the aamc project on the clinical education of medical students

The AAMC Project on the ClinicalEducation of Medical Students

Donald Nutter, MDRobert G Petersdorf Scholar-in-ResidenceAssociation of American Medical Colleges andProfessor of Medicine EmeritusNorthwestern University Medical School

Michael Whitcomb, MDSenior Vice President for Medical Education Association of American Medical Colleges

For more information about this publication contact

Michael E.Whitcomb, M.D.

2450 N Street, NW

Washington, DC 20037-1127

(202) 828-0505

In recent years, advances in knowledge in the bio-medical sciences and in the development of tech-nologies applicable to medicine have occurred atan unprecedented rate. During the same period,there also have been extraordinary changes in theways that medical care is organized and delivered,and in society’s expectations of medicine. As aresult of all of these changes, the knowledge, skills,and attitudes that doctors will need to provide highquality medical care in the 21st Century are differ-ent from those that have been needed in the past. Itfollows, therefore, that these changes have impor-tant implications for the ways in which doctorsare educated.

The formal education of doctors occurs in twodistinct phases. The purpose of the medical schoolexperience is to allow future physicians to beginto acquire the knowledge, skills, and attitudes thatthey ultimately will need for medical practice. Thepurpose of the residency experience is to allowmedical school graduates to build on the founda-tion established in medical school so that theybecome competent to enter practice in one of thespecialties or subspecialties of medicine.

During the past quarter century, the clinical facultyof medical schools have become more directlyinvolved in the care of patients admitted to teachinghospitals. As a result, they have increasingly focusedtheir attention on the education of resident physi-cians who assist them in the care of their patients,and have been less attentive to the clinical educa-tion of medical students. However, the education of

medical students is the sine qua non of a medicalschool, and the quality of the medical student edu-cation program is critically important to ensuringthat medical students will acquire the knowledge,skills, and attitudes that they need to construct astrong foundation for lifelong learning. Thus, theprimary responsibility of the clinical faculty mustbe to ensure the quality of the clinical educationof medical students.

During the past few years, the Association ofAmerican Medical Colleges (AAMC) has beencommitted to stimulating changes in medical edu-cation to create a better alignment of educationalcontent and goals with evolving societal needs,practice patterns, and scientific developments. Inpursuit of this strategic commitment, theAssociation has embarked on a number of pro-grammatic activities designed to assist medicalschools in their efforts to reform their curricula,and to improve the pedagogical approaches beingused to promote student learning. In the course ofpursuing these objectives, the Association becameincreasingly aware of apparent deficiencies in thedesign, content, and conduct of the clinical educa-tion of medical students.

In order to begin to address this concern, theAssociation embarked on a project that wasdesigned to define the state of medical students’clinical education. This report describes thedesign of that project, and presents a number ofobservations of, and conclusions about, the cur-rent state of medical students’ clinical education.The report begins with background informationabout the evolution of the clinical education ofmedical students in the United States in order toprovide a context for understanding the rationalefor the project and for interpreting the project’sfindings.

The AAMC Project on the Clinical Education of Medical Students

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Until late in the 19th century, medical schools inthe United States, with few exceptions, includedno formal instruction in clinical medicine in theircurricula. In general, medical school graduateswould learn clinical medicine (such as there wasto learn) once they had entered independent prac-tice, or by apprenticing themselves to communitypractitioners. Graduates who desired formalinstruction in clinical medicine would spend aperiod of time studying in Europe where medicaleducation was more advanced, or they would finda “house officer” position at a hospital in thestates where they could learn under the watchful,albeit somewhat distant, eyes of local practitioners.

The opening of the Johns Hopkins Hospital in 1893is generally considered the sentinel event thatestablished clinical instruction as a necessary andrequired component of the formal education ofmedical students. Indeed, the approach to clinicalinstruction, which Sir William Osler established atJohns Hopkins, became the model that was adoptedby other medical schools as they began to includeformal instruction in clinical medicine in their cur-ricula. Osler believed that third year studentsshould receive formal instruction in clinical medi-cine by attending clinical demonstrations conductedin the clinic and amphitheater. He believed thatfourth year students should learn clinical medicineby being assigned responsibility for the care of acertain number of patients on the hospital wards,rotating every few months from one clinical serviceto another to gain experience in different clinicaldisciplines.

The basic structure of the medical school curricu-lum had become reasonably standard by the endof the 1920s. In most schools, the first two yearswere composed of a number of discipline specific,departmentally administered basic science cours-es. The last two years were composed of requiredclinical clerkships in internal medicine, surgery,obstetrics/gynecology, pediatrics, and ultimatelypsychiatry, and elective rotations in a variety ofclinical disciplines.

In the 1950s, the organization of the educationalprogram began to change. For example, someschools began to experiment with new approachesfor organizing the material taught in the first twoyears of the curriculum. Rather than teaching thebasic sciences in individual, discipline-specificcourses, they taught relevant material drawn fromeach of the sciences in units organized aroundindividual body organs or systems. In virtually allschools, the clinical clerkships were moved fromthe fourth year of the curriculum (the Osler model)to the third year, and the fourth year becamedevoted to rotations in hospital clinics and oninpatient services devoted to clinical disciplinesnot represented in the required clerkships. Overtime, schools set aside much of the fourth year forelective experiences, so that students could gainexperience in clinical disciplines of particularinterest to them.

