Does the experience on a clinical clerkship effect performance?

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.