Scholarly article on topic 'A clinical clerkship collaborative program in Taiwan: Acquiring core clinical competencies through patient care responsibility'

A clinical clerkship collaborative program in Taiwan: Acquiring core clinical competencies through patient care responsibility Academic research paper on "Clinical medicine"

CC BY-NC-ND
0
0
Share paper
OECD Field of science
Keywords
{"clinical clerkship" / "clinical skills" / mentorship / "patient care" / "undergraduate medical education"}

Abstract of research paper on Clinical medicine, author of scientific article — Yong A. Wang, Cheng-Feng Chen, Chen-Huan Chen, Ging-Long Wang, Andrew T. Huang

Background/Purpose Traditionally, clinical clerkship training in Taiwan does not provide medical students with sufficient patient care responsibilities and often results in inadequate clinical skills. Methods We implemented a pilot clerkship program at a comprehensive cancer center that emphasizes core clinical competency through direct patient care and dedicated faculty and mentors. Students were an integral part of the patient care team held accountable for providing coordinated and holistic care. Students' self-assessment of clinical competencies, faculty evaluation, and objective structured clinical examination were compared against their peers trained by traditional clerkship at a main teaching hospital. Results Fifty medical students completed the clerkship program in the first 3 years. At the end of the clerkship, participants rated themselves significantly higher than their peers in almost all patient care and clinical skill domains. The most significant areas included physical examination, clinical reasoning, developing management plan, holistic approach, handling ethical issues, and time management skills. The students rated their clerkship teachers significantly higher in time spent with students, skills and enthusiasm in teaching, as well as giving students appropriate patient care responsibilities. There was no significant difference in the end-of-clerkship objective structured clinical examination performance, but participants of the program achieved better grades in their subsequent internship. Conclusion This pilot collaborative program presented a successful model for clinical education in the teaching of core clinical competencies through direct patient care responsibilities at the clerkship stage. It is hoped that the project will become a catalyst for medical education reform in Taiwan and regions with similar traditions.

Similar topics of scientific paper in Clinical medicine , author of scholarly article — Yong A. Wang, Cheng-Feng Chen, Chen-Huan Chen, Ging-Long Wang, Andrew T. Huang

Academic research paper on topic "A clinical clerkship collaborative program in Taiwan: Acquiring core clinical competencies through patient care responsibility"

+ MODEL

Journal of the Formosan Medical Association (2015) xx, 1-8

ORIGINAL ARTICLE

A clinical clerkship collaborative program in Taiwan: Acquiring core clinical competencies through patient care responsibility

Yong A. Wang a, Cheng-Feng Chen a, Chen-Huan Chen b,c, Ging-Long Wang a, Andrew T. Huang a,d *

a Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan

b Division of Faculty Development, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan

c Faculty of Medicine, National Yang Ming University, Taipei, Taiwan d Department of Medicine, Duke University, Durham, NC, USA

Received 17 March 2015; received in revised form 12 May 2015; accepted 13 May 2015

KEYWORDS

clinical clerkship; clinical skills; mentorship; patient care; undergraduate medical education

Background: Traditionally, clinical clerkship training in Taiwan does not provide medical students with sufficient patient care responsibilities and often results in inadequate clinical skills. Methods: We implemented a pilot clerkship program at a comprehensive cancer center that emphasizes core clinical competency through direct patient care and dedicated faculty and mentors. Students were an integral part of the patient care team held accountable for providing coordinated and holistic care. Students' self-assessment of clinical competencies, faculty evaluation, and objective structured clinical examination were compared against their peers trained by traditional clerkship at a main teaching hospital.

Results: Fifty medical students completed the clerkship program in the first 3 years. At the end of the clerkship, participants rated themselves significantly higher than their peers in almost all patient care and clinical skill domains. The most significant areas included physical examination, clinical reasoning, developing management plan, holistic approach, handling ethical issues, and time management skills. The students rated their clerkship teachers significantly higher in time spent with students, skills and enthusiasm in teaching, as well as giving students appropriate patient care responsibilities. There was no significant difference in the end-of-clerkship objective structured clinical examination performance, but participants of the program achieved better grades in their subsequent internship.

