Association of Professors of Medicine

The Future of Medical Student Education in

Internal Medicine

o celebrate its 50th anniversary, the Association of

Professors of Medicine (APM) has dedicated its
pages in The American Journal of Medicine in
2004 to the future of academic internal medicine. In this
issue, the APM invited the Clerkship Directors in Internal
Medicine to discuss the future of medical student education.
Sir William Oslers observation in 1900 that all medical
students will do well (1) serves as a reminder that any
reflection on the history of the traditional internal medicine clerkship and projection on the future of that clerkship should be tempered by an understanding that medical students have and will adjust to the extrinsic and
intrinsic forces that shape medical education. It is, however, appropriate for clerkship directors to assess periodically how best to facilitate students learning in the clerkship in light of changes taking place in the broader
medical community. Although tumult since the early
1990s has led internists and internal medicine organizations to reexamine the role and definition of todays internist, the third-year internal medicine clerkship remains one of the seminal clinical experiences for medical
students (2).
Within the core clerkship, the experiential teaching
method of decades past has given way to methodologies
to deliver and assess mastery of a rigorous curriculum.
Training in the clerkship has evolved from a teacher-centered to a learner-centered approach. Students in the core
internal medicine clerkship are expected to hone many of
the core skills of a physician, such as physical examination, generation of differential diagnoses, doctor-patient
communication, and clinical decision-making. These
students are also expected to develop the core knowledge
and learn the core values of internal medicine, including
the importance of rigorous, scientific, evidence-based
thinking in comprehensive, personalized care of the adult
patient and a commitment to embrace the care of the
complex patient (3). The internal medicine clerkship has
always featured a commitment to giving students an active, meaningful role in the care of real patients. Although
clerkship directors remain committed to these educational goals, external pressures on the faculty and environment of the clerkship affect every aspect of learning.
In this paper, the Clerkship Directors in Internal Medi576

cine (CDIM) the organization of individuals responsible for teaching internal medicine to medical students
summarizes the intrinsic and extrinsic changes that are
affecting the internal medicine clerkship and suggests approaches to managing these changes proactively.

MEDICAL STUDENTS
The environment in which medicine is taught and practiced is changing at all levels of the profession. There is
decreasing interest in medicine as a profession, as evidenced by a decline in the total number of applicants for
medical school (4); despite this decline, as yet there has
been no decline in the qualifications of students accepted
to medical school (5). The percentage of women in medical school classes is rising, and the cumulative debt burden of graduating medical students continues to rise (Table). These trends may influence the types of students and
residents attracted to internal medicine.

TEACHING WORKFORCE
Changes in the work environment of internists have created substantial impediments to the education of medical
students that are likely to continue. Rising health care
costs and decreasing rates of reimbursement generate
increased pressure on faculty to improve clinical productivity. The presence of a student frequently impedes such
improvement. In response to this new reality, newly graduated physicians are leaning away from primary care
disciplines and toward sub-specialization (8), which may
leave fewer generalist physicians to teach students the
fundamentals of internal medicine. On the inpatient side,
patients are progressively less well, with decreasing
lengths of stay. The hospitalist movement, partially born
from these pressures, has created a new cadre of potential
teaching faculty, but this movement has also created a
new set of concerns, including the shifting of students
interest away from the practice of primary, longitudinal
care. These adaptations, nevertheless, provide opportunities for new approaches that may help departments
better achieve the core goals of the internal medicine
clerkship. For example, if hospitalists are effectively incorporated into the teaching service, they can be an excellent resource for teaching and modeling high quality

2004 by Association of Professors of Medicine. Published by Excerpta Medica Inc.

All rights reserved.

