Background

Many medical schools have incorporated clinical reasoning (CR) courses into their pre-clinical curricula to address the quality and safety issue of diagnostic error. It is unknown how students use concepts and practices from pre-clinical CR courses once in clerkships.

Objective

We sought to understand how students utilize CR concepts from a pre-clinical course during clerkships and to identify facilitators and barriers to the use of reasoning concepts.

Design

We used structured interviews to gain insight into medical students' experiences with CR concepts in clerkships.

Participants

We interviewed 16 students who had completed a pre-clinical CR course and subsequently completed a neurology, internal medicine, or pediatrics clerkship.

Approach

We used constructivist grounded theory to perform a qualitative analysis and to develop a theoretical model to describe findings.

Key results

Insights fell into three main areas: (1) CR concept carryover, representing concepts taught in the CR course, such as problem representation, illness scripts, schema, and prioritized differential diagnosis, which were utilized in clerkships; (2) CR concept reinforcers, which included the clerkship setting and supervising physicians who emphasized and provided feedback on CR; and (3) CR concept diminishers, which included time constraints and supervisors who were unfamiliar with or did not reinforce CR concepts.

Conclusions

Concepts taught in a pre-clinical CR course influenced how students prepared for and navigated clinical encounters. Contextual factors both enhanced and inhibited the utilization of CR concepts. Our findings align with social learning theories including social cognitive theory and ecological psychology. This contextual view-taking into account interactions between personal, social, and environmental factors-can help educators integrate CR education from the classroom to the clinical setting.

Background

Medical students often struggle to apply their nascent clinical skills in clerkships. While transitional clerkships can orient students to new roles and logistics, students may benefit from developing clinical skills in inpatient environments earlier in their curriculum to improve readiness for clerkships.

Intervention

Our four- to six-session elective provides pre-clerkship students with individualized learning in the inpatient setting with the aim of improving clerkship preparedness. Students work one-on-one with faculty who facilitate individualized learning through mentoring, deliberate practice, and directed feedback. Second-year medical students are placed on an attending-only, traditionally 'non-teaching' service in the hospital medicine division of a Veterans Affairs (VA) hospital for half-day sessions. Most students self-select into the elective following a class-wide advertisement. The elective also accepts students who are referred for remediation of their clinical skills.

Outcome

In the elective's first two years, 25 students participated and 47 students were waitlisted. We compared participant and waitlisted (non-participant) students' self-efficacy in several clinical and professional domains during their first clerkship. Elective participants reported significantly higher clerkship preparedness compared to non-participants in the areas of physical exam, oral presentation, and formulation of assessments and plans.

Conclusions

Students found the one-on-one feedback and personalized attention from attending physicians to be a particularly useful aspect of the course. This frequently cited benefit points to students' perceived needs and the value they place on individualized feedback. Our innovation harnesses an untapped resource - the hospital medicine 'non-teaching' service - and serves as an attainable option for schools interested in enhancing early clinical skill-building for all students, including those recommended for remediation.

Abbreviations

A&P: Assessment and plan; H&P: History and physical; ILP: Individual learning plan.