* Corresponding author. Koo Foundation Sun Yat-Sen Cancer Center, 125 Lih-Der Road, Pei-Tou District, Taipei 11259, Taiwan, ROC. E-mail address: athuang@kfsyscc.org (A.T. Huang).

http://dx.doi.org/10.1016/j.jfma.2015.05.008

0929-6646/Copyright © 2015, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

+ MODEL

2 Y.A. Wang et al.

Conclusion: This pilot collaborative program presented a successful model for clinical education in the teaching of core clinical competencies through direct patient care responsibilities at the clerkship stage. It is hoped that the project will become a catalyst for medical education reform in Taiwan and regions with similar traditions.

Copyright © 2015, Elsevier Taiwan LLC & Formosan Medical Association. All rights reserved.

Introduction

Taiwan's medical training consists of 7 years of post-secondary medical school followed by residency and fellowship training. Medical students enter clinical clerkship in their 5th year followed by internship. Traditionally, during clinical clerkship, medical students observe attending physicians and residents without being involved in the direct care of patients.1 Fundamental clinical skills are acquired through lectures, observations, practicing on peers, or developed on their own initiative without supervision rather than hands-on supervised learning through patient care. When students enter internship or residency, these skills are no longer emphasized. In addition, clerkships have almost always been carried out in academic medical centers where patient care is highly specialized and clinical faculty lack adequate time and motivation to teach the fundamentals of general medicine. These factors contributed to poor clinical skills and overreliance on imaging and laboratory tests when students graduate from medical school.2'3

Early exposure to specialized practice of medicine during undergraduate and postgraduate training may have contributed to the uncoordinated and inefficient health care delivery. Patients in Taiwan frequently seek care from many specialists, resulting in the delay of proper management and wasteful spending of health care resources. Remedies for the fragmented care include strengthening general medical training and core clinical competencies, including history taking, physical examination, communication, integrated teamwork, professionalism, medical humanities, and essential knowledge and skills of medi-cine.4 The Taiwan Medical College Accreditation Council, which was founded in 1999,5 has been promoting a series of medical education reform, one of which is clinical education that emphasizes essential clinical skills and provision of holistic medical care.

We report here the first 3 years of a collaborative clerkship program in which medical students of a national university medical school undertook medicine and surgery clerkship at a comprehensive cancer center. The program focused on building clinical skills through direct patient care responsibilities, taught by a group of dedicated clinical teachers, and with close mentorship by senior physicians. We evaluated the program by comparing participating students' self-assessment of clinical skills, evaluation of their clerkship experience, performance in the objective structured clinical examinations (OSCEs),6 and pre- and post-clerkship grades with those of their peers who had undergone traditional clerkship training concurrently.

Methods

Description of the program

The National Yang Ming University (NYMU) is one of the three government-funded medical schools in Taiwan. The Koo Foundation Sun Yat-Sen Cancer Center (KF-SYSCC) is a comprehensive cancer center whose missions are to provide state-of-the-art holistic cancer care and to promote excellence in medical education. For years prior to the clerkship program, KF-SYSCC had accumulated a significant number of experienced clinician educators and had been actively involved in medical education reform because its members value medical education as one of the primary mechanisms for solving current issues in health care, in parallel with the views of the Institute of Medicine of the United States.7 In 2006, NYMU and KF-SYSCC formalized their educational collaboration by establishing the clerkship program aimed at innovation, diversity, discipline in clinical education, and emphasis on humane patient care. The collaborative program had obtained funding from the National Science Council of Taiwan and approval from the Ministry of Health and Welfare.

