Different formats for a neurology clerkship do not influence written examination scores

Military Medicine, Nov 2003 by Gunderson, Carl H, Dougherty, David S, Ford, Gwendolyn C, Schwab, Karen

Objective: Changes in health care delivery required substitution of a number of alternatives for the traditional inpatient clerkship used in the neurology education of fourth-year medical students at the Uniformed Services University of the Health Sciences and for third-year medical students from Georgetown University. Methods: We retrospectively analyzed grades on a locally generated multiple-choice examination based on a student objective list. Scores from students rotating on ambulatory neurology, neurosurgery, child neurology, neurorehabilitation, and rotations at other military hospitals over a 2-year period were compared with those achieved by students in a traditional clerkship at Walter Reed Army Medical Center. Results: There were no significant differences in the grades between any of the groups. Conclusions: Student acquisition of factual material was not influenced by the type of clinical experience or by whether the student is in the third or fourth year of medical school.

Introduction

For the last 20 years, the Uniformed Services University of the Health Sciences (USUHS) has required a 4-week neurology clerkship in the fourth year. Until 1995, this usually consisted of a traditional inpatient clerkship within the context of the neurology training programs at either Walter Reed Army Medical Center (WRAMC) or the National Naval Medical Center (Bethesda, Maryland) (NNMC). Small numbers of students rotated on the neurology services supporting family practice programs at Malcolm Grow Air Force Medical Center and Dewitt Army Hospital. A few were allowed to substitute neurosurgery, child neurology, or neurorehabilitation at one of the two major neurology programs, and some took their clerkships at military (and rarely civilian) teaching hospitals outside of the national capital area.

The practice of academic medicine, in general, and neurology, in particular, began to change in the 1990s. These changes included a shift from inpatient to ambulatory care, admission of patients for more limited purposes, the rise of subspecialty services, and the expansion of primary care, all of which combined to produce important changes within our major teaching hospitals. In June 1996, the neurology inpatient services of WRAMC and NNMC were consolidated at WRAMC, although a few selected stroke patients were still admitted to the NNMC. Because more patients were evaluated and treated in the ambulatory setting, the number of patients hospitalized and available for student study declined remarkably. In 1997, the Neurology Training Programs at WRAMC and the NNMC were integrated within the National Capital Consortium (NCC), an entity created to provide institutional sponsorship for all military graduate medical education programs within Washington, DC and the surrounding areas of Maryland and Virginia including WRAMC, NNMC, Malcolm Grow Air Force Hospital, and the USUHS. Subsequently, the programs at Dewitt Army Hospital have been transferred to the NCC.

These changes in the "learning environment" required changes in our program. There were simply not enough traditional clerkship spaces at WRAMC to go around. More students were scheduled for rotations on neurosurgery, child neurology, and neurorehabilitation. USUHS students at the NNMC were assigned to the Neurology Outpatient Clinic. Georgetown University School of Medicine Students, assigned to the neurology ward at NNMC in 1995-1996, were assigned to the NNMC clinic in 1996-1997.

We became concerned that these changes in the student's clinical experiences and the attendant changes in lectures and conferences required by these changes in organization and provision of care might negatively impact on learning adult clinical neurology. We formed the hypothesis that those assigned to other rotations would learn less factual material than those who took the traditional inpatient clerkship at WRAMC, To test this hypothesis, we studied exit examination grades among student groups defined by the nature of their clerkship experience, their university affiliation, and year of training and compared them with the WRAMC clerkship as the "gold standard."

Design/Methods

We retrospectively studied exit examination grades of fourth-year USUHS students whose clerkships were held in a variety of clinical settings as well as third-year Georgetown University (GU) students rotating at the NNMC during the 1995-1996 and 1996-1997 academic years, comparing them against the grades of the students who took the traditional inpatient clerkship at WRAMC during those same years. This is an observational study of the effect of self-selected rotations upon test scores. Two analyses were conducted: a test of the overall effect of clerkship options upon examination scores and comparison of each clerkship to the WRAMC inpatient clerkship.

Neurology Rotation Type and Characteristics

During the study period, USUHS students were assigned by a "lottery system" to neurology clerkship opportunities at military hospitals in the national capital area. Students drew numbers and were allowed to select their clerkship site and rotation in order from an established grid. They could elect alternative clerkships at military hospitals (and occasionally civilian institutions) outside of the national capital area as long as an appropriate neurologist served as preceptor. These rotations were at their own expense. Fifty-eight students over the 2 years elected these alternative experiences, usually for personal reasons such as proximity to a spouse or parent or to enhance their competitive position for intern selection. GU students selected the NNMC rotation via their own internal system.