Surgical clerkship: Do examination scores correlate with clinical performance?

BACKGROUND: This study aims to determine if there are correlations between clinical performance and objective grading parameters for medical students in the third-year surgery clerkship. METHODS: Clerkship grades were compiled from 2016 to 2020. Performance on clinical rotations, NBME shelf exam, oral exam, and weekly quizzes were reviewed. Students were divided into quartiles (Q1-Q4) based on clinical performance. Standard statistical analysis was performed. RESULTS: There were 625 students included in the study. Students in Q1+Q2 were more likely than those in Q3+Q4 to score in the top quartile on the shelf exam (29% vs. 19%, p = 0.002), oral exam (24% vs. 17%, p = 0.032), and quizzes (22% vs. 15%, p = 0.024). However, there was negligible correlation between clinical performance and performance on objective measures: shelf exam (R2 = 0.027, p < 0.001), oral exam (R2 = 0.021, p < 0.001), and weekly quizzes (R2 = 0.053, p = 0.092). CONCLUSIONS: Clinical performance does not correlate with objective grading parameters for medical students in the third-year surgery clerkship.

A Nationwide Survey Study on Medical Student Experience in Acute Care Surgery.

BACKGROUND: There is little known about medical student education in acute care surgery (ACS)-how much and what type of exposure students receive in the specialty. The aim of this study was to investigate the current status of ACS education provided to students in U.S. medical schools. MATERIALS AND METHODS: We created an online survey tool covering the surgical clerkship and ACS curriculum and distributed this survey to the official email list of the Association for Surgical Education Committee on Clerkship Directors. RESULTS: A total of 57 of 294 (19.4%) responses were received. All respondents reported that at least some of their major teaching hospitals are affiliated with an ACS service and have a level 1 or 2 trauma center. Although almost two-thirds (61.8%) of respondents believe that medical students should have formal ACS education in the form of a clinical rotation, an ACS rotation is mandatory at only 16.4% of programs and is optional at 69.1% of programs as part of the surgical clerkship curriculum. The duration of ACS rotations ranges from 1 to 6 wk, and half of programs require students to take overnight call (most often 1-2 nights/wk). The most common pathologies that students see on ACS include appendicitis, biliary disease and cholecystitis, intestinal obstruction, and trauma. CONCLUSIONS: Medical students across the nation have varying exposure to ACS during their clinical training. With the continued growth of the ACS specialty, further study is warranted to examine the impact of undergraduate ACS education on student career planning.

"There Is a Lot of Change Afoot": A Qualitative Study of Faculty Adaptation to Elimination of Tiered Grades With Increased Emphasis on Feedback in Core Clerkships.

PURPOSE: Medical schools responding to challenges with fairness, equity, learning environments, and student wellness have reconsidered clerkship grades. This study used the Concerns-Based Adoption Model (CBAM) to explore how faculty responded to a change in the approach to assessment from focus on grades toward focus on feedback. METHOD: This qualitative study used an inductive approach to analyze data from semistructured interviews with teaching faculty and education leaders at University of California, San Francisco, School of Medicine 6 months following the elimination of traditional tiered clerkship grades. Participants were recruited in 2019 using purposive sampling. Interview questions addressed participants' perceptions of the new approach to assessment and grading that emphasizes assessment for learning, including advantages and concerns. The authors analyzed data using thematic analysis informed by sensitizing concepts from CBAM. RESULTS: Nineteen faculty participated (11 medicine, 8 surgery). Faculty expressed optimism about the impact of the change on their clinical educator roles and sought faculty development to enhance feedback and assessment skills. Perceived benefits to students addressed learning and wellness, with concern for students' motivation and professional development. Faculty shared uncertainty about their roles and larger systemic consequences involving the residency match and institutional reputation. Participants acknowledged that traditional grading is imperfect, yet felt a departure from this system represented significant culture change. CONCLUSIONS: Faculty perceptions of the assessment and grade change in 2 large departments demonstrated tensions around grading. Their descriptions of change as an ongoing process aligned with CBAM and required them to consider new approaches and perspectives. While discourse about assessment and grading frequently focuses on learners, these findings support institutional consideration of the impact of changes in assessment on teaching faculty.

