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Ready for Rotations

By Sue Byrne
Einstein’s new Transition to Clerkship program helps third-year medical students shift from the classroom to the clinic

A 10-month-old girl sits in a pediatrician’s office with her grandmother. Two days ago she was in the hospital because a piece of a candy bar was lodged in the airway leading to her right lung. Doctors removed it successfully and she’s breathing comfortably now, but her grandmother, who speaks limited English, has some questions.

She doesn’t understand the handout about choking hazards that they were given when they left the hospital or why they received it. She also wonders if the mold in their apartment might be contributing to the baby’s wheezing and to her other granddaughter’s asthma.

As the baby’s physician, what do you focus on during this visit? The choking risks, certainly. But what about addressing what you suspect is food insecurity? And what about the mold problem?

Dr. Stephen Baum seated at desk with students at his left and right. ABOVE, Stephen Baum, M.D., distinguished professor of microbiology & immunology, leads a workshop on clinical reasoning. TOP, clockwise from left: Third-year medical students Xavier Quezada, left, and Marouf Hossain use a ventilation device on an adult mannequin as part of basic life-support training; Eden Gelman practices on a baby model; and a student tries out lifesaving compression techniques on an adult model.

Cases like the real-life one above happen regularly in medicine. Third-year Einstein medical students used it as an opportunity last summer to learn about what they might face as they began their clerkships at various clinics and hospitals in the Bronx. “We want students to start thinking about all the aspects that contribute to the overall picture of their patients’ health and what they can do to help,” says Todd Cassese, M.D., assistant dean for clinical sciences at Einstein.

From School to Hospital

The first two years of medical school are much like regular college work—lots of studying, memorization, classwork, and practice exams with volunteers and actors. But things change with the start of the third year, when medical students begin a series of clerkships on hospital wards to learn how to take care of patients under the supervision of medical professionals.

“Students have to apply their classroom knowledge in ways they haven’t been asked to before,” Dr. Cassese explains. “Now they will need to go on rounds with doctors and residents, make oral presentations, and create daily progress notes. That can be stressful and involve long hours. And as the most junior members of the team, they won’t have as much say regarding what they have to do and when they have to do it as they did in years one and two.”

An increasing number of medical schools are recognizing the importance of better orienting students to the rigors of the clerkship years. To help students cope with the demands of their new roles, Einstein’s senior associate dean for medical education, Joshua Nosanchuk, M.D., asked the offices of medical education and student affairs to develop a plan to expand Einstein’s student training from one day to a full week. “We convened focus groups of third- and fourth-year medical students, and many told us that they faced challenges in the hospital they weren’t prepared to manage,” Dr. Nosanchuk says.

A working group spearheaded by Dr. Cassese asked colleagues nationwide to come up with authentic experiences that would give students the tools needed to succeed once they started their rotations.

Introduced last June to 196 third-year students, the Transition to Clerkship program involved five days of classes and hands-on workshops and help from more than 150 Einstein and Montefiore physicians, nurses, social workers, respiratory therapists, and other volunteers.

We want students to start thinking about all the aspects that contribute to the overall picture of their patients’ health and what they can do to help.

— Dr. Todd Cassese

Essential Exercises

To third-year student Deborah Schwartz one of the week’s most important exercises involved the clinical reasoning session on how to present patient cases to other health professionals on rounds.

“Learning how to summarize all the relevant patient information and condense it into a short, informal presentation was very helpful to a third-year, because that is an essential skill on the wards,” Ms. Schwartz says. “Without that workshop, I would not have understood what was expected of me, how to structure my presentations, or what content to put in them.”

M.D./Ph.D. candidate Niloy Jafar Iqbal says that learning clinical science is quite different from learning basic science. “There is a change in mentality. You’re applying your scientific knowledge to human patients,” he explains. The session on seeking and receiving feedback was among the most helpful, he says. “We learned to take feedback as constructive criticism and not to be defensive about it. You can voice your opinion, but you have to be open to the idea that you still have a lot to learn.”

Young man reclines on examining table while man in center points to his throat while young woman looks on. Alan Engler, M.D., shows third-year medical student Lucy Oh how to conduct a physical exam of “patient” Shayon Mottahed, also a third-year.

Applying Science to Patients

The Transition to Clerkship week began with a disease-mapping exercise. Students were presented with a fictional patient who had acute rhinosinusitis, a common inflammatory condition of the upper airways that affects nearly 40 million Americans every year.

Third-year students were given key clinical features of the condition, such as congestion, loss of sense of smell, and nasal drainage; then, working in small groups, they mapped those features to their possible causes—for example, a viral infection, an allergic reaction, or nasal polyps. Using those maps, the students were asked to list four medications that could potentially be effective in treating the root causes of rhinosinusitis and not just its symptoms.

“This session was meant to help students better understand how basic-science principles are linked to clinical reasoning,” Dr. Cassese says.

Another exercise focused on the hypothesis-driven physical exam, in which students practiced physical examination maneuvers on their peers in the Clinical Skills Center in the Van Etten Building. As a leader of one of the small-group sessions, Alan Engler, M.D., a clinical assistant professor in the department of surgery, presented a scenario to the third-years: “I’m having trouble breathing. What should you do? Examine my abdomen? My neck? What questions should you ask me?”

Students took part in basic life-support training, also in the Clinical Skills Center, practicing effective compression techniques using different ventilation devices on adult and baby mannequins. Other sessions included work-life balance (see “A Stressful Learning Environment”), best practices regarding electronic health records, note writing in different specialties, clinical informatics at the bedside, medical interpreters, the student’s role on the interdisciplinary healthcare team, developing a professional identity, and career planning.

Now many weeks into his clerkship, Mr. Iqbal reports that “the days are long but the weeks are short. Medicine is one of the hardest careers as far as hours per week, but it’s one of the most gratifying. So far it has been an amazing experience. Nothing beats learning on the job.”

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