|ORIGINAL RESEARCH PAPER
|Year : 2008 | Volume
| Issue : 3 | Page : 192
Easing the Transition: Medical Students' Perceptions of Critical Skills Required for the Clerkships
RM Small, RP Soriano, M Chietero, J Quintana, V Parkas, J Koestler
Department of Medical Education, Mount Sinai School of Medicine, New York, USA
|Date of Submission||02-Apr-2008|
|Date of Acceptance||11-Oct-2008|
|Date of Web Publication||18-Dec-2008|
R M Small
50 East 98th St, #14E
Source of Support: None, Conflict of Interest: None
Objectives: The preclinical years of undergraduate medical education provide educational content in a structured learning environment whereas clerkships provide clinical training in a more experiential manner. Although early clinical skills training is emphasized in many medical schools, students still feel unprepared and anxious about starting their clerkships. This study identifies the skills medical students perceive as essential and those skill areas students are most anxious about prior to starting clerkship rotations.
Methods: Open-ended questionnaires were administered to two cohorts of students, preclinical students (PCS) completing their second year and clinical students (CS) in the ninth month of the clinical training of their third year at a single urban US medical school. The following questions were addressed in the survey: which three clinical skills do they perceive are most essential for the clerkships; which skills are students most anxious about as they enter clerkships; and what additional skills training should be provided to students to ease the transition into clerkships.
Results: Response rate to the questionnaire was 84%. PCS (n=93) reported the three most essential skills to be prepared for clerkships are: history taking/physical examination (73%), proficiency in oral case presentations (56%), and generation of differential diagnosis (46%). CS (n=105) reported interpersonal skills (80%), history taking/physical examination (37%), and time management (26%) as most essential. PCS were most anxious about their oral case presentation skills (30%), but CS were most concerned about time management and self care (40%).
Conclusions: This study identified the skills that students at one school regard as most important to have mastered before beginning clerkship training and the areas students find most anxiety provoking before and after they make the transition into clerkships. These results can inform medical educators about needed curriculum to facilitate this transition and decrease the anxiety of students entering the clinical realm.
Clerkships, clinical skills, medical students, transition
|How to cite this article:|
Small R M, Soriano R P, Chietero M, Quintana J, Parkas V, Koestler J. Easing the Transition: Medical Students' Perceptions of Critical Skills Required for the Clerkships. Educ Health 2008;21:192
|How to cite this URL:|
Small R M, Soriano R P, Chietero M, Quintana J, Parkas V, Koestler J. Easing the Transition: Medical Students' Perceptions of Critical Skills Required for the Clerkships. Educ Health [serial online] 2008 [cited 2021 Apr 19];21:192. Available from: https://www.educationforhealth.net/text.asp?2008/21/3/192/101548
Training medical students to provide patient care requires that they gain competency in core clinical skills. These skills include proficiency in history taking and physical examination, oral and written communication, clinical procedures, basic radiology, evidenced-based medicine, and professionalism (Windish, 2000; Chumley et al, 2005). The foundation for these skills is provided during what generally is termed the "preclinical curriculum" and solidified during the clerkship years prior to postgraduate (residency) training. Preclinical training generally provides educational content in a structured, classroom learning environment, whereas the clinical years provide hands-on clinical experiences in various patient care sites, predominantly in hospital-based settings in a less structured and more experiential manner.
The transition students face moving from the preclinical to the clinical setting is extraordinarily stressful (Alexander & Haldane, 1979; Prince et al., 2005); students feel anxious and unprepared for this transition. The stress that students experience relates to the sharp differences in the learning environments, teaching styles, workload, and performance expectations between the preclinical and clinical arenas (Radcliffe & Lester, 2003). Prince et al. (2005) further describe this transitional period as one of required "professional socialization," which involves the students' "gradual assimilation of the values and attitudes of the medical profession." Students must adjust to being a member of a medical team, often in an uncertain role, while simultaneously caring for patients and acclimating to longer work hours and a more demanding schedule than experienced in their preclinical years (Prince et al., 2005). Students oftentimes find it difficult to balance the increased workload with required study time (Prince et al., 2000).
In order to ease this transition, many medical schools teach data gathering (medical interview and physical examination) and communication/interpersonal skills during the preclinical years. Some schools have added problem-based learning (PBL) courses to the preclinical curriculum to help students integrate their basic science knowledge with diagnostic and clinical reasoning skills early in their training (Newble & Clarke, 1986). Despite these efforts to prepare preclinical students for clerkships many students remain anxious.
In this study, we sought to identify the skills that students at one US medical school believe are essential for clerkships and the anxieties students have about starting clinical training. Responses from students in two medical school class years, one at a preclinical stage and the other at a clinical stage, were assessed to compare how student expectations of necessary skills and their anxieties change from before to after they make the transition. We also relate students´┐Ż anxieties to the amount of curricular time this school devotes to various topics.