Medical students' reflections on surgical educators' professionalism: Contextual nuances in the hidden curriculum.

INTRODUCTION: Surgical educators' professional behavior constitutes a hidden curriculum and impacts trainee's professional identity formation. This study explores the nuances of professional behaviors as observed in varying surgical settings. METHODS: 411 Transcripts originated from essays written by MS3 students during their surgical clerkship from 2010 to 2016 were collated. Employing a qualitative research methodology, we conducted a thematic analysis to uncover specific meaning emerging from medical student reflections' on surgical professionalism. RESULTS: In clinics, taking time and protecting patient privacy; in the OR, control over emotion during difficult situations and attention to learners; and in the inpatient setting, showing accountability above normal expected behavior were noted as professional. Similarly, unprofessional behaviors in these contexts paralleled lack of these attributes. CONCLUSIONS: Behaviors observed and the attributes of professionalism in the surgical learning environment have contextual nuances. These variations in professionalism can be utilized in deliberate development of professionalism in surgery.

Are We Measuring What Matters? How Student and Clerkship Characteristics Influence Clinical Grading.

PURPOSE: Given the growing emphasis placed on clerkship performance for residency selection, clinical evaluation and its grading implications are critically important; therefore, the authors conducted this study to determine which evaluation components best predict a clinical honors recommendation across 3 core clerkships. METHOD: Student evaluation data were collected during academic years 2015-2017 from the third-year internal medicine (IM), pediatrics, and surgery clerkships at the University of Alabama at Birmingham School of Medicine. The authors used factor analysis to examine 12 evaluation components (12 items), and they applied multilevel logistic regression to correlate evaluation components with a clinical honors recommendation. RESULTS: Of 3,947 completed evaluations, 1,508 (38%) recommended clinical honors. The top item that predicted a clinical honors recommendation was clinical reasoning skills for IM (odds ratio [OR] 2.8; 95% confidence interval [CI], 1.9 to 4.2; P < .001), presentation skills for surgery (OR 2.6; 95% CI, 1.6 to 4.2; P < .001), and knowledge application for pediatrics (OR 4.8; 95% CI, 2.8 to 8.2; P < .001). Students who spent more time with their evaluators were more likely to receive clinical honors (P < .001), and residents were more likely than faculty to recommend clinical honors (P < .001). Of the top 5 evaluation items associated with clinical honors, 4 composed a single factor for all clerkships: clinical reasoning, knowledge application, record keeping, and presentation skills. CONCLUSIONS: The 4 characteristics that best predicted a clinical honors recommendation in all disciplines (clinical reasoning, knowledge application, record keeping, and presentation skills) correspond with traditional definitions of clinical competence. Structural components, such as contact time with evaluators, also correlated with a clinical honors recommendation. These findings provide empiric insight into the determination of clinical honors and the need for heightened attention to structural components of clerkships and increased scrutiny of evaluation rubrics.

The Influence of an Acting or Subintern on Third-Year Medical School Surgery Clerkship Students.

BACKGROUND: Previous reports demonstrated a positive relationship between the surgical clerkship and student likelihood of pursuing a surgical career, but no studies have examined the influence a peer has on comfort during a surgical clerkship. We hypothesized that a fourth-year acting intern (AI) would positively impact third-year medical students' experience during their surgical clerkship. METHODS: All third-year medical students at our institution who completed their surgical clerkship in 2019 were surveyed regarding the preclerkship and postclerkship perceptions. RESULTS: Of the 110 students surveyed, 52 responded (47.3% response rate), and 25 students (48.1%) reported having an AI during their clerkship rotation, and 27 did not (51.9%). Presence of an AI had no significant effect on the postclerkship perception of surgery, likelihood of pursuing general surgery, or comfort in the OR. Analysis of all responses demonstrated the surgery clerkship had no significant impact on students' perception of surgery or likelihood of pursuing general surgery but did statistically increase students' comfort in the OR. CONCLUSIONS: The results of this study suggest that AI presence did not significantly influence a student's clerkship experience or comfort in the OR. Further studies are needed to determine what, if any effect, an AI could have on third-year clerkship students.