The collaborative program established an overall supervisor, two clerkship directors (1 for medicine and 1 for surgery), and a liaison business office. The program provided clerkship rotations lasting 3 months each in general medicine and surgery, with the remaining rotations still carried out at the main teaching hospital (Figure 1). Thus, NYMU students enrolled in the collaborative program spent 6 months at KF-SYSCC for medicine and surgery. The

Clerkship Months

0m 3m 6m 9m

Ob-Gyn/Peds/Rad Medicine Surgery

Surgery Ob-Gyn/Peds/Rad Medicine

Medicine O Surgery Ob-Gyn/Peds/Rad

Figure 1 Block rotation schedule of the 5th-year clinical clerkship at the National Yang Ming University. Students were divided into three groups, each starting with medicine, surgery, or a combined obstetrics/gynecology, pediatrics, and radiology (Ob-Gyn/Peds/Rad) rotation. Each rotation was 3 months in length. Koo Foundation Sun Yat-Sen Cancer Center accepted six students for medicine and surgery in each block. Ob-Gyn/Peds/Rad rotation was offered only at the main teaching hospital.

ARTICLE IN PRESS

^ + MODEL ^^^B

A clinical clerkship program in Taiwan 3

program accepted a maximum of 18 students each year, or six students per rotation block. These students were included as an integral part of the clinical service teams and involved in hands-on direct patient care. Clinical skills were emphasized in teaching sessions and daily patient care. The goals of clinical competency for the clerkship were discussed prior to the start of the rotation.

General medicine clerkship

The basic competencies included history taking, physical examination, patient presentation, medical record writing, interpretation of imaging and laboratory tests, clinical reasoning, communication with patients/families and colleagues, professionalism, and self-directed learning. Patient-centered approach to learning was accomplished in the following aspects: (1) team-based care of the patient, (2) integrated and coordinated general medical care supervised by teaching physicians, (3) bedside rounds and patient-based conferences, and (4) participation of care managers and nursing service for teaching.

Each team consisted of an attending physician, a resident, interns, two to three clerks, and a nurse care manager, and cared for 10—12 patients. Team members rotated monthly to expose students to a range of styles in teaching, supervision, and interaction with the other members of the team and consultants. Attending physicians were selected from a panel of internists enthusiastic in clinical teaching and general medicine inpatient practice. The attending physicians held responsibilities for all patients cared for by the team. During the month, other clinical duties were reduced so that the attending physician could focus on teaching and inpatient care. Although KF-SYSCC is a cancer center, a clinical service was set up specifically to handle general medical issues. The clinical issues varied significantly, requiring the team to have a broad knowledge and skill base in all areas of medicine, as well as to understand one's limitations where consultants were invited to join in decision-making and management. The teaching physicians tailored their teaching with a general medicine approach focusing on foundations of medicine. Periodically, renowned clinical educators from abroad, mainly the United States, were invited for a 2-week visiting professorship demonstrating clinical teaching, giving both teachers and students valuable opportunities for growth.

Each day, the team met for work rounds, teaching rounds, and radiology rounds that lasted the entire morning. The rounds centered around patient presentations by students, clinical reasoning, decision making, issues and topics arising during the care of the patients, and communication with patients and their families. Clinical pharmacists, nurse care managers, nutritionists, and social workers also participated. The students learned through active participation on rounds and interaction with consultants and other health care disciplines.

Each student took care of one to three patients concurrently. Continuous and in-depth involvement in the care of their assigned patients from admission to discharge was emphasized, including presenting on daily rounds, daily clinical care needs, communication with consultants, daily notes, and acquisition of relevant clinical knowledge.

Students were given progressive patient care responsibility in both quantity and quality across the clerkship months. Through the direct responsibility for patient care and self-directed learning, students acquired all essential clinical skills.

A full-time nurse care manager in each team assisted the medical students and helped in coordinating patient care. She also helped the students to adjust to the clinical environment, communicate with other team members and patients, and understand nursing issues. A nursing unit was designated for the program. Almost all inpatients cared for by the teaching teams were located on the same unit. The patients were informed of the arrangement at the time of admission. The nursing staff became familiar with the team model so that students received support from all patient care disciplines.

