Clinical Clerkships: The Heart of Professional Development


Peter Ways, John D. Engel & Peter Finkelstein

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    For decades, clinical training for medical students took place on the wards of teaching hospitals. Now, many former full-time faculty members are in private practice and teach at community hospitals, outpatient clinics, or their private offices. Patients with rare and esoteric conditions, once prized as teaching subjects, may be seen less often and those with common illnesses more often. Physicians, new and old, must learn to care for patients expertly and efficiently within the constraints of the managed-care system.

    Some things, however, have not changed. The basic clinical clerkships of medicine, surgery, OB-GYN, pediatrics, psychiatry, and family medicine still take place in teaching hospitals and continue to require long hours, insufficient sleep, and emotional hardiness. A dehumanizing hierarchy still demands mastery of technical facts and often excludes or minimizes the affective aspects of medicine.

    Clinical work continues to be not only a defining professional experience but a salient life experience as well, one that can bring about major changes in one's style of work, perspectives, and values. The professionalization that occurs during the clinical rotations sometimes comes at the expense of emotional and spiritual health. Furthermore, students or faculty rarely perceive this deficiency.

    This superb book is written by three of the nation's leading medical educators. While at Michigan State University's College of Human Medicine, Peter O. Ways, MD, developed the first problem-based learning approach now used in preclinical training in many U.S. medical schools. Later, at the University of Illinois—Chicago, he was commissioned by the Association of American Medical Colleges (AAMC) to organize and manage an interview study of student reactions to the first two years of medical school. Since the mid-1980s, Dr. Ways has worked in addiction medicine and has continued to champion health prevention and maintenance.

    John D. Engel, PhD, Executive Associate Dean at Northeastern Ohio University College of Medicine, is responsible for the school's education programs and evaluative efforts. As a pioneer in the definition and use of qualitative research paradigms in medical education, Dr. Engel directed a qualitative study (the first time these three authors collaborated) of students during their clinical clerkships, observing over 500 hours of clerkship activities. He developed the University of Delaware-Jefferson Medical College integrated program, where students are accepted for premed studies with the understanding that if they complete their courses satisfactorily, medical school admission will follow without further application.

    Peter Finkelstein, MD, a psychiatrist in private practice, has acted as preceptor for numerous psychiatry residents in the Stanford Medical School program. While a resident at Stanford, Dr. Finkelstein conducted a five-year study of the anatomy lab experience. He spent 300 hours directly observing medical student affect, reactions, and adaptations to working with human cadavers. He found a causative connection between students' preclinical experiences and the ways they function in their clinical rotations the last two years of medical school.

    These distinguished authors provide a wealth of important and interesting information and ideas to make your clinical clerkships satisfying, productive, and potentially healthier.

    Robert HolmanCoombsProfessor of Biobehavioral Sciences, UCLA School of Medicine Series Editor

    NOTE: Throughout the text, key points appear in italics, and key behaviors appear in boldface.


    With deep respect and gratitude we dedicate this book to our primary mentors Andrew D. Hunt, MD, and Hilliard Jason, MD (Dr. Ways), Anthony LaDuca, PhD, and Betty Risley, PhD. (Dr. Engel), and Tom Johnson, MD (Dr. Finkelstein). They have enlivened our thinking, honored our feelings, nurtured our talent, and encouraged risks.

    This work is also dedicated to the late Marianne (Tracy) Paget, sociologist, philosopher, and dear friend. Tracy probed the institutions and rituals of medicine with deep criticism while holding its practitioners and students in respect and love.

    We also honor our students, past and present, who have endured remarkable trials yet emerged as sensitive and caring physicians. They have triumphed despite a traditional, often archaic educational milieu that can objectify its students, sever head from heart, engender mind-numbing exhaustion, and fail to provide constancy of focus on quality patient care and service.


    Our former colleagues in the phenomenologic/anthropologic study of clerkships, Constance Filling, Karen Johnson, Richard Foley, and Larry LaPalio, helped substantially to define the nature and salient issues of the implicit curriculum. We owe them our deepest thanks. We are also particularly grateful to Eric Cassell for his landmark work on suffering, and to Allen Enelow and Scott Swisher, who wrote so definitively and helpfully about the interview process in medicine. Lura Pethtel, John Foglio, Howard Brody, Barry Rosen, and Heather, Carol, Martha, and Peter F. Ways, have all validated and stregthened our belief in the necessity to explore and access the spiritual dimension as a requisite part of integrated, whole-person care.

    Our greatest editorial debt is to Brigid Ways Marcuse, a lively and perspicacious critic of both the health care system and of educational process. Ms. Marcuse spent untold hours critiquing the ideas and syntax of the manuscript. As a result, the product is unquestionably clearer, truer, and more reader friendly. We are also extremely grateful to Carol Coombs and to Gretchen Gundrum (Ways), who read earlier versions and offered many important suggestions for change and emphasis. Larry Hulbert and David Zucker offered valuable criticism in selected areas and repeatedly boosted our morale. Our thanks also to Gillen Nagy who spent many patient and skillful hours reprocessing the manuscript, and to Isaac Dockter and Zach Gundrum who created some of our figures and tables.