Shortened pre-clerkship medical school curriculum associated with reduced student performance on surgery clerkship shelf exam.

BACKGROUND: Many U.S. medical schools are modifying their curricula with limited understanding of the impact on students' clinical knowledge. METHODS: The surgical rotations and Surgery Shelf Exam score reports of 1514 students at a single medical school over nine academic years (2010-2018), which included a four-year transition period to a condensed pre-clerkship curriculum. Subject-specific results were compared by rotation type using Mann-Whitney tests. Regression analysis was used to assess the relationship between scores and time. RESULTS: Data from 1514 students were included. Shelf scores decreased each year of the transition curriculum compared to the reference year (2014-2015). However, clinical exposure to specific rotations resulted in better scores in related shelf subjects. For example, students who rotated on Vascular Surgery achieved statistically better scores on the related subject than their colleagues (3.62 vs. 3.44; p = 0.0014). CONCLUSIONS: The transition curriculum was associated with a lower performance on the surgical shelf exam when compared to the traditional curriculum, regardless of when surgery was taken during their clerkship year.

The Impact of a Multidisciplinary Third-Year Oncology Elective Rotation on Decisions to Pursue Oncologic Careers and Oncology Exposure.

PURPOSE: The majority of oncologic care is provided in the outpatient setting, yet at many medical schools, the dominant means of exposure to oncology occurs during inpatient rotations. Given the multidisciplinary nature of the specialty, radiation oncology departments are well positioned to lead outpatient oncology rotations within medical schools. Since 1992, the University of Cincinnati's Department of Radiation Oncology has administered a 2-week, third-year clinical oncology elective. This report characterizes the rotation and evaluates the impact of the rotation on students' oncology exposure and career choices over the past 10 years. METHODS AND MATERIALS: A list of medical students who participated in the MS3 clinical oncology elective rotation from 2008 to 2018 was reviewed. A search engine was used to locate the physicians and identify their specialty choices. A survey of 7 questions was distributed to the oncologists to evaluate how the rotation influenced their oncology exposure and career choice. RESULTS: Two hundred sixty-eight medical students participated in the MS3 Clinical Oncology Specialty Clerkship from 2008 to 2018. Thirty-nine students (15%) ultimately pursued a career in oncology. Seventy-four percent of the oncologists are radiation oncologists. Eighty-eight percent of the physicians surveyed had a positive to very positive experience with the rotation. The rotation was the first clinical exposure to the field of oncology for 48% of the respondents and the first exposure to the field of radiation oncology for 69% of the physicians. Seventy-two percent of the oncologists attributed the MS3 rotation as providing a moderate or great deal of early exposure to the field of oncology. CONCLUSIONS: Radiation oncology departments are well positioned to lead multidisciplinary, ambulatory oncology electives within US medical schools. A majority of participating oncologists viewed the rotation positively and attributed the rotation with their entrance into oncology.

The Current Status of Medical School Clerkship Grades in Residency Applicants.

