By: Karen Hauer (https://profiles.ucsf.edu/karen.hauer)
When asked, ‘How are you doing in your core clerkships?’, a medical student might share stories of the patients and conditions they have encountered, or the teachers they have met. However, the student might also reply:
- “I have finished clerkships in these specialties and have these left to do.”
- “I have received this many honors grades.”
- “I don’t receive enough useful feedback.”
These replies exemplify the fragmented structure of the core clerkship year for many students, in which their longitudinal, progressive learning takes backstage to discreet, disconnected experiences within the rotational model of education.1 In medical education, immersion in full-time clinical training begins in a core clerkship year in which most medical students rotate through a variety of specialties and clinical systems or microsystems. Whereas some programs incorporate longitudinal, integrated clerkships, the block clerkship model still predominates, and hampers the implementation of competency based medical education (CBME).
CBME is an outcomes-based approach to education in which learners progress in the development of the abilities and knowledge toward readiness for unsupervised practice. This blog post will consider the implications of the block clerkship model of clinical education for CBME, and the challenges it presents for fulfilling the core components of CBME.
The block clerkship model is a form of the rotational model of medical education, in which learners rotate through practice sites and switch supervisors and clinical contexts every day, week or month. This model of education prioritizes structure and process of education because the curriculum is organized around the number of weeks or amount of exposure to different disciplines. In contrast, in a CBME program, outcomes are prioritized, and backwards design is employed to guide the learning and assessment activities needed to enable learners to achieve those outcomes. Students progressing toward achieving outcomes can be increasingly entrusted by patients and team members with responsibilities aligned with their growing competence.2,3
From the perspective of a medical student, a year of block clerkships might entail: approximately 6 to 9 discipline-specific clerkship orientations and learning at multiple sites with dozens of faculty and resident supervisors who switch on their own schedules distinct from the student rotational schedule. Feedback to the student may be provided from many who have brief encounters with the student and limited awareness of the student’s prior learning or feedback. The student receives a summary evaluation and grade 4-6 weeks after finishing each clerkship. At this point, the student is immersed in a subsequent clerkship or has moved on to the next year of medical school.
The rotational model of medical education poses problems for fulfilling the core components of CBME,4 listed below:
Outcomes competencies.
Outcome competencies define the goals of the training program in behavioral terms. In contrast, the block clerkship model draws primary focus to discipline-specific knowledge and skills.
Progressive sequencing of competencies.
For a student in the block clerkship model, every 4-8 weeks brings a new clerkship with a new orientation and a fresh start in a new discipline. Teachers are not familiar with the student’s prior learning or skills, and may adopt a ‘blank slate’ approach to teaching about their discipline in which they assume the student knows nothing and start fresh with teaching and feedback. Hence, the student is not building on prior knowledge and skills nor receiving feedback at the leading edge of their learning.
Learning activities tailored to competencies.
Within the discipline-based structure of the block clerkship model, students are incentivized to participate in the care of patients with conditions typical of that specialty, and sometimes with conditions considered complex and interesting within that discipline. The conditions themselves are relegated to each specialty for tracking completion, and a student who sees a patient with a condition in one specialty for education tracking purposes within another specialty may not be able to ‘count’ that experience.
Teaching tailored to competencies.
Teachers in block clerkships typically have time- limited contact with students. The teacher does not have knowledge of what the student has learned or practiced in prior clerkships unless the student shares that information; this approach puts the burden on the student to repeatedly summarize their learning for their teachers and to feel vulnerable sharing what they don’t know or need to practice.
Programmatic assessment.
Programmatic assessment integrates information from multiple assessment methods and data points to provide a comprehensive, holistic, and continuous determination about of a learner’s abilities, progress, and readiness for clinical practice.5 Programmatic assessment emphasizes regular and formative feedback, allowing students to understand their strengths and areas for improvement continuously.6 This ongoing feedback supports their learning and development. Two aspects of programmatic assessment that are particularly challenging to achieve in the block clerkship model are:
- Decision-making based on aggregation and triangulation of data from multiple assessments rather than relying on a high-stakes assessment. In block clerkships, every 4-8 weeks a high-stakes assessment is generated and a grade is assigned. This high-stakes environment encourages a performance mindset over a growth mindset that could supports feedback-seeking and acknowledgement of gaps in learning.
- Individualized learning through identification of one’s learning needs, enabling personalized support and learning plans enacted and revised over time to address specific gaps in competence. The rapid pace of the rotational model hampers the ability to enact repeated cycles of observation, feedback, and re-observation. Larger or more serious deficiencies may not be recognized or confirmed until after the student finishes a rotation, in which case needed remediation happens during a subsequent rotation.
Successful implementation of CBME requires curricular structure that enables longitudinal, progressive sequencing of learning experiences and feedback tailored to the learner and their growth. Shifting the core clerkship year from discrete blocks that prioritize structure and process as well as discipline specific knowledge and skills to a focus on building competence will support the implementation of CBME in undergraduate medical education.
About the Author: Karen Hauer, MD, PhD is Vice Dean for Education and Professor of Medicine at University of California, San Francisco (UCSF), USA. She designed the program of assessment at UCSF School of Medicine and has published research on trust and entrustment, learner assessment, clinical competency committees, EPAs, grading, and equity in assessment. ORCID: 0000-0002-8812-4045.
References
- Holmboe E, Ginsburg S, Bernabeo E. The rotational approach to medical education: time to confront our assumptions? Medical education. 2011 Jan;45(1):69-80.
- Hauer KE, Hirsh D, Ma I, Hansen L, Ogur B, Poncelet AN, Alexander EK, O’Brien BC. The role of role: learning in longitudinal integrated and traditional block clerkships. Medical education. 2012 Jul;46(7):698-710.
- Tekian A, Ten Cate O, Holmboe E, Roberts T, Norcini J. Entrustment decisions: Implications for curriculum development and assessment. Medical Teacher. 2020 Jun 2;42(6):698-704.
- Van Melle E, Frank JR, Holmboe ES, Dagnone D, Stockley D, Sherbino J. A core components framework for evaluating implementation of competency-based medical education programs. Academic Medicine. 2019 Jul 1;94(7):1002-9
- van der Vleuten CP, Schuwirth LW, Driessen EW, Dijkstra J, Tigelaar D, Baartman LK, Van Tartwijk J. A model for programmatic assessment fit for purpose. Medical teacher. 2012 Mar 1;34(3):205-14.
- Hauer KE, O’Sullivan PS, Fitzhenry K, Boscardin C. Translating theory into practice: implementing a program of assessment. Academic Medicine. 2018 Mar 1;93(3):444-50.
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