Guidebook for Clerkship Directors
Katherine Margo, MD, Lead Author
Medical schools have many missions, including education, research, and clinical care. However, education of medical students is paramount because only medical schools graduate physicians and medical school faculty fill a critical in ensuring the competence and professionalism of the future physician workforce. Clinical clerkships form the foundation of student education during the third year. Sir William Osler created the first clerkship and established the traditional format more than a century ago. The student was involved initially as an observer and then, with more experience, as a participant in patient care on inpatient wards. Since that time, overseeing organizations such as the Liaison Committee on Medical Education (LCME) have required more structure to the experience; clerkship goals and objectives must be clarified, the numbers and types of patients to be seen by students must be determined for each clerkship, and activities that address specific competencies must be formulated for each clerkship (www.LCME.org). The Accreditation Council of Graduate Medical Education (ACGME) recently developed six competencies that must be taught and evaluated in residency programs. Medical schools will likely soon be required to assess similar competencies, ensuring adequate preparation of students for the transition to residency (www.ACGME.org). Additionally, formal summative and formative assessments of student performance are required for each clerkship.
As the clerkship format has evolved, so have the expectations and roles of the clerkship director. Clerkship Directors ensure that the rotation’s curriculum complements the school’s pre-clinical and overall clinical curriculum, coordinate resident and faculty teaching of students within the department, and assume responsibility for evaluation of student performance. Clerkship Directors often serve as mentors to students who are interested in their specialty and may conduct education research. Within the institution, Clerkship Directors often perform administrative functions, serving as members or leaders of curriculum or promotions or other committees. The role of a Clerkship Director has evolved into a career pathway. To be successful in this pathway, Clerkship Directors require appropriate knowledge and skills to administer their clerkship and assume an education leadership role within the department. This introductory chapter will review the role of the Clerkship Director and set the stage for in-depth discussions in subsequent chapters.
Clerkship Directors should have a strong interest in medical student education and be knowledgeable about the school’s values, culture, and educational goals and objectives. Many faculty become Clerkship Directors at the request of department chairs who recognize a faculty member’s desire to become a departmental education leader. As the Clerkship Director often serves as the chair’s spokesperson regarding education matters within the medical school, an effective working relationship is essential. The Clerkship Director is a critical member and leader of a department’s education team, and serves as a liaison between students and residents, and faculty of the department, other departments, and the school’s administration. Few Clerkship Directors are formally trained as education leaders or teachers and, therefore, usually receive mentoring by former Clerkship Directors or by the chair. Increasingly, specialty societies offer training opportunities for new Clerkship Directors. In many institutions, Clerkship Directors from all required clerkships have periodic meetings during which experienced Clerkship Directors from other specialties and associate deans may serve as mentors for new Clerkship Directors. Finally, much of the knowledge and skills as Clerkship Directors comes from “on the job training.”
Many Clerkship Directors consider the coordination of student education as their major job responsibility and remain at their posts for many years. 1, 2 Long-term career development for the successful Clerkship Director includes the development of innovative approaches to student education and educational scholarship.3 Clerkship Directors may gain the experience and skills to progress to higher level administrative positions.
Interest in and understanding of medical student education is essential. New Clerkship Directors should have experience teaching medical students in didactic or clinical settings to ensure they enjoy teaching students and understand the differences between educating students and residents. Clerkship Directors must understand their medical school’s curriculum as well as national expectations for medical school curricula. New Clerkship Directors benefit from meeting with Clerkship Directors from other specialties to learn about common clerkship issues. Meeting with the dean responsible for the undergraduate curriculum helps give the Clerkship Directors perspective on the goals and objectives of the curriculum. Developing relationships with educational leaders in the institution provides an invaluable foundation for success as a Clerkship Directors. Experience in running an administrative program is helpful, but can be gained “on the job.” Most Clerkship Directors are physicians in the given specialty, ensuring a thorough understanding of the field and credibility with students. However, some Clerkship Directors are EdDs or PhDs with a special interest in the given specialty. Many departments have an education committee or division, and Clerkship Directors often serve as department education leaders. Clerkship Directors must have good interpersonal skills and enthusiasm for the work. Establishing rapport with students, staff, and administrators is essential. Being able and willing to collaborate with individuals at all levels of the institution is critical in developing and maintaining a successful clerkship. Flexibility is another indispensable trait, given the inevitable differences of opinions that Clerkship Directors encounter in their role as liaison between students and others. Pangaro et al. 4 published a widely distributed manuscript describing the qualifications of a clerkship director. In some specialties, specialty-specific qualifications are enumerated. 5
Recommended qualifications of a clerkship director:
Table 1 lists clerkship directors’ tasks and links them to the pertinent chapters in this guidebook.
