Not your Father’s (or Mother’s) Clinical Clerkship

Meds 2015 students get their white coats and begin the contemporary Clinical Clerkship 

This week, the students of Meds 2015 begin the phase of medical education still referred to as the Clinical Clerkship.  Last Friday afternoon, family and friends joined them to celebrate the White Coat Ceremony, a longstanding tradition that marks this important transition.  It was a pleasure to meet many family members, some of whom were physicians who remarked on the changes between their own educational experiences and those of their offspring.

white-coats

The 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 their 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 education within the context of clinical service.  flexnerThe role of medical students within service delivery, largely in hospital settings, became consolidated into the discrete role that came to be known as the Clinical Clerkship.  Being a “Clerk” was to have a job or role within the hospital’s complex 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 and 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 the ability to engage patient care independently after graduation.  The service delivery component of the clerkship was eventually recognized as such with the provision of a modest stipend, which continues today.  Interestingly, 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.

As the “service” component of the clerkship grew and hospital care became more procedurally driven, understandable concerns were raised regarding the balance between service delivery and education.  Medical educators, buttressed by increasingly specific and prescriptive accreditation standards, developed standards and objectives for the medical student role, coupled with a need for more structured and objective assessment.  At the same time, our students were developing an increasing need to use clerkship experiences to explore career options in an increasingly complex and competitive postgraduate training environment.

Today’s clinical clerkship has evolved considerably from the model experienced by most mid or late career practitioners.  Now usually consisting of the final 2 years of medical school, it is intended to provide clinical exposures that vary not only in focus but also in setting, recognizing the reality that our students have a critical need to explore career options and to encounter patients in a variety of settings that will reflect their own career paths.  The rotations are enhanced with formal educational experiences, formalized feedback on all curricular objectives, and structured assessments of various types.  To illustrate the modern clerkship, the following example profile is provided to illustrate the journey of one medical student through a clerkship:

  • A six week General Surgery rotation on an in-hospital unit at either Kingston General Hospital or our affiliated teaching hospital in Oshawa.
  • A six week Peri-operative Medicine rotation rotating through a series of experiences with surgical subspecialties (such as Plastics, Orthopedics, Urology), Anaesthesia and Emergency Medicine.
  • Six weeks on Core Internal Medicine spent as part of the care team assigned to a Clinical Teaching Unit in Kingston, Oshawa or Peterborough.
  • A further six weeks on Specialty Medicine spent undertaking consultation or out-patient clinics within three medical sub-specialties.
  • Six weeks of Psychiatry in Kingston, Oshawa or Markham, generally office or consultation- based.
  • Six weeks of Family Medicine working with a community family physician or Family Health Team.
  • Six weeks of Pediatrics, provided in either a hospital ward or community practice.
  • Six weeks of Obstetrics and Gynecology, consisting of shifts in Labour and Delivery, gynecology ward, or outpatient clinics.
  • Sixteen weeks of electives, during which the students a series of 2 week experiences in specialty services and locations across Canada designed to broaden their clinical experience and exposure to career options.
  • Three 4 week “Core Curriculum” rotations placed at the beginning, within and at the end of the clinical rotations, intended to provide common instruction and assessment in advanced topics and practice related instruction.

All these rotations feature, in addition to the clinical experiences, structured teaching, all guided by objectives linked to the overall Curricular Goals and Competency Based Objectives document which was developed and is regularly reviewed by our Clerkship Committee and approved by the Curriculum Committee. 

In addition, students can elect to undertake our Integrated Community Clerkship, consisting of an 18 week placement within a smaller community working with community tutors and Family Health Teams, intended to provide longitudinal experiences in Family Medicine, Pediatrics and Psychiatry.

Students can also apply for an increasing number of International exchanges which allow them to undertake a core rotation at universities in another country.

All rotations feature content relevant to the various Professional Competencies (Professionalism, Advocacy, Collaboration, Management) and their achievement in these domains is a component of rotation assessments.

All students continually log their clinical experiences and technical procedures in order to ensure all learning objectives are being met.  They also undertake comprehensive structured clinical examinations (OSCEs) in order to ensure core clinical skills are mastered and maintained.

So…a far cry from the service dominated Clinical Clerkship so familiar to most practicing physicians.  A key, and very reasonable question could be posed: Does it matter?  Are our students better prepared for the demands and rigours of residency and practice than their predecessors?  This intriguing question will be the subject of my next Blog.

 

 

 

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Visiting with Dr. Vincent Lam Making the case for Humanities in Medical Education

I have always loved reading novels.  I’m particularly drawn to those that feature complex and fully fleshed out characters battling various personal “demons”, confronting sundry human challenges in interesting contexts.  I must confess to having always regarded the reading of such books as something of a “guilty pleasure”, a self-indulgence taking time away from more immediate, directly relevant pursuits.

This week, vincent_lambthanks to the efforts and insight of the Aesculapian Society, particularly Michael Chaikoff and Soniya Sharma, many of us had the opportunity to hear from and meet with Dr. Vincent Lam, who was this year’s H.G. Kelly Memorial lecturer.  Dr. Lam is an Emergency Medicine physician and award-winning author of a number of works including “Bloodletting and Miraculous Cures” and “The Headmaster’s Wager”.  In his address, Dr. Lam made the case for the role of storytelling as a way of understanding and deepening communication between physicians and their patients, not only as a means of transferring important information, but he also spoke of how it can contextualize the relationship in more human and personally meaningful terms.  In conversation afterward, I asked him about the process of novel writing.  I had always naively assumed that the author begins the process with an outline of the completed story and goes about adding detail and context.  Apparently not so.  Most authors, including Dr. Lam, begin by imagining and developing their characters as fully formed people with all their individual traits and uniqueness.  They then go about studying and researching the context in which those characters will “live”.  Using characters and contexts with which the author is already somewhat familiar is obviously a good start, but considerable research and immersion is required in order to produce stories with depth, realism and relevance.  In researching for “The Headmaster’s Wager”, Dr. Lam made two trips to Vietnam in order to better appreciate the environment in which his story would evolve.  With character and setting in place, the author allows his characters to “live”.  Their actions and reactions become a natural consequence of the interaction of their personality with the times and situations in which they find themselves.