Throughout most of the 20th Century, the focus ofthe clinical education of medical students remainedon the care of seriously ill, hospitalized patients,even though most practicing physicians spent themajority of their time caring for ambulatorypatients. In virtually all cases, the educationaldesign of the clerkship and elective experiencesconsisted solely of assigning students to teamscomposed of resident physicians and an attendingphysician. This approach was governed largely bythe notion that students would learn what theyneeded to know by assigning them to inpatientservices where they could learn by observing resi-dent physicians and attending physicians in action,and by doing whatever they were asked to do.

From an educational perspective, this design con-cept was highly flawed, primarily because theclerkship experiences, even in the individual clinicaldisciplines, were highly variable. The variabilitywas inevitable, because of the varied nature of theclinical sites to which the students were assignedover the course of any given year, the variablespectrum of the conditions encountered at thosesites, and the variable quality of the supervisionand teaching provided by resident physicians andattending physicians at those sites. As a result, it


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was not possible for medical schools to ensurethat all students were having comparable educa-tional experiences during the last two years of thecurriculum.

In the early 1980s, the Association of AmericanMedical Colleges established a blue ribbon panelto review the education of physicians in the UnitedStates (General Professional Education of Physiciansand College Preparation for Medicine). In 1984,the panel (GPEP Panel) issued its final report,Physicians for the Twenty-First Century, and thereports of a number of working groups that hadbeen established to inform the panel’s deliberations.The panel’s Working Group on Fundamental Skillswas particularly critical of the clinical educationof medical students. The working group notedthat the clinical clerkships were often little morethan unstructured apprenticeship experiences thatcontributed little to the overall learning objectivesof the educational program, and questioned thevalue of a largely elective fourth year. Based onthese observations, the panel recommended that acomprehensive review of the clinical education ofmedical students be conducted, with particularemphasis on the clerkship experiences.

A seminar sponsored by the Macy Foundation in1988 reinforced these observations and concludedthat the clinical education of medical students hadnot kept pace with changes in American medicineand the society it serves. In the same year, a formerHarvard Medical School dean and a distinguishedhealth economist authored a paper in which theyrecommended elimination of the fourth year ofmedical school, because it offered little to theeducation of medical students.

In 1992, a commission sponsored by the RobertWood Johnson Foundation recommended that theentire curriculum, to include the clinical years,needed to be redesigned to provide greateremphasis on the social and behavioral sciences,clinical epidemiology, and medical informatics.Subsequently, others recommended that the cur-riculum also needed to accommodate new knowl-edge about genomics, and the interaction of genes

and the environment in determining the health ofindividuals and the community.

A project conducted by the AAMC in the early1990s (Assessing Change in Medical Education –the Road to Implementation) determined that fewschools had responded to the recommendationsset forth by GPEP and the other panels that hadreviewed the state of medical students’ education.However, as the decade progressed, many medicalschools did begin to make changes in their curric-ula. These efforts were catalyzed in part by cur-riculum reform grant programs sponsored by theRobert Wood Johnson Foundation and the federalgovernment’s Bureau of Health Professions. A lim-ited number of schools were awarded grant fundsto support curriculum reform activities consistentwith the projects’ goals. However, the availabilityof grant funds prompted many schools to examinetheir curricula in order to determine if their edu-cational programs were designed to provide ahigh quality education for their students.

In the late 1990s, the AAMC Medical SchoolObjectives Project (MSOP) set forth guidelinesthat schools could use in designing their educationalprograms. The Association also conducted severalprojects that were designed to gain insight into thescope of the curriculum changes being adoptedand implemented in U.S. medical schools. Theresults of those projects indicated that while therewere dramatic changes occurring in the curricula ofmany medical schools, those changes were largelylimited to the first two years of the educationalprogram. Indeed, schools that were making, or hadalready made, major changes in their curriculareported that it had been difficult, if not impossible,to implement any changes in the third and fourthyears despite compelling reasons for doing so.

Given these observations, and being deeply con-cerned about the impact on medical education ofthe dramatic changes that have occurred in recentyears in the patient care environments in whichclinical medicine is practiced and taught, theAssociation felt compelled to undertake the projectdescribed in this report.


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Phase IIn order to achieve the Phase I objectives outlinedabove, the co-directors of the project conductedthe following activities:

Conducted a comprehensive review of the literature dealing with issues relevant to the clinical education of medical students and clinical educators

Analyzed information relevant to the clinical education of medical students contained in a number of AAMC databases and reports

Conducted site visits to seventeen U.S. medicalschools for the purpose of interviewing edu-cation deans and staff, clerkship directors, and senior medical students

Conducted similar site visits to two Canadianmedical schools

Collected information on the clinical curricu-lum from three additional U.S. schools that were site visited primarily for other educa-tional purposes

Conducted an Internet query of the undergraduate education deans of U.S. medical schools to elicit information about efforts underway to implement innovations in the clinical curriculum

Conducted structured telephone interviews with the education deans of nine schools to collect detailed information about innovationsof special interest

The onset of Phase II activities overlapped to somedegree the conduct of Phase I activities. SincePhase II of the project is ongoing, those activitieswill be described in a subsequent report.