Create and Maintain Effective Learning Experiences
A clerkship director must establish and maintain a vibrant, clinically oriented learning experience for students. The clerkship curriculum is built around clearly stated goals and objectives that reflect the field’s core knowledge and the clinical volume available to students. Clinical and didactic experiences that enable the students to attain these goals must be carefully planned and implemented. Fair assessments of clinical performance and didactic knowledge must be developed and continuously evaluated.
Relationships with Students
A mutually respectful relationship between the clerkship director and students is an outgrowth of careful planning and organization of clerkship orientation and activities, enthusiasm in conducting the clerkship, and the implementation of assessment and grading policies that are fair and non-arbitrary. Regular meetings with students, both as a group and, at least once during the clerkship as individuals, are invaluable for the clerkship directors in assessing the educational value of clinical and didactic clerkship activities. Additionally, an “open door” policy, where students have a standing invitation to discuss issues with the clerkship director, may reveal a personality conflict or identify professionalism problems that may deter a student from having a productive clerkship experience.
Relationship with Chair
The clerkship director provides a critical link in the department, keeping the department chair apprised of undergraduate education activities, and serving as a link between students and the faculty and residents. The clerkship director functions as the chair’s advisor in matters of student education. The clerkship director's relationship with the chair is critical both for success in negotiating for resources and for support in developing and implementing new ideas.
Relationship with Residency Program Director
Because residents play a major role in educating medical students, the clerkship director must collaborate with residents and residency program directors. It is important to minimize “conflicts of interest” between education for residents and students. Since the ACGME 80-hour-work week requirements have been in place, continuity of teaching has been more challenging. Frequent communication with the residency program director and the coordination of student and resident goals and objectives will foster an environment that meets the needs of both. Just as meetings with students help to identify problems, periodic meetings with the residents facilitate their understanding of the student curriculum and allow them to voice questions and concerns. The clerkship director may participate in presentations to residents on how to teach medical students.
The clerkship director plays an important role in faculty development. The clerkship director, in cooperation with the chair, gives departmental faculty information regarding the goals and objectives for the students’ learning experience on the clerkship, expectations for student performance, and criteria for grading and feedback. Faculty development can include conferences or institution and department level training in teaching techniques. Access to faculty development opportunities is very helpful in recruiting and retaining faculty who are dedicated to educating medical students. The clerkship director may function as an information clearinghouse for such opportunities. (return to top )
An effective clerkship director must devote considerable time to developing, administering and evaluating the clerkship as well as to direct teaching activities and evaluation of students. The clerkship cirector must have adequate time dedicated to these functions. In the 1990s, internal medicine department chairs endorsed the recommendation that clerkship directors devote 25% of their time to directing the clerkship and receive 25% salary support for this activity. 6 A survey of internal medicine clerkship directors showed that clerkship directors generally require about 25% of their time for administrative clerkship activities. 3 However, the performance expectations of clerkship directors have increased with a greater emphasis on scholarly work in the area of medical education. Most recently, a minimum of 50% time allocation has been strongly recommended for clerkship administration, teaching, and scholarly work. 4 Psychiatry has recommended 55% time. 5 It is critical to negotiate with the department chair for adequate time and monetary support to ensure successful clerkship administration and teaching and attending faculty development conferences that help bring educational innovations to the clerkship. (return to top )
Faculty become clerkship directors from many different pathways, some at the beginning and some at the end of their careers.
Some clerkship directors complete a faculty development fellowship. Family medicine and internal medicine have such fellowships that emphasize teaching skills, assessment strategies, and research techniques. This training is helpful but not necessary in becoming a competent clerkship directors. (See also, Chapter 12, professional and career development.)