BACKGROUND: Two criteria that have been investigated for evaluating orthopedic surgery residency candidates are achieving an "honors" grade during a surgery clerkship and the total number of honors grades received in all clerkships. Unfortunately, the rate of honors grades given and the criteria for earning an honors grade differ between medical schools, making comparison of applicants from different medical schools difficult. OBJECTIVE: We measured the rate of honors grades in clerkships at different medical schools in the United States to examine the utility of clerkship grades in evaluating orthopedic surgery residency applicants. METHODS: Adequate data via the Electronic Residency Application Service were available for 86 of 142 Association of American Medical Colleges medical schools from the 2017 Match cycle. Descriptive statistics and Wilcoxon rank sum tests were performed to identify differences in grade distributions within each clerkship and in school ranking for research by U.S. News & World Report. RESULTS: For the surgery clerkship, the median rate of honors grades given was 32.5% (range 5%-67%). There was a high rate of interinstitutional variability in all clerkships. We were unable to demonstrate a statistically significant relationship between research ranking and percentage honors grades given for individual clerkships. CONCLUSIONS: A standardized method for grading medical students during clinical clerkships does not exist, resulting in a high degree of interinstitutional variability. Surgery clerkship grades are an unreliable measure for comparing orthopedic surgery residency applicants from different medical schools. Standardized measures of applicant evaluation might be helpful in the future.

Medical Student Exposure to Radiation Oncology Through the Pre-clerkship Residency Exploration Program (PREP): Effect on Career Interest and Understanding of Radiation Oncology.

Medical students receive little exposure to Radiation Oncology (RO) during pre-clinical training and clerkship. Pre-clerkship Residency Exploration Program (PREP) was developed by medical students at our institution to provide students with exposure to disciplines like RO with which they may not have had previous exposure, with the goal of helping with career decision making. The purpose of this study was to review how PREP affected self-reported interest in RO. PREP is a 2-week intensive elective developed by students at Dalhousie University that provides exposure to 12 specialties, including RO. PREP includes five components: half day clinical rotations, skills sessions, simulations, specialty-specific workshops, and lunchtime panel discussions. PREP participants completed questionnaires pre- and post-participation to assess career interest and understanding of Radiation Oncology. Forty participants took part in PREP. Thirty-six responded to pre-PREP questionnaires and 37 to the post-PREP questionnaire. Participants reported increasing interest in RO (24 students, 64.8%) and an increase in the understanding of the role and responsibilities of a radiation oncologist such that they felt comfortable making a career decision about RO. In pre-PREP, five (13.8%) participants listed RO as a top 3 career choice. Post-program, this number increased to nine (25.0%) of the same surveyed participants. PREP has demonstrated early exposure to RO can increase interest in RO as a career choice. Early clinical exposure experiences like we describe here may be useful for specialties such as RO, which is having difficulty filling residency positions in Canada despite an optimistic job forecast for trainees.

National Radiation Oncology Medical Student Clerkship Trends From 2013 to 2018.

PURPOSE: The purpose of this study was to assess national trends in fourth-year medical student radiation oncology clerkships over the past 6 academic years. Results demonstrate a national trend toward inclusion of structured didactics in radiation oncology clerkships coinciding with the implementation and expansion of the Radiation Oncology Education Collaborative Study Group (ROECSG) clerkship curriculum. However, over half of clerkship experiences continue to lack a structured didactic curriculum. Over the past 6 years, the ROECSG implemented and expanded upon a national standardized curriculum for the fourth-year medical student radiation oncology clerkship. This study hypothesized that this would lead to increased use of structured clerkship educational methods on a national level. METHODS AND MATERIALS: From 2013 to 2018, all applicants to a single United States radiation oncology residency program were sent an anonymous clerkship experience survey. The χ2 test was used for statistical analysis. RESULTS: Of 1183 students, 488 completed the survey (41.3% response rate); 1303 total clerkship experiences were described. From 2013 to 2018, there has been a significant increase in clerkships with lectures designed for medical students, from 28.3% of clerkships in 2013 to 43.2% in 2018 (P = .02). Students who received ≥1 formal lecture perceived greater postclerkship confidence in radiation oncology-related knowledge (P < .01) and overall confidence in their ability to function as a postgraduate year-2 resident (P = .02). CONCLUSIONS: These results demonstrate a national trend toward inclusion of structured didactics in radiation oncology clerkships coinciding with the expansion of the ROECSG curriculum and support the addition of structured didactics to the clerkship experience to provide medical students with foundational radiation oncology knowledge to function as residents.