One can’t help but recognize parallels within the physician-patient relationship.  Our patients come to us as uniquely formed individuals who find themselves in a new, baffling and threatening context, specifically an illness or health challenge of some type.  Our role as physicians is to come to the encounter already prepared with understanding of the illness, or “setting” of that challenge.  Our “art” is to find within ourselves ways to efficiently and effectively engage the patient, understand the uniquely individual responses to the illness and guide the patient through the terrain.  In doing so, the physician must develop a broad appreciation of the human experience in all its fascinating complexity.  In this sense, the reading and appreciation of quality literature would seem at least as valuable as reading the latest thrombolysis trial.  Certainly the former is likely to be of more enduring significance.

At Queen’s, we have benefitted over the years from the efforts of numerous faculty who have steadfastly championed various components of the Humanities within and around our curriculum.  Dr. Jackie Duffin, herself an award-winning author, has been providing History of Medicine lectures integrated with various teaching blocks for many years, as well as student projects and excursions intended to deepen their appreciation of the history of their chosen profession.  Students have consistently found her teaching to be a highlight of their medical school experience, as evidenced by Dr. Duffin being a recipient of the Connell Teaching Award which the graduating class bestows annually on the faculty member considered to have had the greatest influence on their education at Queen’s.  Drs. Shayna Watson and Peter O’Neill have provided, largely on their own initiative, contributions to elective courses devoted to various themes related to literature, spirituality and the humanities.  We have maintained strong curricular content in Medicine and the Law (led by Patti Peppin of the Faculty of Law) and Medical Ethics (led by Drs. Cheryl Cline, Susan MacDonald and previously Ellen Tsai).  Many others have contributed in informal but highly meaningful ways.

The challenge, of course, is determining how best to integrate the Humanities and Social Sciences within a rather dense and highly scrutinized curriculum.  How does a Curriculum Committee, charged with meeting the various competencies and objectives established by professional bodies, accrediting agencies and well-intentioned interest groups, ensure these are achieved and balanced?  How does it weigh the value of medical literature or history against understanding the management of hemoptysis or causes of renal failure?

As a means of engaging this challenge, I recently asked Drs. Duffin, Cheryl Cline and Shayna Watson to develop a review and make recommendations on the teaching of Humanities within our school.  They involved three of our students, Alicia Nicke-Lingefelter (Meds ‘16), Amanda Lepp (Meds ‘15) and (now Dr.) Renee Pang (Meds ‘13).  That excellent report has already motivated changes in representation within our curricular committees and is leading to changes in how we “label” and integrate various teaching opportunities within our curriculum.  It has also raised a consciousness about the Humanities and Social Sciences that is always the first step to ensuring appropriate balance.  I’m arranging for the report to be posted on the UG Website and welcome feedback from all faculty and students.  It can be accessed at: https://meds.queensu.ca/central/community/curriculumcommittee:reference_material

I’m most grateful to the authors of this report and to all who have and continue to champion the Humanities within our school.  I’m also very grateful to Dr. Lam who has made me feel much better about my guilty pleasure.

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Upcoming dates for Undergraduate Medicine at Queen’s

Curricular Council: Dr. Sanfilippo is calling meetings of the Curricular Council on the following dates at 4:30 p.m.
Oct. 2, Jan. 22 and May 14.

Professional Development Days for Curricular Leaders: There will be a full day Professional Development retreat for Curricular Leaders on Friday Nov. 22 and Friday, June 13.

Stay tuned for more details, sent via email.

Writing for Health Care Providers Workshop: Carrying on the theme of narratives in medicine, so ably begun by Dr. Lam at the HG Kelly address, please note that Dr. Hilton Koppe is presenting a writer’s workshop “Beyond the Medical Record: Creative writing as burnout prevention for health professionals” on Oct. 16, 1:30-5:00 at the Bracken Library. Please see attached folder for more details.
Please contact The Office of Faculty Development at fac.dev@queensu.ca to sign up.

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Upcoming dates for Undergraduate Medicine at Queen’s

Curricular Council: Dr. Sanfilippo is calling meetings of the Curricular Council on the following dates at 4:30 p.m.
Oct. 2, Jan. 22 and May 14.

Professional Development Days for Curricular Leaders: There will be a full day Professional Development retreat for Curricular Leaders on Friday Nov. 22 and Friday, June 13.

Stay tuned for more details, sent via email.

Writing for Health Care Providers Workshop: Carrying on the theme of narratives in medicine, so ably begun by Dr. Lam at the HG Kelly address, please note that Dr. Hilton Koppe is presenting a writer’s workshop “Beyond the Medical Record: Creative writing as burnout prevention for health professionals” on Oct. 16, 1:30-5:00 at the Bracken Library. Please see attached folder for more details.
Please contact The Office of Faculty Development at fac.dev@queensu.ca to sign up.

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