ABSTRACTBackground: Medical student rotations in community practice settings are increasingly common within pediatric clerkship curricula yet little evidence exists to support the quality of the educational exposure. Purpose: To assess the impact of clerkship site (community setting vs. exposure to an Academic Health Sciences Center) on the following educational outcomes: 1. Clinical Performance; 2. Examination Performance; 3. Written Assignment Performance; and 4. Successful Matching to a Canadian Pediatric Residency Program.Methods: 340 medical students from the graduating classes of 2007 and 2008 at the University of Toronto, Canada were studied. Rotation performance (clinical assessment, examination mark, and written assignment mark) and acceptance into a Canadian pediatric residency program were assessed in relation to clerkship rotation site. These outcomes were assessed while controlling for the following potential confounders: 1) Pre-clerkship career preference and 2) Pre-rotation site preference as expressed by each medical student. Results: 172 medical students completed rotations that included exposure to an academic health sciences center, while 168 medical students had exclusive exposure to the community setting. Students who completed exclusively community-based pediatric rotations received slightly higher clinical evaluations (p=0.006), but not exam marks (p=0.812) nor written assignment marks (p=0.086). Students who had expressed an interest in paediatrics as a career prior to beginning their clerkship performed better during paediatric clerkship regardless of site (p= .0003) and were more likely to choose a clerkship setting that included exposure to an Academic Health Sciences Center (p=.052). Clerkship setting was not found to impact on successful matching to a Canadian pediatric residency program (p=0.171).Discussion: These results help support the decision of curriculum committees to incorporate the use of community practice settings and inform students and faculty as to the validity of distributed medical education within the field of pediatric medical education

Atenafu, Eshetu

Bollegala, Natasha

Brenneis, Fraser

Feldman, Mark E.