0002-9343/04/$see front matter

doi:10.1016/j.amjmed.2004.02.001

Association of Professors of Medicine

Table 1. Changes in the learning environment in the United States: 19972002

19971998

20002001

20022003

Number (%)
Applications to medical schools
Medical students
Women enrolled
Underrepresented minorities enrolled
Full-time faculty
Average cumulative medical student debt
PGY-1 internal medicine positions filled
through the National Resident
Matching Program

43,016
66,748
28,447 (42.6)
7712 (11.6)
96,773
$80,462 (1997 graduates)
4506 (in 1999)

37,089
66,295
29,576 (44.6)
7066 (10.7)
103,553
$99,089 (2001 graduates)
4494 (in 2000)

33,625
66,677
31,290 (46.9)
7086 (10.6)
109,526
$103,855 (2003 graduates)
4395 (in 2002)

Data from references 4, 6, and 7. PGY postgraduate year.

inpatient care (9). Hospitalists represent a new and growing niche for academic internists, and exposure to role
models in this area may bolster interest in careers in internal medicine.
Residents, who have served a major teaching role for
medical students, are also faced with limitations to their
time. Shorter lengths of stay and increasing acuity appear
to have increased the workload of residents. In 2003, the
Accreditation Council on Graduate Medical Education
(ACGME) approved new program requirements (10), including the 80-hour workweek restriction. The requirements regarding duty hours reduce the availability of residents and interrupt continuity of care, which will affect
the role of residents in teaching medical students.
For residents, accreditation program requirements include not only duty-hour restrictions but also requirements relating to the six ACGME competencies, which
reflect many of the core values of internal medicine: patient care, medical knowledge, practice-based learning
and improvement, interpersonal and communication
skills, professionalism, and systems-based practice. The
increased emphasis on the development of these competencies, as well as tools for their evaluation, can be beneficial to student teaching. The CDIM is working with the
Society of General Internal Medicine to update the Core
Medicine Curriculum Guide (3) and assign each of the
objectives in this guide at least one corresponding
ACGME competency. If internal medicine clerkships
adopt the revised core curriculum, it will provide an important link between medical school and residency and
reinforce the value and reality of the continuum of medical education.
High quality educational experiences for medical students demand teachers who are well prepared. Developing the knowledge and skills of these educators should be
a priority for all internal medicine clerkship directors and
departments. Many unique faculty development pro-

grams have been developed in print, workshop, video,

and computer-based formats. Role-playing, standardized
learners (11), and objective structured teaching exercises
(12) have all been used. Reaching community preceptors
with such programs can be especially challenging (13,14).
Residents have a great deal of contact with medical students, and developing residents teaching skills should
also be a priority. Programs that focus on basic educational principles directly relevant to the day-to-day activities of the resident may be particularly helpful (i.e. learning climate, team leadership, feedback, and evaluation)
(15).

TEACHING SITES
Shifts in inpatient and outpatient care have been dramatic since the early 1990s and have forced a reconsideration of where clinical teaching should occur. The majority of medical care takes place in the outpatient setting,
whereas most undergraduate clinical education still occurs in the inpatient setting. However, concern that replacing an inpatient with an ambulatory rotation diminishes the educational impact is not supported by the
literature (16,17). Additionally, ambulatory rotations are
associated with positive perceptions of, attraction to, and
choice of a career in internal medicine (18). Additional
opportunities arise from increased ambulatory education.
Some schools have chosen to combine multiple primary care specialties (e.g. medicine, pediatrics, and family medicine) into an integrated primary care clerkship.
Such programs may offer unique opportunities for effective primary care education (19). Continuity experiences
may improve the understanding of doctor-patient relationships, psychosocial aspects of care, and the management of chronic illnesses, without apparent differences in
the knowledge acquired (20 23).
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Association of Professors of Medicine

TECHNOLOGY
There has been an explosion of electronically available
medical information since the early 1990s. Online textbooks, full-text journals, and clerkship-specific material
have become core resources for many clerkship programs. The use of personal digital assistants continues to
grow among medical students and residents, primarily
for the ability of the devices to provide just-in-time
learning and medical information. Wireless technology
and electronic medical records are likely to become
widely available and to serve as the primary method
through which providers interact with the hospital information system. This infrastructure also may allow for
greater tracking of the individual experiences of students
in the clerkship, which is important for clerkship curriculum planning and evaluation.
One novel potential vehicle for education is computerized order entry systems for providers that are designed
to reduce medical errors. These programs intercept potential errors during order entry and prompt the provider
to review the order; they are linked to built-in clinical
decision support systems designed to provide immediate
expert feedback to the user and to reduce errors, but they
also have the potential to be powerful educational tools
for students. A major goal of the clerkship is to demonstrate effectively the use of new technology to locate and
interpret the proper information at the appropriate time.

