This article is the fifth in a series that addresses various aspects of John A. Burns School of Medicine (JABSOM) medical education related to the LCME accreditation process.1 JABSOM is scheduled for its LCME visit in early 2017. This installment, provides an overview of clerkship education at JABSOM vis-à-vis LCME standards.
Introduction
The Clerkship Education Program occurs during the last two years of medical school. During the third year, students rotate through the required core clerkships of Pediatrics, Family Medicine, Internal Medicine, Surgery, Obstetrics and Gynecology (OB/GYN), and Psychiatry. The students have a choice of participating in a longitudinal or block schedule for their third year curriculum (Table 1). During the fourth year, all students participate in the required clerkships of Emergency Medicine and Geriatric and Palliative Medicine as well as electives of their choosing. These electives are often in their chosen specialty.
Table 1.
Clerkship education during the third year, Block and Longitudinal sample schedule
| BLOCK SCHEDULE | ||||||
| Pediatrics (PED531) | Family Medicine (FMCH 531) | Internal Medicine (MED531) | Surgery (SURG 531) | OB/GYN (OB/GYN 531) | Psychiatry (PSTY 531) | |
| 7 wks | 7 wks | 11 wks + 2 weeks optional elective | 7 wks | 7 wks | 7 wks | |
| LONGITUDINAL SCHEDULE | |||||
| Outpatient Semester | Inpatient Semester | ||||
| Weekly schedule: ½ day in Pediatrics, Internal Medicine, Surgery, OB/GYN, and Psychiatry and two ½ days in Family Medicine | PED 532 | MED 532 | SURG 532 | OB/GYN 532 | PSTY 532 |
| 4 wks | 6 wks | 4 wks | 4 wks | 4 wks | |
The majority of core clerkship courses are 7 weeks long for the block schedule; Internal Medicine is 11 weeks long. Students participating in the longitudinal curriculum spend one semester in the outpatient setting rotating through Pediatrics, Family Medicine, Internal Medicine, Surgery, OB/GYN and Psychiatry clinics. During the other semester of the longitudinal curriculum, they participate in abbreviated inpatient blocks.
All third year students also participate in colloquia sessions throughout their third year. These sessions occur approximately every 5 weeks. Colloquia sessions include topics that are important interdisciplinary curricular topics such as transitioning care of patients or patient ethics. At the end of their clerkships, all students take a standardized National Board of Medical Examiners (NBME) Shelf Exam. The curriculum of the third and fourth year is overseen by the Clerkship Education Committee (CEC), which is a subcommittee of the Curriculum Committee.
Voting members of the Clerkship Education Committee consists of:
Clerkship Directors of Family Medicine and Community Health, Internal Medicine, Obstetrics and Gynecology, Pediatrics, Psychiatry, and Surgery
Clerkship Directors of Emergency Medicine and Geriatric and Palliative Medicine
Director of the Longitudinal Clerkship Program
Course Directors of the Third-Year Colloquia and Senior Seminars
Non-voting members of the Clerkship Education Committee consists of:
Director of the Office of Medical Education
Director of the Office of Student Affairs
Longitudinal Clerkship Program Departmental Directors
Clerkship Coordinators for each clerkship
The CEC oversees the curriculum of the third and fourth years and the day to day operations of the clerkship years. The roles of the CEC include:
Review and coordinate implementation of the curriculum for each clerkship experience.
Review educational outcomes relevant to the clerkship curriculum.
Review educational outcomes relevant to the Accreditation Council for Graduate Medical Education (ACGME) expectations that students be ACGME Level-1 Milestone Ready upon the end of their fourth year.
Periodically review the clerkship curriculum for gaps and redundancies.
Recommend and implement curriculum adjustments based upon student need or feedback.
The following are examples of LCME Elements related to clerkship education and how the CEC have addressed these items.
Element 6.2 Required Clinical Experiences
LCME Element 6.2 states:
The faculty of a medical school define the types of patients and clinical conditions that medical students are required to encounter, the skills to be performed by medical students, the appropriate clinical settings for these experiences, and the expected level of medical student responsibility.
The respective clinical departments determined clinical conditions that students are expected to experience during the required clinical clerkships. The mechanism used to determine the list of required conditions and the appropriate clinical settings for these experiences included a review by clerkship directors and their respective department educational committee of the following:
Receive input from guidelines endorsed by national organizations within their specialty (for example the Council of Medical Student Education in Pediatrics)
Evaluate epidemiology of various conditions including their clinical importance in Hawai‘i and the Pacific region
Review data on the number and type of patient encounters that students have had in each clerkship.
Annually, the faculty of the respective clinical departments reviews departmental required clinical conditions, level of responsibility and clinical settings. These required clinical conditions are then reviewed by the CEC to ensure adequate coverage and avoidance of redundancy across all clerkships. Finally, these expectations are reviewed and approved by the JABSOM curriculum committee.
LCME Element 6.4: Inpatient/Outpatient Experiences
LCME Element 6.4 states:
The faculty of a medical school ensure that the medical curriculum includes clinical experiences in both outpatient and inpatient settings.
The balance between inpatient and outpatient clinical experiences is monitored closely at different levels at the medical school. The amount of time a student spends in the outpatient or inpatient setting is dependent on the respective clerkship objectives. Each of the required clerkships regularly monitors student progress in meeting set clinical objectives. Students follow clinical schedules determined by each clerkship to ensure they meet the requirements and learning objectives. The clerkships report on their individual curriculum as it relates to their specialty area to the Clerkship Educational Committee, which in turn, reports to the JABSOM Curriculum Committee annually on its various activities completed in the previous academic year.