Garfield, Hartley

Scott, Ian

Wright, Bruce

Canadian Medical Education Journal

English

University of Calgary Journal Hosting

Canadian Medical Education Journal 2010, 1(1) e51 Canadian Medical Education Journal Brief Report The Clerkship Pediatric Rotation: Does Setting Matter? Natasha Bollegala,1 Hartley Garfield,1,2 Ian M Scott,3 Bruce J Wright,4 Fraser R Brenneis,5 Eshetu Atenafu,2 and Mark Feldman1,2 1University of Toronto, Toronto, Ontario, 2Hospital for Sick Children, Toronto, Ontario, 3University of British Columbia, Vancouver, British Columbia, 4University of Calgary, Calgary, Alberta and 5University of Alberta, Edmonton, Alberta, Canada Published: 15 March, 2010 CMEJ 2010, 1(1):e51-e55 Available at http://www.cmej.ca © 2010 Bollegala, Hartley, Scott, Wright, Brenneis, Atenafu and Feldman; licensee Synergies Partners This is an Open Journal Systems article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Background: Medical student Pediatric rotations in Community Settings (CS) are increasingly common. The purpose of this paper is to assess the impact of setting (CS vs. exposure to an Academic Health Sciences Center (AHSC)) on the following: Clinical Performance, Examination Performance, Written Assignment Performance, and Successful Matching to a Canadian Pediatric Residency Program. Method: 340 medical students from the University of Toronto, Canada were studied. Rotation performance and acceptance into a Canadian pediatric residency program were assessed in relation to pediatric clerkship rotation site, while controlling for pre-clerkship career preference and pre-rotation site preference. Results: 172 medical students completed rotations that included exposure to an AHSC, while 168 medical students had exclusive exposure to a CS. Community based students received slightly higher clinical evaluations (p < 0.01), but not exam marks (p = 0.81) nor written assignment marks (p = 0.09). Students who had expressed career interest in pediatrics prior to clerkship performed better regardless of site (p < 0.001) and were more likely to choose an AHSC (p = 0.05). Clerkship setting had no demonstrated impact on successful matching to a Canadian pediatric residency program (p = 0.17). Conclusions: These results help validate the community setting for clerkship training in pediatrics and the shift toward distributed medical education.  Correspondence: Mark Feldman, MD, FRCPC, Hospital for Sick Children, Room 10215 Black Wing, 555 University Avenue, Toronto, Ontario, Canada, M5G 1X8; Tel: (416) 813-6933; Email: mark.feldman@utoronto.ca     Canadian Medical Education Journal 2010, 1(1) e52 Introduction It may not be feasible to find appropriate clinical resources within an academic health center to accommodate all medical students requiring clerkship placement. Moreover the setting of a tertiary care pediatric center in a highly sub-specialized environment may not be the most appropriate learning environment for students who must first learn about common medical conditions affecting children. These considerations have been used to justify the shift to community pediatric settings as teaching sites. However, students may be unfairly advantaged by one type of rotation site over another. This issue is of particular importance to medical students considering a future career in pediatrics as well as curriculum committees attempting to ensure consistency between educational experiences.  Limited research has been done to address this area of uncertainty in medical education however four studies examining pediatric clerkship rotations in the community were found that best address the area of interest. A recent study from Dalhousie University in Nova Scotia, Canada investigated medical students placed in a Community Practice Setting (CS) vs. an Academic Health Sciences Center (AHSC) finding that there was no difference in end-of-rotation examination performance or Objective Structured Clinical Examination (OSCE) performance.1 Similar studies have examined educational outcomes including end-of-rotation examination performance and USMLE scores, for which there have been no differences found between students placed in CS vs. AHSC.1,2,3 McCurdy et al., however, did find that students placed in CS encountered a heavier case load4. None of these studies assessed the impact of rotation site on achieving a pediatric residency position. Previous studies may also be limited in their interpretation as they did not take into account the potential confounders of pre-rotation site preference nor pre-clerkship career choice.5,6,7 The aim of this study was to assess the impact of clerkship site (exclusive CS vs. some exposure to an AHSC) on the following educational outcomes within the context of the pediatric clerkship rotation: 1. Clinical Performance; 2. Examination Performance; 3. Written Assignment Performance; and 4. Successful Matching to a Canadian Pediatric Residency Program. These outcomes were assessed while controlling for the following potential confounders: 1) Pre-clerkship career preference and 2) Rotation site preference as expressed by each medical student prior to the start of the rotation. Methods The Faculty of Medicine at the University of Toronto is one of Canada’s largest medical schools and provides a four-year medical degree consisting of two years of pre-clerkship studies (primarily lecture based) and two years of clerkship studies (primarily clinical). Each year approximately 200 third year medical students participate in a six week pediatrics rotation as part of their clinical clerkship year. While this rotation was historically at the Hospital for Sick Children (HSC) (Toronto’s tertiary care children’s hospital) recent changes have incorporated community practice settings into the clerkship curriculum. The Exposure Currently students have one of two placement options: 1) Six weeks entirely in the community (inpatient and outpatient setting) or 2) Three weeks in an academic health sciences center (HSC) and three weeks in a community pediatrician’s office. The clinical experience via exposure to the academic health sciences center (The Hospital for Sick Children) may be an advantage, no advantage or even a disadvantage in terms of the influence it may have on the performance and indeed the career of medical students. For both groups, didactic teaching by faculty within the Department of Pediatrics occurred at a centralized location (often HSC) on a weekly basis. Medical students were excused from their clinical duties in order to attend these sessions. The clerks’ performance was evaluated through a final examination, a clinical evaluation and submission of a written assignment (a case write-up detailing a patient encounter in which a lifestyle issue such as nutrition, physical activity, alcohol, tobacco or another drug is implicated). Verbal feedback was given from the student’s clinical preceptor and there was an opportunity for the student to provide anonymous written feedback on the rotation. The graduating classes of 2007 and 2008 were studied (n = 340). The first choice career preference of students Canadian Medical Education Journal 2010, 1(1) e53 in their first and second years of medical school (pre-clerkship) was assessed through a previously administered national career survey entitled “How Medical Students Choose Their Careers”. Given that students with a career interest in pediatrics might choose one clerkship exposure over the other, the survey response (career preference for pediatrics, a binary outcome) was used to control for the possibility of confounding. It may be that career preference for pediatrics was a greater predictor of successful outcomes than was the exposure to the clerkship site. Pediatric clerkship rotation site preference as expressed by each medical student prior to the start of the rotation and final rotation site were obtained through the Faculty of Medicine, University of Toronto. Rotation performance was based on three components: 1) Clinical assessment (a subjective evaluation by faculty preceptors) 2) Written examination mark (administered to each student at the end of their six week pediatrics rotation) and 3) Written assignment mark (a subjective evaluation by a faculty member based on a standardized marking scheme). Performance results were obtained through the Faculty of Medicine, University of Toronto. Acceptance into a Canadian pediatric residency program was assessed using pediatric residency admission records for 2007 and 2008. Statistical Analysis Data from 2007 and 2008 were pooled. Descriptive summary statistics were explored for all the variables.  