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The future of medical student education in internal medicine
Association of Professors of Medicine
The Future of Medical Student Education in Internal Medicine
T
o celebrate its 50th anniversary, the Association of Professors of Medicine (APM) has dedicated its pages in The American Journal of Medicine in 2004 to the future of academic internal medicine. In this issue, the APM invited the Clerkship Directors in Internal Medicine to discuss the future of medical student education. Sir William Osler’s observation in 1900 that all medical students will do well (1) serves as a reminder that any reflection on the history of the traditional internal medicine clerkship and projection on the future of that clerkship should be tempered by an understanding that medical students have and will adjust to the extrinsic and intrinsic forces that shape medical education. It is, however, appropriate for clerkship directors to assess periodically how best to facilitate students’ learning in the clerkship in light of changes taking place in the broader medical community. Although tumult since the early 1990s has led internists and internal medicine organizations to reexamine the role and definition of today’s internist, the third-year internal medicine clerkship remains one of the seminal clinical experiences for medical students (2). Within the core clerkship, the experiential teaching method of decades past has given way to methodologies to deliver and assess mastery of a rigorous curriculum. Training in the clerkship has evolved from a teacher-centered to a learner-centered approach. Students in the core internal medicine clerkship are expected to hone many of the core skills of a physician, such as physical examination, generation of differential diagnoses, doctor-patient communication, and clinical decision-making. These students are also expected to develop the core knowledge and learn the core values of internal medicine, including the importance of rigorous, scientific, evidence-based thinking in comprehensive, personalized care of the adult patient and a commitment to embrace the care of the complex patient (3). The internal medicine clerkship has always featured a commitment to giving students an active, meaningful role in the care of real patients. Although clerkship directors remain committed to these educational goals, external pressures on the faculty and environment of the clerkship affect every aspect of learning. In this paper, the Clerkship Directors in Internal Medi576
cine (CDIM)— the organization of individuals responsible for teaching internal medicine to medical students— summarizes the intrinsic and extrinsic changes that are affecting the internal medicine clerkship and suggests approaches to managing these changes proactively.
MEDICAL STUDENTS The environment in which medicine is taught and practiced is changing at all levels of the profession. There is decreasing interest in medicine as a profession, as evidenced by a decline in the total number of applicants for medical school (4); despite this decline, as yet there has been no decline in the qualifications of students accepted to medical school (5). The percentage of women in medical school classes is rising, and the cumulative debt burden of graduating medical students continues to rise (Table). These trends may influence the types of students and residents attracted to internal medicine.
TEACHING WORKFORCE Changes in the work environment of internists have created substantial impediments to the education of medical students that are likely to continue. Rising health care costs and decreasing rates of reimbursement generate increased pressure on faculty to improve clinical productivity. The presence of a student frequently impedes such improvement. In response to this new reality, newly graduated physicians are leaning away from primary care disciplines and toward sub-specialization (8), which may leave fewer generalist physicians to teach students the fundamentals of internal medicine. On the inpatient side, patients are progressively less well, with decreasing lengths of stay. The hospitalist movement, partially born from these pressures, has created a new cadre of potential teaching faculty, but this movement has also created a new set of concerns, including the shifting of students’ interest away from the practice of primary, longitudinal care. These adaptations, nevertheless, provide opportunities for new approaches that may help departments better achieve the core goals of the internal medicine clerkship. For example, if hospitalists are effectively incorporated into the teaching service, they can be an excellent resource for teaching and modeling high quality
© 2004 by Association of Professors of Medicine. Published by Excerpta Medica Inc. All rights reserved.
