Prepping Younger Med Students for Clinic

Five years ago, the Association of American Medical Colleges (AAMC) convened the Coalition for Physician Accountability to address some of the many challenges that medical students face when transitioning from their undergraduate medical education (UME) to graduate medical education. For 10 months, the coalition identified the issues and discussed the potential solutions to improve this period of physician training. The result was a report containing 34 final recommendations, organized around nine themes.

The fact that the AAMC deemed such a coalition and report necessary speaks volumes — medical schools and students alike recognize that sometimes gaps exist between UME and graduate medical education. [Maybe UME first since it comes first?]. To improve the experience for everyone — and ultimately for patient outcomes — academia is looking hard at how to better bridge the gap.

“It’s worth mentioning that the first 2 years of medical school are completely divorced from the practice of medicine,” said Jared L. Ross, DO, an emergency medicine physician and assistant professor at the University of Missouri, Columbia, Missouri. “It’s really about rote learning and memorization, and it’s hard to imagine another career where the first half of school is so different from the actual career.”

With the first 2 years of undergraduate education spent in books and lectures, followed by third and fourth years spent in a clinical setting, many academics agree with Ross that change is in order.

“With new [graduate medical education] members, we don’t see an issue with their medical knowledge,” said Scott Holliday, MD, associate dean of Graduate Medical Education at The Ohio State University College of Medicine, Columbus, Ohio. “But they often don’t have context or understanding of where they fit into the big picture.”

While students change from one generation to the next, Holliday pointed to the complexity of today’s medical systems for some of the issues graduate residents face.

“They know a lot about medicine and the care of patients, but they don’t have much experience working in teams,” he said. “For many years, we’ve taught med students to grow as individuals and have tested them that way. But they’re missing out on working as a team.”

Today’s medicine is simply more complex than ever before, and medical school education needs to better prepare students to move seamlessly into residency. “Institutional leaders are noticing that there is less preparedness in certain areas,” said Edward L. Ha, MD, assistant dean for Clinical Education at UCLA’s David Geffen School of Medicine, Los Angeles.

Aanika Balaji, MD, finished her residency at Johns Hopkins University in Baltimore last year and agrees that learning to work as part of a team should receive more focus. “Medicine is becoming so specialized, and we rely on each other to address patient issues,” she said. “Patients can be complex, and if we don’t come to residency prepared to collaborate, that can be an issue.”

Holliday said there is an awareness of this issue and a push to provide more interprofessional education between various types of students. Managing patients as a team of pharmacy students, nursing students, and residents, for instance, is good practice for today’s complex medicine.

“I think curriculum that focuses on the introduction of health systems science is a good idea,” he said. “That can be a big part of success.”

There’s room for improvement in the critical transition period between UME and graduate level, and teaching collaboration is just one facet of that.

Addressing the Issues

According to Ha, there are a couple of generalized issues that medical school directors are noticing with students transitioning from undergraduate to graduate, and along with that, a response.

“Because we’re noticing students aren’t as well prepared to manage large volumes of patients and complex patients, there’s a push to get students to see patients more quickly,” he said. “We’re trying to shorten the period of lecture hall time and get them to the patients’ bedsides earlier.”

At Ha’s UCLA school, for instance, twice a week in the preclinical years, students work with an educator and clinician before class to practice getting a patient’s history, elicit important information on the patient’s status, and perform a high-quality physical exam.

Ross supports this idea.

“Early clinical exposure in the first or second years can give students time to have experiences in a limited setting,” he said. “This could be half a day a week, for instance. It’s challenging because it takes away study time, but bringing clinical time into the preclinical years can go a long way toward preparedness.”

Balaji said that at Johns Hopkins University, one step in that direction was a class called “Clinical Foundations of Medicine,” which taught basic exam skills.

“We started with simple cases, patients with one problem,” she explained. “By the end of the course, our final exam involved interviewing actual patients and getting all their information.”

Still, the exam fell short of involving complex patients, Balaji said, something she wishes she’d had more exposure to prior to residency. “That’s not always easy to do, especially with big specialties like internal medicine or pediatrics,” she noted. “But some specialties are now increasing exposure to patients before you can even apply to residency.”

Emergency medicine, said Balaji, is one such example. The requirement there is that applicants do rotations with at least two different institutions before applying. This is among the AAMC’s list of “resident readiness” recommendations. Specifically, it suggests “away rotations” to allow students to get to know programs and systems in surrounding communities. While the report acknowledges this can be costly and complex, it recommends a cost-benefit assessment, accompanied by stipends to support students for whom this is a hardship.

Students themselves can also take steps to improve their experience and education while in the UME stage.

“My personal observation is that students need to not be a passenger on the bus,” said Ha. “Find ways to be proactive. Seize every chance you can to develop, whether your exam skills, your interpersonal skills, or a chance to explain a topic to peers or someone coming in behind you. Make the most of every opportunity to grow in every dimension.”

The national movement to improve the transition from undergrad to grad student is well underway and will reinforce Ha’s suggestion.

“Instead of dropping students into these systems and expecting them to sink or swim, we need to do better,” said Holliday. “We need to be thoughtful in making medical training a continuum and better understand the challenge in transitioning to residency.”

The issues of the transition are complex, and the first step is an awareness of that. Medical schools are at that stage — now the hard part of solving the problem is starting.

“We’re trying to make the development of doctors a holistic endeavor,” said Ha, “so that it’s not medical education in one course, physical exams in another, and communication with staff in yet another. We need to develop ways to integrate all these aspects.”

Change doesn’t happen overnight, and the debate on how to best go about it will continue.

“There’s no perfect solution,” said Ross. “But I think we can agree that bringing more clinical into the preclinical years is the goal.”