Mentoring from previous clerkship directors, the department chair, and from clerkship directors of other disciplines and/or institutions is crucial for new clerkship directors. Many specialties have organizations or divisions of organizations that focus specifically on undergraduate medical education, (See Table 2). These organizations often sponsor faculty development seminars that address the needs of clerkship directors, particularly those who recently have taken the position of clerkship directors. In addition, larger specialty educational meetings may offer presentations that are pertinent.
On line Resources
Some groups have active listserves where new clerkship directors can post a question, or find old discussion threads that address issues relevant to their clerkships. There are a number of online resources as well: the AAMC MedEdPORTAL is an online registry for a comprehensive collection of peer-reviewed education materials. There are other such repositories such as HEAL (health education assets library (http://www.healcentral.org/index.jsp) and the Family Medicine Digital Resource Library (http://www.fmdrl.org/).
The most important administrative support for the clerkship director is the clerkship coordinator. This individual performs a wide range of functions, including the implementing the logistics of student work schedules, arranging meetings, scheduling rooms for teaching and compiling evaluation data and grades. The clerkship coordinator must also have excellent interpersonal skills as s/he is on the front line with students, faculty, residents, and school administrators. Much of the students’ impression of the overall clerkship depends on positive interactions with the clerkship coordinator. The clerkship coordinator may also provide secretarial support to the clerkship director.
Clinical faculty in the department play a major role in student education as preceptors in the out-patient office, operating room, and wards. They may also help with didactic sessions, evaluation, and grading, and assist in development and implementation of curricular innovations. Some departments have dedicated faculty whose primary non-clinical responsibilities are related to student education. Their involvement and enthusiasm are critical to the clerkship’s success. Faculty must be supported and recognized for their contributions to student education, since teaching is only one of multiple competing duties. Providing direction, training in teaching techniques and mentorship to faculty is a core task for a clerkship director.
Residents participate extensively in the education of medical students on many core clerkships and are often the primary teachers on in-patient rotations. They do much of the one-on-one teaching, they can lead small groups to help with clinical skills acquisition, and they can help with didactic sessions. Most, but not all, enjoy teaching. Residents’ efforts in educating medical students should be supported and recognized. Like faculty, residents have many competing duties and may lose enthusiasm for teaching if their efforts are unacknowledged. The clerkship director should work with the Associate Dean for Graduate Medical Education and residency program directors to ensure residents acquire effective teaching skills.
Some departments have non-physician educators and many institutions contain offices dedicated to educational functions such as assessment, faculty development and research assistance. Clerkship directors should identify these resources in their departments and institutions. These individuals and offices can help in many facets of the clerkship director's job such as curricular planning, assessment, and educational research. Standardized patient (SP) program staff are also key resources. They assist with planning formative SP activities and objective standardized clinical examinations (OSCEs).
Dean’s office staff and resources may be a source of important support. In medical schools with centralized (often on-line) evaluation systems. Dean’s staff collect evaluations and distribute results to clerkships. Staff may also provide comparative data across clerkships and coordinate student schedules. Student Affairs deans and staff help with problems related to specific students or situations. There is a trend toward integrated, centralized management of clinical (and basic science) curricula and collaboration through the Dean’s office and may be a major source of innovative ideas and integrated programs. The Dean’s office also may help to fund new programs in which they are invested.
Clerkship Director Committee
In schools where the clerkship directors of the required clerkships meet regularly, this group can be a great support and source of inspiration for clerkship improvement. These groups may be involved with curricular innovations that span several or all clerkships, standardization of certain elements (such as assessment) across clerkships, and solving shared problems. Information is shared and regular meetings provide opportunities for collaboration that might not otherwise be available. (return to top )
Some clerkship directors report to the department chair and others to a director of student education (or “predoctoral director,” a term often used in Family Medicine departments). In some departments, clerkship directors direct preclinical courses such as introduction to clinical medicine or organ systems courses. Depending on the workload, some clerkship directors have an associate clerkship director to help them accomplish the multiple tasks of administering the clerkship.