EDUCATIONAL GOVERNANCE
A final area of dramatic change is the increasing central
oversight of the medical school curriculum. The Liaison
Committee on Medical Education (LCME), the Association of American Medical Colleges (AAMC), and the National Board of Medical Examiners (NBME) all influence
the mission and goals of the medical school. The recent
trend by these organizations to influence the environment, curriculum, and assessment of medical school education has increased the responsibility and accountability of the clerkship director in complying with these
organizations mandates and new expectations. To ensure that such compliance occurs, the deans office is now
required to demonstrate: integrated institutional responsibility for the design, management and evaluation
of the curriculum (24). Typically, it is the medical school
that determines the structure of the clerkship (length, sequence, number of students, affiliate liaisons), the crossdiscipline content to be included in a specific clerkship,
and, ultimately, much of the job description and demands on the clerkship director.
Since the early 1990s, the emphasis on evidence-based
medicine has grown exponentially, with the challenges of
teaching it shifting from the department of internal medicine to the medical school. Educating medical students
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about the principles of evidence-based medicine should

occur at all levels of the curriculum, particularly in preclinical biostatistics, clinical epidemiology, and practice
of medicine courses, and in the core clinical clerkships.
Certainly, internists have been at the forefront of the evidence-based medicine movement and internal medicine
clerkship directors should have a well-defined plan to include its principles in the clerkship curriculum. More difficult tasks are to find time in the curriculum and to have
faculty and residents support the curriculum and model
evidence-based medicine principles in clinical practice.
These tasks require extensive faculty development.
Calls for accountability for medical schools have
greatly increased the focus on the process of evaluation of
medical students, particularly the objective structured
clinical exercise. The Institution of the United States
Medical Licensing Examination Step 2 Clinical Skills Examination will make it effectively mandatory for all medical schools to prepare medical students for such testing.
Clerkship-based and end-of-third-year objective structured clinical exercises have become relatively common
(25). Developing, implementing, and maintaining high
quality, accurate, and reliable objective structured clinical
exercises are formidable tasks, particularly at the individual clerkship level. Facilities, funds, administrative support, standardized patients, and a certain degree of expertise are all prerequisites, and support from the dean is
crucial. However, the CDIM firmly agrees that teachers
must continue to have a key role in assessing trainees
skills and that medical educators must not abdicate this
responsibility to standardize patients and simulation (26).
The positive contributions of increased central curriculum oversight and accountability are enhanced communication and collaboration among educators, even across
departments, who are working to achieve the same goals.
Shared resources and programs may also be useful in faculty development and assessment of educational outcomes. In addition, specifically defining goals and objectives may make it easier for students to assess themselves
and direct their own learning. Such a coordination of
effort should facilitate the move to a competency-based
curriculum and allow students flexibility.
However, as the CDIM has previously stated, it is important to consider the distinction between central oversight and control.
Moving control of the clerkship out of the hands of
clinical departments has potentially serious consequences, including the loss of innovative teaching and
evaluation method.
. . . Such a move begs the question of ownership of
the clinical curriculum. Centralized control raises the
specter of curricula reflecting the desires and vision of a
few rather than being the collective view of the education
community (i.e., the faculty at the local level) (27).