    Last, but far from least, we thank Dr. Robert Coombs, who believed in our ability to effectively illuminate the clinical learning experience, and to Sage Publications for investing in his judgement. At Sage, Heidi van Middlesworth made valuable and important suggestions for shortening the manuscript, and Linda Gray, was an empathetic and skillful copy editor—her surgery was virtually painless! Sanford Robinson and Rolf Janke were patient and graceful in easing the manuscript through editing, formatting, and publication to achieve its metamorphosis as a real book.

  • Glossary

    Affective blunting: See diminished emotional responsiveness.

    Attending physician: The physician with ultimate responsibility for patients. The attending serves for two to eight weeks at a time, conducts rounds with house staff and/or students, and is generally available for advice 24 hours a day. In some hospitals, patients may have different attendings, each responsible for their own patients.

    Circadian rhythms: Periodic biological cycles recurring at about 24-hour intervals.

    Code: A euphemism for an urgent cardiac or respiratory emergency that threatens life. It is frequently used as part of the announcement or signal for such an emergency, as in “code blue.” The verb form is also employed, as in “we coded the patient.”

    CPR (cardiopulmonary resuscitation): The procedures used to resuscitate the patient who has undergone cardiac or respiratory arrest. “We did CPR.”

    Critical questions: Questions that serve to advance or improve the care of a particular patient (Is there a potentially better way to protect this patient's immunologic capability than what we're doing now?) or to suggest an approach that might advance our knowledge of the patient's disease or a related problem (How might one develop evidence to support the hypothesis that this is primarily an infectious disorder rather than a degenerative one?).

    Curing: The resolution or elimination of disease. “Her strep throat was cured.”

    Disease: A disorder or abnormality in structure or function of an organ or an organ system.

    Diminished emotional responsiveness (DER) (also affective blunting): An impaired or severely restricted ability to feel one's own anger, sadness, fear, anxiety, and other emotional pain, and/or to deal with these feelings in ways that are healthy. Those who “stuff” their emotions are a common example. Commonly, among caregivers, DER includes decreased or absent capability to acknowledge, be open to, and work effectively with the emotional and spiritual needs and reactions of one's patients.

    DNR (do not resuscitate): An alternate designation for the “no-code” patient.

    Healing: Amelioration or resolution of an illness or the effects of an illness on the patient. The word may be used in reference to quite specific and tangible manifestations, as in “her wound has healed well,” or it may be used to mean transition to a state of acceptance and greater peace in the face of prolonged illness or impending death. In Healers on healing, Carlson and Shield (1989) say, “Without love, there can be no true healing. For healing means not only a body without disease or injury, but a sense of forgiveness, belonging, and caring as well” (p. 3).

    Illness: A broadened perspective of a pathological condition, disease, or sickness that encompasses the impact (effects) on the patient's personal life, job, family, friends, and at times, even the larger community (as when an individual's mental condition results in harm to others in the community or when one has a readily communicable disease). Illness also includes any roots of the sickness or pathology in the patient's personality, family dynamics, social status, or ethnic background. The patient's suffering and that of family and other loved ones is also part of illness.

    Implicit curriculum: Highly significant aspects of almost every clerkship experience that most students do not anticipate and that often seem unrecognized by faculty as the highly formative phenomena they are. They include (a) the almost inevitable sad and draining aspects of patient care inevitably experienced in almost every clerkship; (b) certain teaching and evaluation strategies that demean, objectify, and often isolate students, and although not inevitable, are all too common; and (c) certain aspects of the environment. It is also referred to in this book as the unstated curriculum and the hidden curriculum.

    Intellectual vitality: A state of robust and flexible intellectual activity with the salient traits of curiosity, creativity, the capability for divergent thinking, integrative capacity, medical problem solving, and tolerance for ambiguity. In medicine, intellectual vitality also includes a practical understanding of research methods.

    Impairment: Physician impairment can range widely from simple inattention and carelessness to poorly managed anger and drug dependence (see Table 16.1).

    Medical education: A term used to include the four years of medical school, residency training, and continuing education for practicing physicians.

    MRI (magnetic resonance imaging) A technique that provides more sophisticated, more detailed X-ray-like images used for diagnostic purposes.

    No-code: The status of an individual patient for whom the decision has been made (by the patient himself or herself, relatives, or loved ones) to not do CPR if the patient stops breathing or has a cardiac arrest.

    Premedical education: Usually the four years of college prior to entering medical school. For those who enter abbreviated (six-year) programs, the two years prior to entering medical school.

    Rounds: In this book, rounds are sequential discussions about, and/or visitations paid to patients by the physicians and students responsible for their care.

    Scut work: The work, sometimes considered demeaning, of performing essential tasks in patient care that may be simple and repetitive and that often seem uninteresting. Common ones include drawing blood for lab work; transporting blood, urine samples, and cultures to the lab; passing tubes of various kinds; doing throat and wound cultures; and starting IVs. Many of these tasks are exciting when you have never done them before but may feel boring and repetitive after you have done a few.