Univariate associations of the individual outcome variables exam, project and clinical with potential covariates were explored using ANOVA. Univariate associations of the binary outcome variable, residency matching, with potential independent variables were explored using Fisher’s exact test. Chi-square association test was used to determine the association between pre-clerkship preference and final clerk site. Multivariate analysis of covariance (MANCOVA) was implemented to explore differences of the three dependent variables exam, project and clinic for the independent variables, using Wilks' Lambda test statistics. Logistic regression was also used for the binary dependent variable residency matching, to examine its association of with independent variables. Data were analyzed using the statistical software SAS (Version 9.1, SAS Institute Inc., Cary, NC, USA). A p-value of 0.05 or less was considered statistically significant. Results  In total 340 medical students from the graduating classes of 2007 and 2008 were studied. One hundred and seventy-two medical students completed rotations that combined both exposure to an academic health sciences center with a community setting, while 168 medical students had exclusive exposure to a community setting. Students who completed exclusively community based pediatric rotations received slightly higher clinical evaluations (84.51 vs. 83.17, p < 0.01), but not exam marks (p = 0.81) nor written assignment marks (p = 0.09). Clerkship setting had no significant impact on pediatric residency placement (p = 0.17). However, for the pediatric residency placement analysis, numbers were small. There were 10 matches from the group exposed to an academic health sciences center vs. 4 matches from the group exposed exclusively to a community setting (see Table 1). Career interest in pediatrics during the second year of medical school positively and significantly impacted clinical performance (84.97 vs. 82.70, p < 0.001). Students who expressed a pre-clerkship career interest in pediatrics were more likely to prefer some exposure to an academic health sciences center (p = 0.05). Pediatric clerkship rotation site had a small but statistically significant impact on clinical performance (students exposed exclusively to CS scored higher, p < 0.01). Rotation site did not demonstrate an impact on examination performance, written assignment marks or match rate to a Canadian pediatric residency program. Based on the MANCOVA, adjusting for career choice and clerkship site choice, there were no differences on clerkship performance between clerkship site (p = 0.14). On the other hand CHOICE of career (interest in pediatrics) even after adjusting for clerkship site preference and final site placement indicates differences on rotation performance (p < 0.01). These differences, while statistically significant, were small. Conclusion Our findings support previous work showing that students placed in community settings perform as well or better than students exposed exclusively to academic health science centers as assessed by traditional educational outcomes.   Canadian Medical Education Journal 2010, 1(1) e54 Table 1.  Pediatric clerkship rotation site impact on examination, written assignment, clinical performance and match rate to a Canadian pediatric residency program.   Examination   (M %) Written Assignment (M out of 10) Clinical Performance (M %) Successful Match to a Canadian Pediatric Residency 6 Weeks Community Setting (n=168) 80.40 8.00 84.51 4 3 Weeks Academic & 3 Weeks Community Setting (n=172) 80.57 7.85 83.12 10 p Value p = 0.81 p = 0.09 p = 0.01 p = 0.17   Moreover, students who expressed interest in pursuing pediatrics as a career were subsequently found to perform slightly better during their pediatric clerkship regardless of site and were more likely to choose their clerkship site at the AHSC. This could be due to the perception that because the pediatrics residency program is organized from the Hospital for Sick Children, medical students are more likely to encounter faculty members and residents involved with the residency program admissions process. Medical students are more able to liaise with residents and obtain more insight into life as a pediatrics resident. Additionally, students may be more motivated to experience the case load encountered at a tertiary care center.  More importantly, this study did not demonstrate an advantage to an academic exposure for medical students on successful matching to a pediatric residency program in Canada. The non-significant trend favoring an academic setting appears to be offset by pre-rotation site choice and pre-clerkship career preference. In other words, the career preference of the medical student may be a better predictor of subsequent pediatric residency matching success than is the pediatric clerkship type. The response rate for the “How Medical Students Choose Their Career” survey was incomplete. Although the response rate of first year medical students was 98%, the pre-clerkship response rate for second year medical students was 72%. The latter data were used to control for the potential confounding relationship between career interest, pre-clerkship site preference and pediatric residency matching. It is conceivable that non-responders differed significantly from responders in terms of initial career interest and proportions choosing different clerkship settings.  To our knowledge this is the first study examining the relationship between pediatric clerkship type, career and clerkship site preference and outcomes. The small absolute number of medical students matching to a Canadian pediatric residency limits data interpretation. While non-significant, more than double the number of students from the AHSC group matched to a pediatric residency program. However, when coupled with data showing that students with a career interest in pediatrics were more likely to perform better regardless of site and were also more likely to choose an AHSC clerkship placement, it may well have been the career interest and not the exposure that led to the observed trend in successful pediatric residency matching. Additional studies at other medical schools may generate greater confidence in this conclusion. This study supports the pedagogical value of community-based pediatric clerkship rotations, showing students from these settings perform as well as or better than students from academic pediatric settings with respect to important educational outcomes. These results help support the decision of curriculum committees to incorporate the use of community clerkship rotations and inform students and faculty as to the validity of distributed medical education within the field of pediatrics. References  1. Rashid M. Performance of clinical clerks doing community rotations in a community hospital versus a university hospital. Paediatr Child Health. 2007;12(9):761-764. Canadian Medical Education Journal 2010, 1(1) e55 2. White CB, Thomas AM. Students assigned to community practices for their pediatric clerkship perform as well or better on written examinations as students assigned to academic medical centers. Teach Learn Med. 2004;16(3):250-254. 3. Kurlandsky LE, Potts M, Kumar A. Pediatric clerkship performance in diverse community clinical settings. Pediatrics. 1994;93(4):608-610. 4. McCurdy FA, Sell DM, Beck GL, Kerber K, Larzelere RE, Evans JH. A comparison of clinical pediatric patient encounters in university medical center and community private practice settings. Ambul Peds. 2003;3(1):12-15. 5. Liaison Committee on Medical Education. LCME Accreditation Standards: Educational Program for the M.D. Degree. Washington, DC: Association of American Medical Colleges, 2003. Available at: http://www.lcme.org/functionsnarrative.htm#educational%20program.  6. Kaplowitz PB, Boyle R, Lu J. The effect of pediatric clerkship on medical student attitudes toward pediatrics at 11 medical schools. Arch Pediatr Adolesc Med. 1996;150(4):435-439. 7. Solomon DJ, DiPette DJ. Specialty choice among students entering the fourth year of medical school. Amer J Med Sci. 1994;308(5):284-287. 