We designed clerk-level patient-based conferences to help students reflect on their experiences and learn certain skills in depth. These included observed history taking and physical examination on admitted patients followed by group discussion, disease-specific physical examination with didactics and applications on patients with real abnormalities, clinical reasoning through student case presentations, cardiac auscultation using Harvey (a cardiopulmonary simulator), and interpretation of electrocardiograms and chest X-rays.

Chart writing has always been a major area of weakness in physician training in Taiwan because English is not the country's primary language yet medical care is documented in English. Our students' notes were extensively reviewed and commented on by several experienced physicians. After each correction, students were expected to demonstrate improvement on subsequent write-ups.

Surgery clerkship

Surgery rotation resembled medical clerkship in its emphasis on basic clinical skills. In addition, core competencies included general surgical principles, basic surgical techniques, preoperative evaluation, and postoperative care. The program also emphasized critical appraisal of surgical literature and communication pertaining to informed consent and surgical care.

Each clinical team consisted of two attending physicians, a resident, and two clinical clerks. The inclusion of two attending physicians per month increased case variety and teaching styles. Similar to medicine, students were assigned patients so they could assume direct supervised responsibilities in preoperative preparation and postoperative care. Students attended daily teaching rounds and chief resident rounds. In addition, students assisted during surgical procedures performed by the attending physicians on the team and sometimes by other surgeons. Basic surgical skills such as sterile and suture techniques were taught in the operating room.

An important component in surgical clerkship was the outpatient clinic. Students participated in the initial evaluation of ambulatory patients in clinics, where they learned indications and contraindications for surgery, informed consent, clinical assessment, and workup in patients with an unestablished diagnosis.

+ MODEL

4 Y.A. Wang et al.

Clerk-level conferences included observed bedside evaluation, case presentation, critical appraisal of research literature, chart writing, and small group topic series focused on general surgical concepts. Students were asked to keep a "learning diary" to reflect on ongoing issues, solutions, or experiences. These were reviewed weekly by the surgical clerkship director, and sometimes shared with the student group anonymously if the student author had agreed. Students also kept a procedure log to keep track of basic surgical skills.

Medical humanities, evaluation, and mentorship

Medical humanity was a key element of the clerkship program at KF-SYSCC and represented a common learning module continuing throughout rotations in medicine and surgery. At the cancer center, students frequently encountered life-changing events, extreme emotions, and ethical challenges. Biweekly humanities-in-medicine seminar moderated by psychiatrists and senior clinicians allowed students to discuss humanity issues encountered in the care of their patients. An optional module was offered to students to follow a cancer patient over the entire clerkship period. Participating students would select a willing patient they had taken care of early on during their rotation, keep regular contact with them, and accompany the patient to appointments as time permitted. They shared their experiences in biweekly meetings.

We placed a strong emphasis on formative evaluations. At the end of each month, all clinical team members met together in an evaluation meeting and discussed each student's performance from various perspectives of the attending physician, the resident, the care manager, and seminar moderators. The meeting allowed the program directors and teachers to discuss the progress of the students and foster continuity of teaching tailored to each student. The clerkship director then gave one-on-one feedback of the collective evaluation to the student. Ongoing feedback allowed both faculty and students to identify the problems early and offer opportunities for targeted improvement. Formative evaluation was also done with feedback often given in real time in specific areas including case write-up, clinical evaluation exercise (mini-CEX), and direct observation of procedural skills.

Summative evaluations were carried out at the end of the rotation for clinical performance, chart writing, and OSCE, and were identical for the entire medical school class. Students were also asked to evaluate their teachers and the program. In addition, a student representative at KF-SYSCC was asked to render collective feedback to the program directors and mentors.

Mentorship is especially important in the early phase of the clinical career of physicians-in-training. In addition to an academic mentor (clerkship director), we assigned a separate mentor for each student for the entire duration of the clerkship year. These mentors were selected from a panel of senior physicians in medicine, psychiatry, radiology, and pathology, who were passionate about medical education but were not involved in evaluating the student's clinical performance. They met with their mentee(s)

regularly and provided guidance and support, sometimes even beyond clerkship.

