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The transition from preclinical classroom learning to clerkship education is a major challenge for third-year medical students in US-based medical schools.¹ To ease this transition, many schools, including John A. Burns School of Medicine (JABSOM), have incorporated clinical skills sessions and preceptorships in the pre-clerkship years to improve medical student preparation for and comfort with the start of third year.² However, these pre-clerkship experiences do not completely prepare the students for the new roles, responsibilities and skills needed when immersed in a clinical environment as members of a team directly caring for patients. They must master skills learned during their pre-clerkship years that include performing history and physical examinations, presenting patients, and writing progress notes. In addition, they must cope with the stress inherent in assuming new responsibilities and the emotions that come with caring for patients in both the ambulatory care and inpatient hospital settings. To address these issues, in 2009, JABSOM replaced its one-day clerkship orientation with a Transition to Clerkship Week (TCW) at the start of their third year. The following are current goals, major topics, student feedback, and future direction for this curriculum.

The goals of the TCW are to provide students:

• An understanding of their roles and responsibilities, and the school's policies and procedures with respect to clerkship.

• Active, realistic practice of the skills required at both ambulatory and inpatient sites.

• An understanding of workplace rules, safety precautions, and professionalism expectations.

• A centralized delivery of pre-clerkship requirements (TB testing, CPR/BLS certification, electronic medical record training, etc)

All six clinical departments involved in the third-year clerkships contribute to the one-week course. Students meet all the Clerkship Directors and Coordinators, who will later present a detailed orientation to the students at the start of their respective clerkships. An example of the 2011 TCW Schedule (shown in Table 1) includes a review of the adult, child, and infant physical exam; practice with injections, other procedural skills and presenting patients; instruction on writing progress notes and universal precautions; information on student well-being, academic policies, and grading; and mentorship sessions with fourth-year students. The schedule has evolved since 2009 based on the student feedback, and includes more clinical skills, time with the fourth-year students, and opportunities to visit all clerkship stations.

Table 1.

Sample Student Schedule for Transition to Clerkship Week, 2011.

Day	Morning	Afternoon
Monday	Orientation (Large Group) - Welcome and Overview - First Day of 3rd Year Video - Meet Clerkship Directors & Coordinators - Introduction to T-Res Didactics (Large Group) - Your Role in Patient Care - Injection Workshop and Needlestick Precaution	Orientation (Large Group) - Introduction to Ambulatory Clinic Didactics (Large Group) - History and physical (H&Ps) and subjective-objective-assessment-plan (SOAP) notes - Oral Case Presentations - Things You Need to Know (includes school policies, practices and grading, universal precautions student responsibilities, student well-being and professionalism)
Tuesday	Clerkship Requirements (Small Group Rotations) - Respirator Mask Fitting - CPR Certification	Orientation (Small Group Rotations) - Block 1 Orientation Clinical Experience (Small Group Rotations) - Ambulatory Care Clinic
Wednesday	Orientation (Large Group) - Hawai‘i Pacific Health	Didactics (Large Group) - T-Res - Safety Precautions - Gowning and Gloving
Thursday	Clerkship Requirements (Small Group Rotations) - CareLink Training	Clinical Experience (Small Group Rotations) - Pre-Rounds - Clinical Skills Stations
Friday	Orientation (Large Group) - Tripler Hospital Mentorship from Fourth Year Students (Large Group) - First Aid for the JABSOM Third Year	Mentorship from Fourth Year Students - MS4 Clerkship Stations (Small Group Rotations through 6 stations) - MS4 Clerkship Panel (Large Group) Wrap-Up

Workplace learning theory suggests that students are prepared best by practicing “authentic” tasks that accurately simulate the skills they would be asked to exhibit during their clerkships.^2,3 This theory is incorporated into the TCW Clinical Experience Sessions. For example, following a session on presenting patients, students are asked to perform a history and physical examination, and “round” on hi-fidelity manikins programmed to display key physical findings as if the students were seeing their own patients in the hospital. The patients are modeled after the patients in their health care problems (HCP) studied during their pre-clerkship problem-based learning (PBL) sessions. This process adds a unique continuity to the curriculum. Students must round during breaks in their day just as a medical student must find time to see and assess their patients in between structured educational activities. At a designated time, students are asked to meet “at the bedside” with a faculty member to whom they present their patient, simulating bedside or “attending” rounds. Faculty members question the students, as would occur on wards, and provide feedback to the students on their presentation and responses. In another exercise, students interview fellow students playing the role of ambulatory patients with common problems such as a sore throat, hypertension, and low back pain. After gathering their information, the students present their ambulatory care case to a faculty member, as they would do during clerkships. Faculty members provide feedback on their presentation and guide them through clinical reasoning to formulate an assessment and plan for their patient.