0002-9343/04/$–see front matter doi:10.1016/j.amjmed.2004.02.001
Association of Professors of Medicine
Table 1. Changes in the learning environment in the United States: 1997–2002 1997–1998
2000–2001
2002–2003
Number (%) Applications to medical schools Medical students Women enrolled Underrepresented minorities enrolled Full-time faculty Average cumulative medical student debt PGY-1 internal medicine positions filled through the National Resident Matching Program
43,016 66,748 28,447 (42.6) 7712 (11.6) 96,773 $80,462 (1997 graduates) 4506 (in 1999)
37,089 66,295 29,576 (44.6) 7066 (10.7) 103,553 $99,089 (2001 graduates) 4494 (in 2000)
33,625 66,677 31,290 (46.9) 7086 (10.6) 109,526 $103,855 (2003 graduates) 4395 (in 2002)
Data from references 4, 6, and 7. PGY ⫽ postgraduate year.
inpatient care (9). Hospitalists represent a new and growing niche for academic internists, and exposure to role models in this area may bolster interest in careers in internal medicine. Residents, who have served a major teaching role for medical students, are also faced with limitations to their time. Shorter lengths of stay and increasing acuity appear to have increased the workload of residents. In 2003, the Accreditation Council on Graduate Medical Education (ACGME) approved new program requirements (10), including the 80-hour workweek restriction. The requirements regarding duty hours reduce the availability of residents and interrupt continuity of care, which will affect the role of residents in teaching medical students. For residents, accreditation program requirements include not only duty-hour restrictions but also requirements relating to the six ACGME competencies, which reflect many of the core values of internal medicine: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The increased emphasis on the development of these competencies, as well as tools for their evaluation, can be beneficial to student teaching. The CDIM is working with the Society of General Internal Medicine to update the Core Medicine Curriculum Guide (3) and assign each of the objectives in this guide at least one corresponding ACGME competency. If internal medicine clerkships adopt the revised core curriculum, it will provide an important link between medical school and residency and reinforce the value and reality of the “continuum of medical education.” High quality educational experiences for medical students demand teachers who are well prepared. Developing the knowledge and skills of these educators should be a priority for all internal medicine clerkship directors and departments. Many unique faculty development pro-
grams have been developed in print, workshop, video, and computer-based formats. Role-playing, standardized learners (11), and objective structured teaching exercises (12) have all been used. Reaching community preceptors with such programs can be especially challenging (13,14). Residents have a great deal of contact with medical students, and developing residents’ teaching skills should also be a priority. Programs that focus on basic educational principles directly relevant to the day-to-day activities of the resident may be particularly helpful (i.e. learning climate, team leadership, feedback, and evaluation) (15).
TEACHING SITES Shifts in inpatient and outpatient care have been dramatic since the early 1990s and have forced a reconsideration of where clinical teaching should occur. The majority of medical care takes place in the outpatient setting, whereas most undergraduate clinical education still occurs in the inpatient setting. However, concern that replacing an inpatient with an ambulatory rotation diminishes the educational impact is not supported by the literature (16,17). Additionally, ambulatory rotations are associated with positive perceptions of, attraction to, and choice of a career in internal medicine (18). Additional opportunities arise from increased ambulatory education. Some schools have chosen to combine multiple primary care specialties (e.g. medicine, pediatrics, and family medicine) into an integrated primary care clerkship. Such programs may offer unique opportunities for effective primary care education (19). Continuity experiences may improve the understanding of doctor-patient relationships, psychosocial aspects of care, and the management of chronic illnesses, without apparent differences in the knowledge acquired (20 –23). April 15, 2004
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116 577
Association of Professors of Medicine
TECHNOLOGY There has been an explosion of electronically available medical information since the early 1990s. Online textbooks, full-text journals, and clerkship-specific material have become core resources for many clerkship programs. The use of personal digital assistants continues to grow among medical students and residents, primarily for the ability of the devices to provide “just-in-time” learning and medical information. Wireless technology and electronic medical records are likely to become widely available and to serve as the primary method through which providers interact with the hospital information system. This infrastructure also may allow for greater tracking of the individual experiences of students in the clerkship, which is important for clerkship curriculum planning and evaluation. One novel potential vehicle for education is computerized order entry systems for providers that are designed to reduce medical errors. These programs intercept potential errors during order entry and prompt the provider to review the order; they are linked to built-in clinical decision support systems designed to provide immediate expert feedback to the user and to reduce errors, but they also have the potential to be powerful educational tools for students. A major goal of the clerkship is to demonstrate effectively the use of new technology to locate and interpret the proper information at the appropriate time.