Selection of students

For program Year 1, all applicants were accepted. For Year 2, the success of the 1st year led more students to express interest, which exceeded the maximum capacity of 18. After prospective students were informed of the proposed selection process through application and interview, only 18 officially applied and all were then accepted. For Year 3, we held an information session for all interested students and formalized the application process. Written application and in-person interviews were conducted. Students were accepted based on personal attributes, enthusiasm for learning, and expectations for the clerkship, but not on preclinical academic performance.

Evaluation of program performance

At the end of the clerkship, all students from both the main teaching hospital and KF-SYSCC were asked to anonymously fill out self-assessment questionnaires on knowledge, skills, and attitudes developed during the clerkship, and to evaluate faculty teaching. The questions were rated on a 5-point Likert-type scale with 5 being excellent and 1 being poor. For self-assessment questions, we calculated the proportions of scores 4 and 5 (good and excellent), and obtained p values using Chi square test comparing students from the two sites. For faculty evaluation questions, we grouped the ratings into three—excellent (5), good (4), and average or below (< 3). We separated scores 4 and 5 here, because they represented the vast majority of ratings in both sites. We obtained the proportions of each rating group and p values using Chi square test comparing the two sites. Students in each of the 3-month blocks from both sites took the same OSCE developed by the faculty of the main teaching hospital at the end of medicine or surgery clerkship. We compared those scores using a two-sample t test with unequal variance. Student characteristics and grades before, during, and after the 5th year clerkship were compared between the two sites using Chi square test for categorical measures and two-sample t test for continuous measures. For all tests, we defined an alpha value of 0.05 for the level of significance.

Results

A total of 50 students out of 351 NYMU medical students from three consecutive classes undertook medicine and surgery clerkship at the KF-SYSCC. The characteristics and academic performance of students at the two clerkship sites are summarized in Table 1. No significant difference was found in terms of age, sex, type of admission to the school, or premedical course grades between students at the two clerkship sites, but the KF-SYSCC group had slightly higher grades in the preclinical years. During this 3-year period, the number of students interested in and applying to the KF-SYSCC clerkship increased (Table 2), suggesting student appreciation for the program. This may reflect

Data are presented as n (%) unless otherwise indicated.

KF-SYSCC = Koo Foundation Sun Yat-Sen Cancer Center; SD = standard deviation. a The p values were obtained using the Chi-square test for sex and type of admission to medical school, and two-sample t test for age and grades in medical school.

b Admission to medical schools in Taiwan is traditionally based on national college entrance examination (written) scores. Medical education reform introduced a new type of admission process wherein some students are admitted through applications and personal interviews.

1 A clinical clerkship program in Taiwan + MODEL 1 5

Table 1 Student characteristics and academic performance.

KF-SYSCC (n = 50) Main hospital (n = 301) pa

Age, mean (SD) 23.0 (0.79) 23.2 (1.44) 0.28

Sex 0.29

Male 29 (58.0) 198 (65.8)

Female 21 (42.0) 103 (34.2)

Type of admission to medical schoolb 0.73

Via application/interview 16 (32.0) 89 (29.6)

Via written entry exam 34 (68.0) 212 (70.4)

Grades (0-100), mean (SD)

Year 1-2 (premedical) 84.86 (5.07) 83.55 (4.64) 0.09

Year 3-4 (preclinical) 81.61 (3.84) 80.20 (4.62) 0.02

Year 5 (clerkship) 85.45 (2.70) 84.17 (2.77) 0.003

Year 6-7 (internship) 89.35 (1.37) 88.72 (1.66) 0.004

greater selectivity and motivation in participating students during Year 2 and Year 3.