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The primary goals of the AAMC Project on the Clinical Education of Medical Students are to conduct acomprehensive review of the clinical education of medical students and to affect changes in the design andconduct of the clinical curriculum, which will improve the quality of medical students’ education. The spe-cific objectives of the project are:

Phase ITo define the organization, structure, content, and conduct of the clinical curriculum (primarily thethird and fourth years of medical school)

To identify examples of innovations being implemented in the design and conduct of the clinical curriculum

To identify issues of concern related to the clinical education of medical students

Phase IITo disseminate information about the state of the clinical curriculum

To promote a national dialogue on the kinds of changes needed to improve the clinical education ofmedical students

To assist individual medical schools in their efforts to improve the quality of the clinical education oftheir students

The observations set forth in this section of thereport are based on a synthesis of all of the infor-mation available to the project co-directors uponcompletion of the Phase I activities outlinedabove. Needless to say, the observations reported,and the conclusions drawn from those observa-tions, do not necessarily apply to every school inthe country. However, because the schools thatwere site visited are, as a group, reasonably repre-sentative of the diversity and geographic distribu-tion of all U.S. medical schools, it is reasonable toassume that the conclusions reached by generaliz-ing from the observations made during those visitsare valid.

The Clinical Curriculum:Organization and StructureAs a result of changes that have occurred duringthe past decade, the clinical curriculum is no longerlimited to the last two years of the educationalprogram. In the great majority of medical schools,clinical content has been integrated into the basicscience course work offered during the first twoyears of the educational program. In addition,many schools offer courses in the first two yearsthat focus on various aspects of the doctor-patientrelationship, with specific emphasis on taking ahistory, performing a physical examination, andcommunicating with patients and patients’ families.Finally, in a number of schools, clinical experi-ences, generally in the form of community-basedpreceptorship experiences, often begin in theearly months of year one and continue throughoutthe first two years. However, since the clinicaleducation of students is concentrated in the thirdand fourth years of the curriculum, the focus of theproject, and of this report, is on the educationalexperiences provided during those years.

The required clinical clerkships in the major disci-plines (family medicine, internal medicine, obstet-rics and gynecology, pediatrics, psychiatry, andsurgery) generally occupy the entire third year ofthe curriculum. In a limited number of schools,

the clerkship rotations begin during the secondhalf of year two. In most schools, the requiredclerkships must be taken in sequence, and mustbe completed before students can take electiverotations. Some schools allow students to deferone or more of the required clerkships until yearfour, although this is becoming less frequent asschools add more requirements to the fourth year.Very few schools currently allow students toschedule elective time in year three. However, thismay become more frequent if, as seems to be thecase, more schools decide to begin the clinicalclerkships during the latter half of year two.

During the past decade, some schools havechanged the organization of the third year by cre-ating block rotations. Each of the blocks is com-posed of several clerkships that students musttake in sequence within the block period. Morethan half of the schools that were site visited haveadopted this structure. The block structure hasbeen adopted primarily as a means of promotingintegration of clinically relevant content acrossrelated disciplines (e.g. psychiatry and neurology,pediatrics and obstetrics/gynecology, family medi-cine and general internal medicine). Several schoolshave established interdisciplinary ambulatory careclerkship blocks that run for three to six monthsduring the third year. In those schools, the disci-pline-specific, departmental orientation of individualclerkships has been largely eliminated.

As a general rule, the required clinical clerkships,with the exception of family medicine, continue toutilize inpatient services as the primary venue forthe clerkship experiences. However, the amountof time devoted to ambulatory care-based experi-ences is substantial in pediatrics, and in obstetricsand gynecology. Internal medicine clerkships mayoffer a block of ambulatory care-based experience,or schedule students to rotate through one ormore clinics on a half-day basis while beingassigned to an inpatient service. The amount ofambulatory care-based experience in surgery andpsychiatry is extremely variable, but tends to beless than in the other disciplines. In some schools,students also attend continuity clinic experiences


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in year three, which are conducted independent ofany of the required clerkships. In the schools thatwere site visited, approximately 25 percent of thetime allocated for required clerkships is devotedto ambulatory experiences.

The organization of the ambulatory experienceswas quite variable in the schools that were sitevisited. As noted above, several of the schools hadcreated multidisciplinary ambulatory clerkships ofthree to six months duration. Other schools hadcombined several discipline-specific ambulatoryexperiences into a single block, thus disassociatingthe inpatient and ambulatory components of a singleclerkship. In some schools, this approach, by frag-menting a discipline-specific experience into twocomponents that were not juxtaposed, seemed toundermine the integrity of the educational experi-ence and, therefore, was not viewed favorably byfaculty and students. In other schools, theapproach seemed to be working well.

In order to accommodate current class sizes, virtuallyall schools use multiple clinical venues to provideclerkship experiences for students rotating througha clerkship during any given period of time. The125 medical schools use more than 800 hospitalsas inpatient sites for one or more of the requiredclinical clerkships. In many cases, the hospitalsthat serve as clerkship sites are quite distant fromthe medical school. Indeed, it is not uncommonfor a clerkship site to be located in a different city,or even in a different state. The hospitals that areused by a given medical school for a single clerk-ship may have quite different patient populations,may sponsor different residency programs thatare of variable quality, and the relationships of theclinical faculty to the medical school also may bequite variable. Each of these factors complicatesthe ability of the medical school to ensure to areasonable degree that during a single clerkship,all students are having comparable educationalexperiences. In fact, many schools recognize thatthis is not the case.

The fourth year of the curriculum is highly variable,although in most schools the majority of the fourth

year is available for students to elect rotations ofinterest. It is quite common for fourth year studentsto take elective rotations at sites that are not directlyaffiliated with their medical school, including sitesout of the country. For practical purposes, themedical school faculty has no involvement in anyof those experiences. However, there does appear tobe a trend underway to limit the number of elec-tives that can be taken at sites that are not direct-ly affiliated with the medical school, and the num-ber that can be taken in a single specialty.

