean = 4.6, SD = 0.66) sessions.
We measured the impact of the TTCC on students’ performance by comparing summative clinical performance evaluations for students from 3 different groups: (1) Group 1 received the standard curriculum in 2013–2014 (standard), (2) Group 2 received the first iteration of the TTCC in 2014–2015 (TTCC), and (3) Group 3 received the second iteration of the TTCC with the ward simulation in 2015–2016 (TTCC + simulation).
For each group, we collected data on students who completed at least the first 6 of 8 core clerkships within a given academic year. Students who completed fewer than 6 clerkships were excluded because they often participated in more than one orientation. Similarly, we did not require that students complete all 8 clerkships because that would have excluded students who struggled in their clerkships. For these reasons, 30 students in the standard group, 38 in the TTCC group, and 31 in the TTCC + simulation group were excluded from our analysis. Our final analysis included 157 students (71 [45.2%] female) in the standard group, 152 students (64 [42.1%] female) in the TTCC group, and 162 students (71 [43.8%] female) in the TTCC + simulation group.
To account for the timing of each clerkship, we converted students’ actual clerkship schedules (i.e., internal medicine, pediatrics, psychiatry, etc.) to clerkship numbers (i.e., clerkship 1, 2, 3, etc.) based on the order in which the student completed each one. Doing so allowed us to compare performance in all students’ first clerkships (clerkship 1) regardless of specialty.
From 2013 to 2016, all clerkship final grades were calculated using the same combination of knowledge (i.e., examinations) and performance (i.e., clinical assessment) measures. Since we were concerned with students’ clinical performance, we considered only the performance measures, not the knowledge measures or grades. We converted the numerical scores from the performance measures to a standard score (mean = 50, SD = 10) to assist in interpretation.
We used a repeated measures analysis of covariance to test for differences in performance between groups. After controlling for United States Medical Licensing Examination Step 1 scores, a significant between-subjects main effect was found (F [2,148] = 3.30, P = .04, eta2 = 0.02), indicating a small effect of intervention on performance across clerkships. We also performed post hoc tests using the Bonferroni correction to test for differences in mean performance scores for each group. There were statistically significant differences in performance across clerkships (P < .001–.04, Cohen’s d range = 0.23–0.62) for students in the TTCC + simulation group compared with those in the standard group. For students in the TTCC group compared with those in the standard group, there was only a statistically significant difference in performance in clerkships 1 (P = .02, Cohen’s d = 0.27) and 5 (P = .004, Cohen’s d = 0.33). For students in the TTCC group compared with those in the TTCC + simulation group, there was only a statistically significant difference in performance in clerkships 2 (P < .001, Cohen’s d = 0.40), 3 (P = .006, Cohen’s d = 0.31), and 4 (P < .001, Cohen’s d = 0.42). All other comparisons were not statistically significant. See Figure 2 for a summary of the mean performance scores across all 3 groups.
While the TTCC required significant indirect costs (e.g., faculty time) and few direct costs (e.g., $3,500 for the SPs) to design and implement, it resulted in a substantial improvement in closing the gap between students’ preclinical training and their clinical performance. In addition, we believe that it is preferable to grading on a curve4 to level the playing field for students and improve their overall performance throughout the clinical phase of training. Thus, we have continued to offer the TTCC for each subsequent class of medical students with small modifications. For example, to assist in the recruitment of faculty facilitators, we expanded the pool to include chief residents and fellows. Next steps include evaluating the TTCC to determine its impact on student well-being throughout their clerkships.
One potential limitation of our findings is that students’ clerkship performance may have been affected by reforms to the preclinical curriculum rather than by the TTCC alone. However, we think that this is unlikely since the length of the preclinical phase was reduced and no inpatient training was incorporated into this phase. An additional limitation is that the TTCC was implemented at a single institution. Further study is required to determine if it would have a similar impact at other institutions.
While our initial efforts to improve students’ preparedness for the clinical phase of the curriculum were focused on the development and implementation of the TTCC, we have since reflected on the limitations of interventions implemented only at a transition point. Across the continuum of medical education, transition courses (e.g., capstone courses, boot camps) are a common model for improving learners’ readiness for the next stage of training.10 However, the optimal intervention also may require reconfiguration of the preceding phase of the curriculum. We are currently working to introduce more of the TTCC elements into the preclinical phase to further improve students’ transition to clerkships.
The authors would like to thank Sally Santen, MD, PhD, for critically reviewing an earlier version of this article.
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