EDUCATIONAL GOVERNANCE A final area of dramatic change is the increasing central oversight of the medical school curriculum. The Liaison Committee on Medical Education (LCME), the Association of American Medical Colleges (AAMC), and the National Board of Medical Examiners (NBME) all influence the mission and goals of the medical school. The recent trend by these organizations to influence the environment, curriculum, and assessment of medical school education has increased the responsibility and accountability of the clerkship director in complying with these organizations’ mandates and new expectations. To ensure that such compliance occurs, the dean’s office is now required to demonstrate: “integrated institutional responsibility for the design, management and evaluation of the curriculum” (24). Typically, it is the medical school that determines the structure of the clerkship (length, sequence, number of students, affiliate liaisons), the crossdiscipline content to be included in a specific clerkship, and, ultimately, much of the job description and demands on the clerkship director. Since the early 1990s, the emphasis on evidence-based medicine has grown exponentially, with the challenges of teaching it shifting from the department of internal medicine to the medical school. Educating medical students 578
April 15, 2004
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about the principles of evidence-based medicine should occur at all levels of the curriculum, particularly in preclinical biostatistics, clinical epidemiology, and “practice of medicine” courses, and in the core clinical clerkships. Certainly, internists have been at the forefront of the evidence-based medicine movement and internal medicine clerkship directors should have a well-defined plan to include its principles in the clerkship curriculum. More difficult tasks are to find time in the curriculum and to have faculty and residents support the curriculum and model evidence-based medicine principles in clinical practice. These tasks require extensive faculty development. Calls for accountability for medical schools have greatly increased the focus on the process of evaluation of medical students, particularly the objective structured clinical exercise. The Institution of the United States Medical Licensing Examination Step 2 Clinical Skills Examination will make it effectively mandatory for all medical schools to prepare medical students for such testing. Clerkship-based and end-of-third-year objective structured clinical exercises have become relatively common (25). Developing, implementing, and maintaining high quality, accurate, and reliable objective structured clinical exercises are formidable tasks, particularly at the individual clerkship level. Facilities, funds, administrative support, standardized patients, and a certain degree of expertise are all prerequisites, and support from the dean is crucial. However, the CDIM firmly agrees that teachers must continue to have a key role in assessing trainees’ skills and that “medical educators must not abdicate this responsibility to standardize patients and simulation” (26). The positive contributions of increased central curriculum oversight and accountability are enhanced communication and collaboration among educators, even across departments, who are working to achieve the same goals. Shared resources and programs may also be useful in faculty development and assessment of educational outcomes. In addition, specifically defining goals and objectives may make it easier for students to assess themselves and direct their own learning. Such a coordination of effort should facilitate the move to a competency-based curriculum and allow students flexibility. However, as the CDIM has previously stated, it is important to consider the distinction between central oversight and control. Moving control of the clerkship out of the hands of clinical departments has potentially serious consequences, including the loss of innovative teaching and evaluation method. . . . Such a move begs the question of ‘ownership’ of the clinical curriculum. Centralized control raises the specter of curricula reflecting the desires and vision of a few rather than being the collective view of the education community (i.e., the faculty at the local level) (27).