The Clerkship Pediatric Rotation: Does Setting Matter?

ABSTRACT
Background: Medical student rotations in community practice settings are increasingly common within pediatric clerkship curricula yet little evidence exists to support the quality of the educational exposure. 
Purpose: To assess the impact of clerkship site (community setting vs. exposure to an Academic Health Sciences Center) on the following educational outcomes: 1. Clinical Performance; 2. Examination Performance; 3. Written Assignment Performance; and 4. Successful Matching to a Canadian Pediatric Residency Program.
Methods: 340 medical students from the graduating classes of 2007 and 2008 at the University of Toronto, Canada were studied. Rotation performance (clinical assessment, examination mark, and written assignment mark) and acceptance into a Canadian pediatric residency program were assessed in relation to clerkship rotation site. These outcomes were assessed while controlling for the following potential confounders: 1) Pre-clerkship career preference and 2) Pre-rotation site preference as expressed by each medical student. 
Results: 172 medical students completed rotations that included exposure to an academic health sciences center, while 168 medical students had exclusive exposure to the community setting. Students who completed exclusively community-based pediatric rotations received slightly higher clinical evaluations (p=0.006), but not exam marks (p=0.812) nor written assignment marks (p=0.086). Students who had expressed an interest in paediatrics as a career prior to beginning their clerkship performed better during paediatric clerkship regardless of site (p= .0003) and were more likely to choose a clerkship setting that included exposure to an Academic Health Sciences Center (p=.052). Clerkship setting was not found to impact on successful matching to a Canadian pediatric residency program (p=0.171).
Discussion: These results help support the decision of curriculum committees to incorporate the use of community practice settings and inform students and faculty as to the validity of distributed medical education within the field of pediatric medical education

The Clerkship Pediatric Rotation: Does Setting Matter?

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