Student self-assessment

Questions on the "Readiness for Clinical Career" survey taken at the end of the clerkship year are listed in Figure 2. As students were moving on to the next stage of the clinical training, those who had clerkship at KF-SYSCC felt more ready to take on patient care responsibilities than their peers. A higher percentage of students rated themselves as having good to excellent preparation in areas of patient care, communication with colleagues, dealing with clinical uncertainty and ethics, and ability in self-directed learning and time management. The most statistically significant differences were in "compassion for patients" (98% vs. 74%, p = 0.001), "holistic patient care" (98% vs. 59%, p < 0.001), "time management skills" (68% vs. 39%, p < 0.001), and "handling issues in medical ethics" (90% vs. 51%, p < 0.001). The area where KF-SYSCC students felt less prepared was in "understanding Taiwan's health care system" (29% vs. 55%, p = 0.002), as during the clerkship training KF-SYSCC had placed more emphasis on patient care than on the insurance reimbursement scheme.

In acquisition of clinical skills, KF-SYSCC students also rated themselves significantly better in the majority of areas (Figure 3). The difference in physical examination

was particularly significant (93% vs. 48%, p < 0.001), which had been a weak area in traditional clerkship programs in Taiwan. Moreover, encouraging students to think through clinical problems and develop management plans was emphasized during teaching rounds at KF-SYSCC, and this was reflected in the student assessment—"clinical reasoning" (78% vs. 45%, p < 0.001) and "developing management plans" (66% vs. 30%, p < 0.001). These two areas were more difficult for beginners, and we observed a lower absolute percentage, but a much larger margin of difference, in comparison with their peers at traditional clerkship. The other substantial areas of difference were "case presentation and oral communication" (78% vs. 49%, p = 0.001), "history taking" (95% vs. 79%, p = 0.014), and "chart writing and written communication" (85% vs. 66%, p = 0.014). Overall, the results aligned with the program goal for the learners, which was to acquire core clinical competency and to provide holistic patient care.

Evaluation of clinical faculty

Student evaluations of medicine and surgery faculty were compared (Figure 4). In the area of clinical knowledge, there was no difference between the percentages in the "excellent" category in KF-SYSCC faculty and the main teaching hospital faculty. However, the KF-SYSCC faculty had much higher percentages of "excellent" rating in the aspects of attitudes, skills, enthusiasm and time spent in teaching, and giving students appropriate clinical responsibilities (all p < 0.001).

Student performance in OSCE and clinical grades

OSCE was the only short-term assessment of student's clinical performance that was identical for both sites and may be relatively standardized. It was designed and developed by the faculty at the main teaching hospital. Stations included evaluation of one standardized patient

Table 2 Number of applicants for the KF-SYSCC clerkship program.

Program Expressed Submitted Accepted

interest application

Year 1 14 14 14

Year 2 25 18 18

Year 3 35 25 18

KF-SYSCC = Koo Foundation Sun Yat-Sen Cancer Center.

Y.A. Wang et al.

Figure 2 Student self-assessment in the "Readiness-for-Clinical-Career" questionnaire at the end of clinical clerkship. Percentages of students who rated each question as "excellent" or "good" are shown; p values were calculated using the Chi-square test comparing students who had clerkship at the main teaching hospital (n = 290, light dotted bars) and Koo Foundation Sun Yat-Sen Cancer Center (n = 42, dark hatched bars).

and basic skills on interpretation of electrocardiogram and chest X-ray, basic life support, and several procedural skills. We found no significant difference between the KF-SYSCC group (n = 50) and the main teaching hospital group

(n = 301). The mean scores were 88.3 versus 87.7 (p = 0.39) for surgery OSCE, and 81.3 versus 80.9 (p = 0.63) for medicine. The possible reasons for the lack of difference between the two sites may be because the

Figure 3 Student self-assessment in basic clinical skills and medical knowledge at the end of clinical clerkship. Percentages of students who rated each area as "excellent" or "good" are shown; p values were calculated using Chi-square test comparing students who had clerkship at the main teaching hospital (n = 286, light dotted bars) and Koo Foundation Sun Yat-Sen Cancer Center (n = 41, dark hatched bars).