Association of Professors of Medicine
THE INTERNAL MEDICINE CLERKSHIP IN THE FUTURE The rapid pace of change in medical information, information technology, and educational requirements, coupled with ever increasing external pressures on faculty time and curricular time, are changing the core clerkship in internal medicine. Clerkship directors must proactively manage these changes or face erosion of the core values and goals of the clerkship. The internal medicine clerkship of the (not so distant) future must have strong, core ambulatory and inpatient experiences. The pool of teachers must include a broad array of internists: hospitalists, general internists, subspecialists in the ambulatory and inpatient settings, residents, and fellows. Effective programs to develop the teaching skills of residents, fulltime faculty, and community preceptors must be disseminated. These skills should include basic teaching skills and teaching evidence-based medicine, information management, and other new clinical content in the context of the clinical encounter. Students should be trained to use their hand-held computers to access information at the point-of-contact, manage medical information, and track their clinical encounters and achievement of learning goals. The learning goals must remain consistent with the core clerkship curriculum but should be framed in the context of the ACGME competencies to facilitate the transition from student to resident and to emphasize the continuum of medical education. Assessment will need to be more competency-based and will likely include more standardized patients and simulations, as direct observation of student performance will be critical to ensuring mastery of required competencies. Finally, greater cooperation is needed to ensure that the objectives of the internal medicine clerkship are more integrated with the goals of other clerkships and preclerkship courses. These changes will only occur if the clerkship director in internal medicine embraces change within the clerkship, acts as an advocate for the program’s teachers, and articulates the importance of the core values of internal medicine. In addition, substantial investment in the educational mission is urgently needed. Appropriate recognition and reward of excellence in educational activities must be developed, and adequate financial and administrative support for the clerkship director and for clinical teachers must be assured, likely through missionbased management. In addition, internal medicine clerkship directors must continue to be among the educational leaders at their school, serving on medical school and departmental educational committees (28). They need to collaborate with other clerkship directors, course directors, and residency directors to address LCME, NBME, and ACGME mandates and to create an integrative set of learning experiences in a competency-based curriculum
that extends from introduction to clinical medicine through the clerkships and into internship. When caring for patients, internists strive to incorporate rigorous, scientific, evidence-based thinking in the comprehensive, personalized care of the adult patient and to embrace the care of the complex patient. Similarly, internist educators must strive to incorporate rigorous, evidenced-based thinking into the development of a competency-based, personalized curriculum for students in the internal medicine clerkship and to embrace the current complexity of medicine and medical education. Following these tenets, the clerkship may be dramatically altered, but the core mission and values will not only be maintained, but also perhaps more nearly achieved. Alison Whelan, MD Joel Appel, DO Eric J. Alper, MD Thomas M. De Fer, MD Todd A. Dickinson Sara B. Fazio, MD Erica Friedman, MD Mary Ann Kuzma, MD Shalini Reddy, MD
REFERENCES 1. Silverman M, Murray J, Bryan C., eds. The Quotable Osler. American College of Physicians; 2003:173. 2. Association of American Medical Colleges, 2003 Medical School Graduation Questionnaire, All School Report. Washington, D.C., 2003. Available at: http://www.aamc.org/data/gq/allschoolsreports/ 2003.pdf. Accessed December 24, 2003. 3. CDIM, CDIM/SGIM Core Medicine Clerkship Curriculum Guide. Washington, D.C. Available at: http://www.im.org/CDIM/ ResourcesFor/CDIMeducationaltools.htm. Accessed December 22, 2003. 4. Barzansky B, Etzel SI. Educational programs in US medical schools, 2002-2003. JAMA. 2003;290:1191–1193. 5. AAMC Data Book 2003. Available at: https://www.aamc.org/ findinfo/aamcpubs/databook/tableb14.pdf, Accessed January 16, 2004. 6. AAMC Data Book 2003. Available at: https://www.aamc.org/ findinfo/aamcpubs/databook/tableb7.pdf, Accessed January 16, 2004. 7. National Resident Matching Program 2003 Match Data. Available at: http://www.nrmp.org/res_match/tables/table5_2003.pdf, Accessed November 11, 2003. 8. Society of General Internal Medicine. The Future of General Internal Medicine, 2003. Available at: www.sgim.org/futureofGIM.pdf. Accessed January 16, 2004. 9. Palmer H, Armistead N, Elnicki M. The effect of a hospitalist service with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627–632. 10. Accreditation Council for Graduate Medical Education, Program Requirements for Residency Education in Internal Medicine. Available at: http://www.acgme.org/downloads/RRC_progReq/ 140pr703.pdf. Accessed December 24, 2003. April 15, 2004
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Association of Professors of Medicine 11. Gelula MH, Yudkowsky R. Using standardised students in faculty development workshops to improve clinical teaching skills. Medical Education. 2003;37:621–629. 12. Stone S, Mazor K, Devaney-O’Neil S, et al. Development and implementation of an objective structured teaching exercise (OSTE) to evaluate improvement in feedback skills following a faculty development workshop. Teaching & Learning in Medicine. 2003;15:7– 13. 13. Langlois JP, Thach SB. Bringing faculty development to community-based preceptors. Academic Medicine. 2003;78:150 –155. 14. Alliance for Academic Internal Medicine. General Internal Medicine Faculty Development Project, Projects and Reports. http:// www.im.org/facdev/gimfd/PubOverview.shtml. Accessed January 16, 2004. 15. Hemmer PA, Pangaro L. Using formal evaluation sessions for casebased faculty development during clinical clerkships. Acad Med. 2000;75:1216 –1221. 16. Butterfield PS, Libertin AG. Learning outcomes of an ambulatory care rotation in internal medicine for junior medical students. J Gen Intern Med. 1993;8:189 –192. 17. Kalet A, Schwartz MD, Capponi LJ, et al. Ambulatory versus inpatient rotations in teaching third-year students internal Medicine. J Gen Intern Med. 1998;13:327–330. 18. Elnicki DM, Halbritter KA, Antonelli MA. Educational and career outcomes of an internal medicine preceptorship for first-year medical students. J Gen Intern Med. 1999;14:341–346. 19. Carney PA, Pipas CF, Eliassen MS, et al. An analysis of students’
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20.
