I am a medical student in the era of active learning. Our curriculum, grounded in small group learning and patient simulations, was designed with consideration of the adult learning theory, acknowledging that knowledge retention is poor from traditional lectures.1 Despite the extensive changes implemented at the pre-clinical level, the third-year clerkship didactics remain for the most part in the traditional lecture-based format. These didactics are approximately 4 hours per week during clerkship and typically cover common clinical conditions. The lecturer speaks about a topic and the learners passively sit in the audience and listen. The only interactive portion is when the lecturer called on a student to answer a question. There is a consensus among my colleagues that clerkship didactics in this format are unhelpful. If they are not helpful, then why should students spend so many hours in didactics? What are they adding to the clerkship experience? If didactics are intended to fill in gaps in our clinical knowledge or to help us prepare for the shelf exams, then it has fallen short of its purpose. It is not uncommon for students to have their computers out completing question banks during the didactics paying little attention to the speaker. As a third-year medical student, I aim to share my perspectives on didactics in undergraduate medical education and offer suggestions to reform these sessions to meet students’ needs through a collaborative effort between faculty and students.
Are Didactics Important to the Clerkship Experience?
The value of clerkship didactics to clinical performance and/or shelf exam score is not well studied. Additionally, researchers often group structured learning time of all formats into the same category limiting the ability to determine if one format is more effective than another. In a study of 1,817 students from 17 medical schools in 2002-03, researchers separated didactics by their format to determine if there was an association with the internal medicine shelf exam score. Time in traditional lectures during the clerkship was not associated with the shelf exam score. In students with “high” step 1 scores, clinical factors (i.e., patients cared for and length of rounds) were most important; however, in students with “low” step 1 scores, time in small groups, separate structured learning time with a teaching attending, and length of the clerkship were related to the shelf exam performance.2 This suggests that students who struggled with test taking benefited more from structured learning time than those who did not. While structured learning time within the clerkship may be important depending on the type of student, lecture-based learning as a format does not seem to be helpful for anyone.
How Can Didactics Be Modified to Meet Students’ Needs?
I believe didactics should improve clinical knowledge and performance on the shelf exam, and if they do not, then they should be omitted to allow students to spend more time on the wards to learn from patients or to independently study. I think the first step in redesigning didactics is to determine the purpose of each session (i.e., is it to gain practical knowledge for the wards or to help with the shelf exam). The next step is to determine the best format for the given session based on its purpose. In my experience, the following have been the most memorable didactics:
- Simulation. On my neurology rotation we learned to use the NIH stroke scale through simulation on a standardized patient. There is a large body of evidence to support the use of simulations for improving performance in medical emergencies, resuscitations, surgical skills, and in functioning on an interprofessional team.3 Practicing skills in a lower stress environment may improve confidence participating in high stakes events.
- Team-based (TBL) or case-based learning. In my internal medicine clerkship we applied an approach to anemia through patient cases. The benefits of TBL include application of knowledge, experience working on a team, and opportunity to practice self-reflection and peer feedback. When TBL is compared to lecture-based learning, there is improvement in engagement and knowledge retention.4 Perhaps students are more engaged during these sessions and thus more likely to participate and retain material.
- Gamification. In my family medicine clerkship we played a game of jeopardy to learn commonly tested scenarios on shelf exams for women’s health. There is evidence to suggest that incorporating elements of games into didactics improves engagement. It is hypothesized that the use of points/leaderboards may improve learning outcomes by improving attitude and participation.5 The use of games is ideal for learning common test scenarios and buzzwords.
My reflection offers a first step in opening a dialogue between faculty and students to redesign clerkship didactics. I believe it is time to investigate the purpose of clerkship didactics and take the necessary steps to make them meaningful and help students focus their self-learning. I recognize that this is not an easy task and will require significant faculty participation. However, if the true purpose of didactics is to enhance clinical knowledge and to improve performance on the shelf exam, then reforming didactics would be a step in the right direction.
- Masters K. Edgar Dale’s Pyramid of Learning in medical education: Further expansion of the myth. Med Educ. 2020 Jan;54(1):22-32. doi:10.1111/medu.13813. Epub 2019 Oct 1.
- Griffith CHI, Wilson JF, Haist SA, et al. Internal medicine clerkship characteristics associated with enhanced student examination performance. Acad Med. 2009;84(7):895. doi:10.1097/ACM.0b013e3181a82013.
- Herrera-Aliaga E, Estrada LD. Trends and innovations of simulation for twenty-first century medical education. Front Public Health. 2022 Mar 3;10:619769. doi:10.3389/fpubh.2022.619769. eCollection 2022.
- Alimoglu MK, Yardım S, Uysal H. The effectiveness of TBL with real patients in neurology education in terms of knowledge retention, in-class engagement, and learner reactions. Adv Physiol Educ. 2017;41(1):38-43. doi:10.1152/advan.00130.2016.
- Van Gaalen AEJ, Brouwer J, Schönrock-Adema J, et al. Gami-fication of health professions education: a systematic review. Adv Health Sci Educ Theory Pract. 2021;26(2):683-711. doi:10.1007/s10459-020-10000-3.
Medical Education, SGIM
Ms. Garb (email@example.com) is a third-year medical student at Case Western Reserve University School of Medicine. Dr. Cruz (firstname.lastname@example.org) is a Health Professions Education Evaluation and Research (HPEER) fellow at the Louis Stokes Cleveland VA Medical Center and an assistant professor at Case Western Reserve University School of Medicine.
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