There also is a trend in progress for schools toincrease the amount of time in year four devotedto meeting specific course requirements. Manyschools now require a neurology clerkship, andalmost two-thirds require one or more sub-intern-ship experiences. Some schools also requireambulatory care, radiology, emergency medicine,critical care medicine, or surgical subspecialtyexperiences. On average, schools now havecourse requirements that occupy 14 weeks of thefourth year of the curriculum. Nonetheless, someschools have no specific course requirements inthe fourth year, and few schools have organizedthe fourth year to ensure that it contributes in acoherent way to the general professional educationof their students.

Most medical schools recognize the need to devotetime in the third and fourth years to cover topicsrelated to contemporary issues in medicine, whichdo not necessarily fall in the purview of a singleclinical discipline. End of life care, the principlesof population health, nutrition, and bio-medicalethics are several examples of the kinds of topicsinvolved. Schools face a formidable challenge intrying to integrate these topics into the clinicalcurriculum, primarily because the third and fourthyears are organized as a series of discipline-specificclinical experiences.

In an attempt to cover these topics, schools arebeginning to utilize a number of different strategies.As mentioned above, some schools have organizedthe third year of the curriculum into several blocks,each block consisting of several clerkships. In


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some of those schools, the topics of interest may beassigned to different blocks, with the faculty of thedisciplines within the blocks responsible for inte-grating the material into existing learning exercises(lectures, seminars, etc). In other schools, a regulartime is scheduled each week, or every other week,when all students break away from clerkship respon-sibilities to attend learning exercises where thecontent is covered. These breakout sessions areoften several hours in length. Regardless of whichof the strategies are employed, schools have hadvariable success in meeting the desired objective.

The inter-session model is a particularly innovativeapproach being used by some schools for coveringthis material. This model entails scheduling severaldays between blocks or clerkships (inter-sessions)to cover the material in various classroom orsmall group learning exercises. Almost one-half ofthe schools that were site visited had implemented,or were in the process of implementing, the inter-session model. Finally, some schools that havebeen unable to integrate the material into the thirdyear attempt to cover the topics of interest byoffering a series of seminars or capstone coursesin year four. Once again, the success of theseapproaches is quite variable.

The Clinical Curriculum:Management and Oversight In general, the responsibility for the managementand oversight of the clinical curriculum as a wholeis shared between the dean’s office (administration)and the school’s curriculum committee (facultygovernance). Traditionally, the responsibility forthe design and conduct of the clerkships has beendelegated almost entirely to the individual clinicaldepartments. This situation is responsible to agreat extent for the difficulty that schools haveexperienced in attempting to reform the clinicalcurriculum, particularly in integrating contentacross clerkships, and to improving teachingmethods.

Recognizing the need to reform the clinical curricu-lum, many schools have taken steps to centralizein the dean’s office the management and oversight

of the curriculum. These efforts have met withvariable degrees of success, but some degree ofcentralization has occurred in most schools. As aresult, the senior member of the dean’s staff (asso-ciate dean or vice dean), who is responsible for themedical student education program, is assuming amore prominent role in managing, and providingoversight of, the clinical curriculum.

However, on a day-to-day basis, the individualclerkship directors have responsibility for themanagement of their clerkships. These individualshave an extremely important role to play in theschools’ efforts to improve the quality of the clini-cal education of their students. Despite the keyrole played by clerkship directors, they are withfew exceptions appointed to those positions bydepartment chairmen without being subject toapproval by the dean’s office. In this regard, itshould be noted that many clerkship directors arevery junior members of the faculty who have hadlittle, if any, administrative experience and no for-mal training in educational theory and practice.Furthermore, it appears that they often receive lit-tle material support from their department chairs.Despite the circumstances within which theyfunction, the clerkship directors are generallyhighly motivated, enthusiastic, and committed toovercoming the challenges they face.

In a few medical schools, clerkship directorseither are appointed by the dean, or their appoint-ment is subject to approval by the dean. In mostschools, clerkship directors have an informalreporting relationship to the “education dean,”who often convenes regular meetings of the clerk-ship directors as a group to discuss and resolveissues common to the clerkships. In addition, agrowing number of schools are beginning to offerstructured educational programs that provideopportunities for clerkship directors (and otherfaculty, as well) to become more knowledgeableabout medical education theory and practice, andthe issues facing academic institutions.

Clerkship directors face a number of extraordinarychallenges. One of the most challenging is to pro-


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vide, to the degree possible, comparable educa-tional experiences for students rotating through theclerkship at multiple and, at times quite distant,sites. In an effort to meet this challenge, someclerkship directors hold annual or biannual meet-ings with the clerkship coordinators from the vari-ous sites to address issues of educational quality.In the same vein, clerkship directors are beginningto use the Internet to provide a common set ofresources for small group, case-base learningexercises for students assigned to different sites.In addition, clerkship directors are, on occasion,using teleconferencing, to provide a common setof didactic presentations to those students.Nevertheless, schools have not yet committed theresources that are required to allow clerkshipdirectors to take full advantage of informationtechnology applications in managing, and provid-ing educational materials for, their increasinglydistributed clinical education experiences.