21.
22.
23. 24.
25. 26. 27.
28.
clinical experiences in an integrated primary care clerkship. Acad Med. 2002;77:681–687. Papadakis MA, Kagawa MK. A randomized, controlled pilot study of placing third-year medical clerks in a continuity clinic. Acad Med. 1993;68:845–857. Pangaro LN, Gibson K, Russell W. A prospective randomized trial of a six-week ambulatory internal medicine clerkship. Acad Med. 1995;70:537–541. Ogrinc G, Mutha S, Irby DM. Evidence for longitudinal ambulatory care rotations: a review of the literature. Acad Med. 2002;77:688 – 693. Peters AS, Feins A, Rubin R, et al. The longitudinal primary care clerkship at Harvard Medical School. Acad Med. 2001;76:484 –488. Liaison Committee on Medical Education, Functions and Structures of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree, Washington, D.C., 2003. Available at http://www.lcme.org/ functions2003september.pdf. Accessed December 24, 2003. Barzansky B, Etzel SI. Education programs in US medical schools, 2002-2003. JAMA. 2003;290:1190 –1196. Holmboe ES. Faculty and the observation of trainees’ clinical skills: problems and opportunities. Acad Med. 2004;79:16 –22. Hemmer PA, Griffith C, Elnicki DM. The internal medicine clerkship in the clinical education of medical students. Am J Med. 2003; 115:423–427. Hemmer PA, Elnicki DM. Albritton. The responsibilities and activities of internal medicine clerkship directors. Acad Med. 2001;76: 715–721.
The Future of Medical Student Education in Internal Medicine
T
o celebrate its 50th anniversary, the Association of Professors of Medicine (APM) has dedicated its pages in The American Journal of Medicine in 2004 to the future of academic internal medicine. In this issue, the APM invited the Clerkship Directors in Internal Medicine to discuss the future of medical student education. Sir William Osler’s observation in 1900 that all medical students will do well (1) serves as a reminder that any reflection on the history of the traditional internal medicine clerkship and projection on the future of that clerkship should be tempered by an understanding that medical students have and will adjust to the extrinsic and intrinsic forces that shape medical education. It is, however, appropriate for clerkship directors to assess periodically how best to facilitate students’ learning in the clerkship in light of changes taking place in the broader medical community. Although tumult since the early 1990s has led internists and internal medicine organizations to reexamine the role and definition of today’s internist, the third-year internal medicine clerkship remains one of the seminal clinical experiences for medical students (2). Within the core clerkship, the experiential teaching method of decades past has given way to methodologies to deliver and assess mastery of a rigorous curriculum. Training in the clerkship has evolved from a teacher-centered to a learner-centered approach. Students in the core internal medicine clerkship are expected to hone many of the core skills of a physician, such as physical examination, generation of differential diagnoses, doctor-patient communication, and clinical decision-making. These students are also expected to develop the core knowledge and learn the core values of internal medicine, including the importance of rigorous, scientific, evidence-based thinking in comprehensive, personalized care of the adult patient and a commitment to embrace the care of the complex patient (3). The internal medicine clerkship has always featured a commitment to giving students an active, meaningful role in the care of real patients. Although clerkship directors remain committed to these educational goals, external pressures on the faculty and environment of the clerkship affect every aspect of learning. In this paper, the Clerkship Directors in Internal Medi576
cine (CDIM)— the organization of individuals responsible for teaching internal medicine to medical students— summarizes the intrinsic and extrinsic changes that are affecting the internal medicine clerkship and suggests approaches to managing these changes proactively.