Association of Professors of Medicine

THE INTERNAL MEDICINE CLERKSHIP

IN THE FUTURE
The rapid pace of change in medical information, information technology, and educational requirements, coupled with ever increasing external pressures on faculty
time and curricular time, are changing the core clerkship
in internal medicine. Clerkship directors must proactively manage these changes or face erosion of the core
values and goals of the clerkship. The internal medicine
clerkship of the (not so distant) future must have strong,
core ambulatory and inpatient experiences. The pool of
teachers must include a broad array of internists: hospitalists, general internists, subspecialists in the ambulatory
and inpatient settings, residents, and fellows. Effective
programs to develop the teaching skills of residents, fulltime faculty, and community preceptors must be disseminated. These skills should include basic teaching skills
and teaching evidence-based medicine, information
management, and other new clinical content in the context of the clinical encounter. Students should be trained
to use their hand-held computers to access information
at the point-of-contact, manage medical information,
and track their clinical encounters and achievement of
learning goals. The learning goals must remain consistent
with the core clerkship curriculum but should be framed
in the context of the ACGME competencies to facilitate
the transition from student to resident and to emphasize
the continuum of medical education. Assessment will
need to be more competency-based and will likely include more standardized patients and simulations, as direct observation of student performance will be critical to
ensuring mastery of required competencies. Finally,
greater cooperation is needed to ensure that the objectives of the internal medicine clerkship are more integrated with the goals of other clerkships and preclerkship
courses.
These changes will only occur if the clerkship director
in internal medicine embraces change within the clerkship, acts as an advocate for the programs teachers,
and articulates the importance of the core values of internal medicine. In addition, substantial investment in the
educational mission is urgently needed. Appropriate recognition and reward of excellence in educational activities must be developed, and adequate financial and administrative support for the clerkship director and for
clinical teachers must be assured, likely through missionbased management. In addition, internal medicine clerkship directors must continue to be among the educational
leaders at their school, serving on medical school and
departmental educational committees (28). They need to
collaborate with other clerkship directors, course directors, and residency directors to address LCME, NBME,
and ACGME mandates and to create an integrative set of
learning experiences in a competency-based curriculum

that extends from introduction to clinical medicine

through the clerkships and into internship.
When caring for patients, internists strive to incorporate rigorous, scientific, evidence-based thinking in the
comprehensive, personalized care of the adult patient
and to embrace the care of the complex patient. Similarly,
internist educators must strive to incorporate rigorous,
evidenced-based thinking into the development of a
competency-based, personalized curriculum for students
in the internal medicine clerkship and to embrace the
current complexity of medicine and medical education.
Following these tenets, the clerkship may be dramatically
altered, but the core mission and values will not only be
maintained, but also perhaps more nearly achieved.
Alison Whelan, MD
Joel Appel, DO
Eric J. Alper, MD
Thomas M. De Fer, MD
Todd A. Dickinson
Sara B. Fazio, MD
Erica Friedman, MD
Mary Ann Kuzma, MD
Shalini Reddy, MD

REFERENCES
1. Silverman M, Murray J, Bryan C., eds. The Quotable Osler. American College of Physicians; 2003:173.
2. Association of American Medical Colleges, 2003 Medical School
Graduation Questionnaire, All School Report. Washington, D.C.,
2003. Available at: http://www.aamc.org/data/gq/allschoolsreports/
2003.pdf. Accessed December 24, 2003.
3. CDIM, CDIM/SGIM Core Medicine Clerkship Curriculum
Guide. Washington, D.C. Available at: http://www.im.org/CDIM/
ResourcesFor/CDIMeducationaltools.htm. Accessed December 22,
2003.
4. Barzansky B, Etzel SI. Educational programs in US medical schools,
2002-2003. JAMA. 2003;290:11911193.
5. AAMC Data Book 2003. Available at: https://www.aamc.org/
findinfo/aamcpubs/databook/tableb14.pdf, Accessed January 16,
2004.
6. AAMC Data Book 2003. Available at: https://www.aamc.org/
findinfo/aamcpubs/databook/tableb7.pdf, Accessed January 16,
2004.
7. National Resident Matching Program 2003 Match Data. Available
at: http://www.nrmp.org/res_match/tables/table5_2003.pdf, Accessed November 11, 2003.
8. Society of General Internal Medicine. The Future of General Internal Medicine, 2003. Available at: www.sgim.org/futureofGIM.pdf.
Accessed January 16, 2004.
9. Palmer H, Armistead N, Elnicki M. The effect of a hospitalist service
with nurse discharge planner on patient care in an academic teaching hospital. Am J Med. 2001;111:627632.
10. Accreditation Council for Graduate Medical Education, Program
Requirements for Residency Education in Internal Medicine.
Available at: http://www.acgme.org/downloads/RRC_progReq/
140pr703.pdf. Accessed December 24, 2003.
April 15, 2004

