One interesting aspect of clerkship is you get a lot more exposure to students who are going or went to different medical schools across the country. We have elective students rotating through working with us, and many of our residents trained at other schools originally. I go to an Ontario school, so most people I encounter are from Ontario schools as well, but there's still a fair bit of variety. One topic that's come up a lot in conversation - and I swear I'm not initiating these because I'm a medical education geek - is how our schedules in clerkship and medical school in general differ. It's interesting to see what each school considers important enough to specifically highlight in clerkship, or what parts of school come where during the 3 or 4 years. Talking with the McMaster students has been the most interesting, because they have a 3 year program that's all over the place.
In broad strokes, most schools still do the traditional North American model for medical school:
Years 1 & 2: Pre-clerkship, consisting of lectures, small groups, plus some training taking a basic history and physical.
Year 3: Core clerkship, consisting of a standard set of rotations (IM/Gen Surg/FM/Psych/Peds/OBGYN with ER and/or Anesth often thrown in there somewhere)
Year 4: Electives, where you do whatever you want wherever you want to tailor your education (but mostly to impress whoever you want to impress for CaRMS).
Pre-clerkship years typically come with a few months of summer while Year 4 ends early to allow time off before residencies which start in July.
Talking to current or former students from other schools, I've gleaned a few take-aways on how medical school could or should be set up:
1) Rotation length isn't that important in clerkship. My school does 6 week blocks for its core rotations, often broken down into sub-rotations of 2 weeks each. IM and Surgery are combined into 12 week blocks, but get some more selective time. Other schools seem to do 4 week blocks and include selective-only blocks. Doesn't seem to make much difference. I generally like the way my school has broadly organized its clerkship, but see nothing wrong with the other systems.
2) Core rotations should come before electives. McMaster doesn't just do a 3 year program, it does a very jumbled 3-year program. Electives come before core rotations in a lot of cases and students don't seem to like that at all.
3) Electives are for CaRMS - and the more pre-CaRMS electives the better. Regardless of what schools or programs think electives are for, students are very clear: they're for finding out what the right residency is and matching to it.
4) 3-year programs are completely viable. McMaster unfortunately has a reputation that its clerks are less knowledgeable than clerks from 4-year schools. I've seen signs of this, but nothing consistent or egregious. More importantly, the school's match rate is good, former Mac students do fine as R1s and also do fine once they get out into practice. Maybe there's a small deficit in medical school, but who cares? School's meant to be a learning experience and the end-outcomes are fine.
With these in mind, I'd like to propose the following broad curriculum schedule for medical schools:
Year 1 (Sept-May): Preclerkship, consisting of lectures & small groups, with a heavy emphasis on practical skills like taking a basic history and physical. One month of summer in June for travel and stuff.
Year 2 (July-June): Clerkship, consisting of the standard set of core rotations. Some weeks of didactic training would be interspersed to make up for a shortened pre-clerkship.
Year 3 (July- May): Electives, consisting of in-hospital electives until end of Dec with in-class/simulation electives and consolidation from Jan-May.
The idea here is to sacrifice a good chunk of pre-clerkship and some in-hospital training during clerkship itself in favour of increased elective time (particularly pre-CaRMS elective time) and one less year of training. First year would be an utter crash course in medicine, focusing on the sheer basics. Some things undoubtedly get lost by cutting out what amounts to about 9 months of in-class instruction, but short training times also force some efficiency on curriculum designers and mean there's not much time for knowledge to be lost before clerkship. Pre-clerkship is pretty inefficient, with plenty of low-yield content and poor approaches to long-term learning. Off the top of my head I can think of several months worth of material that could be tossed from my school's pre-clerkship curriculum without much consequence - there's plenty of fat to cut before getting to the meat of pre-clerkship.
The chance to make up that depth comes in increased clerkship classroom-based instruction. I'm pretty outspoken about how lectures are rather useless, but there is a role for hands-off learning in applied fields like medicine. By linking teaching more closely with clinical experiences, the chances of long-term retention are much higher.
The increased elective time is pretty self-explanatory and mostly just represents a re-scheduling. At my school, we get quite a few selectives through our third year, which are often quite enjoyable rotations, but are hardly necessary. By switching these out for true electives students can get a bit more control over their future and have more time to feel out their career goals, especially before having to apply for residencies.
This system would not be without its own downsides, but I think on the balance far more is gained than lost. As always, I'd love to hear opinions on such a system, positive or negative - it's something that's been rattling around in my head for a while, and it's been good to type it out!
No comments:
Post a Comment