It’s time to re-invent the Clinical Clerkship

FlexnerThe need to provide supervised learning within the clinical setting has always been regarded as essential to the development of future physicians. Indeed, early versions of medical education consisted entirely of what could only be termed apprenticeships under the direction of a fully- qualified physician who was engaged by the student as the tutor, mentor and assessor. It was largely as a result of Abraham Flexner’s (pictured) transformational 1911 review of medical education in North America that medical schools were required to provide formal instruction in the basic and medical sciences. However, Flexner continued to emphasize the critical role of learning with the clinical setting. This became consolidated into the discrete role that came to be known as the Clinical Clerkship.

group72Being a “Clerk” was to have a job or role within a hospital’s complex system of service delivery. The role consisted of “clerking” patients (carrying out admission histories and physicals), following the progress of patients through their hospital stay, arranging and following up on investigations, and coordinating discharge and post hospitalization follow-up. In addition, Clerks had unofficial but widely accepted service delivery roles of their own within hospitals, including phlebotomy, administering intravenous medications, performing simple procedures such as Foley catheter insertion, cast removal, simple suturing and recording electrocardiograms. Appropriately supervised and monitored, this role provided opportunities to engage patient care in all its complexity in a transitional fashion, leading eventually to more independent practice after graduation. The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today. Importantly, the role of the Clerk varied very little between services, specialties and differing patient populations, the goal being to develop strong foundational skills in patient assessment and management, which were felt to be consistent and “learnable” within any patient care context.

In short, being a Clinical Clerk was a job. Clerks had a widely understood and (dare we say) useful role within the hospital. As a Clinical Clerk, a medical student felt part of the service delivery because they were making a tangible contribution. They therefore felt, and were, valued.

Many factors have combined to, gradually and without deliberate intention, dramatically alter the role:

  1. The service components came to be recognized as excessive and non-educational, to the point of diminishing true educational opportunities. Accreditation standards confirm and reinforce this perspective.
  2. Our hospitals have become much more focused on efficient, focused, therapeutic management of patients with complex and critical diseases. Diagnostic processes, so important to the Clerkship learning experience, have largely shifted to the outpatient setting.
  3. Career selection and the CaRMS application process have become a major focus for our students, making multiple, shorter service assignments preferable to the longer, continuing assignments that allowed the Clerk to develop a clear role within service teams.
  4. Hospitals are much more regulated environments that require clear definitions of roles and scope of practice for all providing care.

Although these issues are all valid, one must now ask what price we’ve paid for this evolution. A few questions come quickly to mind, and are being asked by our students, faculty and hospital personnel on a daily basis :

  • What aspects of patient charting are Clerks expected to provide?
  • To what extent are Clerks empowered to write patient orders?
  • What diagnostic tests are Clerks empowered to order?
  • Is a Clerk permitted to submit a consultation request or requisition for an invasive investigation?
  • What medications can a Clerk prescribe, if any?
  • What procedures are Clerks expected to provide?
  • Can a Clerk obtain informed consent for procedures? If so, what procedures?
  • To what extent should a Clerk be expected to provide care for a patient in an emergency (arrest) situation?
  • In all these issues, what degree of supervision is required, and by whom?

Clearly, the application of all these aspects of service provision will vary between clinical assignments, but their fundamental nature (or, to use hospital terminology “scope of practice”) should be consistent throughout. It should not be necessary to re-define the Clerk role for every rotation.

Our Hospital Liaison Committee, capably chaired by Christopher Gillies with representation from all teaching hospitals, faculty, administration and students, has recently been considering solutions to the Learning Environment concerns described in previous articles (meds.queensu.ca/blog/undergraduate/?p=2026). They recognized that many of these concerns may have their roots in this lack of clarity regarding the Clerk role and have therefore advocated a redefinition of the role. To this end, our Clerkship Committee (Chaired by Andrea Winthrop and consisting of all Clerkship Course Directors) met this past week to re-define the role or “job” of the Clinical Clerk, recognizing our current educational requirements and current reality of the hospital based learning environment. They have already made excellent progress in addressing the various issues listed above.

To short, our senior medical students (Clinical Clerks) are able to make valuable contributions to patient care in the hospital environment. It is in doing so that they truly grow as physicians. That can only happen with a clearly articulated and widely accepted role description, appropriate to the modern hospital environment, developed jointly by medical education and hospital leadership.

 

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

2 Responses to It’s time to re-invent the Clinical Clerkship

  1. Michael Storr says:

    the process of performing a capable history and physical involves considerable practice. a large component of the history and physical is a psychomotor skill. Just like in high level sports, dancing and music, regardless of the practitioners database, without extensive practice, they will not develop competence. We now have a situation in which clerks practice “smorgasbord” medicine. They dabble in various disciplines and don’t acquire substantial competence in the core skills. I continue to be surprised by clinical clerks who do not know basics such as how to measure pulsus paradoxus, identify the surface anatomy of the lungs for auscultation purposes or recognize the value of inspiratory/expiratory flow ratio. Repeatedly, presentations consist of variations on “the breath sounds were clear everywhere but slightly reduced to the bases and there were other sounds, but I am sure they were transmitted upper airway”.Moreover, even at the resident level, developing a smooth and efficient physical examination technique is problematic. Much more time is spent, accessing the computer database, managing the other house staff etc. rather than the core competencies of histories and physicals.

    There is a recent publication that followed pediatric residents in nine major tertiary hospitals in the United States. 3400 hours of time and motion analysis including overnight calls demonstrated that they spend only 12.5% on direct patient contacts.

    We spend a lot of time on inpatient pediatrics, going over fundamentals of physical examination for which clinical clerks are generally very enthusiastic. Certainly there are variations required for specifics of pediatrics, however, a large number do not have the ability to implement the basics. I’m of the generation that complained vociferously about “scut work”, however the four or five surgical admission histories and physicals each evening resulted in me acquiring much better technique.

    I believe that the evolution of the clerkship process is in response to pressures divorced from the ultimate imperative which is competent history and physical technique. There is the recent phenomenon of a clerkship program where we have a clinical clerk spend one day on the inpatient service. That is not an effective way for them to learn how to examine a three-year-old. When I demonstrate how to do that, it will not be sufficient until they have practiced that same combination of sub skills, multiple times.

    The description of posited responsibilities for a clerk such as providing care for patients in the emergency situation (debating the degree of supervision provided) has us asking clinical clerks to run before they have begun to walk.

    Clinical clerks, would do better if they are on stable, high-volume rotations for longer periods of time and four weeks should be the minimum. In contrast to bygone eras, this should be supported by high-frequency, high quality observation and feedback by experienced clinicians. In the sports analogy, “practice doesn’t make perfect, perfect practice makes perfect”.6

    PS I have not made any specific comments on the acquisition of history. I am heartened by such medical school processes as the session on adolescent interviewing. However, I have the same concerns regarding the lack of high-volume practice with constructive feedback.
    recently, I had an impromptu opportunity to overhear many house staff taking histories whilst lying behind curtains,on a stretcher in the emergency department. I was dismayed at the multiple times I experienced an “opportunity to make a teaching point ” reflecting a real need to improve their skills.

    • All excellent points Michael. The challenge is to find roles and settings within our ever-evolving teaching hospitals, clinics and outpatient care centres that will these fundamental skills to be be applied and practiced by our students. We’re undertaking that dialogue, and the input of all clinical teachers will be welcome. Thanks for your interest and commentary.

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