Curriculum Description and Setting: This study was carried out in a large urban academic medical center in the United States. This institution has a traditional, non-PBL, Flexnarian curriculum, with basic science study in years one and two, and clinical exposures in years three and four. Core clinical skill preparation is addressed in three preclinical courses, the Art & Science of Medicine (ASM) and the Clinical Skills course. ASM is a two-year course that provides first and second year medical students with the core knowledge, skills, and professional attitudes essential to provide patient-centered care in a humanistic manner. Students learn to gather accurate clinical information through the medical interview, physical examination, and chart review; accurately communicate information both orally and in writing; and function as an ethical and professional team member. In addition to small group skill workshops and weekly patient encounters in the hospital, simulated patients are used during these first two years to assess student skill progress (Table 1).
Table 1: Curricular Time Spent on Clinical Skills in Medical School Years 1 & 2
Clinical Skills Week (CSW) is a four-day required course for rising third year students prior to their first clerkship. During this course clinical skills learned in the first two years are reviewed and students receive additional training in procedural skills, note writing, evidenced-based practice, communication skills, and medical error avoidance.
Clerkship training begins in year three and is offered in a block schedule with rotations in the following disciplines: Medicine/Geriatrics, Surgery/Anesthesia, Pediatrics/Obstetrics & Gynecology, and Neurology/Psychiatry/Family Medicine (Figure 1).
Figure 1: Curriculum & Survey Administration
Subjects: Two cohorts of students comprised the targeted population: (1) preclinical students (PCS, n=121) at the end of second year in the graduating class of 2008 and (2) clinical students (CS, n=116) in the ninth month of the third year in the graduating class of 2007. All students of these two classes were invited to complete questionnaires.
Data collection: We created a self-administered questionnaire that asked for open-ended responses to the following three questions: (1) What three clinical skills are essential for third year? (2) What is most anxiety provoking prior to beginning third year? and (3) What additional skill training would ease the transition between the preclinical and clinical years?
Paper questionnaires were handed to PCS during the last session of ASM at the end of their second year before the start of clinical skills week. The questionnaire was administered to CS as part of a required online evaluation at the end of the third year. Student responses to the questionnaire were anonymous.
Analysis: Student responses were coded into themes developed by the research group based on an initial read of the data. Two reviewers independently coded all responses, settling coding differences through consensus. Coded responses from the two cohorts were compared using a two-tailed Fischer Exact Test and evaluated for statistical differences based on a 95% confidence interval. (Calculations were made using http://www.statpages.org/ctab2x2.html.) The study was given exempt status by the institutions' IRB.
Of the 237 total students surveyed, 198 (83.5%) completed the questionnaire. Seventy-seven percent (n=93) of PCS and 90% (n=105) of CS responded.
Essential Skills Before Starting Third Year
The responses from the two cohorts differed. While PCS most often responded that history/physical examination (73%), oral case presentations (56%), and differential diagnosis generation (46%) were essential skills, CS most often reported that interpersonal skills (80%), history/physical examination (37%), and time management/ self care (26%) were essential (Table 2). In addition, significantly more PCS than CS stated that history/physical examination (73% v 37%; p< 0.05), oral case presentations (56% v 16%; p < 0.05) and differential diagnosis generation (46% v 10%; p<0.05) were essential. In contrast, more CS than PCS indicated that interpersonal skills (80% v 15%; p<0.05), knowledge of the student role in the hierarchy system (15% v 5%; p<0.05), and time management/self care (26% v 4%; p<0.05) were essential.
Table 2: Skills Students Perceive as Necessary Before Starting Clinical Clerkships
Most Anxiety Provoking Before Starting Third Year
Issues causing anxieties for students were similar in both cohorts and included time management/self care, medical knowledge and the student role in the hierarchy system (Table 3). PCS were more concerned about giving oral case presentations (30% v 6%; p<0.05) in their clerkships than CS, who recall being most anxious about time management/self care (40% v 25%; p<0.05).
Table 3: Areas Reported as Provoking Most Anxiety in Students Prior to Beginning Clinical Clerkships
Suggested Interventions to Ease the Transition into Third Year
PCS suggested that additional review addressing how to generate differential diagnoses and clinical reasoning would ease the transition into the clinical years (Table 4). Preclinical students also indicated that they would benefit from additional review and practice in history taking, performing physical examinations, note writing and presenting cases orally before beginning clerkships. When CS were asked about skills that would have eased their transition to third year clerkships, one quarter reported feeling well prepared through the current preclinical training and did not offer any suggestions for changes. In addition to the curricular areas shown in Table 4, the CS cohort suggested scheduling sessions with senior medical students who could, through their experience, provide advice on specific specialty rotations.
Table 4: Additional Curricular Content Suggested by Medical Students to Ease the Transition from the Preclinical to Clinical Years
Preparing students to transition to the clinical training environment of clerkships continues to challenge educators. Even when students are provided early contact with patients and early clinical skills training, they still struggle with this transition (Prince et al., 2000; Van Gessel et al., 2003; Prince et al., 2005). Preclinical students at our institution believe it is essential to have mastered basic clinical data gathering, clinical reasoning skills, and team communication. Having experienced the transition, the clinical student cohort had come to also recognize the importance of interpersonal skills and time management. Issues causing anxieties were generally similar for the two student groups; however, time management and self care issues caused more anxiety for students who had experienced the rushed pace of learning in the clinical setting, while the concern over oral case presentations lessoned with experience and practice.
