The 84 weeks of clinical education encompass 8 weeks spent in a research facility, 4 weeks spent in Introduction to Clinical Medicine, 48 weeks of core rotations, and 24 weeks of electives. The core rotations define the third year of medical school and include twelve weeks of internal medicine, twelve weeks of surgery and six weeks each of pediatrics, obstetrics/gynecology, psychiatry and family medicine. The third year is a structured educational experience similar for all students. The Office of Clinical Sciences along with the affiliated hospitals controls the scheduling of the third year. The fourth year consists of four weeks of each elective. XUSOM allows two sub internships that can be done at hospital settings.
There is no optimal sequence of core rotations. They are generally completed before taking sub internships, additional requirements or electives.
- All core rotations must be done at affiliated hospitals.
- All electives are four weeks at a time, except for the research elective, which is 8 weeks.
- Completion of Kaplan CS assessment is required for graduation.
- ALL core rotations must be completed and a minimum passing score of 216 must be achieved on the Comprehensive Clinical Science Exam (CCSE) before students can take USMLE step 2 CK.
The Clinical Curriculum Breakdown
- Introduction Courses
8 Weeks Introduction to Clinical Research at Lankenau Medical Center and Research Institute
4 Weeks Introduction to Clinical Medicine (FM1/IM1)
- Internal Medicine:
- Obstetrics and Gynecology:
- Family Medicine:
TOTAL: 84 weeks
The Role of Preceptors and Clinical Faculty
The teaching cornerstone of the core rotation is the close relationship between the student and the attending physicians and/or residents who act as preceptors. Many hours per week are spent in small group discussions involving students and their clinical teachers as they make bedside rounds. Together, they discuss the patient’s diagnosis, treatment and progress.
Discussion revolves around a critical review of the patient’s history, physical examination findings, imaging studies and laboratory results. The preceptors assess students medical knowledge, clinical and communication skills and professional behavior as well as serving as a role model. Related basic science background, critical thinking and problem solving are woven into the discussion of individual cases. The single most important factor that determines the educational value of the clerkship is the quality and quantity of interaction between students, residents, teaching physicians and patients.
Clinical teachers are evaluated by the program Director on a daily basis. The basis for student evaluation of faculty is the confidential electronic questionnaire that all students complete at the end of each clerkship. The hospital DME’s, Department Chairs and XUSOM administration have access to the students responses which are all confidential.
The basis for senior faculty evaluation is the on-going process required by postgraduate accreditation agencies which includes peer review. Informal “word of mouth” local knowledge of faculty, although difficult to formalize, forms an integral part of faculty evaluation. Written reports of site visits by School of Medicine Chairs and Deans add a third level of evaluation.
In summary, the program Director is responsible to assure that:
- 1. The faculty teaching the XUSOM students is of high quality.
- 2. The faculty teaching the XUSOM students at each hospital is evaluated appropriately.
- 3. Feedback to the faculty is timely.
The Clinical Clerk
Medical students are called clinical clerks in their clinical years. They enter into the health care team of postgraduate trainees, attending physicians, nurses, technicians and other health care providers and should quickly learn their role in the health care team.
An essential feature of the clerkship consists of in-depth contact with patients; students are strongly encouraged to make the most of such opportunities. Students take histories, examine the patient, formulate different diagnosis, suggest different diagnostic evaluations (workups) and treatment plan. The students record their findings, present cases to the team, perform minor procedures under supervision, attend all scheduled lectures and conferences, participate in work rounds and teaching rounds with their peers and teachers, maintain a patient log and read extensively about their patients’ diseases. In surgery and gynecology, attendance in the operating room is required. In obstetrics, attendance is mandatory in prenatal and postpartum clinics; patients must be followed through labor and delivery.
A physician, nurse or other health care provider must be present in the room as a chaperone when students examine patients. This is especially true for examinations of the breasts, genitalia or rectum. Student orders in the chart or electronic medical records must be authorized and countersigned by a physician. Minor procedures may be performed on patients after adequate instruction has been given and written certification documented in the Logbook of Manual Skills as permitted by hospital policy and governmental regulations. Students working in hospitals are protected by liability insurance. Students must soon become familiar with the electronic medical record or patients’ charts and know where to locate its individual components. Students are responsible for patient workups and might also write daily progress notes as stipulated by the XUSOM clerkship curriculum and hospital policy.
Clinical clerks are expected to be on duty throughout the hospital workday, Monday through Friday. Evening, weekend, and holiday on-call schedules may be the same or less than those for the resident team to which the student is assigned. Student duty hours must take into account the effects of fatigue and sleep deprivation on students’ education. Medical students are not required to work longer hours in patient care than residents. Allowing for some modifications at different hospitals and for different cores, the average workday or week should consist of approximately 50% patient care activates, about 20% conferences, lectures and/or preceptor sessions and about 30% protected academic time for independent learning.
All students during the last week of their medicine and surgery cores will be given at least two days off before their NBME clinical subject exam as well as the day of the exam. All students during their last week of OB/GYN, Pediatrics, Family Medicine and Psychiatry rotations are to be given at least one day off before the exam as well as the day of the exam. These days are protected academic time for self-study and exam preparation and considered an integral part of these rotations. While all clerkship directors must comply with this policy, they do have the option of allowing additional time off for study.
Medical Knowledge and Competencies
The clinical years of the XUSOM curriculum aim to transform students who have learned the basic sciences into students who can deal with patients and their problems in a hospital or outpatient milieu. To do this, numerous new clinical skills, professional behaviors and considerable medical knowledge must be added to that which the student has previously acquired. The clinical years in this way prepare students for postgraduate training.
The vast amount of knowledge required and the ever accelerating rate of discovery reinforces the notion that the practicing physician must forever be a student of medicine and a continual learner. Conceptual knowledge includes the development of efficient methods for the acquisition, interpretation and recording of patient information and a systematic approach to patient care. This provides a framework on which to arrange rapidly changing and increasingly detailed medical information.
XUSOM is committed to a competency based curriculum. These competencies are detailed in Section Two. Those students who plan to undertake post-graduate training in the US should become familiar with the Accreditation Council for Graduate Medical Education Core Competencies.
The six ACGME competencies are:
- Patient Care
- Medical Knowledge
- Practice Based Learning and Improvement
- Systems Based Practice
- Interpersonal Skills and Communication
Involvement with Patients
Students are encouraged to make the most of the opportunity to learn about, learn from and spend time with their patients. A student frequently becomes involved with a small group of patients, on the average of 2-4 per week. Indeed, the student often spends more time with the patient than does the resident or attending, establishes rapport, gains the patient’s confidence and might be in the best position to advise, comfort, give solace, explain and answer the patient’s questions.
Only through a detailed approach to a small number of patients can the student begin to acquire an understanding of clinical problems. In addition to the initial work-up and daily progress notes, all diagnostic and therapeutic maneuvers are closely monitored. Although a smaller group of patients are the core of the student’s educational experience, exposure to a large number of other patients on a less detailed basis is also useful in broadening knowledge. The student derives considerable benefit from exposure to other students’ patients who are being discussed and by being present when attendings or consultants see their own patients. Patients seen by students must be entered into the SMS (see below). The clerkship director reviews the patient encounter log at the mid-core formative assessment and when completing the final clerkship evaluation form. This review, most importantly, assesses students’ commitment to documentation as well as patient involvement. The Clinical department also monitors each student’s electronic log to ensure that the each student has seen patients required by each clerkship. Gaps in students’ “must see list” can be filled in during other rotations or during the fourth year, or through online case files.