MEDICAL STUDENTS The environment in which medicine is taught and practiced is changing at all levels of the profession. There is decreasing interest in medicine as a profession, as evidenced by a decline in the total number of applicants for medical school (4); despite this decline, as yet there has been no decline in the qualifications of students accepted to medical school (5). The percentage of women in medical school classes is rising, and the cumulative debt burden of graduating medical students continues to rise (Table). These trends may influence the types of students and residents attracted to internal medicine.
TEACHING WORKFORCE Changes in the work environment of internists have created substantial impediments to the education of medical students that are likely to continue. Rising health care costs and decreasing rates of reimbursement generate increased pressure on faculty to improve clinical productivity. The presence of a student frequently impedes such improvement. In response to this new reality, newly graduated physicians are leaning away from primary care disciplines and toward sub-specialization (8), which may leave fewer generalist physicians to teach students the fundamentals of internal medicine. On the inpatient side, patients are progressively less well, with decreasing lengths of stay. The hospitalist movement, partially born from these pressures, has created a new cadre of potential teaching faculty, but this movement has also created a new set of concerns, including the shifting of students’ interest away from the practice of primary, longitudinal care. These adaptations, nevertheless, provide opportunities for new approaches that may help departments better achieve the core goals of the internal medicine clerkship. For example, if hospitalists are effectively incorporated into the teaching service, they can be an excellent resource for teaching and modeling high quality
© 2004 by Association of Professors of Medicine. Published by Excerpta Medica Inc. All rights reserved.
0002-9343/04/$–see front matter doi:10.1016/j.amjmed.2004.02.001
Association of Professors of Medicine
Table 1. Changes in the learning environment in the United States: 1997–2002 1997–1998
2000–2001
2002–2003
Number (%) Applications to medical schools Medical students Women enrolled Underrepresented minorities enrolled Full-time faculty Average cumulative medical student debt PGY-1 internal medicine positions filled through the National Resident Matching Program
43,016 66,748 28,447 (42.6) 7712 (11.6) 96,773 $80,462 (1997 graduates) 4506 (in 1999)
37,089 66,295 29,576 (44.6) 7066 (10.7) 103,553 $99,089 (2001 graduates) 4494 (in 2000)
33,625 66,677 31,290 (46.9) 7086 (10.6) 109,526 $103,855 (2003 graduates) 4395 (in 2002)
Data from references 4, 6, and 7. PGY ⫽ postgraduate year.
inpatient care (9). Hospitalists represent a new and growing niche for academic internists, and exposure to role models in this area may bolster interest in careers in internal medicine. Residents, who have served a major teaching role for medical students, are also faced with limitations to their time. Shorter lengths of stay and increasing acuity appear to have increased the workload of residents. In 2003, the Accreditation Council on Graduate Medical Education (ACGME) approved new program requirements (10), including the 80-hour workweek restriction. The requirements regarding duty hours reduce the availability of residents and interrupt continuity of care, which will affect the role of residents in teaching medical students. For residents, accreditation program requirements include not only duty-hour restrictions but also requirements relating to the six ACGME competencies, which reflect many of the core values of internal medicine: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. The increased emphasis on the development of these competencies, as well as tools for their evaluation, can be beneficial to student teaching. The CDIM is working with the Society of General Internal Medicine to update the Core Medicine Curriculum Guide (3) and assign each of the objectives in this guide at least one corresponding ACGME competency. If internal medicine clerkships adopt the revised core curriculum, it will provide an important link between medical school and residency and reinforce the value and reality of the “continuum of medical education.” High quality educational experiences for medical students demand teachers who are well prepared. Developing the knowledge and skills of these educators should be a priority for all internal medicine clerkship directors and departments. Many unique faculty development pro-
grams have been developed in print, workshop, video, and computer-based formats. Role-playing, standardized learners (11), and objective structured teaching exercises (12) have all been used. Reaching community preceptors with such programs can be especially challenging (13,14). Residents have a great deal of contact with medical students, and developing residents’ teaching skills should also be a priority. Programs that focus on basic educational principles directly relevant to the day-to-day activities of the resident may be particularly helpful (i.e. learning climate, team leadership, feedback, and evaluation) (15).