    Service: The term is sometimes used in a way that is synonymous with unit, but more usually it denotes an entire specialty or subspecialty department, including the venues (in- and outpatient) in which patient care is delivered and the administrative and research areas as well. (If you are told the medical service is on the fourth floor, it usually means that both the patient care units and the administrative offices are there.)

    Suffering: To endure pain, death, or some other discomfort or distress. In this realistically more complex view of suffering, distress often includes that associated with events that threaten the intactness of the person. Suffering, then, is predominately subjective on the part of the patient; it is wrapped in the meaning that patients' give to their illness or injury, and it can be completely known only through careful inquiry.

    Teaching hospital: In the broadest sense, any hospital in which training of students and house staff occurs. A more insular meaning would insist that a teaching hospital is a university hospital or a closely and legally affiliated (for teaching purposes) hospital (such as the county hospital or the Veterans Administration) that trains large numbers of that university's students and residents.

    Unit: A term used to indicate a geographically distinct set of rooms and spaces for the care of patients belonging to a particular specialty or subspecialty (“the cardiac unit”). Most clerkship assignments are to one such unit, although occasionally they involve more than one (e.g., in fourth year, your clerkship on nephrology might center on the inpatient renal unit but involve two half-days a week in the renal outpatient or follow-up clinic).

    Abbreviations Used in This book

    CPR—cardiorespiratory resuscitation (see glossary)

    CSF—cerebrospinal fluid


    DNR—do not resuscitate (see glossary)

    H&P—history and physical exam

    HCD—high-caloric density

    LCD—low-caloric density

    MAP—major active problem

    MCD—medium-caloric density

    MI—myocardial infarction (heart attack)

    MRI—magnetic resonance imaging (see glossary)

    MSW—medical social worker

    NP—nurse practitioner

    PA—physician's assistant

    PCCC—primary care continuity clerkship

    PE—physical exam

    URI—upper-respiratory infection


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    About the Authors

    Dr. Peter Ways has taught students in all four years of medical school—as a lecturer and group leader in biochemistry and laboratory science, and in clinical medicine as an internist and hematologist. At Michigan State University's College of Human Medicine, he devoted himself entirely to curriculum development, implementation, teaching, evaluation, and educational research. He conceived and implemented “Focal Problems,” the first major commitment to early, integrated, problem-based learning in any medical school. With Dr. Tom Johnson, he also organized the four primary clinical teaching campuses for the College of Human Medicine, carried out (basic science/clinical science) faculty development, and later co-led the development of the upper peninsula program—a module for medical education in the rural setting. While at the Center for Educational Development, University of Illinois, Chicago, he participated in the clerkship study led by Dr. Engel. He was then commissioned by the Association of American Medical Colleges to organize and manage an interview study of student reactions to the first two years of medical school. Since the mid-1980s, his clinical work has been in addiction medicine. He has led numerous workshops and support groups for physicians, medical students, and other health care professionals on personal and professional coping and emotional and spiritual growth and development. Throughout his career, Dr. Ways has championed prevention and health maintenance. In recent years, he has founded and worked on Conscious Parenting, an enterprise devoted to formulating a set of “Prime Principles of Parenting,” conducting workshops for parenting educators and physicians, and developing a set of assessments and operating principles for detecting and resolving problems in affective parenting at different stages of child development. He has gained additional perspectives on the vicissitudes and rewards of the medical education process by supporting the progress and careers of three daughters, all physicians. Dr. Ways is based in Seattle, where he consults in parenting, health promotion, and educational change. He is Visiting Professor of Medical Education at Northeastern Ohio Universities College of Medicine.

    Dr. John D. Engel, trained as a social psychologist, has spent the majority of his professional career as a medical educator. He has been a pioneer in the definition and effective use of qualitative research paradigms in medical education. While he was on the faculty at the Center for Educational Development, he directed a qualitative phenomenological portrayal of the clinical clerkship in which six observers (including Dr. Ways and himself) were paired with medical students and spent over 500 hours in direct observation of clerkship activities. The rich and intricate culture of the clerkship, including its shadow side, was revealed in intimate detail. He has been principal investigator for many other studies of medical education and process. He is also the architect and founder of the University of Delaware-Jefferson Medical College integrated program wherein a student is accepted for premed with the understanding that if courses are completed satisfactorily, medical school admission is guaranteed without further application. The program is rich in behavioral science material. Currently, Dr. Engel is Vice President for Academic Affairs and Executive Associate Dean of Northeastern Ohio Universities College of Medicine.

    Dr. Peter Finkelstein attended Michigan State University's College of Human Medicine when it was still in its formative stages and experienced much of the excitement and frustration of a clinical training experience that pioneered the community-based paradigm, with increased emphasis on the outpatient experience. His interest in the anatomy lab grew out of his own experience as a medical student. While a psychiatry resident and fellow at Stanford, he conducted a five-year study of the anatomy lab. He did 300 hours of direct observation and interviewing in an unparalleled study of student affect, reactions, and adaptations to working month after month with cadavers. This work has furnished a number of important insights as to how the preclinical experience influences the ways in which students approach and function (personally and professionally) in their clinical rotations. Dr. Finkelstein practices psychiatry in Woodside, CA. He also regularly coaches and consults with troubled corporate leadership.

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