Opinion
VIEWPOINT
Paul R. Massey, MD Transitional Year Program, University of Texas Southwestern– Austin, Austin. Jeffrey H. Anderson, MD Department of Surgery, University of Washington School of Medicine, Seattle.
Corresponding Author: Paul R. Massey, MD, Transitional Year Program, University of Texas Southwestern– Austin, 601 E 15th St, Austin, TX 78701 (paulrmassey@gmail .com). 1440
Resuscitating Inpatient Clinical Clerkships A Medical Student Perspective Inpatient clinical clerkships in the third year of medical school are the touchstones of traditional medical education in the United States and have remained so since they were originally suggested by Abraham Flexner in 1910.1 Historically, the third year is when a physician is forged from a student and when classroom experience is transformed into clinical acumen. It is a pivotal time for medical students to adapt to the work of the hospital and to revel in the responsibilities of patient care. Unfortunately, the third year of medical school is no longer quite so. As medical school graduates in 2014, we give voice to a fact that both students and academic physicians alike should acknowledge. Despite the best efforts and intentions of all involved, the role of the medical student has changed in clinical clerkships, and changed in ways that may be harmful to students’ preparation to practice medicine. Put simply, medical students spend too much time observing others and too little time directly participating in patient care. Although fourth-year subinternships bring greater responsibilities where skills can be honed, the reality is that traditional medical student roles in academic hospitals have largely been superseded and often not replaced with meaningful tasks. Go back a decade or more, and the role of thirdyear medical students was vital. Students took meaningful initial histories and conducted meaningful physical examinations of patients, drew blood for laboratory tests and spun blood samples for hematocrits, performed manual urinalyses, measured arterial blood gas concentrations in patients with dyspnea, and inserted peripheral intravenous lines. These activities, often performed in exchange for teaching points from hardworking residents, brought students to the bedside, facilitated the growth of interpretive skills, and ensured full involvement in patient care. On the hospital wards, students developed that critical sixth sense that all good physicians must learn, to discern sick from not sick, and— perhaps most important—when to call for help.2 In his memoir, C. Everett Koop, who served as Surgeon General of the United States from 1982 to 1989, recalled making obstetrics home visits as a medical student in the 1930s, independently placing nerve blocks and delivering babies.3 Although this recollection should justifiably frighten us 80 years later, Koop’s memoir demonstrates an important concept: until recently, medical students played active roles in caring for patients on their paths to becoming physicians. It was inevitable that the medical student role in clinical clerkships would evolve, a result of broader changes in hospital medicine. Increases in support personnel and advances in technology have eased the workload of physicians in training. Students no longer typically draw
blood from patients or collect laboratory specimens— there are phlebotomists and technicians to do that. They no longer typically retrieve radiographs and other imaging studies from a file room and discuss them in person with experienced radiologists. Rather, the studies appear, along with a preliminary interpretation, in a patient’s electronic medical record. Duty hour restrictions designed to increase patient safety have meant less time in the hospital for residents and, in turn, less time for residents to teach students. As the medical knowledge base has grown exponentially, specialty and subspecialty practice are emphasized more than ever. Changes in medicine have inadvertently conspired to make the very academic medical centers that delight in the words teaching hospital less suited for active medical student involvement. At some hospitals, many patients are cared for on nonteaching services, with no involvement of students or residents whatsoever. These changes are not all bad. Increased attention in the hospital to quality of care, informed consent, patient safety, supervision of trainees, and the provision of high-value medical care are good for patients and for clinical practice. Freedom from scut work provides medical students with more opportunities to take ownership of their own education. There is more time to read, to synthesize information, and to understand complex problems and management issues. There is more time to sit with patients at their bedsides and listen; to help them to understand what is wrong with them, what is happening in the hospital, and what is likely to happen after discharge. There is more time to engage with attending physicians. The problem is that these changes should not come at the expense of active medical student involvement in the full range of patient care, which is fundamental to the transition from student to physician. The need for better clinical clerkship experiences is evident. We are hardly unique in raising the concern that medical students are not well prepared to practice medicine.4 There are ongoing efforts to address gaps in the practical skill sets of students before they enter residency training.2,4 Several institutions have developed alternative clerkship year paths, in which medical students follow patients and preceptors longitudinally. Prompted by a recent Carnegie Foundation report5 and other initiatives, many medical schools are considering how to reform their curricula. In our view, the success of such initiatives hinges in large part on whether they successfully alter the fundamental role of the medical student in the hospital by creating and fostering an environment of active student participation in patient care. We offer 3 recommendations to improve thirdyear clinical clerkships.
