Clerkship Chiefs: Introducing Students to the Role of Physician Educator

Abstract

As a Clerkship Chief, senior medical students prepare for future roles as physician leaders and future medical educators. The Clerkship Chief elective offers senior students an opportunity to work with junior students on their core clerkships. Chiefs assume an educational leadership role as they mentor and provide supplemental formative feedback to junior students in real time. As educators, Chiefs answer questions, prepare study materials and didactics, and assist clerkship students with time management. This early experience and behind-the-scenes view of medical education may influence attitudes and decisions of senior students in pursuit of education leadership.

Introduction

Medical education continues to struggle to recruit physician educators [1]. One possible method of continuing to deliver quality experiences without increasing clinical faculty is to utilize senior students. These students in undergraduate medical education (UME) focus on completing sub-internships, away or visiting rotations, and electives in addition to significant nonclinical preparation for recruiting, graduation tasks, and preparation for residency. During this time, highly motivated students seek to develop skills useful as future professionals and are ready for new opportunities to assume the role as a physician educator and team leader [2]. Electives allow students to advance their skills and explore career opportunities [3]. Offering a Clerkship Chief elective during the final UME year allows students to explore medical education as a component of their career, while earning elective credit practicing teaching and leadership skills necessary for physician educators [3, 4]. Modifying academic culture to integrate teaching as a natural component of physician’s tasks aligns with the Hippocratic Oath call to train future physicians.

Kolb’s 4-stage learning cycle is a pedagogical method that is effective for the Clerkship Chief to use to facilitate students’ real-world clinical problem-solving skills [5]. Experience has long been recognized as a learning strategy and students’ preference for hands-on leadership experiences provide added interest to being selected as a Clerkship Chief [2, 6]. Under the supervision of the Clerkship Director (CD), a Clerkship Chief offers near-peer support to medical students as they rotate in their respective core clerkships plus administrative support for the CD. A Clerkship Chief’s prior successful completion of the clerkship creates a relationship based on similar shared experiences with the current junior students. Near-peer support for rotating junior students consists of peer mentoring, peer coaching, and providing emotional support. Clerkship students receive formative assessment from a trusted source without the concern of punitive feedback, since accepting a Chief’s help and support explicitly does not impact their grade as they learn nuances of the specialty [7].

However, the development is symbiotic, as a Clerkship Chief simultaneously benefits as a physician educator by learning the art of giving appropriate feedback in the process of providing feedback to rotating students [8]. While clinical preceptors or CDs may communicate to students’ feedback using terms reflecting years of clinical experience which is specific to the core entrustable professional activities (EPAs), clerkship students inherently benefit from a Clerkship Chief who can communicate on a day-to-day basis to pragmatically provide feedback which promotes growth in the clinical environment from a trusted ally [9, 10]. Clerkship Chiefs draw upon their own clinical experiences and reflections of their core clerkship year when working with rotating students. The utilization of implicit memory and retrieval of previous experiences is essential to helping current clerkship students develop their clinical competencies, as the Clerkship Chief relies on automatic retrieval of their own clerkship experiences as new experiences are interpreted. As Chiefs process new experiences by reflecting and consciously remembering the knowledge and skills required, they internalize their interpretation of how to navigate new clinical situations. When a Clerkship Chief helps a student with deliberate practice, both the educator and the learner use repetitive retrieval to solidify core clinical practices [11]. The repetition of deliberate practice helps clerkship students perfect their skill development while the Clerkship Chief practices recalling knowledge of the success in developing the skill as feedback is provided to the student. Later, when the Clerkship Chief and student individually reflect on their shared experience, both gain insight on the skill. This mutually arranged experience provides the intelligent development and direction needed in education and moves the learner through the 4 stages of learning [5, 12].