It is important to note that as a general rule, thechairmen of clinical departments are uninvolvedin the clinical education of medical students. Overthe years, the role of the clinical department chairhas evolved to include a major responsibility forthe clinical practice activities of the faculty. As thishas occurred, the chairman has delegated respon-sibility for the day to day management of both res-ident physicians’ and medical students’ educationto members of the faculty (program directors andclerkship directors). Although chairmen oftenremain quite active in resident physicians’ educa-tion, particularly the chairs of smaller departments,many have only sporadic contact with medicalstudents. As a result, the faculty of many depart-ments, seeing that the medical student educationprogram is a not a high priority for the chairman,are uncertain about the degree to which theyshould agree to participate in teaching activitieswhen requested to do so by the clerkship directors.

The Clinical Curriculum: TheEducation ProgramThe purpose of the medical student educationprogram is to provide opportunities for medicalstudents to acquire a solid foundation in the

knowledge, skills, attitudes, and behaviors thatthey will ultimately need for the practice of medi-cine. In pursuit of this goal, they must achieve alevel of mastery that will allow them to assumethe responsibilities they will be expected to meetas entry-level resident physicians. In keeping withthese goals, the clinical curriculum must be viewedas an integral component of the entire four-yeareducational program, and each of the clinical rota-tions that compose the clinical curriculum mustserve the overall educational objectives of theprogram as a whole. Thus, each required and elec-tive clerkship experience must have well-articulat-ed learning objectives that are consistent with theoverall program objectives, the experiences mustbe designed and conducted so that students canachieve the stated objectives, and students’ per-formances during each experience must beassessed against those objectives.

Unfortunately, it does not appear that these educa-tional principles are being followed in the majorityof medical schools. In most schools, clerkshiplearning objectives that are quite appropriate formedical students’ education do exist. Often, theselearning objectives reflect guidelines developed bythe national clerkship directors’ organizations toassist individual clerkship directors in developinglearning objectives for their own institutions. Alltoo often, however, the majority of the clinical fac-ulty is unaware of the objectives, and the designand conduct of the clerkships, including theassessment of students’ performance during theclerkships, have no relationship to the statedobjectives.

As noted above, medical schools must use multipleand varied patient care sites to provide studentswith clinical experiences during each of therequired clerkships. Despite this, students may nothave an adequate experience in having first contactwith patients whom they are able to followthroughout their hospitalization. In some cases,the patient populations that students are exposedto are not optimal for medical students’ education.This is more often a problem in major academicmedical centers where patients may have very


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complex, highly specialized problems, and may becritically ill. Similarly, the clinical faculty who pro-vide care in those institutions – generally the full-time medical school faculty – may have organizedtheir clinical services in such a way that they donot provide opportunities for students to be exposedto a wide range of clinical problems. Finally,because many patients who formerly would havebeen cared for in the hospital now receive theircare in ambulatory-care settings, the number ofpatients on inpatient services may be inadequate.As a result, a number of schools have found thatthey must rely on community hospitals and practicesites to provide students with adequate first contactexperiences with patients who have a suitablearray of common problems.

In considering these issues, it is important to rec-ognize that the degree to which they are problemsis somewhat discipline specific. For example, it isextremely difficult, if not impossible, to providestudents with a general surgery experience on aninpatient service of a major academic medical center.One of the major reasons for this is that most ofthe routine surgical cases that provide appropriatelearning experiences for medical students are nowmanaged as outpatients, and the surgery is con-ducted in ambulatory surgery centers. In addition,the inpatient surgical services in major academicmedical centers are highly organ specific. Generalsurgery services have been replaced by, for exam-ple, thyroid, breast, and GI services. Thus a med-ical student might spend an entire month seeingonly breast cases.

Medical students’ experiences in psychiatry havebeen affected also by changes in the practice ofpsychiatry. Due to the remarkable advances in drugtherapy and changing practice patterns, psychia-trists do not manage most of the common psychi-atric disorders that medical students should see. Inconjunction with this, hospital stays have becomemuch shorter for those psychiatric patients stilladmitted to an inpatient service, thus decreasingthe number of inpatients and limiting students’exposure even to hospitalized patients. As a resultof these changes, many psychiatry departments

are quite challenged to provide adequate patientexperiences for the students rotating through theclerkship.

In most schools, there is inadequate attention paidto ensuring that students acquire fundamentalclinical skills, particularly physical diagnosis skills.This deficiency is due primarily to the failure ofthe clinical faculty to focus their efforts on “bed-side teaching.” An extremely important element ofthis deficiency is the failure of faculty to assessstudents’ performances adequately and to providethem with timely feedback (formative, as opposedto the summative assessment that is used for grad-ing purposes). Contributing to the problem is thefailure of most schools to take advantage of newtechnologies by establishing patient simulator andclinical skills facilities.

Most medical schools are developing well-organizedapproaches for conducting summative assessmentof students’ performances at various times in thecourse of the clinical curriculum. During the pastdecade, there has been a substantial increase inthe use of standardized patients for this purpose,not only for comprehensive examination purposesat specific points in the curriculum, but also for endof clerkship examinations. In addition, the greatmajority of schools use National Board of MedicalExaminers subject examinations and observedhistory taking and physical examination perform-ance, to determine students’ grades. However, thefailure of faculty to provide formative assessmentduring the clerkships was the main complaint thatsenior students had about their clinical educationat every school that was site visited. In keepingwith this, over a quarter of all of the medical stu-dents who completed the AAMC GraduationQuestionnaire indicated that faculty observationof their history taking and physical examinationskills was inadequate.

