Learning in the Real Place: Clerkships and Socialization

Abstract

This study interviewed 12 medical students before, during, and after their clerkship year and observed them in clinical settings, linking learning expectations, processes, and outcomes. Students expected hands-on participation in patient care and the development of clinical reasoning; in practice they secured learning opportunities by reading shifting environments and faculty expectations and by managing impressions. Confidence in interactions and clarity about specialty choice grew, while chances to observe and practise diagnostic thinking under guidance fell short. The study specifies how participation in a real workplace translates into learning at the level of relationships and tasks.

The Clerkship as a Place of Learning

The medical school clerkship is an educational process in which students apply acquired knowledge to actual patients and learn to work as members of a clinical team. While meeting patients and assisting with the team’s tasks, students learn whom to ask questions, which behaviors are seen as active participation, and how much responsibility they can assume. Understanding what students learn during the clerkship requires examining both the relationships in which they participate and the activities they have opportunities to undertake. This study examines this process through learner expectations, learning experiences, and outcomes after completing the clerkship (Han et al., 2015).

Post-clerkship interviews alone make it difficult to distinguish initial expectations from retrospective accounts shaped by experience. Early clerkship experiences cannot fully capture the confidence and judgments students develop as they adapt to an unfamiliar environment. The research team followed the 2011–2012 clerkship year. Three questions guided the study: what students expect to learn, how they learn, and what they believe they have learned.

The analytical lens is legitimate peripheral participation within situated learning (Lave & Wenger, 1991). From this perspective, newcomers learn by gaining access to a community’s activities, interacting with skilled members, and gradually participating in more central tasks. Students expect to observe medical care alongside practicing physicians, begin with limited roles, and develop competence as physicians through expert guidance. Meeting patients and becoming a team member must be distinguished from gaining access to physicians’ processes of interpreting information, constructing differential diagnoses, and determining care plans.

Longitudinal Qualitative Design Following One Year

The research site was the Southern Illinois University School of Medicine (SIU SOM). This school taught basic science and clinical knowledge through a PBL curriculum during the first and second years. Clinical education involved faculty from a medical school-based multispecialty group practice, a community-based multispecialty group practice, and local family medicine clinics. The school was affiliated with two hospitals. During the third year, students completed six clerkships: internal medicine, surgery, psychiatry, pediatrics, family and community medicine, and obstetrics and gynecology (OB/GYN). The fourth year added neurology, electives, and preparation for specialty selection. The study focused on the third-year clerkship year. Three in-depth interviews—pre-, mid-, and post-clerkship—with each participant, together with full-day observations, allowed the research team to compare learning expectations, experiences, and outcomes as each student progressed through the year.

All 78 third-year students were invited to participate; of the 12 who volunteered, 7 were female, and compensation for one year of participation was $100 per person. All three researchers had been involved in the curriculum. Drawing on that experience, they determined that the participants represented high, medium, and low academic achievement levels. The participants were racially diverse, but information about race was withheld to protect confidentiality. The sample was not selected to statistically represent the full student population. Participant compensation was supported by the SIU SOM Department of Medical Education. The study received an exemption from review by the SIU SOM institutional review board. No conflicts of interest were disclosed.

The semi-structured interview protocol was developed from the research questions and prior studies of the transition from school to the workplace. Pre-clerkship interviews took place in June and July 2011, after the second year ended and before the first day of the clerkship. They addressed prior healthcare experiences, learning expectations, and concerns about the clerkship. Mid-clerkship interviews took place between November 2011 and January 2012. They covered four domains: comparisons between actual experiences and prior expectations, application of medical knowledge, interpersonal interactions, and learning the norms of practice. Post-clerkship interviews took place in June and July 2012 and built on the previous two interviews to elicit reflections on learning outcomes. The three researchers generally attended the interviews together. One followed the interview protocol, while the other two asked follow-up questions. The researchers used the critical incident technique to prompt recall of specific events, such as occasions when students felt included in patient care activities. All interviews were audio-recorded and transcribed. The researchers discussed emerging and recurring insights immediately afterward. The research team agreed that no new information was emerging by the 11th and 12th interviews and determined that saturation had been reached. Observations were arranged in conjunction with the mid-clerkship interview phase, with consent from the students and clerkship departments. Observation dates ranged from September 2011 to June 2012. An observation could involve following a clerkship day from 6:00 a.m. to 5:00 p.m., for example. The three researchers completed a total of 11 observations; one participant could not be observed because of scheduling conflicts. Rather than using a standardized recording form, the researchers documented key activities, interactions, and their contexts.