Incorporating a Clerkship Chief into a core clerkship has a myriad of benefits for all parties. The Clerkship Chief has an opportunity to practice physician leadership as an educator. Academic activities, such as developing didactics (lecture, simulations, and shelf exam review), can be delivered by a Clerkship Chief. On an inpatient service, a Clerkship Chief can be paired with a new resident to help onboard the resident on the health system’s administrative protocols and electronic health record. Adding the Clerkship Chief can accelerate a clerkship student’s clinical knowledge and skill development, which may translate to increased proficiency in core competency development. The CD can more effectively juggle their clinical and administrative responsibilities as Clerkship Chiefs can generate and manage routine group emails, oversee real-time communication (texts), and help students with basic clinical workflows. Clerkship Chiefs observe the real-time impact of providing support and assistance to clerkship students who need extra attention to meet the competency requirements of the clerkship. Tremendous satisfaction and pride is realized in seeing a student achieve success in their clerkship administrative work, clinical care with patients, interdisciplinary team communication, and advanced skills. A Clerkship Chief has the opportunity to experience one of the true joys of participating in medical education.

Many medical educators associate a “Chief” with only Graduate Medical Education; however, “Chiefs” can provide value to UME. This monograph shows how “Chiefs” are utilized at two medical schools in three specialties by identifying generalizable initial steps for consideration when integrating Clerkship Chiefs into core clerkships. Refer to Fig. 1 and benefits Clerkship Chiefs can add to different clerkship rotation in Table 1. The following essential steps for creating a Clerkship Chief elective are designed to allow adaptability to any clerkship specialty and resources.

Fig. 1.

Steps to creating a Clerkship Chief elective

Table 1.

Benefits Clerkship Chiefs add to a clerkship rotation

Specialty/campus	Hospital-based	Community-based
Internal Medicine	• Time-management • Direct observation of junior peers’ clinical skills • Coach around oral presentations • Provide feedback around documentation (i.e., organization, EMR) • Formative feedback • Prepare materials to educate students for their NBME subject exam • Role model professionalism	• Integrate students within the ambulatory team (MA, intern or resident, preceptor) • Coach around modified skills for ambulatory patient presentations • Provide feedback around documentation (i.e., organization, EMR) • Serve as a resource for real-time clinical knowledge and skill development • Debrief challenging patient encounters or interactions with team members
Family Medicine	• Work with inpatient and ambulatory teams • Teach MS3 during didactics • Prepare for shelf test • Present at state conferences • Represent specialty at state/national activism days • Update lectures • Present material relevant to core topics of Family Medicine	• Teach MS3 during didactics via Zoom • Share test taking skills • Work with ambulatory team (MA, office managers, NP/PA) • Coordinate community-based efforts for patients (provide screenings and education) • Improve ambulatory workflow • Measure quality incentive metrics-blood pressure, colonoscopy, screenings, vaccines
Surgery	• Help with orientation, suturing and knot tying, trauma simulation and hospital tours • Assist in independent sessions on note writing and presentations • Coach board prep if clerkship director not available	• Provide deliberate skill practice to struggling students • Assist students during procedure labs • Assist students during simulation training • Schedule surgeries for students to ensure variety/scope • Communicate with OR scheduler, techs • Perform post-op phone checks • Engage in community events/outreach

Creating the Clerkship Chief Elective

An experienced Medical Educator (ME) is beneficial when creating a Clerkship Chief elective. It is essential that the ME have an understanding of the core clinical experiences/clerkships, the health system, the stakeholders in UME and graduate medical education (GME), and how to integrate the Clerkship Chief learning objectives to the core clerkship learning process across their institution’s clinical curriculum. Table 2 gives characteristics for identifying an experienced ME. When a CD is interested in creating a Clerkship Chief elective, collaboration with the ME makes it easier to navigate the formal tasks required for course creation. Formal tasks consist of the process of developing the idea and navigating through the institution’s curriculum committee and educational leadership. Guidelines for creating an elective vary by institution. Medical educators have to work closely with the CD to understand the needs of both the Clerkship Chief and clerkship students as learners. The ME can then take responsibility for writing learning objectives, processing paperwork required to create an elective and overseeing meeting the formal curriculum requirements established by the curriculum oversight committee. Once the elective is approved, a ME can be utilized for onboarding a new Clerkship Chief to ensure the administrative expectations and general roles are known and understood by the Chief [13]. The day-to-day responsibilities and integration into the core clerkship remain the duty of the CD.

