The Clerkship Experience
Rishindra M. Reddy
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The preparation of medical students to become physicians is changing dramatically as medical schools recognize that they cannot cover all of the current practice of medicine as medical knowledge increases exponentially. Educational goals are shifting to the creation of lifelong learners who have strong foundational knowledge, the ability to interpret new research, and the tools to incorporate new knowledge into practice. The new physician may not have the same grounding in anatomy as generations past but will be better prepared to learn on the go as new medical treatments and techniques are developed. The core clerkship experience for many schools has shifted to the second year of medical school, allowing for a broader, more diverse curriculum during the third and fourth years. Changing educational formats require educators to reflect on the core goals and function of the Surgery Clerkship within an Academic Surgery program and to examine how diversity, equity, and inclusion can impact the surgical exposure of future physicians.
GOALS OF A SURGICAL CLERKSHIP
The traditional goals of the surgery clerkship are (1) teaching students about surgical diseases and surgical management, (2) teaching technical skills related to surgery (tying, suturing), (3) teaching students how to communicate with patients and other physicians, and (4) recruiting future generations to the field (Figure 13.1). While these goals apply to all core clerkships, surgery tends to provide the most exposure to technical skills development and to acute patient scenarios—e.g., how to recognize a sick patient. These goals have not changed as curricula have been modified, but when building a clerkship experience for the future, one can emphasize certain aspects to improve a student’s experience and future practice.
Traditional patient care has focused on specific diseases without explicitly recognizing that different populations may have different treatment needs relative to the majority population. The social determinants of health (socioeconomic status, education, etc.) have been increasingly recognized to affect a host of illnesses. Access to cancer surgery has been well documented to be reduced in patients with lower financial means and in underrepresented minorities. A lack of insurance status has been associated with increased mortality after pediatric trauma.1 Understanding health disparities that occur currently in the health system is critical to training future physicians. Prior curricula taught students about screening for breast or colon cancer but failed to highlight the poor rates of screening in African-American populations. Cardiovascular care for everyone is important, but knowing that women are much less likely to receive appropriate intervention should become a standard part of new curricula.
A focus on underserved populations with regard to surgical diseases helps the learner understand how surgical treatments can have a broader impact for more people. For example, women with Medicaid or of Hispanic status are less likely to
receive a minimally invasive hysterectomy for benign disease.2 As another example, African-American race is associated with higher rates of limb amputation.3
receive a minimally invasive hysterectomy for benign disease.2 As another example, African-American race is associated with higher rates of limb amputation.3
 Figure 13.1 Goals of the surgical clerkship. |
Communication skills are a hallmark of the LCME and ACGME training paradigms. In the past, the surgery clerkship focused on how surgeons communicate with patients, but in the future, surgeons will need to teach students, residents, and faculty how to better communicate with each other as well as with patients as they encounter a more diverse population. The majority of graduating medical students in the United States have been female for over 15 years. Schools are actively recruiting a more diverse candidate pool so that graduates will better reflect the population of this country. With each new generation comes new expectations, and current students want clearer communication from their colleagues. For example, the frequency of transgender people within the population is estimated to be 2%, and understanding how people prefer to be addressed is something novel to many workplaces and can be especially challenging in more traditional arenas, such as surgery.
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