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