"Becoming a Clerk": An Observational/Interview Study of Student
Acculturation to the Clerkships
Proposal to the Academy of Medical Educators
Jessica H. Muller, PhD and David Irby, PhD
BACKGROUND INFORMATION
The goal of this project is to conduct a qualitative study, using observations
and interviews, of the ways in which medical students are acculturated to the
core clinical clerkships as they make the transition from the second to the
third year. As the focus of our curriculum reform efforts shifts from the essential
core to the third and fourth years, a greater understanding of the intense forces
of acculturation to the different clerkships -- and the students' lived experiences
of these forces -- will be invaluable to our development of appropriate curricular
material. To our knowledge, this type of research, and its relevance for curriculum
reform, has not been discussed in the medical student literature.
The process of becoming a physician involves more than the accumulation of
medical knowledge and skills. As students move through the third year from clerkship
to clerkship, they also are required to comprehend, in a short amount of time,
the cultures of the different clerkships. In addition to general standards for
acceptable performance, each clerkship has its own customs, rituals, practices,
and norms for professional behavior and identity. In order to succeed as clerks,
students must learn, among other things, how to be culturally competent members
of a clerkship. This means not only learning how to navigate their way through
physical spaces and daily routines, but it also entails learning for each clerkship
the expected and accepted ways of acting in that environment, e.g. how a student
should act on a team, how team members interact with each other and their patients,
how attendings expect students to "present" their patients, how non-conforming
behavior is sanctioned and good performance rewarded, or how students should
approach patients and other health care providers. Because students change clerkships
every 6-8 weeks, they need to be able to adapt quickly to different standards
and practices. Some students swiftly grasp how a particular clerkship "works"
and are able to act accordingly; for others, this becomes a challenge almost
equaling the task of learning clinical medicine.
It is the premise of this proposal that this learning occurs not only through
what is taught formally to students, but also through what Hafferty (1998) and
others have called the hidden curriculum. The hidden curriculum includes the
informal curriculum (the students' encounters, role models, interactions with
colleagues and supervisors) as well as the structural curriculum (the organization,
values, rituals, and customs of the institution). This research will focus particularly
on these aspects of the clerkship experience.
GOALS
Building on Irby's research on expert teachers (1992, 1994a, 1994b) and
Muller's studies of the socialization of physicians-in-training (1987, 1994),
this project will use the notions of the hidden curriculum, social learning,
and situated learning to examine medical students' transition to third year.
The project has three goals:
1. To conduct a descriptive study using observations and interviews to explore
the following three questions:
1) In addition to medical knowledge and skills, what are the norms and practices
that students need to know in order to be successful clerks on different clerkships?
2) What are the processes of acculturation? (How do learners acquire the culture
of a clerkship and learn to act like clerks?)
3) What learner strategies facilitate acculturation to the clerkship environments?
2. To describe the factors that both facilitate and impede successful acculturation
to the clerkships.
3. To generate a series of recommendations for improving the formal clerkship
experience, and for faculty and student development, including learner strategies
for succeeding in the clinical arena.
Information from this study should provide important data as we rethink the
curriculum for the third year, and will complement Ann Poncelet's project funded
by the Academy to develop a bridging curriculum from the pre-clerkship to clerkship
years.
PLAN FOR MEASUREMENT AND DOCUMENTATION OF PROJECT EFFICACY AND OUTCOME
Because this project is an exploratory research study, it is difficult to
measure project efficacy. The intended outcomes are described below:
1. Completion of research tasks (data collection and analysis)
2. Production of a report outlining findings and recommendations
3. Review and discussion of the findings and recommendations with appropriate
faculty members and students, as well as in relevant curriculum committees.
4. Implementation of appropriate recommendations
5. Dissemination of results of the study through presentations at national meetings
and publications in medical education journals
We will develop a time line of the dates by which each outcome will be achieved.
PLAN FOR CONTINUATION OF PROJECT AT THE END OF FUNDING CYCLE:
This is a one-time study. Once we have results, we will incorporate our
findings into ongoing curriculum development work in the School of Medicine
For further information, please contact:
Jessica Muller, MD at mullerj@fcm.ucsf.edu
David Irby, PhD at irby@medsch.ucsf.edu
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