Guidebook for Clerkship Directors
The clerkship director's first contact with medical students is usually at an orientation to the clerkship. Orientation is a very important meeting that presents challenges, especially for new clerkship directors, often junior faculty members who ‘inherit’ the job. New clerkship directors are faced with the choices of doing ‘the same old, same old’ or trying to apply educational innovation to student education. If you have not had formal exposure to medical education theories and practice, the choice is obvious. However, if you are a risk-taker and willing to promote change as a way to improve student education and hopefully patient care, you may want to try some evidence-based and /or best practice recommendations in this chapter. Whatever your approach, the orientation is an opportunity for you as the clerkship director to set the tone for the rotation, establish the 'gold standards' regarding expected knowledge, performance, and attitudes, and negotiate with the students regarding their learning objectives and expectations for the rotation.
In this chapter we suggest topics you may want to include in the orientation. Many are based on adult learning principles and evidence-based literature that documents effective learning. 1 The overriding philosophy of each clerkship should help students become more self-directed learners by empowering them to be responsible for their own learning while emphasizing the overarching goal of improving the health of patients. Understanding and meeting the needs of patients should frame the clinical educational process. Some of the issues covered during orientation should first be introduced earlier in the medical school curriculum and, therefore, represent a continuum into the clinical years (Table 1). (return to top)
The mechanics of orientations differ from school to school and program to program. One size does not fit all and the clerkship director must decide the most effective and efficient way to orient students. Some students on a clerkship may be assigned to the academic health center and others to community sites, locally or across the state. While the Y generation might prefer an on-line orientation, in-person orientation represents a critical opportunity for the clerkship director to set the tone and discuss the educational philosophy for the rotation. The orientation should be planned carefully, limited in volume of material, and organized. Information about curriculum content, expectations, evaluation and grading, and policies should be easily available to the students electronically or as hard copy. Limited interaction on issues, rather than pure lecture, involves the students and makes the exercise less hierarchical, or top-down. If the clerkship director cannot attend the orientation, an able administrative assistant or a colleague should conduct the orientation session and direct students to written materials. (return to top)
Creating a Safe Learning Climate
A safe learning climate is one of the essential ingredients to effective learning during the clerkship. Pratt describes this as establishing the 'the nurturing perspective.' 2 In contrast to the traditional, hierarchical approach in which there is a large social, organizational, and cultural gap between teacher and learner, a safe learning climate is one in which faculty can be viewed as senior learners and students as neophyte learners. This approach creates a more level playing field in which students perceive, perhaps guardedly, that they are important and valued as team members. 3,4 This relationship begins with setting expectations for how students will contribute substantially to the care and education of their patients and other members of the team.
Setting the Tone for the Clerkship
You can set the tone even before the students arrive by sending a welcoming letter 2 to 4 weeks before the start of the rotation. In this letter, you can express enthusiasm about the students' arrival, your commitment to their education, and provide a brief outline of the orientation. We believe the letter should express with confidence, if true, that this will be one of the best educational experiences they will have in medical school. There is nothing wrong with setting high expectations as long as they are justified. A personal welcome, when students arrive for orientation, from the key academic leaders in your department, such as the department chair and chief residents, also reinforces that students are valued. Of course, the faculty and residents who oversee students on different parts of the clerkship need to 'walk the walk' after you 'talk the talk.' This probably sounds like a 1-hour workshop on establishing the learning climate! 5
Sharing the Reasons You Chose Your Specialty
You should convey enthusiasm by sharing your own personal reasons for choosing your specialty and the aspects you find particularly rewarding, thereby role modeling the honest and open communication you want to foster between students and attendings during the rotation. Students may have rotated together on several rotations, but they do not often talk about professional and personal issues with each other, except in cliques. In our experience, the following exercise can help you get to know students. Ask them to write three important facts about themselves, their previous experience with the types of patients they will be encountering on the clerkship, and their top five goals for the rotation. Their goals could form the basis for a learning contract. They could share their background and expectations with another student, and then present them to the clerkship director and other students, either written or verbally. We find this exercise conveys that you are interested in them as individuals and as involved learners.
Developing a Learning Contract
The use of the learning contract has evolved from the adult learning literature as a way to reconcile a learner's internal needs and interests with the goals and objectives of an organization, in this case, the clerkship. 6 Traditionally, the clerkship director and others tell learners the objectives they need to master. This imposed curriculum can be repressive to learners who are self-directed. A learner must understand the core knowledge, skills, and attitudes that must be mastered during the clerkship and balance the core with meeting her own educational needs. Self-directed learners use the curriculum in their own unique way as they experience different learning opportunities. For example, a student determined to enter orthopedics as a career might focus more intensely on problems of the lower extremities in pediatrics than colleagues going into primary care.