TEACHING SITES Shifts in inpatient and outpatient care have been dramatic since the early 1990s and have forced a reconsideration of where clinical teaching should occur. The majority of medical care takes place in the outpatient setting, whereas most undergraduate clinical education still occurs in the inpatient setting. However, concern that replacing an inpatient with an ambulatory rotation diminishes the educational impact is not supported by the literature (16,17). Additionally, ambulatory rotations are associated with positive perceptions of, attraction to, and choice of a career in internal medicine (18). Additional opportunities arise from increased ambulatory education. Some schools have chosen to combine multiple primary care specialties (e.g. medicine, pediatrics, and family medicine) into an integrated primary care clerkship. Such programs may offer unique opportunities for effective primary care education (19). Continuity experiences may improve the understanding of doctor-patient relationships, psychosocial aspects of care, and the management of chronic illnesses, without apparent differences in the knowledge acquired (20 –23). April 15, 2004
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116 577
Association of Professors of Medicine
TECHNOLOGY There has been an explosion of electronically available medical information since the early 1990s. Online textbooks, full-text journals, and clerkship-specific material have become core resources for many clerkship programs. The use of personal digital assistants continues to grow among medical students and residents, primarily for the ability of the devices to provide “just-in-time” learning and medical information. Wireless technology and electronic medical records are likely to become widely available and to serve as the primary method through which providers interact with the hospital information system. This infrastructure also may allow for greater tracking of the individual experiences of students in the clerkship, which is important for clerkship curriculum planning and evaluation. One novel potential vehicle for education is computerized order entry systems for providers that are designed to reduce medical errors. These programs intercept potential errors during order entry and prompt the provider to review the order; they are linked to built-in clinical decision support systems designed to provide immediate expert feedback to the user and to reduce errors, but they also have the potential to be powerful educational tools for students. A major goal of the clerkship is to demonstrate effectively the use of new technology to locate and interpret the proper information at the appropriate time.
EDUCATIONAL GOVERNANCE A final area of dramatic change is the increasing central oversight of the medical school curriculum. The Liaison Committee on Medical Education (LCME), the Association of American Medical Colleges (AAMC), and the National Board of Medical Examiners (NBME) all influence the mission and goals of the medical school. The recent trend by these organizations to influence the environment, curriculum, and assessment of medical school education has increased the responsibility and accountability of the clerkship director in complying with these organizations’ mandates and new expectations. To ensure that such compliance occurs, the dean’s office is now required to demonstrate: “integrated institutional responsibility for the design, management and evaluation of the curriculum” (24). Typically, it is the medical school that determines the structure of the clerkship (length, sequence, number of students, affiliate liaisons), the crossdiscipline content to be included in a specific clerkship, and, ultimately, much of the job description and demands on the clerkship director. Since the early 1990s, the emphasis on evidence-based medicine has grown exponentially, with the challenges of teaching it shifting from the department of internal medicine to the medical school. Educating medical students 578
April 15, 2004
THE AMERICAN JOURNAL OF MEDICINE威
Volume 116
about the principles of evidence-based medicine should occur at all levels of the curriculum, particularly in preclinical biostatistics, clinical epidemiology, and “practice of medicine” courses, and in the core clinical clerkships. Certainly, internists have been at the forefront of the evidence-based medicine movement and internal medicine clerkship directors should have a well-defined plan to include its principles in the clerkship curriculum. More difficult tasks are to find time in the curriculum and to have faculty and residents support the curriculum and model evidence-based medicine principles in clinical practice. These tasks require extensive faculty development. Calls for accountability for medical schools have greatly increased the focus on the process of evaluation of medical students, particularly the objective structured clinical exercise. The Institution of the United States Medical Licensing Examination Step 2 Clinical Skills Examination will make it effectively mandatory for all medical schools to prepare medical students for such testing. Clerkship-based and end-of-third-year objective structured clinical exercises have become relatively common (25). Developing, implementing, and maintaining high quality, accurate, and reliable objective structured clinical exercises are formidable tasks, particularly at the individual clerkship