Medical clerks in a national university hospital: improving the quality of medical care with a focus on spinal surgery.

In our institution, which is a national university hospital, medical clerks were introduced in 2009 to improve the doctor's working environment. Seventeen clerks were assigned to 9 separate departments and the work content differed greatly among departments, but sufficient professional work was not done efficiently. The purpose of this study is to investigate the effects of the work of medical clerks on improvement of medical quality in recent years. In 2011, we established a central clerk desk on our outpatient floor to improve efficiency and centralize the clerk work. Since 2013, periodic education of clerks on spine disease has been provided by spine doctors, and this has facilitated sharing of information on spinal surgery from diagnosis to surgical treatment. This has allowed medical clerks to ask patients questions, leading to more efficient medical treatment and a potential reduction of doctors' work. In 2016, a revision of the insurance system by the Ministry of Health, Labour and Welfare of Japan increased the amount of medical work that clerks can perform, and it became possible to increase the number of medical clerks. Currently, we have 30 medical clerks, and this has allowed establishment of new clerk desks in other departments to handle patients. A training curriculum will be developed to reduce the burden on doctors further and to improve the quality of medical treatment.

Student use and perceptions of mobile technology in clinical clerkships - Guidance for curriculum design.

BACKGROUND: We examined the types of technology used by medical students in clinical clerkships, and the perception of technology implementation into the curriculum. METHODS: An online survey about technology use was completed prior to general surgery clinical clerkship. Types of devices and frequency/comfort of use were recorded. Perceptions of the benefits and barriers to technology use in clerkship learning were elicited. RESULTS: 125/131 (95.4%) students responded. Most students owned a smart phone (95.2%), tablet (52.8%), or both (50%); 61.6% spent > 11 h/week learning on a device at the Johns Hopkins School of Medicine for educational purposes. Technology use was seen as beneficial by 97.6% of students. Classes that used technology extensively were preferred by 54% of students, although 47.2% perceived decreased faculty/classmate interaction. CONCLUSIONS: Students use mobile technology to improve how they learn new material, and prefer taking classes that incorporate information technology. However, in-person/blended curricula are preferable to completely online courses.

Are the kids alright? Review books and the internet as the most common study resources for the general surgery clerkship.

BACKGROUND: To define resources deemed most important to medical students on their general surgery clerkship, we evaluated their material utilization. METHODS: A prospective study was conducted amongst third-year medical students using a 20-item survey. Descriptive statistics were performed on the demographics. Kruskal-Wallis and Mann-Whitney analyses were performed on the Likert responses (α = 0.05). RESULTS: Survey response was 69.2%. Use of review books and Internet was significantly higher compared to all other resources (p < 0.05). Wikipedia was the most used Internet source (39.1%). 56% never used textbooks. Analyses of surgery subject exam (NBME) results or intended specialty with resources used showed no statistical relationship (all p > 0.05). CONCLUSIONS: Resources used by students reflect access to high-yield material and increased Internet use. The Internet and review books were used more than the recommended textbook; NBME results were not affected. Understanding study habits and resource use will help guide curricular development and students' self-regulated learning.

Dermatology teaching in Australian Medical Schools.