Table 2.

Experienced medical educator characteristics

Characteristics of an experienced medical educator
Established formal relationship with Clerkship Directors
Experience in clinical education (3 + years)
Observed medical students in clinical environments
Standardizes common structure of the elective at a site
Supports creative curriculum development
Demonstrates translational application of elective across multiple specialties and settings

Identifying Clerkship Chiefs’ Role

There is not one way to best utilize a Clerkship Chief since the elective varies by specialty, campus, setting (inpatient versus outpatient), and/or timing within the academic year. The important task is for the CD to clearly communicate expectations for the Chief role on the first day of the elective during a brief orientation. Set a time to meet regularly to discuss weekly plans, make adjustments, and take advantage of new opportunities. An example of variance by specialty is a Clerkship Chief for the surgery clerkship who may elect to have more time supporting clerkship students in the operating room whereas a Clerkship Chief for the family medicine clerkship may want to increase their opportunities for community engagement. Refer to the essential Clerkship Chiefs responsibilities in Table 3. Roles may differ by campus since Academic hospitals have residents who rotate with UME students and provide feedback to students whereas Community-based hospitals may or may not have residents. Rotating students benefit from a Clerkship Chief in settings with or without residents as their role as a near-peer mentor is adapted to the situation. In a hospital with GME and multiple residencies, the clerkship student can benefit from a Clerkship Chief’s knowledge of how to prepare for rounding with a particular specialty “ward” or teaching team. This includes the nuances of oral presentations and documentation as well as strategies to advance clinical knowledge, as part of the students’ shelf exam preparation. Clerkship students in an ambulatory setting can benefit from regular check-ins with a Clerkship Chief by text or Zoom to ask questions about workflow, how to study for shelf exams, or strategies for managing work-life balance with their new clinical demands. In both settings students receive extra attention, which a CD’s schedule may otherwise not be able to accommodate. The extra support can be especially comforting for struggling learners as it promotes a safe learning environment.

Table 3.

Standard Clerkship Chiefs’ responsibilities

Clerkship chiefs’ standard responsibilities
Act as a peer-mentor to junior Clerkship students
Assist with Clerkship Orientation and Academic Days
Coach students on oral presentations
Presentation on specialty relevant topics
Provide feedback of student documentation
Assist with shelf exam review

Recruiting Clerkship Chiefs

Identifying future Clerkship Chief candidates can start when a CD observes junior students rotating through their core clerkships who have an interest in their specialty and are engaged in the learning process. CDs may start recruiting their future Clerkship Chiefs by identifying students who have mastery of the knowledge needed to excel at core competencies and clinical skills. A Clerkship Chief candidate is not necessarily a scholastic standout student, but a student who has advanced patient encounter management skills, clinical aptitude, and indications of being an excellent clinician in training with effective self-directed learning skills. Once identified, a CD can inquire if the promising student is interested in being a Clerkship Chief during their final UME year. The longer the elective has been established, students who have the experience of having a Clerkship Chief during their core clerkship become proactive about applying and enrolling as the Clerkship Chief. At this point in time, when there is a critical mass of students, recruiting is no longer needed so transitioning to using an application benefits the selection process. For schools with a high volume of applicants, a standardized blinded application may be necessary to reduce implicit bias. The authors recommend utilizing chiefs during different time periods or at different locations if available to be as inclusive as possible. One method to help with selecting the next Chief is to create an application with a selection of questions for candidates to answer focusing on revealing why students are interested in serving as a Chief. Clerkship Chief selection may be decided by a CD and their vision of the Clerkship Chief’s role. Selection after recruitment is outside the scope of this monograph, as this process will likely vary based on institution-specific criteria, available sites and preceptors, and number of interested students.