level. Facilities, funds, administrative support, standardized patients, and a certain degree of expertise are all prerequisites, and support from the dean is crucial. However, the CDIM firmly agrees that teachers must continue to have a key role in assessing trainees’ skills and that “medical educators must not abdicate this responsibility to standardize patients and simulation” (26). The positive contributions of increased central curriculum oversight and accountability are enhanced communication and collaboration among educators, even across departments, who are working to achieve the same goals. Shared resources and programs may also be useful in faculty development and assessment of educational outcomes. In addition, specifically defining goals and objectives may make it easier for students to assess themselves and direct their own learning. Such a coordination of effort should facilitate the move to a competency-based curriculum and allow students flexibility. However, as the CDIM has previously stated, it is important to consider the distinction between central oversight and control. Moving control of the clerkship out of the hands of clinical departments has potentially serious consequences, including the loss of innovative teaching and evaluation method. . . . Such a move begs the question of ‘ownership’ of the clinical curriculum. Centralized control raises the specter of curricula reflecting the desires and vision of a few rather than being the collective view of the education community (i.e., the faculty at the local level) (27).
Association of Professors of Medicine
THE INTERNAL MEDICINE CLERKSHIP IN THE FUTURE The rapid pace of change in medical information, information technology, and educational requirements, coupled with ever increasing external pressures on faculty time and curricular time, are changing the core clerkship in internal medicine. Clerkship directors must proactively manage these changes or face erosion of the core values and goals of the clerkship. The internal medicine clerkship of the (not so distant) future must have strong, core ambulatory and inpatient experiences. The pool of teachers must include a broad array of internists: hospitalists, general internists, subspecialists in the ambulatory and inpatient settings, residents, and fellows. Effective programs to develop the teaching skills of residents, fulltime faculty, and community preceptors must be disseminated. These skills should include basic teaching skills and teaching evidence-based medicine, information management, and other new clinical content in the context of the clinical encounter. Students should be trained to use their hand-held computers to access information at the point-of-contact, manage medical information, and track their clinical encounters and achievement of learning goals. The learning goals must remain consistent with the core clerkship curriculum but should be framed in the context of the ACGME competencies to facilitate the transition from student to resident and to emphasize the continuum of medical education. Assessment will need to be more competency-based and will likely include more standardized patients and simulations, as direct observation of student performance will be critical to ensuring mastery of required competencies. Finally, greater cooperation is needed to ensure that the objectives of the internal medicine clerkship are more integrated with the goals of other clerkships and preclerkship courses. These changes will only occur if the clerkship director in internal medicine embraces change within the clerkship, acts as an advocate for the program’s teachers, and articulates the importance of the core values of internal medicine. In addition, substantial investment in the educational mission is urgently needed. Appropriate recognition and reward of excellence in educational activities must be developed, and adequate financial and administrative support for the clerkship director and for clinical teachers must be assured, likely through missionbased management. In addition, internal medicine clerkship directors must continue to be among the educational leaders at their school, serving on medical school and departmental educational committees (28). They need to collaborate with other clerkship directors, course directors, and residency directors to address LCME, NBME, and ACGME mandates and to create an integrative set of learning experiences in a competency-based curriculum
that extends from introduction to clinical medicine through the clerkships and into internship. When caring for patients, internists strive to incorporate rigorous, scientific, evidence-based thinking in the comprehensive, personalized care of the adult patient and to embrace the care of the complex patient. Similarly, internist educators must strive to incorporate rigorous, evidenced-based thinking into the development of a competency-based, personalized curriculum for students in the internal medicine clerkship and to embrace the current complexity of medicine and medical education. Following these tenets, the clerkship may be dramatically altered, but the core mission and values will not only be maintained, but also perhaps more nearly achieved. Alison Whelan, MD Joel Appel, DO Eric J. Alper, MD Thomas M. De Fer, MD Todd A. Dickinson Sara B. Fazio, MD Erica Friedman, MD Mary Ann Kuzma, MD Shalini Reddy, MD
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