The 18-Month Curriculum: The Impact of Mixed Learning Clerkships

BACKGROUND: UT Southwestern implemented a new, 18-month, shortened pre-clerkship curriculum in the Fall of 2015 in order to increase the clerkship phase from 1 year to 18 months, beginning mid-second year. In keeping with this new curriculum schedule, it was necessary to combine MS2 and MS3 students on clerkships from January to June; during that time, both MS2 and MS3 students are on the same clerkship simultaneously, creating opportunities for informal near-peer learning. Each clerkship handles this mixing differently: some create mixed-year teams, others group students together with their peers, while still others do not create teams at all. OBJECTIVE: We are interested in determining the impact of mixing students on team dynamics, narrative assessments, and grades. HYPOTHESIS: Upperclassmen and underclassmen participating on the same clerkships in a mixed learning environment will report predominantly positive experiences but will have significant differences in their grades and narrative assessments compared to each other. METHODS: A tri-pronged approach was taken, looking at qualitative student perspectives, qualitative attending perspectives, and quantitative scores on de-identified student evaluations. In the first arm of the study, students in the classes of 2020 and 2021 were sent a voluntary survey seeking comments regarding their experiences on mixed clerkships and to indicate their interest in participating in a follow-up 30-minute focus group interview. Four purposeful focus groups of 4-5 students, two groups from each class, were interviewed to learn more about perceived advantages and disadvantages of mixed clerkships. Interviews were audio-recorded, transcribed, and coded for themes. Transcripts were validated by the interviewees and de-identified prior to analysis. In the second and third arms of the study, student evaluations from 2019 in the Internal Medicine, Pediatrics, and Psychiatry clerkships were gathered and de-identified. From these, 120 narrative assessments were randomly selected for qualitative analysis. Final grades and four scored skills were selected for quantitative analysis. Finally, de-identified quantitative data from 2015-2016, prior to the implementation of the 18-month curriculum, were analyzed for additional insights. RESULTS: In the first arm of the study, interviewees reported overall positive experiences with mixed clerkships. Common perceived advantages as an MS2 paired with MS3s included being able to ask "dumb" questions without being judged; being taught "practical" skills such as how to use the electronic medical record (EMR) and how to write a note; having fears allayed through candid discussions; and having a sense of camaraderie. Common advantages as an MS3 paired with MS2s included satisfaction in teaching MS2s and being motivated by MS2 enthusiasm. Perceived disadvantages were less commonly mentioned but still present, and mostly centered around fears of being compared by evaluators. In the second and third arms of the study, the mixed clerkships of Pediatrics and Psychiatry tended to show more significant differences in MS2 and MS3 evaluations than the non-mixed clerkship of Internal Medicine. However, this was highly nuanced, and there was some, but not consistent, division between differences observed in "learned" skills such as history-taking or note-writing and "inherent" skills such as professionalism or confidence. Comparison with students on the old curriculum also revealed significant differences with different MS2 and MS3 cohorts suggesting both positive and negative effects of the mixed learning environment on student evaluations. CONCLUSION: Overall, students reported more positive experiences and perceived advantages on mixed clerkships than negative experiences and disadvantages. However, attendings reported a higher proportion of significant differences between less and more experienced students on mixed clerkships. Despite this, the impact of cross-class comparison versus other factors, such as natural student improvement, contributing to these differences is unclear, and therefore mixed clerkships resulting from the 18-month curriculum have had a generally positive impact despite some negative effects. Further research, including research into other assessments of educational outcomes such as shelf exam scores as well as research into cross-clerkship comparisons, is needed to provide a fuller picture of the impact of these mixed clerkships.