Timing the Clerkship Chief Elective

The CD may have particular goals for the Clerkship Chief which determines when the Clerkship Chief elective is offered. Having a Clerkship Chief in the first half of their senior year enables senior Chiefs to work with junior students who are still mastering time management, task prioritization, and who are less competent clinicians given their limited experiences. These junior students rely on the near-peer mentoring, formative feedback, work-life balance tips, and medical knowledge of the Clerkship Chief who has successfully completed the clerkship in the past. Further, a Clerkship Chief in the first months of the clerkship year takes the burden of organizing and monitoring students from the residents who are supervising new interns. Both the Clerkship Chief and resident can communicate with the faculty preceptor about all the learners on the team. If the CD wants to have the Clerkship Chief elective as an option throughout the senior year, the nature of the curricular goals may vary. For example, the CD might have “late in the year” Clerkship Chiefs focus on professional development and special projects as clerkships students would be more acclimated to their roles as student clinicians and begin preparing for their acting internships. The Clerkship Chief’s role is similar to being a Chief resident, only the Clerkship Chief works directly with medical students instead of residents. When Clerkship Chiefs rotate later in the academic year, a CD should focus on the Clerkship Chief’s professional growth by incorporating opportunities in leadership as an educator, helping a Clerkship Chief with their transition to residency or activities acclimating the Clerkship Chief for their internship.

Training the Clerkship Chief

When the elective is approved and ready for student registration, medical education training for Clerkship Chiefs will need to be included in course planning. This is where having the ME is helpful as they can plan and deliver the initial Clerkship Chief training sessions during the first week of the elective. This is particularly useful if an institution has Clerkship Chiefs across several specialties as the Clerkship Chiefs for a given elective block can receive training together. The ME can discuss the Clerkship Chief role, provide broad expectations and goals, coach students, and answer questions. The training can introduce the Clerkship Chief student to their role as a medical educator by introducing topics, such as peer formative feedback. Clerkship Chiefs also benefit from learning “in the moment” teaching techniques such as the 1-min preceptor method. Training your Clerkship Chief on providing effective feedback is important for the Clerkship Chief’s development since their role requires peer feedback [4, 14]. Clerkship Chiefs, like residents, have been identified as being potentially excellent teachers since their mastery is still developing and, unlike an expert clinician, they must consciously think as they perform a skill [15]. An important discussion to include in the training is creating a safe learning environment for the clerkship students with the Clerkship Chief’s role as a peer coach. Fundamental to this goal is a reminder for the Clerkship Chief and the rotating clerkship students that the Clerkship Chief has no role in the student’s final assessment. Additionally, a Clerkship Chief should share their preferred contact information with the clerkship students on the first day. Any requirements the Clerkship Chief must complete for their course assessment by the CD should be discussed during training.

Evaluating and Assessing the Clerkship Chief

Electives are a component of the formal curriculum requiring an evaluation of a student’s performance. There are a variety of strategies to utilize for assessing the Clerkship Chief’s competencies as a budding physician leader and medical educator. These strategies will culminate in completion of an institution’s elective assessment form(s).

An educational project may be required by the curriculum oversight committee. Assigning a Clerkship Chief a project to complete during the elective provides insight for completion of the assessment at the end of a course. Creation of the Clerkship Chief Project should focus on benefitting the clerkship students, the Chief and CD. Project topics can focus on improving didactics, scheduling, quality metrics, team-based care, or the business of medicine with educational outputs for improving clerkship training in the future. Projects should be determined by the CD and vary by the Clerkship’s needs such as a specific content presentation during the rotation, weekly reviews to prepare students for their shelf exam, and updating content presentations used by the CD. One author dedicates 45 minutes during weekly didactics for “Chief’s Corner” where the Clerkship Chief constructs a presentation, game or quiz, to review content on the shelf exam. Clerkship Chiefs benefit from project experiences that are reflected on their CV, such as presenting at Grand Rounds or submitting a poster to a meeting. Program directors have called one CD inquiring about her Clerkship Chief elective after seeing the experience listed on applicants’ CVs and expressed intrigue with the potential benefits as discussed above. Besides having a collaborator who functions in the role of a “clerkship assistant” during the elective, CDs benefit from the Clerkship Chief’s project to gain real-time updates to clerkship materials, scholarly activity as it relates to the clerkship, or revisiting and completing previously shelved projects.