Junior Faculty Clerkship Directors
The clerkship director may be a junior faculty at an assistant professor level. An inexperienced junior faculty clerkship director must have strong support from the chair to prevent difficulty recruiting and directing more senior faculty. Student programs may suffer if the departmental culture does not staunchly support student education. With the chair and program director’s support, a junior faculty clerkship director may be highly effective. There are advantages in giving junior faculty this role: junior faculty are often strongly committed to and enthusiastic about student education and innovation, and they stand to benefit most from the role of clerkship director as a stepping stone for their academic careers. However, junior faculty who identify mentors are more likely to be successful academically than those who do not. Junior faculty clerkship directors should engage in educational scholarship if they want this position as clerkship director to become a cornerstone of their career development (see also Chapter 12, Professional Growth and Development, and Chapter 14, Educational Scholarship).
Mid-level or Senior Faculty Clerkship Directors
Senior faculty often report directly to the chair. This relationship may give student education programs more visibility and importance in the department. Some clerkship directors simultaneously fulfill a leadership role in residency education. This dual role gives the clerkship director authority to schedule residents and supervise their teaching responsibilities more directly. However, some of the drawbacks to this arrangement are the large administrative burden associated with both GME and UME responsibilities, student education conflicting with what is best for residents, and conflicting pressures for teaching time which may create difficulty in being the primary advocate for both students and residents. (return to top )
Negotiation skills are critical, starting with negotiating to accept the clerkship director position (see Chapter 2, Educational Administration and Chapter 12, Professional Growth and Development). Before accepting the position, the clerkship director must specifically negotiate time, money, and space, because they are integral to the success of the clerkship. Because many faculty, particularly junior faculty, may have little experience in negotiation of any kind, reading this guidebook and published articles 4 may be helpful. Talking with clerkship directors from other departments within the same or other institutions provides information that may assist in negotiations. After accepting the position, the new clerkship director may need to continue to negotiate with the chair as well as with the dean for additional resources for the clerkship. These negotiations require careful preparation, with well-thought-out reasoning and clear written justifications. Alliances with other clerkship directors with similar needs may help in this process of negotiation. (return to top )
Expectations for scholarly activity vary depending on the institution and on the particular academic track. Clerkship directors usually are expected to produce some form of scholarly work. 7 Participation in scholarly work enhances the experience of the clerkship director and also furthers his/her academic career. Scholarship is creative activity that results in a product that is reviewed by peers for quality and publicly disseminated for others to learn from or build upon. Scholarly work includes articles in peer-reviewed journals, but can consist of many other activities as well. Developing curricula, writing textbook chapters, or creating online cases are a few examples of scholarly work that can be included in an educator’s portfolio. The Clerkship Director should be meticulous in tracking all such activities, as an updated portfolio is critical when promotion and tenure decisions are made.
Educational research may include describing novel teaching modules or assessment modalities, incorporating new clinical experiences, and assessing the effects of these. Curricular innovations should be assessed. Students may be asked to do a pre- and post- test or give a before-and-after opinion of the value of the innovation. Outcomes also can include performance on standardized exams or separately administered questionnaires (See also Chapter 14, Educational Scholarship).
A number of education journals, including Academic Medicine, Teaching and Learning in Medicine, and Medical Education, publish education scholarship. In addition to publishing in peer-reviewed journals, the Health Education Assets Library (HEAL at www.Healcentral.org) and MedED PORTAL www.aamc.org/meded/mededportal/author.htm are on-line resources for peer-reviewed educational material. This is an excellent resource for clerkship directors to access information, but also to “publish” their own educational resources at a peer-reviewed site.Each specialty has national meetings where scholarly work can be presented, as well as interdisciplinary meetings like the Association of American Medical Colleges (AAMC at www.aamc.org/meetings/start.htm) annual meeting. Collaborations with Clerkship Directors from other medical schools who have interest in similar areas add strength to these activities. (return to top )
This guidebook is intended to be a comprehensive manual for clerkship directors as well as other members of the medical student teaching team. Above all, the message should come across that the clerkship director position can be extremely rewarding both personally and professionally. The clerkship director is at the heart of the medical school’s primary mission is the most critical leader of the medical education team. (return to top )
Tasks of a Clerkship Director
National Clerkship Directors Organizations
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