There are a number of ways to understand these findings. The nature of the transition itself, from structured classroom teaching to the self-directed environment of the clerkships, may explain the differences in anxieties between the two cohorts. The perceptions of our PCS stem from what they have been taught in the formal curriculum: history taking and physical examination, differential diagnosis, oral presentation, and clinical assessments based on defined parameters. On the other hand, perception of CS are likely influenced by their experiences in the clinical setting including their own professional socialization and clinical contacts on the wards. While at least 12 course hours were devoted to teaching and refining oral presentation skills prior to the clerkships, we find that our PCS still harbor significantly more anxiety than CS about preparation in this area. This suggests a disconnect between the actual skill development in the preclinical years and the experience of students on the wards. Perhaps students worry about how they will "perform" before their peers and instructors and this fear can only be overcome with practice.
CS more often than PCS reported anxieties related to time management and self care. Our students and those of several prior studies indicate that medical students often feel useless and unable to contribute in a meaningful way to patient care for many reasons, including a perceived insufficient knowledge and uncertainty of the student role on the hospital wards (Gordon et al, 2000; Radcliffe & Lester, 2003; O'Brien et al., 2007). Students in our study school may need more formal instruction than the current four hours to discuss the student role and hierarchy of the medical team. Furthermore, some of our students commented that it would help to include fourth year students as co-facilitators in the preclinical training courses to provide their insights based on firsthand experiences into the roles and expectations of students on the team.
Another issue in the literature is the challenge that transitioning students have balancing their academic and work responsibilities with social and personal obligations apart from their training (Radcliffe & Lester, 2003). Perhaps due to their limited exposure to clinical medicine, PCS in our study did not highlight work-life balance as anxiety provoking, as did the more experienced CS. Medical educators should set aside curricular time to address these issues with students before their training moves to the clinical setting. This may be particularly important for the current "millennium generation" of students who, for reasons related to this issue of work-life balance, seek out medical specialties with fewer hours, increased pay, and better lifestyles than prior generations (Dorsey et al., 2003).
Our students feel competent in taking histories and performing physical examinations, which we believe reflects the amount of curricular time devoted to teaching these skills in the preclinical courses - approximately 81 course hours. Surprisingly, although very little preclinical time is devoted to procedural skills training, very few of our students reported anxiety in this area. We surmise that they anticipate that procedural skills will be taught later in the clerkships. This contrasts with the perspectives of clerkship directors (CD), who favor additional procedural skills training in the clinical years (Chumley et al., 2005). CDs in this same study also preferred that students be more prepared in the areas of communication skills, professionalism, interviewing/physical examination, life-cycle changes, epidemiology and systems of care (Windish, 2000).
The different perspectives and suggestions on how to ease this difficult transition period likely reflects the varying level of clinical experience of our two cohorts. While PCS recommended more time dedicated to a comprehensive review of all clinical skills in the transition course, our CS felt the training was already sufficient. The literature similarly finds that clerks consider themselves well prepared for clinical practice but report deficiencies in clinical reasoning and knowledge (Busari et al., 1997; Gordon et al., 2000; Prince et al., 2000). Our observations further suggest that the most challenging aspects of the clinical transition are the professional socialization and integration of knowledge from the first two years in the clinical setting. To address these issues at our institution, we now place more emphasis on clinical reasoning in the preclinical years and have incorporated discussions on the clinical student role in the ward hierarchy and balancing the increased workload with personal obligations. Small group and individual guidance sessions with senior students also helped ease the transition to the wards.
The limitations of the study include the free-form answer format to the study questionnaire. Although more difficult to categorize into its appropriate thematic areas, the open-ended response format allowed students to express issues and themes (e.g. self-care and well-being) that would have been missed if provided them with forced choice response options. Also, the questionnaire asked CS to recall their concerns from one year earlier in their training, adding the potential for response bias. Another limitation is that our study is of students at a single US institution and therefore may not be generalizable to other institutions, especially those in other countries. Furthermore, the study does not address the perceptions of the clerkship directors themselves; the expectations of clerkship directors are key to understanding our students' responses, particularly the clinical students, who have completed most of their clerkships. We are now planning a formal assessment of the clerkship directors' expectations of their students.
This study identified areas of student anxiety about the transition from the classroom to the clinical training setting as they move from the second to third year of their curriculum. It highlighted how issues differ for students before and after they have made this transition. The formal curriculum of the first two years creates one set of anxieties for PCS, whereas the clinical experiences and professional socialization of the third year raise different anxieties for CS. These differences, which mirror those found in prior studies, should inform medical educators and lead to programmatic changes that more closely align the content of the curriculum with student experiences on the wards. Based on our findings, our school has reinforced its clinical skills exercises in the current preclinical curriculum, added clinical reasoning exercises, increased participation of fourth year students as co-facilitators in didactic sessions, and added sessions addressing student self-care and well-being.
There are no conflicts of interest for any authors. We did not receive any financial or material support for the research and the work.
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