The researchers used grounded theory methods and constant comparison for the analysis. Guided by the research questions, they read the transcripts closely and assigned descriptive codes to statements. They conducted open coding by collecting and rereading statements with the same code. They then compared emerging themes with the raw data from all interviews and grouped the open codes into categories. The analysis began with two calibration meetings to discuss coding rules and agreement. Calibration meetings continued throughout the analysis and involved jointly coding a total of 7 transcripts. Approximately 2 hours were spent coding each transcript, and approximately 14 hours were devoted to improving inter-coder agreement. The remaining 29 transcripts were divided among the researchers and coded independently. The researchers used Atlas.ti version 7 (Berlin, Germany) and generated 2,027 codes across the full set of transcripts. They analyzed and categorized codes using density, defined as how frequently a code was used in the analysis, and groundedness, defined as its degree of connection to other codes. They used observation records to check findings and triangulate the analysis and interpretation. Comparing interpretations developed through repeated interviews with the full set of transcripts and checking them against field observations helped situate students’ accounts within the activities and interactions they experienced.

Pre-Clerkship: What Was Expected to Be Learned

Students approaching the clerkship had high expectations for learning in a clinical setting. Few independently articulated specific learning objectives. Most questioned whether they should have separate learning objectives at all, seemingly viewing themselves as recipients of an established curriculum. Only after further probing by the research team did students describe what they intended to learn. The first expectation to emerge was hands-on experiences. All participants had healthcare-related experience before entering medical school, including shadowing, medical volunteering, medical mission trips, and social work. Some had physicians in their families. They wanted to move beyond observation to see patients directly and perform tasks themselves during the clerkship.

“I think it will be a mix of see one, do one, teach one in some way. Because it is their hope that students learn better when they do that. I just hope it is not just a shadowing experience.” — Participant 9, female

The second expectation was realistic learning to become a real doctor. Students expected to assume professional roles as physician trainees. They hoped to join the clinical team and learn how hospitals and clinics operate. The third expectation was textbook learning translated into real-world practice. Students expected to learn how diseases described in textbooks present in actual patients and which medications and treatments are used in practice. They also recognized that textbooks and practice could differ, as when they had heard that a medication taught in class was not used clinically. The fourth expectation, being more knowledgeable, included the ability to reason while applying knowledge to real cases. Students wanted to practice starting with limited information, selecting appropriate physical examinations and tests, and following an efficient sequence to reach a diagnosis.

“Thinking through clinical situations will get better. Starting from scratch and dealing with a patient case with limited information, knowing what to do next. What physical exam to do, what tests to order, in what order to do them to be most efficient in getting to a diagnosis.” — Participant 2, male

The fifth expectation was deciding on a specialty. Most students had considered specialties of interest based on prior experience. Since they had not experienced every specialty, they remained open to changing their preferences during the clerkships. Participant 2 expected to spend the upcoming 12 months considering options and reaching a decision, anticipating being 100% certain of the specialty after one year.

Mid-Clerkship: Learning by Reading Environments and Managing Impressions

Some students started with longer clerkships lasting 10 weeks, such as surgery and internal medicine. Others began with shorter clerkships lasting 6 weeks, such as pediatrics, OB/GYN, psychiatry, and family and community medicine. The first process common to these rotations was navigating environments. Students reported needing several days to establish what to do, how and where to do it, and why it was done that way. Teaching styles, expectations, and evaluation criteria varied by attending, and students found evaluations more subjective than expected. Even within a single clerkship, students were assigned to different attendings almost every week. They continually had to identify new clinical faculty members’ preferences and expectations.

