Journal Club

Wimmers, PF, Schmidt, HG, and Splinter, TAW (2006). Influence of Clerkship Experiences on Clinical Competence. Medical Education, 40, 450-458.

Reviewed by Antoinette Spoto-Cannons, USF

Medical student experience in the clinical years varies between students, different clinical sites, different preceptors, and different schools. It is imperative to determine the consequences of this variation on clinical competence. The evidence regarding the learning value of the patient encounter and clinical supervision is limited.

The objectives of the study by Wimmers, et al were "to determine the variation in students' clinical experiences within and across sites, to identify the causes of this variation, and to investigate the consequences of this variation on students' competence."

During the 1999-2000 academic year, 227 medical students were studied during their 12-week internal medicine clerkship at Erasmus MC-University Medical Center Rotterdam, the Netherlands while rotating at 14 different hospital sites (3 academic and 11 affiliated hospital sites). The variation in student experiences was established by their clinical patient encounters entered in a logbook and evaluation of the quality of supervision. The variation in patient encounters between different hospitals was evaluated based upon number of beds, number of beds used for educational purposes, number of staff, average length of patient stay, number of patient admissions, site occupancy, and number of peer clerks. Clinical competence was established utilizing 3 indicators: the practical end-of clerkship examination; the theoretical end-of-clerkship examination, and professional performance.

The study supported that differences between hospital sites were greater than expected. Only length of stay, number of patient admissions, and quality of supervision significantly explained the variation in patients. However, this variation did not significantly impact student competence. It was the quality of supervision which had the greatest impact on students' clinical competence; especially, when the number of patients and variability of diseases was low.

Limitations of the study include the reliability of the logbook data, the assessment of clinical competence, and the assessment of the quality of supervision. Furthermore, this was not a multi-center study.

There is no doubt clinical clerkships are an essential part of becoming a clinically competent physician. However, the model currently used to educate students may need to be changed in order to incorporate effective repetitive experiences (‘deliberate practice') in combination with high-quality supervised training. Further studies need to be done on the clinical impact of the patient encounter and what aspects of clinical supervision are important in promoting optimum clinical competence.

(This data validates what several of our COMSEP colleagues have demonstrated in U.S. medical schools. "Numbers and kinds" may be less important than the quality of the teacher. We keep trying to tell the LCME…… - Bruce Morgenstern)