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Bridget O'Brien, PhD, Molly Cooke, MD, and David M. Irby, PhD Perceptions and attributions of third~year student struggles In clerkshlps: do stud ents and clerkship directors agree? Acadonic Medicine, Vol. 82, No. 10. October 2007. pp. 970¬978

Bridget O'Brien, PhD, Molly Cooke, MD, and David M. Irby, PhD Perceptions and attributions of third~year student struggles In clerkshlps: do stud ents and clerkship directors agree? Acadonic Medicine, Vol. 82, No. 10. October 2007. pp. 970¬978

Reviewed by Melissa Held

What is the problem and what is known about it so far?
Medical students often have difficulty tmnsitioning from the pre-clinical years totheclinical rotations in the third year oftraining. Despite the introduction of small group sessions. problem-based leaming courses, and courses oriented towards core clinical skills, students still struggle with the transition to the clinical years.

Why did the researchers do this particular study?
The purpose of the study was to explore the relationship between medical students' and clerkship directors' perceptions of the struggle often found in the transition to the clinical clerkships.

Who was studied?
The data include responses and comments from 16 interviews and eight focus groups with clerkship directors, and II focus groups with third and fourth year medical students. Ten U.S. medical schools were represented from II variety of geographic regions, public and private institutions, community and academic based programs. The study was conducted from 2005•2006.

How was the study done?
Interviews and focus groups were recorded, transcribed and entered into a software program. The transcripts were coded for passages that discussed student struggles at the beginning of their clinical rotations. A list of themes was then generated. Passages were recoded by the authors and discrepancies were discussed. The top five categories of struggle discussed by students and clerkship directors were illustrated. In total, 65 clerkship directors and 83 students contributed to the discussion and analysis.

What did the researchers find?
12 categories of struggles were identified by students and clerkship directors. They included: Roles, responsibi lities, expectations; Adjusting to the culture of the clinical environment; Clinical skills (technical, interpersonal); Logistics; Frequent change (rotations); Cl inical knowledge and reasoning (diagnosis and plan); Methods of assessment and feedback; Professional identity (sense of self as a physician); Self•perception. self• confidence; Self-directed and t!xperientialleaming, self-assessment; Involvement with patients (emotional intensity, boundaries); Time management, prioritizing.

Students and clerkship directors both recognized struggles in the areas including: adjusting to the culture of patient care in various clinical environments; performing clinical skills; engaging in self•directed learning, experiential learning or self assessment; applying or restructuring clinical knowledge to enable clinical reasoning and assessment Clerkship directors less frequently identified areas of importance to students, which included understanding roles, responsibilities, and others' expectations in clinical settings; managing logistical information; handling frequent changes in setting, discipline, and people; and to some extent perfonning cl inical skills.

Overall, clerkship directors focused on the challenges acclimatizing to particular clinical settings and focusing on the patients in those settings. Students felt the challenge was not so much focusing on patients, but more on understanding how best to communicate infonnation appropriately and contribute to patient care in a variety of clinical settings.

What were the limitations of the study?
Some themes or perspectives may have not been captured in the data. Students and directors who had worked together were not matched in the study so interpretations of struggles may have been context specific. The specific clerkship, time of the year or curricular structure was not examined. The schools included in the study had clerkships organized in specialty-specific block rotations (which is not representative of all medical school c1erkships).

What are the implications or the study?
The areas that students identify as struggles in transitioning to the clinical years are different in some respects then those struggles identified by clerksh.ip directors. Th.ese perspectives should be further explored as they could have implications for how curriculum is developed and implemented in the pre-clinical and early Clinical years of medical education. As clerkship directors, we have an important role in shaping the clerkship experience and to create a supportive environment in which students can develop their skills.

Ed Note: This is an important article in that it hightights the different perspectives of students and clerkship directors. These results demonstrate a very quantitative way to describe qualitative data.

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