Learning in Clinical Clerkships: Networks and Engagement

Learning in Clinical Clerkships Occurring Within Work and Relationships

Clinical clerkships provide opportunities for students to learn clinical skills, reasoning, and communication while participating in patient care. Opportunities for practice and feedback vary depending on which patients they see, whom they work with, and the range of tasks they undertake. The curriculum provides standardized training to compensate for these differences, but students allocate time and effort across clinical experiences, exam preparation, and online activities. Understanding learning in clinical clerkships requires examining the opportunities provided by work and relationships alongside the ways students engage with those opportunities.

Feedback Created by Departmental Work and Supervisory Relationships

A 2024 study of workplace feedback examined what feedback students receive, from whom, when, and where, and how they use it. The Southern Illinois University School of Medicine (SIUSOM) reformed its curriculum to strengthen ongoing teacher-student relationships and participation in clinical work. Weekly observations of students’ 8 skills and attributes were required to be recorded on an “On the Fly” (OTF) form. Students reviewed records in the electronic system to adjust their performance. The clerkship grading committee assessed progress using the cumulative records. Students rated OTF records as having limited usefulness for learning while reporting that they received high-quality feedback in the workplace. The study was conducted from July 2021 to February 2022 to understand this discrepancy. At this school, which has a class size of 72, third-year students rotate through 8 core departments over 8 months. The research team selected 18 individuals through maximum variation sampling based on demographic characteristics and prior clinical performance, and recruited 11 (61%). With direct observation limited by COVID-19, the research team collected reports of recent feedback experiences through anonymous surveys sent a total of 30 times on randomly selected weekdays each week and analyzed them using the 5Ws (Who, What, When, Where, Why). The research team jointly revised the codebook and resolved discrepancies in independent coding through meetings. The results and response processes were verified with participants.

The average weekly response rate was 85%. Of the 322 possible responses, 272 (84%) were coded, of which 267 described feedback experiences. In surgery, students tended to receive feedback while suturing under a resident’s supervision toward the end of a procedure in the operating room. Bedside feedback on procedures and skills was also reported in neurology and obstetrics/gynecology. Feedback on patient communication in psychiatry was reported more than twice as frequently as in other rotations. It was generally provided by a resident in a non-private space, such as a hallway, immediately after an interview. In family medicine, students received feedback in private spaces such as a faculty office. They worked with a single attending for 4 weeks in a rural outpatient clinic without residents. In internal medicine, case presentations and feedback during ward rounds were part of the care team’s work. Emergency medicine and family medicine emphasized diagnostic reasoning, reflecting work with patients whose diagnoses had yet to be determined. Technical and clinical skills were addressed in 69% of the experiences, but students reported using feedback to improve these skills in 44%. The corresponding figures for communication were 16% and 23%, respectively. Overall performance was addressed in 8% of experiences, while students used feedback to adjust self-assessment and improve confidence in 21%.

These patterns were interpreted in terms of social learning ecosystems. A department’s social and physical conditions shape whom students work with, what tasks they perform, and which skills become the focus of feedback. The study draws on students’ recollections at a single U.S. medical school. The results are limited to the combinations of work, supervisors, and spaces that students experienced and reported. In response to the findings, the research team reduced the OTF input fields from 8 to 1 while retaining guidance on the same 8 skills and attributes. The wording was also changed to prompt recall of interactions and workplace feedback when treating the student as a “junior member of the clinical team.” The research team identified the usefulness of the revised form and the need for department-specific forms as areas for further review.

Engagement Patterns in Online Clinical Reasoning Training and Exam Achievement

A 2023 study analyzed activity records from the Critical Clinical Competencies (CCC), an online clinical reasoning training program at SIUSOM. The CCC is a mandatory program for Years 1–3, covering 48 diagnoses annually by presenting 1 long case and 3 mini cases with different diagnoses for each of 12 common chief complaints. Students complete activities in 8 sequential steps. Writing diagnostic justifications is mandatory, while self-assessment through comparison with faculty judgments and some reflection questions are optional. The research team used a retrospective extreme-groups design, purposively sampling 64 individuals at the two extremes of Summative Clinical Competency Exam (SCCX) scores from the 2018–2020 graduating cohorts. The SCCX consists of 14 standardized patient encounters of 20 minutes each, with a passing standard of 65% per station. Passing the exam requires passing a minimum of 10 stations. The analysis included 31 students in the Pass All group, who passed all 14 stations, and 33 in the Fail group, who passed fewer than 10 stations.