“Figuring out what is expected right away was really important. Whether it is inpatient or outpatient, depending on who you are with, whether it is with an attending or with a resident, it was different. Just going and asking what they want from me. What is my role? Depending on whether it is psychiatry or the delivery room, everything is a little different, and what is expected of me while I am here is different. If you do that right away, everything goes smoothly the whole time you are there.” — Participant 10, male

The second process was learning by doing through impression management. Students were usually assigned patients during each rotation. They felt recognized as members of the medical team when allowed to see patients or perform simple procedures. When no explicit invitation was offered, they sometimes volunteered for tasks. Through these experiences, students learned how first impressions affected subsequent learning opportunities. Students shared information about individual attendings’ preferences, and adapting to those preferences became a strategy for navigating the clerkship. For students, impression management was a way to secure favorable evaluations and build the trust that provided greater access to clinical participation and learning opportunities.

“What I noticed was the people who put in the most time and showed interest, not just actively listening, but asking relevant questions, knowing things, and being prepared for questions. I think those are the people who showed trustworthiness.” — Participant 3, male

Relevant questions could convey interest and preparedness. Students considered questions that suggested a lack of knowledge or interest to be risky. They believed that failing to answer an attending’s question would create a poor impression and could affect later evaluations. Impression management also extended to clerkships in less preferred specialties. Participant 3 described having to consider how residents might respond to a stated intention not to pursue their specialty. Students also weighed how to divide their energy between appearing interested and studying subjects or preparing for exams of greater personal interest.

The third process was balancing clinical work and studying. Students reported difficulty preparing for the shelf examination at the end of the clerkship while fulfilling ward duties. They carried review materials to study during brief breaks and looked for locations where they could study while remaining visibly available to the team. They sought to avoid appearing to have disappeared, being sidelined, or being assigned only minor tasks. Participant 10 described the most difficult challenge across the clerkships as balancing efforts to help the team and participate in patient care with reviewing clinical foundations and preparing for written exams. When days in the hospital and clinic were relatively short, as in psychiatry, students had time to study and regarded it as an important part of the curriculum.

Post-Clerkship: What Remained

After students completed all six clerkships, the research team asked what they had learned and whether and how their confidence had changed. The team also examined whether initial expectations had been met. The first outcome was increased confidence in interactions. Students reported greater confidence in interacting with patients, residents, attendings, and staff. They felt more comfortable with patient encounters and better able to manage relationships with members of the clinical team. They also understood hospital and clinic workflows more clearly, including the norms governing behavior and work processes. Participant 3 had initially felt comfortable working with people but explained that confidence in working as a medical student had changed through the clerkships.

The second outcome theme was limited opportunities to practice diagnostic thinking. Students had expected to become more proficient at applying medical knowledge and developing differential diagnoses, assessments, and plans. They reported fewer opportunities to practice comprehensive diagnostic thinking or observe experts’ thought processes than expected. Although they could see patients and consider diagnoses independently, they had insufficient opportunities for residents or attendings to regularly hear their hypotheses and coach their reasoning. In the hospital, diagnoses and plans were often established before students saw patients. In surgery, students were not necessarily present in the clinic when surgical decisions were made, limiting their access to the decision-making process. Participant 2’s account of OB/GYN revealed a discrepancy between the immediate task of a healthy delivery and the consideration of varied clinical situations and differential diagnoses that students hoped to practice. Students became more comfortable with simple cases but lacked confidence in reasoning through complex ones and considered their knowledge superficial.

“I feel like third year was a good introduction to everything we needed to be exposed to. But it does not necessarily mean you have deep knowledge or can speak competently about a lot of things. You can just say that you recognize the terminology and so we all share a similar background.” — Participant 11, female

The third outcome was decisions about specialty. After the clerkships, most students had a clearer sense of which specialty to pursue. Several described the selection process as a decision tree. Students who liked procedures considered surgery or obstetrics and gynecology. Among these students, those who liked babies considered obstetrics and gynecology, while others considered other surgical fields. Students who did not prefer procedures considered family medicine or internal medicine, depending on whether they enjoyed variety or the puzzle-solving aspects of clinical thinking. Good relationships with attendings who involved them in clinical activities also influenced their choices. Participant 2 had initially been drawn to neurosurgery but described a shift in interest after performing interventional cardiology procedures during the first two weeks of a clerkship.

