Council on Medical Student Education in Pediatrics


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Susan M. Kies, EdD; Valerie Roth, MD; Michelle Rowland, MD, PhD, MPH. Association of Third-Year Medical Students' First Clerkship With Overall Clerkship Performance and Examination Scores. JAMA 2010; 304(11):1220-1226

Reviewed by: Christopher B. White, MD, COMSEP President, Medical College of Georgia, Augusta, GA

What was the study question? Is there an association between first clerkship specialty and overall medical student performance throughout the remainder of the clinical clerkship year?

How was the study done? This was a retrospective study of third year clerkship performance by students at the University of Illinois from 2000-2008. All but 20 of the 2236 students who completed all 6 core clerkships (IM, FM, Surg, Peds, Ob/Gyn, and Psych) were included. Data collected for each student included USMLE Step 1, Step 2 scores, clerkship order, clerkship clinical grade, clerkship subject examination score, final overall clerkship grade, and clerkship site.

What are the results? First clerkship specialty was significantly associated with higher mean subject examination scores (and overall clerkship grade) but not on subsequent clinical grades or USMLE Step 2 scores. This association was most strongly associated with internal medicine as the first clerkship, although having pediatrics as a first clerkship had a modest effect as well. Having IM as the first clerkship resulted in a mean increase of 1.49-1.92 raw score points on the subject exam tests for Surg, Ob/Gyn, Psych, and FM. Having Peds as the first clerkship resulted in a mean increase of 0.95-1.16 points on the subject exam tests for Psych and FM. The effects were significantly associated with gender (more pronounced for women than men), campus (they have 4 different campuses where students do their clerkships) and Step 1 score.

What are the implications of these findings? At the University of Illinois, the "rumor mill" among the medical students was that taking internal medicine as the first clerkship (their clerkship is 12 weeks, with 8 weeks being inpatient) resulted in better grades and clinical performance in all the remaining clerkships. Hence there was (I assume) significant competition for internal medicine as the first rotation. As clerkship directors, we are constantly trying to squash many of the rumors that infiltrate among the students. Most of these are based on hearsay or are the result of a single vocal disgruntled student. In this case, however, the rumor was actually true! Taking the internal medicine clerkship first resulted in modest increases in NBME subject exam scores in the remaining clerkships (except pediatrics). The difference of 1.5 points on the Shelf exam could mean the difference (in a few cases) between a student achieving an "A" or a "B" (or whatever system your school uses). Interestingly, taking pediatrics first had a similar but smaller positive impact on two clerkship subject exam scores as well. Fortunately, none of this had any impact on USMLE Step 2 scores.

So what should we do in light of this information? First of all, this is the experience of only one school. It would be interesting to see if this is the case in other schools as well. If it can be substantiated, then who knows? Maybe we'll begin to see a national push by students interested in plastic surgery, dermatology, orthopedics, ENT and ophthalmology to take internal medicine as their first rotation! Fortunately Step 2 scores aren't affected, and they are probably far more important in residency applications.

Given the complexities of their training venues, schedules and preceptors, we all try to do our very best to make every student's clinical training as fair, consistent and equivalent as we can, Despite this, there will always be issues that arise that make some students feel their experiences are not comparable to their peers. In those cases, all I can say is that "life isn't fair."

Editor's note:
While it is not feasible to place all clerks in an internal medicine rotation first, the authors wonder if specific, beneficial components of an internal medicine clerkship could be taught in an introduction to clerkship course. Which components these are - perhaps clinical decision making or underlying pathology for complex disease - needs to be determined.

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