The analysis used records of Year 3 CCC activities completed before the SCCX. The research team conceptualized engagement as context-dependent state self-regulation and assessed conscientiousness and cognitive effort using a rubric they developed. The 3 conscientiousness items addressed completion timing, the distribution of completion dates, and participation in optional self-comparison activities. The 4 cognitive effort items assessed responses tailored to the case, revisions to diagnostic justifications based on new information, and reflection on reasons for differences between students’ and faculty members’ judgments. Each item score was converted to a percentage, and the average of all 7 items served as the overall engagement score. Evaluators were blinded to student grades. Of the 64 individuals, 60 completed all 12 exercises, and incomplete exercises were assigned 0 points. Mean cognitive effort scores for the Pass All and Fail groups were 66.6 and 51.7 (p = 0.013), and mean overall engagement scores were 71.7 and 57.5 (p = 0.005), respectively. Mean conscientiousness scores were 81.5 and 68.8, respectively, but the difference was not statistically significant (p = 0.084). In logistic regression, the coefficient for overall engagement was significant after accounting for prior scores on the Year 2 clinical competency exams (Y2 CCXs) (p = 0.043). Holding Y2 CCX scores constant, a 1 point increase in overall engagement was associated with 3.4% higher odds of belonging to the Pass All group. Adding overall engagement increased the Nagelkerke R² from 0.538 to 0.596. Classification accuracy was 81% for the model including both variables and 64.1% for the model using only overall engagement.

Engagement was associated with exam achievement but added little explanatory power beyond prior grades. Mean overall engagement scores in the 2018 cohort were similar across the two groups, at 68.2 and 65.4, but the Fail group scored lower in 2019 and 2020. Changes in completion monitoring, professionalism citations, and the use of remedial assignments following the transfer of program operations were suggested as possible contributing factors. Because the sample represented the extremes of grades and the analysis used CCC activity records, the relationship between engagement scores and achievement is best interpreted alongside information about students with intermediate grades and their engagement in other learning opportunities. Hypothetical patterns were proposed to explain the results. Across the Board Disengagement describes students generally forgoing learning opportunities; Strategic Disengagement describes selectively forgoing opportunities based on their goals. Across the Board Engagement is characterized by broad participation. Unproductive Engagement describes participation that does not lead to exam achievement. For high-achieving students, the study proposed flexibility to meet basic requirements through exams and choose advanced learning opportunities. For low-achieving students, it proposed “soft structure,” such as academic advising.

Reading notes

From the perspective of workplace learning in HRD and the evaluation of education and training, examining connections among the people students work with, the tasks they undertake, the practice activities they select, and changes in performance helps explain learning during clinical clerkships. The OTF form was revised to prompt recall of workplace interactions, using shared tasks as the starting point for evaluation records. The CCC records captured engagement in greater detail by distinguishing case-specific thinking and reflection in addition to completion status.

References

Cianciolo, A. T., Ashburn, C., Han, H., Schwind, C., Matos, S., Rafaquat, A., & Davila, J. (2023). If you build it, will they come? Exploring the impact of medical student engagement on clerkship curriculum outcomes. Medical Science Educator, 33(1), 205–214. https://doi.org/10.1007/s40670-023-01739-6

Cianciolo, A. T., Han, H., Howes, L. A., Klamen, D. L., & Matos, S. (2024). Discovering social learning ecosystems during clinical clerkship from United States medical students’ feedback encounters: a content analysis. Journal of Educational Evaluation for Health Professions, 21, 5. https://doi.org/10.3352/jeehp.2024.21.5