I found an interesting study this
week that I wanted to blog about today. This study was published in Medical Education a couple of years ago. The authors, Dong and colleagues (1) asked an
important and very common question: does the experience that a student has
during a clinical rotation effect their performance on that rotation? This is
important for many reasons. One big reason is that developing and maintaining
adequate clinical experiences is an expensive and time-consuming process. It
would be nice if we knew that the experiences that we were providing for
students were having a positive effect.
The authors describe two
alternative theories of learning in the clinical arena. One idea is that
students need to utilize deliberate practice to learn. In other words, they
need specific learning experiences that are led by a qualified mentor. These learning
experiences are planned and need to be varied and extensive in order for
students to develop expertise. The alternative idea is based on the concept of
cognitive load theory. In this theory, medical students may have difficulty
learning clinical medicine when they are exposed to multiple patients and
clinical problems. Instead, students might learn better if they have more straightforward
instructional formats, such as simulated cases.
Clinical clerkships in all
specialties spend a lot of time trying to demonstrate that the clinical experiences
that they provide are similar across different sites and for different
students. A previous study of clerkship directors from Internal Medicine, found
that they use core cases to compare the clinical experiences of multiple
students.(2) Many clinical clerkships use paper or electronic logs to track the
students’ experiences.
This study was done at the
Uniformed Services University which is the military medical school. It is the
only federal medical school and draws students from across the country. The
authors looked at students on the internal medicine clerkship. The students kept
track of all of their patient contacts using a patient log. They tracked how
many patients each student saw and the number of patients with core problems
that were seen.
The authors compared students’
intensity of clinical exposure with performance on the clerkship. What they
found was a little surprising and maybe a bit counter-intuitive. Student
performance was positively correlated with their clinical
experience, but only weakly . Specifically, after they used a pre-test to control for ability,
there was a weak (r = 0.19) but statistically significant association. The student’s
clinical score improved by two points with every ten extra patients that they saw in
the outpatient setting. Similarly, the number of core clinical problems that
the students saw was correlated to their ambulatory clinical score (r = 0.19; p
< 0.05). In real terms this means that a student who saw patients with all
of the core problems (about 88% of all students), scored less than four points
higher in ambulatory clinical points than those who did not see all of the core
problems.
So what does this all mean? Well,
for one thing, we need to think very carefully about how clinical experiences
should be structured. More is not necessarily better at least when it comes to
number of patients. A targeted approach that is thoughtful and includes more
time to think about patients may actually be better.
References
1) Dong T, et al. Relationship
between clinical experiences and internal medicine clerkship performance. Medical Education 2012: 46: 689–697.
2) Denton GD, Durning SJ.
Internal medicine core clerkships experience with core problem lists: results
from a national survey of clerkship directors in internal medicine. Teach Learn Med 2009; 21: 281–3.