A clinical clerkship program in Taiwan

Figure 4 Student evaluation of medicine and surgery faculty at the end of each 3-month clerkship rotation. Percentages of students who rated each category as "excellent" (black), "good" (gray), and "average" or worse (white) are shown. The p values were calculated using Chi-square test comparing student evaluations for the main teaching hospital (n = 286, upper bar for each category) and for Koo Foundation Sun Yat-Sen Cancer Center (KF-SYSCC; n = 46, lower bar for each category).

OSCE, as designed by the faculty of the main teaching hospital, contained only one station that evaluated skills in approaching a (standardized) patient whereas the remainder were procedure- or skill-based, and that the scoring for each station was given by a single faculty rater from the main teaching hospital. It is known that the reliability and accuracy of the OSCE for clinical skill evaluation can be difficult to assess, and depend on the number of stations, the number of raters per station, and other design features.8

We also compared clinical grades in the clerkship and subsequent internship years (Table 1). The grades were largely based on the supervising physicians' evaluations. We found statistically significantly higher average scores for the KF-SYSCC students compared with their counterparts at the main teaching hospital: clerkship (85.45 vs. 84.17, p = 0.003) and internship (89.35 vs. 88.72, p = 0.004). However, the differences were small, and the scores fell within a very narrow range, suggesting the limitation of interpreting these grades.

Discussion

We successfully implemented a clinical clerkship collaborative program with dedicated clinician educators, and demonstrated the effectiveness of clinical learning integrated with patient care responsibilities. The results from the first 3 years were promising and aligned with the program goal of emphasizing core clinical skills. At the end of the clerkship, students were more confident in their own

clinical skills and were more ready to take on advanced patient care roles than their peers at traditional clerkship.

Similar to most programs in the United States and Can-ada,4'9'10 our clerkship program used a block rotation design for students to become integrated within inpatient care teams. The distinctive features of our program included: (1) explicitly specifying and enthusiastically implementing requirements and goals for students and faculty in patient care responsibilities and core clinical skills, (2) having care managers in bridging education and patient care, (3) frequent multifaceted feedback, and (4) dual mentorship.

Clerkship alumni at various stages of their training returned in yearly reunions and gave us feedback that further reinforced the value of in-depth involvement in patient care and strong clinical foundations during clerkship. Faculty surveys from various specialties and disciplines showed agreement on the program's positive impact on personal reward, self-improvement, quality of patient care, and improvement on medical education. Patient satisfaction was monitored on a regular basis and consistently showed high ratings.

Through these multidimensional evaluations, we identified six key components for the successful implementation of the clerkship program. First, KF-SYSCC had been consistently committed to medical education and identified faculties enthusiastic in clinical teaching. The clear institutional policy played a key role in disseminating the educational culture. A significant amount of manpower went into this educational program, with an estimated equivalent of 13 million TWD (New Taiwan Dollar) per year infused into the program by the cancer center. The reason

ARTICLE IN PRESS

+ MODEL

behind a large financial support to this endeavor is our willingness to provide for the students a more conducive environment that could facilitate learning. Coordination by nursing administrators, encouragement by physician leaders, and designation of supporting nursing units for teaching helped the nursing and operating room staff to become accustomed to having medical students in routine patient care. Second, regular faculty development workshops and meetings not only improved teaching skills but also built consensus in educational goals. One such example was to emphasize oral presentations during rounds and consistency in presentation style. Third, patient care responsibility was tailored to clinical maturity of the students. Students at various stages of the clerkship (Figure 1) had varying degrees of clinical maturity, and we catered to individual differences. We progressively increased the level of patient care responsibility, and gave a more advanced curriculum of bedside teaching to students who had been through prior clinical rotations. Fourth, early and regular formative evaluation was recognized as key steps to trainee maturation. We moved the first "end-of-the-month" evaluation and students—faculty feedback to an earlier time. Through two-way feedbacks, evaluation discussions, and mentor—student encounters, we were able to identify problems earlier and allow sufficient time to show improvements. Fifth, we optimized quantity, time, format, and content of the clerkship seminars to balance patient contact and didactic learning based on iterative student and faculty feedback. Finally, dual mentorship provided close and comprehensive support to students when faced with changing needs in academic growth, professionalism, ethics, and personal growth.

