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Trading Places: Students Give Teachers Lesson on Clerkships

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Trading Places: Students Give Teachers Lesson on Clerkships

The juncture between the second and third years of medical school—when students leave the confines of the Quad and embark on a series of clerkships in the hospitals—is a moment ripe with professional opportunity. Yet many third-year students end up feeling disconnected and disaffected—cut off from their host institutions.

Gordon Harper. Photo by Jeff Cleary

"I've had good days and bad days. And those had everything to do with whether I felt part of a community, of a team," said Michael McWilliams, a third-year student in the Cannon Society. He was speaking during one of the audience exchanges at the Dec. 5 Assembly on Collaborative Problem-solving. A series of presentations by students in the Patient–Doctor III course, the annual session is also a chance to strengthen ties between medical students and the broader HMS medical community.

"The healing impulse, we know, can be directed not only to healing the sick body and the ailing spirit but the fragmented community as well," said Gordon Harper, course director of Patient–Doctor III and the event organizer. Among the more than 150 people attending were students, clerkship course directors, deans, faculty members, and administrators.

The series of five presentations, one from each of the academic societies including HST, is also an occasion for medical students to teach their teachers what is not working in their education and suggest how to fix it. "Newcomers see what old-timers do not," said Harper, an HMS associate professor of psychiatry at the Massachusetts Mental Health Center. "And they may be shaken up by what they see."

Educational Compass

One of the most unsettling aspects of their third year, said Castle Society students, was the abrupt transition from the New Pathway style of learning on the Quad to the "old pathway" practiced in the hospitals. Seeking an explanation for the disparity, the Castle team surveyed nine clerkship directors, asking questions such as: did you receive any direction—or feedback—from HMS about how to run your course? Only half said they had received prior direction and some were not informed about student evaluations until long after the course was over.

Most conceded they spent minimal amounts of time training interns and residents. Almost all traced the roots of the problem to a promotion system that rewards research over teaching—a flaw that could be rectified, said the Castle group, if excellence in teaching were formally recognized and financially rewarded.

In fact, a shift toward more formal teacher training and recognition has already begun at HMS, though the impact is not immediate and universal. The School has put in place a Resident-as-Teacher program, now under way in the Departments of Medicine and Pediatrics at affiliated hospitals with plans to expand to other core clerkships. In February 1999, the School approved the Clinician Teacher (Longer Service) criteria for promoting instructors who demonstrate excellence in teaching and practice but who may not be as widely published as their peers (see Focus Jan. 28, 2000 for both stories). The School is also developing a multimillion dollar endowment to support clinical teaching at the hospitals.

Hands On

The Cannon students, taking a proof-is-in-the-pudding approach to the question of third-year education, conducted a survey to see which clinical skills students had actually learned during their clerkships. "Until now, we haven't unsheathed a needle or inserted it into a patient for any reason at any point in our career," they said. As it turns out, even after their third year, many students were barely more experienced.

A one-day clinical skills fair held sometime before the third year, in which preclinical students had the opportunity to perform basic procedures, would be one way to increase student competency and confidence, the students said. More assiduous monitoring of students' skill acquisition on the wards would also help, as would efforts to encourage and empower students to be self advocates in learning skills.

Student empowerment was the theme of the presentations by HST and Holmes students. Working on the assumption that knowledge is power, members of both societies proposed that third-year students record their experiences of specific clerkships in an informal notebook, The Word on the Wards, in the case of HST, and a formal guide, The Underground Guide to HMS Year Three, in the case of Holmes. Future students could use the guides to investigate, choose, prepare for, and carry out specific clerkships.

Judging by comments from the audience, even faculty members could benefit. Benjamin Davis, clerkship director of medicine at Massachusetts General Hospital, described how he was so galvanized by what he heard from students at last year's assembly that he pushed for the appointment of a student advocate in his clerkship—a senior faculty member with clout, who meets with students to hear their concerns but who is not asked to grade or pass judgment on them. "Learning in the clinical setting is often muddied with being evaluated at the same moment," said Janet Hafler, assistant professor of pediatrics (medical education). A student advocate could help separate out these factors, she said.

—Misia Landau