The Clerkship Chief elective further prepares the senior student for residency by addressing items within several core entrustable professional activities (EPAs) which can be assessed by the CD at the completion of the elective [9]. Clerkship Chiefs’ ability to identify systems that contribute to success for team-based care adds to an overall culture of safety (EPA 13). This is reflected as they lead junior students or in their participation in additional clerkship activities. Additionally, Clerkship Chiefs are expected to demonstrate core competencies in collaborating as a member of an interprofessional team (EPA 9). Chief elective competencies can be mapped to these EPAs.

Reflection is a recognized step in the cycle of self-directed learning that provides a strategy for helping medical students identify the value and expectancies in their learning [15]. Using a reflection at the conclusion of an elective helps the future intern describe the value of their experiences and recognize their strengths as they set expectations for the next step of their learning. Having a Clerkship Chief reflect on their own personal growth during the Clerkship Chief elective can provide valuable insight for the student as well as the CD. The Clerkship Chief reflection letter may help the CD identify missed opportunities and future needs of the elective. This information is useful for modifying the Clerkship Chief elective curricular documents, defining the Chief role in the clerkship, or disseminating at future orientations to future Clerkship Chiefs allowing increased insight from the former Clerkship Chiefs reflections on opportunities.

The end of a Clerkship Chief’s elective is a good time for a CD to reflect on the running of the elective. The Clerkship Chief’s reflection can be used as an impetus for identifying needs and interests of clerkship students [14]. Feedback from the Clerkship Chief often promotes identification of successes and needs encouraging changes to the clerkship by suggesting ideas for teaching modifications to promote helpful and relevant clinical learning. Even if the Clerkship Chief has moved on, a CD needs to independently reflect on the Clerkship Chief experience to identify effectiveness and relevance of how the Clerkship Chief’s time and skills were utilized for improving future Clerkship Chief elective experiences. This is also a time to evaluate course data for feasible scholarly activities in curricular development and peer-to-peer feedback.

Conclusion

Training tomorrow’s medical educators requires innovative thinking in developing electives in various clinical and nonclinical settings. The Clerkship Chief elective is uniquely positioned to provide an opportunity for senior UME students to experience the role of a physician leader by assuming administrative and pedological duties of medical educators. This allows for an active role in the future physician’s personal and professional development. Clerkship Chiefs have direct involvement and experiences in medical education, mentorship, and clinician leadership. In GME, the “Residents as Teachers” curriculum has been disseminated and implemented widely, yet efforts for introducing UME students to the foundational training as future medical educators are not universally applied in near-peer settings.

The steps discussed serve as a guide for implementation in most UME settings and can be utilized in various specialties and in different sizes of hospitals, whether Academic or Community-based. With some thoughtful preparation, this unique elective creates a collective positive experience for the soon-to-be intern, the clerkship students, and the Clerkship Director. These are not absolute steps since resources vary between clerkships, clinical settings, and institutions, but are meant to start the discussion of how Clerkship Chiefs can be implemented at your institution. The custom-built nature of the elective allows flexibility to adjust to clerkship students’ needs and local constraints. Anecdotally, authors in this monograph have received positive comments from students in this leadership experience during their residency interviews from outside faculty and programs. Because of the novelty of this type of elective, there is a lack of quantitative data, highlighting the need for future studies. Medical students’ successes are a win for the entire healthcare team. A medical educator never knows if they are training a future chief resident, clerkship director, or residency program director!

Author Contribution

All authors contributed to the study conception and design. Material preparation was performed by Vicki R. McKinney, Amy E. Bailey, Prashant P. Patel, Melissa H. Olken, and Mary T. Bond. The first draft of the manuscript was written by Vicki R. McKinney, and Prashant P. Patel, Melissa H. Olken, Amy E. Bailey, and Mary T. Bond commented on previous versions of the manuscript. Vicki R. McKinney, Amy E. Bailey, Prashant P. Patel, Melissa H. Olken, and Mary T. Bond read and approved the final manuscript.

Declarations

Ethical Approval

Not applicable.

Informed Consent

Not applicable.

Conflict of Interest

The authors declare no competing interests.