Perspectives on When to Schedule the EM Clerkship and Its Effect on Students in an Environment of Changing Curricula

Abstract

Purpose

This study investigates medical students’ opinions on the optimal timing for taking the emergency medicine (EM) clerkship and its effects on preparedness for subsequent clerkships and the USMLE (United States Medical Licensing Examination) Step 2 examination.

Methods

A cross-sectional survey was conducted among third- and fourth-year students at the Mayo Clinic Alix School of Medicine. The survey collected opinions on the optimal timing for the EM clerkship and its impact on self-efficacy as well as perceived preparedness for future clerkships and the USMLE Step 2 examination.

Results

Only 5% of third-year EM clerkship students felt they would have been more prepared in their fourth year. Conversely, 70% of fourth-year students believed they were more prepared than if they had taken it in their third year. Students were evenly split on if an earlier EM clerkship would have been helpful for subsequent clerkships. 88% of pre-USMLE Step 2 students found it helpful for Step 2, while 37% of post-USMLE Step 2 students felt it would have helped their preparedness. Additionally, 96% of students stated the EM clerkship increased their confidence in seeing patients. 43% of those who took the clerkship in their fourth year reported they would have considered EM as a specialty had they taken it earlier. Most students recommended taking the EM clerkship during the second 6 months of clerkships.

Conclusion

There are mixed opinions among medical students regarding the helpfulness of taking the EM clerkship earlier for subsequent clerkships and USMLE Step 2 preparedness. However, the majority recommend taking the EM clerkship earlier. A significant proportion of participants would have considered EM as a specialty if they had taken the clerkship earlier. Furthermore, 96% reported increased self-efficacy. Therefore, encouraging students to take the EM clerkship earlier may increase self-confidence and allow for earlier career exploration.

Introduction

The curricula of the medical schools across the United States are constantly changing to adapt to new priorities such as increased time spent on clinical experiences. One of the biggest recent changes is a shift from the traditional 24 months spent in pre-clinical learning toward a more condensed 12- to 18-month pre-clinical curriculum. The goal of this change is to increase the time spent in the clinical environment and to increase flexibility for learners. A recent study showed that approximately 50% of respondent institutions had decreased their pre-clinical years to 18 months, and 62% of those who did not already have an 18-month curriculum are anticipating a decrease in their pre-clinical curriculum in the coming years. ¹

With this change, medical students are now confronted with increased time that can be filled with research, unique clinical experiences, and further career exploration. This change also presents flexibility in chronological timing and scheduling of required and elective clinical rotations. While oftentimes such flexibility is welcomed, it is important to recognize that with flexibility comes an increase in critical decision and planning requirements in an already high-stakes educational system. This is a new frontier for medical students as they try to explore different specialties, thrive on their clinical rotations, and score well on United States Medical Licensing Examination (USMLE) board examinations.

Current literature exploring medical student perceptions and choices regarding optimal timing of specific clerkships, the effect on subsequent clerkships, and specialty selection is sparse. One previous study found that students who chose emergency medicine (EM) often had exposure to and decided on EM as their specialty of choice during the third year of medical school. ² Additionally, studies have demonstrated a significant increase in feelings of self-efficacy, defined as one's belief in their capacity to perform at a level to thrive in a specific goal, ie in medicine, in medical students after taking the EM clerkship, which can help with future clerkship experiences. ³ The aforementioned changes to medical school pre-clinical duration and curriculum, and the flexibility and consequentially high-stakes decisions that it presents, demonstrate that further research on this topic is imperative to best guide medical schools and students in their education and discovery of future career path.

Methods

A cross-sectional survey study at the Mayo Clinic Alix School of Medicine (MCASOM) involving third-(MS3) and fourth-year (MS4) students was performed. Students were recruited via email invitations to third- and fourth-year medical students. The reporting of the study followed the STROBE ⁴ protocol for cross-sectional studies (Supplementary File 1). The study was reviewed by an Institutional Review Board (IRB) and was deemed exempt. Written consent was obtained prior to recording participant answers. MCASOM is a tri-site program with approximately 110 students per class with locations in Rochester, Minnesota; Phoenix, Arizona; and Jacksonville, Florida. The EM clerkship is a required 4-week rotation that can be taken any time after their preclinical, and if they have completed their surgery clerkship and one other clerkship. Inclusion criteria were that participants needed to have taken their EM clerkship and be in third or fourth years. Exclusion criteria included not completing the full survey and if the participant had not taken the EM clerkship prior to completing the survey. Opinions regarding optimal timing of when to take the EM clerkship, as well as the effect of taking the EM clerkship on their opinions of self-efficacy, preparedness for future clerkships, and preparedness for the USMLE Step 2 examination, were collected. The survey was electronically distributed and collected between April and June of 2024 (Supplementary File 2).

