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Checking Boxes

“Make sure to note each encounter with the date, supervisor and age of the patient in the book … all encounters are required to be transferred to One45 … Four observed clinical encounters along with weekly feedback forms are required … Don’t forget to complete all hospital training modules…”

Such was the start of clerkship, lost in a sea of paperwork and bureaucracy.  A mountain of bookkeeping distributed to each student: due dates, boxes to check, requirements to fulfill and all with the threat of being held back if any part was deemed incomplete.  I understand the need to track what we experience for assessment, but the framing and focus of this introduction emphasized what should be a secondary to our learning.

I looked forward to entering the hospital and beginning to refine my skills, moving from learning theory to being involved in the care of patients.  Unfortunately, I found the move to be impeded by paperwork, odd requirements and a strange belief that the checking of a certain number of boxes makes one an expert and grants permission to proceed with training.

I saw my peers struggling with similar disillusionment.  Panicking after being locked out of a computer system and unable to complete requirements, or posts on the Facebook group struggling to find answers.  The convoluted nature of the requirements to pass impacting on being present during patient encounters or during instruction is evident.

An aspect of what bothered me about the requirements was that they seem to focus on the concrete experience, which I consider the raw material of learning, not the end product.  The reflection on experiences, sharing among peers, revision and abstraction are all missing from the majority of assessments.  Essentially, we are not being treated as adult learners.  This was also present in preclerkship, but I had hoped it would be behind us entering the hospital.  Addressing our earlier learning, I do not feel that a significant portion of my learning came from lectures or small group sessions provided by the school.  Most of my learning involved resources not included in the curriculum; the materials taught served as a framework and a guide to expectations of testable knowledge.  Similarly, the sessions on physical skills did not prepare us for the OSCE at the end of second year.  It was independent learning, practice with each other and resources outside the curriculum.  Thus, the focus on the concrete experiences or instruction misses where the vast majority of learning takes place.  The internalization, independent study, abstraction and revising of internal models and more are neglected.

Being able to assess such learning is difficult.  I believe that through a greater focus on feedback and the training of instructors in delivery of constructive feedback, a better model of assessment could be constructed.  There are certain skills that are required, and direct observation of learners or the use of simulation could test these skills.  A need to gradually entrust trainees with certain tasks is also required, but after a certain point, the outcomes are what are of importance.  The number of times a task is performed doesn’t capture the quality of the act or the results.  Furthermore, an overall assessment to gauge one’s level knowledge would be useful at certain times.  A comprehensive test that would give feedback on areas of strength and weakness, perhaps taken at the end of each year for one’s own benefit with a passing mark required by the end of clerkship.  Development of proper assessment tools takes time and without more investment in medical education research, finding an optimal approach will take many years.

I also worry about the introduction of competency-based residency programs. New and often ridiculous requirements of documentation of skills, with boxes to check, will put strain on learners, instructors and ultimately detract further from time spent caring for patients.  Being part of the cohort that is going to be trained during the transition, I foresee many years of frustration during our training, with shifting goal posts.

Thus, it appears the focus of clerkship as introduced is not to learn, but to satisfy a certain number of requirements as determined by committees.  To check enough boxes, see enough cases of certain types, complete the required forms — not to learn the skills, care for the patients or learn to work within the health care system.  We are in a time of transition and one where assessment is difficult.  A need to move beyond simple assessments and engage in evaluation that acknowledges the complexity of learning is required to move forward.

Kevin Dueck, MD Kevin Dueck, MD (4 Posts)

Contributing Writer Emeritus

Schulich School of Medicine & Dentistry at Western University

Dr. Dueck practices emergency medicine, primary care, and addiction medicine. He is an adjunct professor in Family Medicine at the Schulich School of Medicine & Dentistry at Western University and completed residency at McMaster University. He is active in the medical humanities, the author of the blog Aboot Medicine, and co-founder of the student wellness project Western Vitals.