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Don't through out the baby with the bath water. Relationship between Clinical Experiences and Internal Medicine Clerkship Performance. Dong T el al. Teaching and Learning in Medicine 2012;46:689–697

Reviewed by Jonathan Gold

What was the study question?
What is the correlation between the number of clinical experiences reported by students and their subsequent performance on clinical rotations and exams?

How was the study done?
Data were retrospectively analyzed from student logbooks, and student performance on clinical evaluations and multiple choice tests for three consecutive years of an internal medicine clerkship in Bethesda, Maryland.

What are the results?
There was a weak positive association between the number of patients seen and the scores on both clinical evaluations and exams.

What are the implications of these findings?
This study supports evidence from earlier studies that more clinical experience (as measured by self-report or student logbooks) does not necessarily result in better test scores. The authors of this study argue that their findings support cognitive load theory, namely that the complexity of real patient encounters overwhelm the cognitive resources of the beginning student, and that perhaps such students would be better served by simpler straightforward cases (such as paper cases).

For the clerkship director who wants to tell his or her students that focusing on patient care rather than studying is better for them in the long term, such results are discouraging. However, I wonder whether there is a simpler explanation than the cognitive load theory suggested by the authors. Perhaps the experience gained by busy students doesn't help them on clerkship exams because they are different skills than those gained in real patient care. I also suspect that the student logbooks are poor measures of "clinical intensity". The number of patients a student sees is probably less important than what one does with the patients he or she does see.

Editor's note: These results are a poignant reminder to us that clinical exposure may not alter test scores. The question is what to change - the clinical exposure or the assessment measures? I would argue that the wrong conclusion of this study would be to limit clinical exposure in the clerkship to improve test grades. Perhaps, altering the assessment measure to include some degree of clinical acumen might be a step in the right direction. (SLB)

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