Statistical Analysis

A power analysis was conducted to determine whether the sample size was sufficient to detect a significant difference in perceived preparedness between third- and fourth-year students regarding the timing of the EM clerkship. The effect size, calculated using Cohen's h for the difference in proportions of students who felt more prepared in their third year (5%) versus their fourth year (70%), yielded a value of 1.47, indicating a large effect size. With a significance level of 0.05 and a power of 0.80, it was determined that a minimum of 27 participants per group would be necessary to detect a statistically significant difference. All analysis was performed using R 4.3.2 (The R Foundation for Statistical Computing, Vienna, Austria).

Results

Of the approximately 150 eligible students, we received responses from 55 participants with 54 completed surveys, giving a response rate of 36%. While small, enough participants were obtained to detect differences between the third and fourth year cohorts. Of those who responded, 19 (35%) took their EM clerkship in their third year, while the remaining 35 (65%) did so in their fourth year. Our analysis indicates that while we achieved adequate power for the fourth-year cohort, we were slightly underpowered for the third-year cohort. Despite this, the overall sample size was close to the required threshold, allowing us to identify meaningful differences between the groups.

Of those who took the EM clerkship in their third year, only 5% (N = 1) answered that they would have felt more prepared taking the EM clerkship in their fourth year. In contrast, 71.4% (N = 25) of fourth-year students responded that they felt more prepared to take the EM rotation in their fourth year compared to the idea of taking it in their third year (Figure 1). When asked if taking the EM clerkship before other required clerkships would have been helpful with subsequent clerkships, all students were evenly split with 50% responding “yes” and 50% responding “no” on whether taking the EM clerkship earlier would have been helpful for subsequent clerkships.

Figure 1.

(A) Relative Percent of Third-year Medical Students Who Believed That Taking the Em Clerkship in the Fourth Year Would Have Made Them Feel More Prepared. (B) Relative Percent Of Fourth-year Medical Students Who Believed That Had They Taken the Clerkship in Their Third Year, They Would Have Been as Prepared As Taking it in Their Fourth Year.

Regarding the impact of EM clerkship timing on perception of preparedness for USMLE Step 2, 17 participants (31%) completed their EM clerkship prior to Step 2, 35 (65%) after Step 2, and 2 (4%) had not completed Step 2 at the time of the survey (Table 1). Participants who had taken the clerkship prior to USMLE Step 2 were more likely to state that the EM clerkship was helpful (88%, N = 15), while those who took the clerkship after were less likely to say that taking the EM clerkship prior to their examination would have helped their preparedness for USMLE Step 2 (37%, N = 13).

Table 1.

Demographic Data for Participants, Including Academic Year, Year of the EM Clerkship, and When Participants took Step 2.

Demographics	N
Academic year
Third	19 (35%)
Fourth	35 (65%)
Year of EM clerkship
Third	19 (35%)
Fourth	35 (65%)
EM clerkship before USMLE Step 2
Number of students	17 (31.4%)
EM clerkship after STEP 2
Number of students	35 (65%)
EM clerkship completed without completing Step 2	2 (3.7%)

Despite conflicting opinions between students who took the EM clerkship earlier (MS3) versus later (MS4) in regard to preparedness of the EM clerkship, preparedness for subsequent clerkships, and preparedness for the USMLE Step 2 examination, 96% (N = 52) of all participants reported that the EM clerkship increased their confidence when seeing patients. (Figure 2) Notably, of those who took the clerkship in their fourth year, 43% (N = 14) reported they would have considered EM as a specialty had they taken it earlier (Figure 3). Finally, when asked specifically when the ideal time for the EM clerkship would be, the majority of all respondents (55.6%, N = 30) recommended during the second 6 months of clerkships (Figure 4).

Figure 2.

Relative Percent of the Opinions of Increased Self-confidence After Their EM Clerkship.

Figure 3.

Relative Percent of Fourth-year Students Who Would Have Considered EM as a Specialty If Taken Earlier.

Figure 4.