The learning contract, which can be written or verbal, enables the learner to participate in the process of identifying her own learning needs based on past experiences and future aspirations. At the beginning of the rotation, the contract usually will be fairly general because students have limited experience in the field they are about to explore. The initial learning contract could be as simple as having students list a few goals for the rotation , or could require more reflection and detail.
Developing a learning contract begins with a personal needs assessment; i.e., where the learner is now and where the learner wants to be at the end of the rotation. The needs assessment leads to identifying learning objectives and projecting how these might be accomplished and evaluated. Few students have been offered empowerment like this and they tend to be very teacher-dependent. The message from the clerkship director is that clinical work is active, different than the mostly passive experiences they have had in the first 2 years. To be successful on the clerkships, students must take responsibility as life-long learners. 7 This is a new concept for some.
Using the Contract
The contract should be in duplicate, one for the student and the other for you. You could review the contracts to compare students' perceptions of their needs vs. pre-determined essential core components of the clerkship. At the conclusion of the rotation, the students can determine whether they accomplished their objectives. You may also use the students’ goals to modify clerkship expectations . (return to top)
Verbal and Written Components
The orientation is likely to include a large amount of information. Concentrate on the key aspects of the rotation you want to discuss verbally to reinforce the written materials. Topics you may want to discuss in the orientation include deadlines for projects, the students’ schedule and daily expectations, examination dates, the evaluation process, and who to notify in the event of an emergency. Some items, such as forms for parking, computer access, and name badges should be completed and returned prior to the students' arrival. Other information is better presented in written or Web-based form in a logical and organized manner so that students can access this information as needed during the rotation (Table 1).
Learning Guide to Encourage Self-directed Learning
Students retain information best if they actively use it, rather than if they are passive recipients. 1 A learning guide can help set the tone for a clerkship in which students are expected to seek information actively rather than passively depending on faculty to convey knowledge. The guide should list questions about key topics for the students to answer, based upon the written information provided in a manual or on the Web. Students may work independently or in small groups to answer the questions and share information with the entire group. The clerkship director clarifies details, but the students convey the majority of the information to each other.
Exploring Students’ Learning Styles or Preferences
You may want to consider exploring student learning styles or preferences as part of clerkship orientation. Repeat assessment can be of benefit to the students even if they were tested in the first 2 years. The timing should be determined by the entire group of clerkship directors and appropriate curriculum committee. If a reassessment will be part of your orientation you might ask students in your welcoming letter to compete the Kolb Learning Styles or Rezler Learning Preference Instrument and calculate their scores. 8,9 Either at orientation or early in the clerkship, lead a discussion about learning styles and preferences, and allow students to post their scores so they can identify peers with similar and dissimilar learning styles or preferences. You might ask them to reflect on how their learning style may be congruent or in conflict with the teaching styles they have experienced. Our students have enjoyed sharing and comparing their results. Grow 7 stages learners on a spectrum from very dependent to self-directed, and recognizes the mismatches that can occur between teachers and learners. Kolb’s or Rezler's instruments have also been used to link learning styles/preferences and career choice. 10
Introducing and Encouraging Reflection
Reflection is considered essential for medical practice and enables the learner to connect past experiences, observations, and judgments in the decision-making process. Reflective learning should be introduced in the preclinical years, and reinforced during the clerkships. 11 Reflection also gives meaning to experience and promotes a deeper approach to learning because it requires learners to reframe problems, question their own assumptions, and look at situations from multiple perspectives vis-a-vis personal experiences. Introducing the concept challenges the students to reflect on critical incidents and may provide feedback to the clerkship director about events that might not be reported otherwise. Teaching students how to be reflective practitioners includes having them assess interactions with patients, residents, and faculty; relationships with staff; and critical incidents that occur during their rotation. Critical incidents might include the death of a patient, how someone gave bad news to a patient, or how a resident reacted when you told him during week 1 that you were getting married and needed to adjust the schedule to accommodate your needs.