JAMA Internal Medicine September 2014 Volume 174, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 05/26/2015
jamainternalmedicine.com
Viewpoint Opinion
Recommendation 1: Adopt standardized clinical metrics for medical students. Residency programs have specialty-dependent clinical requirements that residents must meet. Standardized entrustable professional activities are being considered for assessing the competence of residents and accrediting residency programs.6 Medical schools should follow a similar approach for medical students. Just as it is widely accepted that residents should possess certain procedural and interpretive competencies, medical students should have quantifiable and mandatory experiences with skills that physicians should be able to perform2—such as obtaining thorough histories from patients, performing complete physical examinations, drawing blood, conducting a preliminary review of chest radiographs, or sewing minor lacerations. As the development of such skills is emphasized and the skills are mastered, greater involvement of medical students in patient care should follow. Recommendation 2: Pay attending physicians to teach medical students, and provide academic physicians with teaching opportunities. At a time when how much physicians are paid is often related to how many relative value units (RVUs) they bill, it is vital to affirm the important role of faculty in teaching medical students. Attending physicians who find teaching and mentoring students rewarding and who are excellent in these activities should have opportunities to work on services that emphasize medical student training. Attending physicians on these services should be paid, perhaps with academic RVUs.7 With focused attending physician supervision, perhaps in some instances on services that do not include residents, third-year medical students could have ARTICLE INFORMATION Published Online: July 21, 2014. doi:10.1001/jamainternmed.2014.3233. Conflict of Interest Disclosures: None reported. Additional Information: Drs Massey and Anderson graduated from the Perelman School of Medicine at the University of Pennsylvania in May 2014. REFERENCES 1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: The Carnegie Foundation for the Advancement of Teaching; 1910.
jamainternalmedicine.com
opportunities to assume greater responsibility than is typically possible on a traditional inpatient teaching service. As many medical schools are already in the process of shortening their preclinical curricula,8 academic RVUs could be funded by reallocating resources. Recommendation 3: Provide more opportunities for medical students to fulfill clerkship requirements in outpatient and community clinics. Most medical schools provide volunteer opportunities for medical students in university-affiliated outpatient clinics, where they are closely supervised by attending physicians.9 There should be more structured educational opportunities for medical students in outpatient and community clinics; these should include substantial contact with attending physicians and extended opportunities for active participation in patient care. As teaching hospitals have changed in response to advances in medicine, specialty practice, duty hour restrictions, and new payment systems, the role of the third-year medical student role has also changed. Too often, the role of the inpatient clinical clerk has become that of an observer, not a needed team member and an active participant in patient care. This trend should be reversed. Of course, students should actively seek opportunities to engage and to take responsibility for their own clinical education, but the ample responsibilities of medical schools and teaching hospitals cannot be overlooked. As we enter the next phase of our medical training, we know that what our patients will want most is well-trained, empathetic, and caring physicians who have learned from direct patient care experiences.
2. Angus S, Vu TR, Halvorsen AJ, et al. What skills should new internal medicine interns have in July? a national survey of internal medicine residency program directors. Acad Med. 2014;89(3):432-435.
6. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-547.
3. Koop CE. Koop: The Memoirs of America's Family Doctor. 1st ed. Grand Rapids, MI: Zondervan Publishing House; 1992.
7. Mezrich R, Nagy PG. The academic RVU: a system for measuring academic productivity. J Am Coll Radiol. 2007;4(7):471-478.
4. Chen P. Are Med School Grads Prepared to Practice Medicine? Well, New York Times. April 24, 2014. http://well.blogs.nytimes.com/2014/04/24 /are-med-school-grads-prepared-to-practice -medicine/. Accessed May 19, 2014.
8. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA. 2012;307(11):1143-1144.
5. Cooke M, Irby DM, O'Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA: Jossey-Bass; 2010.
9. Meah YS, Smith EL, Thomas DC. Student-run health clinic: novel arena to educate medical students on systems-based practice. Mt Sinai J Med. 2009;76(4):344-356.
JAMA Internal Medicine September 2014 Volume 174, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 05/26/2015
1441
VIEWPOINT
Paul R. Massey, MD Transitional Year Program, University of Texas Southwestern– Austin, Austin. Jeffrey H. Anderson, MD Department of Surgery, University of Washington School of Medicine, Seattle.