Opinions of All Medical Students on When the Ideal Time Is To Take the EM Clerkship.

Discussion

Medical school curricula are constantly changing to better prepare the next generation of physicians to handle the changing landscape of health care in the United States. In recent years, many medical schools have begun to decrease their preclinical time, making more time available for research, career exploration, and clinical experiences. ¹ As this change occurs, more studies are needed to better advise this new generation on when the optimal time is to take clerkships and how this can affect their success and ultimately their career choices.

In our study, most students recommended taking their EM clerkship earlier than the traditional fourth-year timing in the pre-truncated curriculum (Figure 4). In contrast, in the past, the prevailing wisdom for those who were interested in EM was to take it in the fourth year and stressed the importance of internal medicine and surgery clerkships, as these grades were emphasized during residency selection of prospective residents. ⁵ Now, with the increase in time and flexibility, students can take the EM clerkship earlier allowing them to explore and grow as physicians. This is further supported by our study, which showed that many fourth-year students would have considered EM as a specialty had they taken it in their third year. This shows that having an earlier EM clerkship available may be worthwhile, as it would expose those who may be interested earlier, allowing them to decide sooner and increasing the number of medical students going into EM (Figure 3).

Our study was also interested in the effect of earlier EM clerkships and the perception of USMLE Step 2 preparedness, and most students who took the clerkship after USMLE Step 2 indicated it would not have improved their self-confidence. However, a sizable minority (20%) indicated it would have been helpful, indicating some students may consider taking it earlier and that they would benefit from doing so. Furthermore, participants who took the EM clerkship prior to USMLE Step 2 stated it was helpful for USMLE Step 2. However, it is important to note that the EM clerkships represent a challenge to incoming students who may struggle with the clinical challenges and environment of the Emergency Department. The EM clerkship requires focused physical examinations, and the overall pace is unique compared to other clerkships, and some medical students can struggle with these challenges.

In our study, there was a clear preference by third- and fourth-year students for feelings of preparedness depending on when they took their clerkship. For example, fourth-year students state they would not have been as prepared if they had been third-year students, and third-year students stated waiting until their fourth year would not have made them better prepared. This is likely due to students naturally favoring their own personal experiences and being less inclined to acknowledge that alternative approaches might have better prepared them for the EM clerkship or the USMLE Step 2. These tendencies may shape their preference for a particular method. Importantly, most students indicated their self-efficacy had increased, making the EM clerkship an ideal way to develop clinical self-confidence and preparedness (Figure 2). This increase has been seen in other studies, indicating that taking the EM clerkship earlier may help increase a student's feelings of self-confidence and performance on subsequent clerkships. ³ This result suggests it may be useful for an earlier EM clerkship to exist and integrating more EM experiences earlier in medical school curriculum may also be helpful. Faculty and course directors can use this information to advocate for more students to get involved in EM earlier. This enables them to have greater flexibility in their fourth year, explore possible career paths sooner, grow as clinicians, and potentially boost their confidence when taking Step 2.

There are several limitations to our study. One is the lack of sufficient third-year medical students to have adequate power for that specific group; however, the total number of participants enabled us to make statistically significant conclusions despite this. The relatively low response rate (36%) further limits the generalizability of the findings, as those who chose to participate may have had experiences or opinions that are not representative of the entire cohort. Future studies could benefit from a larger and more representative sample, potentially achieved through a more targeted recruitment strategy and the use of incentives to increase participation. Other areas of future interest would be to investigate the effect of an earlier EM clerkship on Step 2 scores, residency choices, and other clerkship grades. Despite these limitations, the findings contribute to the ongoing discussion about the optimal timing of the EM clerkship in medical education and suggest areas for further research.

Conclusion

Our study underscores the importance of integrating earlier EM clerkships into medical education. Students demonstrated a clear preference for this adjustment, highlighting how early exposure enhances their self-confidence and readiness for subsequent clinical experiences. Moreover, this timing positively influences students’ willingness to consider EM as a career path. Despite some limitations, such as sample size and response rate, the overwhelming majority of participants advocate for an earlier introduction to EM in their training. As medical schools continue to refine their curricula to meet the evolving demands of healthcare, further research is vital to fully understand the long-term impacts of earlier EM experiences. Ultimately, prioritizing timely exposure to diverse specialties will equip future physicians with the necessary skills and insights to navigate the complexities of modern healthcare, fostering a more adaptable and well-rounded medical workforce prepared for a range of challenges.