Selected feedback collected from students about the TCW is summarized in Table 2. In general, students appreciated experiencing mock clinical scenarios, practicing clinical skills, completing clerkship requirements, and having fourth-year students as mentors.

Table 2.

Selected Survey Results from Transition to Clerkship Week, 2011. (N=54)

	Statement	(4) Strongly Agree	(3) Somewhat Agree	(2) Somewhat Disagree	(1) Strongly Disagree	Mean	SD
1	The goals and objectives were met.	40 (74%)	14	0	0	3.7	0.4
2	Overall content delivered helped in my preparation for third year.	37 (69%)	14	1	1	3.6	0.6
3	The Injection Workshop and Needlestick Precautions were useful.	45 (83%)	9	0	0	3.8	0.4
4	The H&Ps and SOAP Notes Presentation was useful.	48 (89%)	7	0	0	3.9	0.3
5	The Ambulatory Clinic session was helpful in allowing me to practice presenting cases in this setting.	39 (72%)	14	2	0	3.7	0.5
6	The Clinical Skills sessions were helpful for reviewing and practicing physical exams for different patient settings.	34 (63%)	17	3	0	3.6	0.6
7	The MS Clerkship Panel was helpful.	42 (78%)	11	1	1	3.7	0.6

Student comments about strengths of TCW include these representative statements:

• “It helps (me) realize what the 3rd year will be like and how to prepare for the next week. It acted as a good transition period.”

• “Talking to MS4s helped ease a lot of anxiety. Practicing presentations was helpful.”

• “Ambulatory clinic helped ease tension about 3rd year.”

• “H&P and SOAP notes orientations, practice presentations to attendings, clinical skills rotations, CPR re-certifications, 4th (year) representatives—Very helpful, really eased my anxiety about 3rd (year).”

• “It did a good job answering questions about third year.”

Of the 126 medical schools in the United States, 68 schools responded by survey to having a Transition to Clerkship Course.¹ The length of these courses ranged from 7 hours (1 day) to 144 hours (18 days). Most courses covered topics such as expectations for medical students, professionalism, stress management, and procedural skills. Lectures and didactic sessions made up the majority of the sessions. Many courses also incorporated hands-on activities. Providing an opportunity for transitioning students to interact with senior students was also commonly incorporated.

Student feedback about the JABSOM's TCW suggests the course has been successful in meeting its objectives. Committees within the Office of Medical Education also regularly review TCW. Implemented through this review process are innovative and interactive learning activities that will meet the needs of our hospitals, clerkship directors, and students for today and into the future. Forthcoming plans include simulations designed to help students cope with some of the emotional trauma associated with clinical medicine, such as the death of a patient and talking with the family. Plans are in place to have students create a well-being plan in anticipation of the stress of their clerkship year, and to provide more curriculum time on professionalism, including a session on giving, receiving, and responding to feedback on professionalism issues. Clerkship course directors hope to provide more activities that take place in clerkship hospitals and clinics to enhance enculturation into these settings. Pre-clerkship course directors plan to provide more experience with skills necessary in the clerkships, such as case presentations, problem lists, and the subjective-objective-assessment-plan (SOAP) format, using the HCPs in PBL. Finally, since the TCW takes place at the start of the third year, many of the themes introduced will be reinforced longitudinally. An issue common to most medical schools is the reported erosion in empathy and the start of cynicism in the third year.⁴ Beginning in the TCW, sessions throughout the third and fourth year that combine reflection on clinical experiences as well as the study of arts and humanities may help to mitigate this erosion.

JABSOM's Transition to Clerkship Week (TCW) is a critical addition to the curriculum that has been successful in providing students with an understanding of their responsibilities and faculty expectations, and opportunity to practice skills necessary as members of a patient care team. Future goals include opportunity to practice skills in real ambulatory and inpatient care settings, and simulated experiences with patient death and talking with family members, so that JABSOM continues to produce skilled, compassionate physicians for Hawai‘i.