Given the changes occurring in the organizationand delivery of health care, and the changingexpectations of patients and their families, medicalstudents must now be exposed to a wide range oftopics that fall outside of the purview of any single


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clinical discipline. Too many students report thattheir exposure to topics such as clinical epidemi-ology, population health, nutrition, geriatrics, endof life care, medical care quality, and cultural com-petence was inadequate. To a very great extent, thissituation exists because the design and conduct ofthe clerkships continue to be viewed as being with-in the purview of individual clinical departments.There has been a reluctance to centralize the man-agement of the clerkships in the dean’s office, despitethe fact that the leadership of the departments,and many faculty, do not assign an appropriatepriority to the education of medical students.

Having noted these serious shortcomings in theclinical education of medical students, it is impor-tant to make clear that many medical schools rec-ognize the deficiencies in their educational pro-grams, and some are beginning to take steps toremedy them. On the last LCME Annual Survey,over forty percent of the schools indicated thatthey had begun a major clinical education reforminitiative. For example, as noted previously, manyschools have increased significantly the amount oftime that students spend in ambulatory care expe-riences during the required clerkships. In addition,some schools are making fundamental changes inthe organization and structure of the third year,primarily for the purpose of creating a means forintegrating into the clinical curriculum topicsrelated to contemporary issues in medicine. Atpresent, it is not possible to determine which ofthe several approaches that are being tested willbe most effective.

Schools also are beginning to reorganize thefourth year of the curriculum. There appears to bea growing trend for schools to establish more spe-cific requirements that students must completeduring year four. Paradoxically, students are not infavor of schools establishing more fourth yearrequirements, but once they are established, theyhighly value the experiences that they have beenrequired to complete. The reason for this favorableoutcome appears to be due to the fact that schoolshave been careful in adding requirements thatclearly contribute to the students’ education. The

introduction of sub-internships, emergency medicine,and critical care medicine have been viewedfavorably, because they provide valuable experi-ences that provide students’ with confidenceabout their preparedness for residency training.

Nonetheless, the majority of time in the fourth yearremains allocated for elective experiences, and itseems clear that schools still do not manage thiselective time well. On the annual AAMC MedicalSchool Graduation Questionnaire, over 25 percentof the students responding reported that they hadnot received adequate faculty guidance in selectingtheir fourth year electives. Although this is begin-ning to change, schools in general do not organizethe fourth year course work to provide a coherenteducational experience for students who wish topursue a particular career path. In addition, fewschools provide any meaningful quality controlover the electives that are offered

It should be noted, however, that a few schoolshave begun to think seriously about a fundamentalredesign of the clinical clerkships that composethe clinical curriculum. Given the fundamentalchanges that have occurred in the practice of thecore clinical disciplines, and the remarkablechanges that have occurred in the patient careenvironments where medicine is practiced andclinical learning occurs, it is surprising that moreattention has not been paid to this issue. It seemsalmost axiomatic that the design of the clerkshipexperience that became established a half centuryago would no longer suffice as an optimal approachfor medical students’ education. At issue, ofcourse, is how the clinical experiences should beredesigned to serve better the educational needsof medical students. This issue will be explored insome detail in Phase II of this project.

Perhaps the most important activities currentlyunderway for improving the quality of the educa-tional program relate to changes being made inthe ways that faculty who are most involved in theprogram are recognized and supported for theirefforts. Several medical schools have established“centers” or “institutes” for medical education.


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These administrative units provide a frameworkfor recognizing and supporting faculty who hold keyeducation roles, and for supporting the managementof the educational program. Many more schoolsare beginning to clearly identify and dedicate fundsfor distribution to individual faculty or to depart-ments to support educational activities, and areestablishing special programs to recognize facultywho make major contributions to the program.

These kinds of programs tend to occur in concertwith administrative and governance changes thatare intended to centralize the management of theeducational program in the dean’s office. Thesechanges tend to grant to the school’s educationdean more authority to manage the entire educa-tional program, while decreasing the autonomy ofindividual departments to design and conduct totheir liking whatever educational experience theyoffer in the curriculum. An important manifestationof these changes is reflected in the composition ofcurriculum committees. Unlike the past whendepartments had roughly equal representation onthose committees, deans are now freer to appointindividuals who are committed to the improvingthe quality of the program as a whole.

The Clinical Curriculum: TheTeachersThe primary responsibility for the clinical educationof medical students rests with the full-time facultyof the medical schools’ clinical departments. Inthe 2000-2001 academic year, US medical schoolsreported a total of 85,902 full-time faculty in theirclinical departments. Since the schools had only16,561 third-year students, medical schools had,on average, 5.2 clinical faculty members for everymedical student rotating through the requiredclerkships. Clearly, the ratio of full time clinicalfaculty to students rotating through clerkship expe-riences must be adjusted to take into considerationthe size of specific departments, and the fact thatmany students are rotating at sites for which thefull time faculty are not responsible. Regardless ofthe actual number, it is clear that the number of full-time clinical faculty far exceed the number requiredto provide a high-quality clinical curriculum.

There are presently frequent claims from manysources that full-time clinical faculty members donot have time to teach. These claims seem torelate primarily to the widespread perception thatmany faculty are unwilling to accept invitations totake on a particular teaching assignment, or todevote special time to students when they areserving as an attending physician on an inpatientservice or in a clinic. This perception has its rootsin the assumption that faculty are hesitant toaccept those teaching responsibilities because ofthe demands placed on their time to conductresearch or to provide patient care.