LCME Element 8.6: Monitoring of Completion of Required Clinical Experiences
LCME Element 8.6 states:
A medical school has in place a system with central oversight that monitors and ensures completion by all medical students of required clinical experiences in the medical education program and remedies any identified gaps.
All students are required to use the centralized computer-based tool for tracking patient logs (T-Res®2 program) as their patient encounter monitoring system in the required third year clerkships and required fourth year rotations (Geriatric and Palliative Medicine and Emergency Medicine). Patient logs are monitored for each of the required clinical rotations as the students rotate through each clerkship. In addition, the extent of completeness of the required clinical encounters for each clerkship and required fourth year rotation are reported to the CEC. The clerkship director regularly monitors the required clinical conditions with the assistance of the clerkship coordinator who checks the students' T-Res®2 logs. The students are provided feedback regularly as to the required clinical conditions that they still need to meet. Feedback is also provided to preceptor (clinical faculty) so the preceptor can help the students complete these conditions. Data on completion rates of these required clinical conditions are reviewed for gaps by the respective departmental medical student committees and used to address and possibly re-evaluate the required clinical conditions. Any changes to the required clinical conditions are then brought before the CEC and ultimately the Curriculum Committee.
Special Projects by the Clerkship Education Committee
The CEC develops programs deemed useful to enhance the third and fourth year curricula.
The following are examples of projects by the CEC.
Fourth year Boot Camp:
At graduation, medical students are expected to possess a wide array of skills and attitudes when they enter residency training programs. “Boot camp” curriculum of intensive procedural and skills training can help teach medical students clinical skills and procedural techniques.3–5 The AC-GME created milestones to assess the competency of learners during residency.6 A school-wide 2-day “boot camp” for fourth year medical students was organized to help students to achieve level 1 milestones preparation for their matched specialty. Because of overlapping milestones or skills, faculty resources were pooled to create workshops for students in the various specialties. For example, students entering Surgery, Obstetrics and Gynecology, Family Medicine and Emergency Medicine residencies attended a suture workshop. Students participated in various workshops including a transition of care workshop, which is an important milestone that is common to all residency specialties. Numerous subspecialty specific workshops were also included. Following the boot camp, students achieved improved confidence in milestone related skills.
Annual Clerkship Reviews:
Annual clerkship reviews were conducted as a method to review clerkship curriculum and to help standardize practices such as evaluation processes. The annual reviews allow the CEC to examine the different clerkships for redundancies in curriculum and share best practices for clerkship administration. Sharing clerkship best practices has enabled clerkship directors to adopt innovations from other clerkships. For example, the pediatric clerkship offered an elective during the seventh week of the clerkship with different pediatric subspecialists such as Pediatric Cardiology and Pediatric Infectious Disease. The surgery clerkship adopted the seventh week elective and offered a surgical subspecialty. This elective week proved to be a popular and well-received elective by the students. The clerkship annual reviews also enabled central monitoring of important curricular elements for residents and faculty, and ensure that students complete required clerkship experiences.
Colloquia:
As part of the third year curriculum at JABSOM, all the students must participate in a course separate from their clerkship rotations named the Third Year Colloquia Series (MDED 563). This course starts with a “Transition to Clerkship” week before the start of their first clerkship block, which includes topics to help prepare students for their clinical clerkships.7 Topics include reviewing history taking and physical exam techniques, presentation skills, surgical gowning and gloving, universal precautions, and other useful skills. This week also allows the faculty to orient students to the hospitals and the electronic health record systems. Throughout the third year, the colloquia series brings the students back to the main campus on one Friday a month for a day of lectures, workshops, and clinical skills activities. These sessions are improved continually to:
Provide the students with topics that bridge all of the clinical disciplines and address overlapping level one residency milestones, such as medical ethics, patient safety, and transitions of care.
Address essential LCME related topics such as student mistreatment, professionalism, cultural awareness and interprofessional education.
Prepare the students for their fourth year with sessions such as addressing the National Residency Match Program and interview process.
Introduce clinical specialties that the students may be interested in pursuing that are not part of the third year rotations (ie, Physical Medicine and Rehabilitation, Radiology, Ophthalmology, etc)
Final Thoughts
The third and fourth year of medical school are known as “the clinical years,” when students learn and practice clinical medicine in a range of specialties including Pediatrics, Family Medicine, Internal Medicine, OB/GYN, Psychiatry, Surgery, Emergency Medicine, and Geriatric and Palliative Medicine. The CEC ensures students to experience an appropriate variety of clinical conditions. By collaborating with faculty across departments, the goal is to assure that students graduating from JABSOM are prepared to begin residency training in the subspecialty field of their choice.
Table 2.
Percent of clerkship spent in outpatient and inpatient settings
| Percentage of Total Clerkship Time | ||
| % Ambulatory | % Inpatient | |
| Family Medicine | 95%–100% | 0–5% |
| Internal Medicine | 40% | 60% |
| Ob-Gyn | 20% | 80% |
| Pediatrics | 50% | 50% |
| Psychiatry | 33% | 67% |
| Surgery | 10% | 90% |
| Geriatrics | 30%–50% | 50%–70% |
| ER | 100% | 0% |
References
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