THE AMERICAN JOURNAL OF MEDICINE

Volume 116 579

Association of Professors of Medicine

11. Gelula MH, Yudkowsky R. Using standardised students in faculty
development workshops to improve clinical teaching skills. Medical
Education. 2003;37:621629.
12. Stone S, Mazor K, Devaney-ONeil S, et al. Development and implementation of an objective structured teaching exercise (OSTE)
to evaluate improvement in feedback skills following a faculty development workshop. Teaching & Learning in Medicine. 2003;15:7
13.
13. Langlois JP, Thach SB. Bringing faculty development to community-based preceptors. Academic Medicine. 2003;78:150 155.
14. Alliance for Academic Internal Medicine. General Internal Medicine Faculty Development Project, Projects and Reports. http://
www.im.org/facdev/gimfd/PubOverview.shtml. Accessed January
16, 2004.
15. Hemmer PA, Pangaro L. Using formal evaluation sessions for casebased faculty development during clinical clerkships. Acad Med.
2000;75:1216 1221.
16. Butterfield PS, Libertin AG. Learning outcomes of an ambulatory
care rotation in internal medicine for junior medical students. J Gen
Intern Med. 1993;8:189 192.
17. Kalet A, Schwartz MD, Capponi LJ, et al. Ambulatory versus inpatient rotations in teaching third-year students internal Medicine.
J Gen Intern Med. 1998;13:327330.
18. Elnicki DM, Halbritter KA, Antonelli MA. Educational and career
outcomes of an internal medicine preceptorship for first-year medical students. J Gen Intern Med. 1999;14:341346.
19. Carney PA, Pipas CF, Eliassen MS, et al. An analysis of students

580

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20.

21.

22.

23.
24.

25.
26.
27.

28.

clinical experiences in an integrated primary care clerkship. Acad

Med. 2002;77:681687.
Papadakis MA, Kagawa MK. A randomized, controlled pilot study
of placing third-year medical clerks in a continuity clinic. Acad
Med. 1993;68:845857.
Pangaro LN, Gibson K, Russell W. A prospective randomized trial
of a six-week ambulatory internal medicine clerkship. Acad Med.
1995;70:537541.
Ogrinc G, Mutha S, Irby DM. Evidence for longitudinal ambulatory
care rotations: a review of the literature. Acad Med. 2002;77:688
693.
Peters AS, Feins A, Rubin R, et al. The longitudinal primary care
clerkship at Harvard Medical School. Acad Med. 2001;76:484 488.
Liaison Committee on Medical Education, Functions and
Structures of a Medical School: Standards for Accreditation of
Medical Education Programs Leading to the M.D. Degree,
Washington, D.C., 2003. Available at http://www.lcme.org/
functions2003september.pdf. Accessed December 24, 2003.
Barzansky B, Etzel SI. Education programs in US medical schools,
2002-2003. JAMA. 2003;290:1190 1196.
Holmboe ES. Faculty and the observation of trainees clinical skills:
problems and opportunities. Acad Med. 2004;79:16 22.
Hemmer PA, Griffith C, Elnicki DM. The internal medicine clerkship in the clinical education of medical students. Am J Med. 2003;
115:423427.
Hemmer PA, Elnicki DM. Albritton. The responsibilities and activities of internal medicine clerkship directors. Acad Med. 2001;76:
715721.