Based on the interviews that were conducted dur-ing the school site visits, it is apparent that thisperception is inacccurate. Most of the clerkshipdirectors that were interviewed stated that theywere able to recruit a sufficient number of qualifiedfaculty to participate in the educational program.Similarly, the medical students that were inter-viewed reported that they were generally quitesatisfied with the amount of time that attendingphysicians spent with them. In both cases, therewas a sense that faculty were willing to committhe time required because many of them enjoyteaching, and decided to pursue an academiccareer, at least in part, so that they would haveopportunities to mentor and teach students.

Nonetheless, students and clerkship directors dosense that many faculty are stressed by thedemands of providing patient care services, and ofcompleting the paper work required to documenttheir involvement in those services. In some casesthese demands have resulted in faculty takingshorter stints as an attending physician. This isparticularly the case on internal medicine services,where the traditional one-month attending rotationis being replaced in many institutions by two-weekrotations. If the attending physician is also servingas the preceptor for the medical students assignedto the service, this practice is very disruptive tothe educational program, since the period is tooshort for the development of an effective student-teacher relationship. A few internal medicinedepartments have begun to employ full-time “hos-


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pitalists” as a means of improving the efficiency ofpatient care. Although the experience is limited todate, it appears that this approach enhances thequality of the students’ educational experiences,since hospitalists are frequently on the units andavailable to interact with students.

As noted previously, members of the clinical facul-ty often believe that teaching medical students hasa fairly low priority both in their department andin the school. Since deans, department chairmen,and promotion committees often do not giveappropriate recognition to faculty efforts and con-tributions in education, they also believe that theirteaching efforts are not highly valued. Indeed, therole of teaching in promotion often has not beenmade clear to clinical faculty. It is clear that aca-demic leaders must do a better job demonstratingto their faculties that teaching medical students isvalued and rewarded, if they hope to improve thequality of their educational program.

Schools are becoming increasingly aware thatthey must provide more resources to assist facultyin their efforts to develop teaching skills, and tobecome medical educators. During the past decademany schools have established structured facultydevelopment programs that provide opportunitiesfor faculty to improve their teaching and evalua-tion skills, and to engage in leadership trainingexercises. In a number of schools, faculty who wishto pursue careers as medical educators can obtainfellowship support from the dean’s office to allowthem to conduct a scholarly project. A few schoolsare establishing, or have established, programs,centers or institutes for the recognition and supportof dedicated medical education scholars.

In this regard, it is important to note that manyfaculty, particularly more junior faculty in clinicaldepartments, are quite confused about the appoint-ment and promotion policies of their schools.During the past two decades, many schools devel-oped multiple “tracks” within the full-time facultysystem. For the most part, the tracks were developedto serve the needs of the clinical departments forfaculty who would spend most of their time engaged

in patient care and, thus, would be unable toaccomplish the scholarly work, generally biomed-ical research, required for promotion and/or tenure.Faculty members appointed to those “clinicaltracks” are required to commit the majority oftheir time to providing patient care, and the balanceof their time to teaching. While they frequently arenot eligible for tenure per se, they may be promotedand remain on the faculty for extended periods.

In some schools, the development of these trackshas had a perverse effect. They have contributedto the demeaning of the core education mission ofthe school by assigning major teaching responsi-bilities to junior faculty who have a difficult timebeing promoted, and who can not be tenured, andrelieving senior faculty of teaching responsibilities.Faculty who are appointed to a clinical track arelargely funded by clinical revenues. Thus, theyoften face an inherent conflict in attempting to meetboth their patient care and their teaching respon-sibilities. A number of the clerkship directorsinterviewed during the site visits had an appoint-ment in a clinical track and, despite the key rolethey played in their department’s and the school’seducation program, received no support for theireducation related activities, and were uncertainabout the likelihood of being promoted.

Resident physicians are an important group ofclinical teachers. In fact, resident physicians seemto be expected to participate in medical students’education even more now than in the past.Recognizing their critical role as teachers, a numberof medical schools and residency programs arebeginning to provide opportunities for residents toimprove their teaching skills. These activities areoccurring at a time when the clinical demands onresidents are increasing. Given the competingdemands on their time, it is difficult to get residentphysicians to take advantage of these programs.Accordingly, medical schools are beginning to rec-ognize that teaching resident physicians to beteachers should begin in medical school. This isbeing accomplished by providing opportunities forsenior students to learn teaching skills, and togain teaching experience by having them tutor more


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junior students who are learning clinical skills orserve as co-facilitators for case-based learningexercises. Senior medical students almost uniformlyenjoy these experiences and find them to be ofvalue. In a few schools, senior students are requiredto participate in these kinds of experiences.

Finally, in the 2000-2001 academic year, medicalschools reported having a total of 137,353 volunteerclinical faculty. Without doubt, many of these fac-ulty members make little if any contribution to themedical student education program. However, manyplay very important roles in the clinical educationof medical students, either by serving as commu-nity-based preceptors for students who spendtime at their practice locations or by serving asteaching attendings for students rotating throughrequired or elective clerkships at sites where full-time faculty are not based.

Some schools report that it is becoming more dif-ficult to recruit or retain volunteer faculty to serveas clinical teachers for students. This is particularlytrue for volunteer faculty who serve as preceptorsfor students who spend time in their practices. Insome cases, this is due to the decrease in efficiencythat occurs when a student is involved in office-based practice. In other cases, the difficulty can betraced to competition for preceptors from othermedical schools, or from competition with otherclinical education programs within the same insti-tution. Most medical schools provide some sort ofrecognition and benefits to those physicians whoserve as preceptors. Less than half of the schoolsprovide monetary payment to some or all of theirclinical preceptors.