BACKGROUND/OBJECTIVES: Although skin disease and skin cancers cause significant morbidity and mortality in Australia, limited time is dedicated to dermatology teaching in most medical courses. The aim of this study was to define the current state of dermatology teaching in Australian medical schools with a view to developing a national core curriculum for dermatology. METHODS: An electronic questionnaire was circulated to the dermatology teaching leads and relevant medical program coordinators of the 18 medical schools in Australia. RESULTS: Replies were received from 17 medical schools. Dermatology was included as part of the core curriculum in 15 schools. Time set aside for dermatology teaching varied, as reflected by the number of lectures delivered (0-21, mean 5, median 3) and minimum clinics attended (0-10, mean 1.2, median 0). Only four medical schools had a compulsory clinical attachment in dermatology. Furthermore, satisfying requirements in dermatology was mentioned in the university examination regulations in only six schools. Certain core learning outcomes were addressed in most schools, including the structure and function of the skin, common conditions such as atopic dermatitis and psoriasis and cutaneous malignancies. However, there were important omissions, ranging from common problems like dermatophyte infections and drug reactions to the recognition of dermatological emergencies. CONCLUSIONS: These results are a compelling impetus to improve current standards of dermatology teaching, learning and assessment. The introduction of a national core curriculum would provide guidelines for dermatology teaching in medical schools, enabling the more effective utilisation of available time for key learning outcomes.

Educational Impact of a Structured Radiation Oncology Clerkship Curriculum: An Interinstitutional Comparison.

PURPOSE: Many medical school clerkships have structured curricula; however, most radiation oncology clerkships do not. The Radiation Oncology Education Collaborative Study Group (ROECSG) implemented a curriculum for fourth-year radiation oncology clerkships at 14 institutions. We hypothesized that students completing clerkships with the curriculum would report greater subjective knowledge and comfort to function as a radiation oncology resident compared with students completing clerkships without the curriculum. METHODS: The ROECSG curriculum included three 1-hour lectures and a 1-hour hands-on radiation treatment planning workshop. Applicants to a single radiation oncology residency program in the 2014-2015 academic year were sent an anonymous, validated clerkship experience survey. Students indicated if clerkships were completed at a curriculum site. Likert-type data (1 = not at all, 5 = extremely) are reported as median (interquartile range). RESULTS: Respondents described 276 clerkship experiences, of which 64 (23.2%) were completed at a curriculum site. Students whose first clerkship was at a curriculum site perceived greater postclerkship confidence in knowledge of radiation biology (3 [3-4] versus 2 [2-3], P < .01), treatment setup/positioning (3 [2-3] versus 2 [2-3], P < .05), treatment planning (3 [2-3] versus 2 [2-3], P < .01), and ability to integrate evidence-based medicine into treatment (4 [2-4] versus 3 [2-4], P < .05). Students who completed any clerkship with the curriculum had greater postclerkship confidence to function as a radiation oncology resident (3 [3-4] versus 3 [2-3], P < .05). CONCLUSIONS: These results support the curriculum's ability to increase student knowledge in radiation oncology, especially in the students' first clerkship. Further, these findings suggest that expanded implementation of such curricula may ensure a rewarding educational experience during radiation oncology clerkships.

Does a Vacation Break Impact the Outcomes of Required Clinical Clerkships?

BACKGROUND AND OBJECTIVES: Our objective was to assess the impact of disruption by a new 2-week vacation break on outcomes of required third-year clerkships. METHODS: Mean scores on National Board of Medical Examiners (NBME) clerkship specific clinical science subject ("subject") examinations and overall student evaluations were compared for clerkships with the break and those over the previous 3 years without the break. Students were surveyed about the impact of the break on learning and the time spent studying during the break. RESULTS: No significant differences were found in examination scores between clerkships with the break and those without. Overall student clerkship evaluations were significantly different only for the surgery clerkship. The break was regarded more favorably by students on the 8-week than the 6-week clerkships, but student perspectives varied significantly by specialty. The time reported studying varied significantly by specialty and campus. Student comments were predominantly supportive of the break and focused on the advantages of opportunity to relax, spend time with family, and to study. Concerns included forgetting content knowledge, losing skills, and having difficulty regaining momentum on return to the clerkship. CONCLUSIONS: Interruption of clerkships by a 2-week break was not associated with any significant change in subject examination scores or overall student evaluation of the clerkship, despite predominantly positive comments. Significant differences were reported by specialty in student perception of benefit and reported time studying during the break.