Corresponding Author: Paul R. Massey, MD, Transitional Year Program, University of Texas Southwestern– Austin, 601 E 15th St, Austin, TX 78701 (paulrmassey@gmail .com). 1440
Resuscitating Inpatient Clinical Clerkships A Medical Student Perspective Inpatient clinical clerkships in the third year of medical school are the touchstones of traditional medical education in the United States and have remained so since they were originally suggested by Abraham Flexner in 1910.1 Historically, the third year is when a physician is forged from a student and when classroom experience is transformed into clinical acumen. It is a pivotal time for medical students to adapt to the work of the hospital and to revel in the responsibilities of patient care. Unfortunately, the third year of medical school is no longer quite so. As medical school graduates in 2014, we give voice to a fact that both students and academic physicians alike should acknowledge. Despite the best efforts and intentions of all involved, the role of the medical student has changed in clinical clerkships, and changed in ways that may be harmful to students’ preparation to practice medicine. Put simply, medical students spend too much time observing others and too little time directly participating in patient care. Although fourth-year subinternships bring greater responsibilities where skills can be honed, the reality is that traditional medical student roles in academic hospitals have largely been superseded and often not replaced with meaningful tasks. Go back a decade or more, and the role of thirdyear medical students was vital. Students took meaningful initial histories and conducted meaningful physical examinations of patients, drew blood for laboratory tests and spun blood samples for hematocrits, performed manual urinalyses, measured arterial blood gas concentrations in patients with dyspnea, and inserted peripheral intravenous lines. These activities, often performed in exchange for teaching points from hardworking residents, brought students to the bedside, facilitated the growth of interpretive skills, and ensured full involvement in patient care. On the hospital wards, students developed that critical sixth sense that all good physicians must learn, to discern sick from not sick, and— perhaps most important—when to call for help.2 In his memoir, C. Everett Koop, who served as Surgeon General of the United States from 1982 to 1989, recalled making obstetrics home visits as a medical student in the 1930s, independently placing nerve blocks and delivering babies.3 Although this recollection should justifiably frighten us 80 years later, Koop’s memoir demonstrates an important concept: until recently, medical students played active roles in caring for patients on their paths to becoming physicians. It was inevitable that the medical student role in clinical clerkships would evolve, a result of broader changes in hospital medicine. Increases in support personnel and advances in technology have eased the workload of physicians in training. Students no longer typically draw
blood from patients or collect laboratory specimens— there are phlebotomists and technicians to do that. They no longer typically retrieve radiographs and other imaging studies from a file room and discuss them in person with experienced radiologists. Rather, the studies appear, along with a preliminary interpretation, in a patient’s electronic medical record. Duty hour restrictions designed to increase patient safety have meant less time in the hospital for residents and, in turn, less time for residents to teach students. As the medical knowledge base has grown exponentially, specialty and subspecialty practice are emphasized more than ever. Changes in medicine have inadvertently conspired to make the very academic medical centers that delight in the words teaching hospital less suited for active medical student involvement. At some hospitals, many patients are cared for on nonteaching services, with no involvement of students or residents whatsoever. These changes are not all bad. Increased attention in the hospital to quality of care, informed consent, patient safety, supervision of trainees, and the provision of high-value medical care are good for patients and for clinical practice. Freedom from scut work provides medical students with more opportunities to take ownership of their own education. There is more time to read, to synthesize information, and to understand complex problems and management issues. There is more time to sit with patients at their bedsides and listen; to help them to understand what is wrong with them, what is happening in the hospital, and what is likely to happen after discharge. There is more time to engage with attending physicians. The problem is that these changes should not come at the expense of active medical student involvement in the full range of patient care, which is fundamental to the transition from student to physician. The need for better clinical clerkship experiences is evident. We are hardly unique in raising the concern that medical students are not well prepared to practice medicine.4 There are ongoing efforts to address gaps in the practical skill sets of students before they enter residency training.2,4 Several institutions have developed alternative clerkship year paths, in which medical students follow patients and preceptors longitudinally. Prompted by a recent Carnegie Foundation report5 and other initiatives, many medical schools are considering how to reform their curricula. In our view, the success of such initiatives hinges in large part on whether they successfully alter the fundamental role of the medical student in the hospital by creating and fostering an environment of active student participation in patient care. We offer 3 recommendations to improve thirdyear clinical clerkships.