Phase I of the AAMC Project on the ClinicalEducation of Medical Students was designed pri-marily to document the state of medical students’clinical education in the United States. The obser-vations made during the conduct of the Phase Ihave revealed a number of major issues of concernregarding the quality of the students’ educationalexperiences. The major concerns include:

The lack of awareness by the clinical faculty of the specific learning objectives establishedfor the clerkship experiences

The lack of adequate teaching of fundamentalclinical skills, including rigorously conducted formative assessment of students’ performances

The lack of appropriate patient populations for medical student experiences, particularly in certain disciplines

The lack of adequate integration into the thirdand fourth year clinical experiences of learningexercises that focus on a number of topics related to contemporary issues in medicine

The lack of attention to creating educational coherence in the design and conduct of the fourth year of the educational program

The lack of support for career development and advancement of clinical educators

The lack of explicit funding of faculty contri-butions to the educational program

The lack of attention to the teaching skills of resident physicians

The lack of adequate attention to the educationof medical students by department chairmen

The lack of adequate centralized oversight and management of medical students’ clinicaleducation

If medical school deans and faculties hope toimprove the quality of the clinical education oftheir medical students, they must address thoseissues in their own institutions. In doing so, theymust be certain to align the design and conduct ofthe clerkship experiences, and the assessment ofstudents’ performances, with well-articulatedlearning objectives. In order to accomplish thisimportant goal, there are five major actions thatthey should consider taking.


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First, they must ensure to the degree possible thatthe clerkships are designed and conducted so thatabove all else students acquire the fundamentalclinical skills that they will need throughout theirprofessional careers.

Second, they must ensure that the clinical experi-ences provided during individual clerkships exposeall students to an adequate number of patientswho are afflicted with the common disorders thatare representative of those seen in the clinicalpractice of the relevant discipline.

Third, they must ensure that topics related to con-temporary issues in medicine, many of which areintroduced during the first two years of the curricu-lum, are integrated throughout the third and fourthyears of the curriculum in ways that emphasizethe importance of the topics to clinical medicine.

Fourth, they must establish policies and proceduresgoverning the management and financing of theeducational program, which will ensure that clinicalfaculty are appropriately recognized and rewardedfor their contributions to the medical students’education program.

Fifth, they must make clear to department chairsand other members of the institution’s leadershipthat medical student education is the primary andunique mission of the medical school, and thatthey are responsible for being attentive to thequality of the educational experiences offered bytheir faculty.

In Phase II of the project, the Association will focusattention on the issues of concern noted above,and will develop programmatic activities that willassist individual medical schools in their efforts toaddress the issues within their institutions. Clearlyit is time for the members of the medical educationcommunity to address satisfactorily the issues thatwere first bought to their attention by the 1984report of the GPEP Panel. Despite the generallyhigh quality of American medical education, deansand faculties must do more if tomorrow’s medicalschool graduates are to meet the expectations of

the profession and the public. Improving the qualityof the clinical education of medical students is animportant challenge that deserves the full attentionof the academic medicine community.

The co-directors of the project wish to acknowl-edge the extraordinary cooperation and supportthat was received from many in the medical edu-cation community during the conduct of the proj-ect. We are particularly grateful to the faculty,staff, and medical students of the nineteenschools that we site visited (see below), who tooktime from very busy schedules to meet with us,and who were extremely candid in sharing theirviews. A particular note of thanks to the “associ-ate deans for education” who arranged our visitsand provided us in advance with the materials werequested, and to the deans who welcomed ourvisits. And finally, thanks to the education deanswho responded to our request for informationabout innovations in their clinical curriculum, andto those who willingly agreed to participate instructured phone interviews.

(UCLA, UCSF, Colorado, Connecticut, Florida,Northwestern, Southern Illinois, Tufts, NewMexico, Mt. Sinai, Wake Forest, Case WesternReserve, Ohio State, Pittsburgh, MedicalUniversity of South Carolina, Baylor, Utah,Toronto, and Dalhousie)

We also want to acknowledge the financial sup-port provided by the Josiah Macy, Jr., Foundation,the Robert Petersdorf Education Fund (AAMCScholar-in-Residence Program), and theNorthwestern University School of Medicine (Dr.Nutter’s salary during the project).


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General References

Physicians for the Twenty-first Century. Report of the Panel on the General Professional Education of thePhysician and College Preparation for Medicine. Washington, D.C.: Association of American MedicalColleges; 1984.

Clinical Education and the Doctor of Tomorrow. New York, NY: Josiah Macy, Jr., Foundation; 1989.

Educating Medical Students. Assessing Change in Medical Education – The Road to Implementation.Washington, DC: Association of American Medical Colleges; 1992.

Medical Education in Transition. Princeton, New Jersey: The Robert Wood Johnson Foundation; 1992.

Learning Objectives for Medical Student Education. Report I. Medical School Objectives Project.Washington DC: Association of American Medical Colleges; 1998.

Ludmerer KM. Time to Heal. American Medical Education from the Turn of the Century to the Era ofManaged Care. New York, NY: Oxford University Press; 1999.

The Education of Medical Students: Ten Stories of Curriculum Change. New York, NY: Milbank MemorialFund; 2000 (co-published with the Association of American Medical Colleges).

Anderson MB.A snapshot of medical students’ education at the beginning of the 21st Century: Report from130 schools. Acad Med 2000; 75: (9 suppl.).


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the aamc project on the clinical education of medical students

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