“I originally wanted to do neurosurgery. I thought it was really great. I liked all the procedures. I liked the science behind it too. That was my plan. But when I started this clerkship, the first two weeks were interventional cardiology, and he let me do the procedures. Even inserting the catheter. After doing something like that a few times, you realize that you can actually do it. It was really fun. I felt like I was hooked. So the focus of what I want to do actually changed.” — Participant 2, male

The Authors’ Interpretations

The experiences of the 12 participants across the clerkship year are interpreted through the social and reciprocal relationships between students and attendings or residents. Students gain learning opportunities by building trust through impression management. Teaching styles and evaluation criteria are ambiguous and subjective, requiring students to determine what counts as appropriate performance in each setting and relationship. A study by Beagan (2001) demonstrated that medical students learn not to challenge clinicians because they fear poor evaluations and subsequent career repercussions if they appear noncompliant. This study reports consistent findings. Social exchange theory offers an interpretation of this relationship: clinical educators respond to students who present themselves positively with greater trust, instruction, and favorable evaluations (Blau, 1986; Cropanzano & Mitchell, 2005). Findings from Wenrich et al. (2010) indicated that students had higher expectations for their own skill development than clinical faculty did. In this interpretation, students who anticipate more learning may seek to create favorable impressions to secure learning opportunities.

The gap between expectations and experience is central to the discussion of clinical reasoning. Prioritizing patient problems and developing appropriate differential diagnoses, diagnostic plans, and management plans was a primary objective of both medical education and the third-year clerkship curriculum. Most participants reported learning less clinical reasoning during the clerkships than they had expected. A study by Audétat et al. (2012) found that clinical educators had received little training in clinical reasoning. They understood their role primarily as providing role models, with less emphasis on systematically guiding reasoning development. In this study, experts’ diagnostic reasoning was not readily visible to students, limiting what they could learn through role modeling alone. A study by Williams et al. (2011) involving five U.S. medical schools also reported that clinical reasoning ability improved significantly during the first and second years but did not increase during third-year clerkships. As in the study by Prince et al. (2005), limited basic science knowledge may help explain difficulties in clinical application. This study also considers students’ opportunities to apply and practice knowledge with expert guidance. Students had expected legitimate peripheral participation in which mentoring and coaching would refine their abilities. These expectations were not sufficiently met during the clerkships.

The study took place at a single medical school and involved student volunteers. The accounts of 12 participants cannot be generalized to all students. The clinical reasoning findings concern perceived learning opportunities and outcomes. They should be distinguished from changes measured through competence assessments. Although these data alone cannot establish the extent of change in clinical reasoning ability or differences between institutions, they identify specific constraints students experienced in gaining access to diagnostic thinking.

The next task is to identify the barriers to learning diagnostic thinking. Areas for examination include time allocated to teaching diagnosis and plan formulation, direct contact with learners where experts can demonstrate their approaches, and time for learners to practice with guidance. Clinical schedules and task allocation, experts’ understanding of their teaching roles, and social relationships between students and clinical faculty may act as barriers. Further evaluation is needed to establish how much the ambiguity created by continually changing environments and clinical educators impedes learning.

Reading notes

Following 12 volunteers out of 78 at three time points and examining their accounts alongside 11 full-day observations provides a comparative framework for workplace learning research in HRD. Expectations for learning diagnostic thinking were documented before the clerkships. Later disappointment cannot readily be attributed solely to retrospectively elevated expectations. The 10-week and 6-week rotations, with attendings changing almost every week, suggest that initial adaptation alone cannot explain subsequent participation. Impression management helped students gain learning opportunities. Career direction changed after performing procedures during the first two weeks of an interventional cardiology clerkship. These experiences allow examination of how relationships with clinical educators influenced learning opportunities and specialty selection. Research on medical education from a workplace learning perspective can explain learning, socialization, and career development together by examining access to clinical reasoning, the formation of trust, and career selection along the same timeline.

References

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