In summary, this pilot clerkship program provided a nurturing environment for learning and direct involvement in patient care where medical students acquired important clinical skills in their 1st year of entering clinical training. Students felt significantly better prepared for their clinical career after the 6-month curriculum. Although this program was tailored to the domestic culture and deficiencies in Taiwan's medical educational system, similar awareness and reform have been undertaken in other Asian countries.11-'13 It is hoped that the NYMU—KF-SYSCC collaborative model for clinical clerkship could be disseminated while Taiwan and similar countries explore their own medical educational reform.

Acknowledgments

This work was supported in part by a grant from the Taiwan Ministry of Science and Technology (formally the National

Y.A. Wang et al.

Science Council; NSC 95-2516-S-368-001-MY3). The authors thank Zhao-Rong Wu for helping to coordinate the clerkship program and collect data at KF-SYSCC, and Dr Shuu-Jiun Wang and Mei-Tsu Liu for organizing and providing student data from NYMU. The authors express their gratitude and respect to all the faculty and mentors for their devotion to the training program, and to all the past and present trainees for their valuable feedback to the program.

References

1. Huang KY, Lai CW. Taiwan white paper for medical education. Taipei: Ministry of Education; 2003.

2. Chan WP, Wu TY, Hsieh MS, Chou TY, Wong CS, Fang JT, et al. Students' view upon graduation: a survey of medical education in Taiwan. BMC Med Educ 2012;12:127-34.

3. Chu TS, Weed HG, Wu CC, Hsu HY, Lin JT, Hsieh BS. A programme of accelerated medical education in Taiwan. Med Teach 2009;31:e74-8.

4. Goroll AH, Morrison G, Bass EB, Jablonover R, Blackman D, Platt R, et al. Reforming the core clerkship in internal medicine: the SGIM/CDIM Project. Society of General Internal Medicine/Clerkship Directors in Internal Medicine. Ann Intern Med 2001;134:30-7.

5. Lai CW. Experiences of accreditation of medical education in Taiwan. J Educ Eval Health Prof 2009;6:2-4.

6. Gaur L, Skochelak S. Evaluating competence in medical students. JAMA 2004;291:2143.

7. Institute of Medicine. Academic health centers: leading change in the 21st century. Washington, D.C.: National Academy Press; 2003.

8. Brannick MT, Erol-Korkmaz HT, Prewett M. A systematic review of the reliability of objective structured clinical examination scores. Med Educ 2011;45:1181-9.

9. Whelan A, Appel J, Alper EJ, De FerTM, Dickinson TA, Fazio SB, et al. The future of medical student education in internal medicine. Am J Med 2004;116:576-80.

10. Veale P, Carson J, Coderre S, Woloschuk W, Wright B, McLaughlin K. Filling in the gaps of clerkship with a comprehensive clinical skills curriculum. Adv Health Sci Educ Theory Pract 2014;19:699-707.

11. Farrell SE, Takada K, Armstrong EG, Tanaka Y, Aretz HT. Reform of a traditional clinical curriculum in Japan: experiences at Tokyo Medical and Dental University. Med Teach 2009;31: 947-9.

12. Lai NM, Sivalingam N, Ramesh JC. Medical students in their final six months of training: progress in self-perceived clinical competence, and relationship between experience and confidence in practical skills. Singapore Med J 2007;48:1018-27.

13. Yu F, Xu L, Lu D, Luo W, Wang Q. The integrated clerkship: an innovative model for delivering clinical education at the Zhe-jiang University School of Medicine. Acad Med 2009;84: 886-94.