JAMA Internal Medicine September 2014 Volume 174, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 05/26/2015
jamainternalmedicine.com
Viewpoint Opinion
Recommendation 1: Adopt standardized clinical metrics for medical students. Residency programs have specialty-dependent clinical requirements that residents must meet. Standardized entrustable professional activities are being considered for assessing the competence of residents and accrediting residency programs.6 Medical schools should follow a similar approach for medical students. Just as it is widely accepted that residents should possess certain procedural and interpretive competencies, medical students should have quantifiable and mandatory experiences with skills that physicians should be able to perform2—such as obtaining thorough histories from patients, performing complete physical examinations, drawing blood, conducting a preliminary review of chest radiographs, or sewing minor lacerations. As the development of such skills is emphasized and the skills are mastered, greater involvement of medical students in patient care should follow. Recommendation 2: Pay attending physicians to teach medical students, and provide academic physicians with teaching opportunities. At a time when how much physicians are paid is often related to how many relative value units (RVUs) they bill, it is vital to affirm the important role of faculty in teaching medical students. Attending physicians who find teaching and mentoring students rewarding and who are excellent in these activities should have opportunities to work on services that emphasize medical student training. Attending physicians on these services should be paid, perhaps with academic RVUs.7 With focused attending physician supervision, perhaps in some instances on services that do not include residents, third-year medical students could have ARTICLE INFORMATION Published Online: July 21, 2014. doi:10.1001/jamainternmed.2014.3233. Conflict of Interest Disclosures: None reported. Additional Information: Drs Massey and Anderson graduated from the Perelman School of Medicine at the University of Pennsylvania in May 2014. REFERENCES 1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: The Carnegie Foundation for the Advancement of Teaching; 1910.
jamainternalmedicine.com
opportunities to assume greater responsibility than is typically possible on a traditional inpatient teaching service. As many medical schools are already in the process of shortening their preclinical curricula,8 academic RVUs could be funded by reallocating resources. Recommendation 3: Provide more opportunities for medical students to fulfill clerkship requirements in outpatient and community clinics. Most medical schools provide volunteer opportunities for medical students in university-affiliated outpatient clinics, where they are closely supervised by attending physicians.9 There should be more structured educational opportunities for medical students in outpatient and community clinics; these should include substantial contact with attending physicians and extended opportunities for active participation in patient care. As teaching hospitals have changed in response to advances in medicine, specialty practice, duty hour restrictions, and new payment systems, the role of the third-year medical student role has also changed. Too often, the role of the inpatient clinical clerk has become that of an observer, not a needed team member and an active participant in patient care. This trend should be reversed. Of course, students should actively seek opportunities to engage and to take responsibility for their own clinical education, but the ample responsibilities of medical schools and teaching hospitals cannot be overlooked. As we enter the next phase of our medical training, we know that what our patients will want most is well-trained, empathetic, and caring physicians who have learned from direct patient care experiences.
2. Angus S, Vu TR, Halvorsen AJ, et al. What skills should new internal medicine interns have in July? a national survey of internal medicine residency program directors. Acad Med. 2014;89(3):432-435.
6. ten Cate O, Scheele F. Competency-based postgraduate training: can we bridge the gap between theory and clinical practice? Acad Med. 2007;82(6):542-547.
3. Koop CE. Koop: The Memoirs of America's Family Doctor. 1st ed. Grand Rapids, MI: Zondervan Publishing House; 1992.
7. Mezrich R, Nagy PG. The academic RVU: a system for measuring academic productivity. J Am Coll Radiol. 2007;4(7):471-478.
4. Chen P. Are Med School Grads Prepared to Practice Medicine? Well, New York Times. April 24, 2014. http://well.blogs.nytimes.com/2014/04/24 /are-med-school-grads-prepared-to-practice -medicine/. Accessed May 19, 2014.
8. Emanuel EJ, Fuchs VR. Shortening medical training by 30%. JAMA. 2012;307(11):1143-1144.
5. Cooke M, Irby DM, O'Brien BC. Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA: Jossey-Bass; 2010.
9. Meah YS, Smith EL, Thomas DC. Student-run health clinic: novel arena to educate medical students on systems-based practice. Mt Sinai J Med. 2009;76(4):344-356.
JAMA Internal Medicine September 2014 Volume 174, Number 9
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 05/26/2015
1441