Reflecting as events occur is reflection-in-action, and helps students develop a greater awareness of how they feel in response to patients. Self-awareness forms the basis for developing an empathetic approach to patients and seems to decline in students during their clinical years. 12 Reflecting after events is reflection-on-action, and projecting how one might behave differently during the next event is reflection-for-action. The latter is important for quality of care and professional development. (return to top)
Commitment to Professional Development
The clerkship director is responsible for informing students about their roles as professionals. This could include the American Board of Internal Medicine's definition of professionalism and advising students how they will be held to these standards not only on the rotation, but also during residency and as future practicing physicians. Learners could be engaged in discussion by seeking their input on how they think faculty and residents should evaluate the professionalism. Some students may see assessment of professionalism as “soft.” However, its importance can be reinforced by confirmation that excelling in knowledge and clinical performance, but not meeting professional expectations (e.g., being altruistic, dutiful, honest), can be grounds for failing the rotation. Complying with ‘dress code’ expectations is appropriate as part of being professional.
Relationships with Patients
Medical students should understand that they may develop closer relationships with the patient and family than other members of the team because they have more time to spend with them. A trusting relationship can lead to discoveries not noted by other team members. However, students must understand the boundaries of their role as students and defer to the resident or attending physician when confronted with difficult questions or issues. 13
Procedures and Skills
Introduce students to procedures or skills that they will be required to use throughout the rotation at the general orientation. Teaching students on surgery for the first time how to scrub, gown, and glove; or those on pediatrics how to examine infants and children of varying ages are examples of skills they must know from the outset to make the most of learning opportunities throughout the rotation. Students should learn to do tasks in the context in which they will be used. For example, they should learn to navigate computer systems to access patient care information while seated at a computer, receiving written and verbal guidance. 14 Skills or procedures specific to certain sites or components of the rotation or that only some students will use should be taught at the time and the point of need. Otherwise, they will likely be forgotten.
Residents or staff may ask students to perform certain procedures or tasks that they assume students know how to do. Emphasize that if they feel uncomfortable about such an assignment or have little experience performing a procedure, they should be honest and not attempt a task about which they feel uncomfortable. This is an example of altruism; i.e., putting the patient first. An empathic resident will demonstrate for the student and supervise at the next opportunity.
Oral and Written Presentations
During orientation, describe how oral presentation and written documentation should be done on your clerkship. The expectations vary from clerkship to clerkship. In pediatrics, for example, an emphasis is placed on documenting growth and development, while on surgery or gynecology students must be able to document an operative procedure. Students should know procedures for writing orders on their patients and getting appropriate countersignatures. An overview of what information should be presented during rounds and why helps students to function better during the first weeks of the rotation. Consider inviting a chief resident to present some of this information, providing a ‘break’ from your overview and enabling the chief resident to meet the group.
Feedback is essential for the growth and development of medical students as they evolve into physicians. Students should be encouraged to ask for feedback because faculty and residents are not always trained to provide timely feedback to students on a regular basis. Ideally, students should receive feedback after every patient encounter, with faculty and residents emphasizing what the student did well and how to improve. The clerkship director may choose to make the feedback process more explicit through use of structured templates, such as the “Structured Clinical Observation Form” for individual patient encounters or a mid-rotation feedback form. 17 The LCME requires mid-rotation feedback for all students on core rotations (See also Chapter 6, Evaluation and Grading of Students).
The clerkship director should guide learners regarding appropriate learning resources for their level of training. Resources include review articles, textbooks, Web sites, interactive multimedia cases, PDA programs, seminars, and lectures. Emphasize that the students will learn the most by reading about patients they see, a concept Knowles 1 referred to as contextualized learning. Students should read about their patients and demonstrate understanding of the material and how it applies to the patient's problems. They should be encouraged to share what they have read with other members of the team. In fact, we are all learners, with faculty being more senior learners than students. The clerkship director should empower students to teach and teaching should be an expectation for everyone on the clerkship. (return to top)
When students arrive at their clinical sites, it is essential to orient them to the physical plant so they get a feel for the work environment. Introducing them to the physicians with whom they will work, and to the nursing and clerical staff, will help make them feel more like part of the team. 15 Socialization of students is important because their learning environment encompasses much more than readings and formal instruction. 16 Students make career decisions based upon the relationships they develop with physicians while on rotations. They learn to care for patients from observing physician-patient interactions and from informal interactions with ancillary staff.
The clerkship director is responsible for discussing roles, responsibilities and expectations of students during the orientation period. In other words, the clerkship director sets the bar. The methods that you employ to convey information should be based on principles of adult learning theory, model desired behavior, and establish the learning environment for the rotation. The orientation may be the most important meeting of the rotation and, therefore, requires careful planning and execution. Consider the traditional 'top down' approach vs. some opportunity for negotiation. The approach you take during the orientation sets the tone for the entire rotation.
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