Understanding medical students’ transition to and development in clerkship education: a qualitative study using grounded theory | BMC Medical Education

From a developmental point of view, this study explored how students form their professional identity as student doctors and what developmental characteristics they show through the transition to clerkship education. Based on the results, the transition process and the features that developed can be discussed in two ways.

Process of transition to clerkship

The participants’ transition process revealed significant growth into “student doctors.” This process involved five stages: anticipation and anxiety, reality check, seeking solutions, practical application, and transition and stability. This finding is significant in that it reveals the process by which students establish their professional identity. Previous studies have elucidated the process of adapting to an organization as a newcomer [19] and have also investigated factors or perceptions that influence this transition process, such as inadequate preparation [10]. Our research, however, uncovers the detailed stages through which students develop into student doctors via self-discovery and problem-solving.

Central to the transition process was the interaction with patients. The students were motivated by the patient, who recognized himself as a student doctor and attempted to establish an identity as one. For example, one participant reported feeling a great sense of responsibility when he saw the patient struggling emotionally during the initial practice and taking his role seriously. This is an experience-oriented curriculum in which clerkship education takes place through dynamic interactions between members within a systematic structure [20], and in particular, interactions with patients prove that students are important not only to acquire knowledge, skills, and attitudes based on learning experiences for individual patients in real situations but also to form their identity as doctors [21].

However, not all patient experiences lead to positive outcomes. Participants who interacted with patients willing to contribute to student education during clerkships were able to transition more quickly due to favorable responses and positive communication. Conversely, participants faced challenges in effectively communicating with patients who were unwilling to participate in student education, resulting in repeated attempts to identify and implement improvement measures that delayed the transition to clerkship education. Moreover, students often experience anxiety in clinical settings, such as patient consultations, due to a lack of clear understanding and readiness for their roles [22], and this insecurity is further exacerbated by inadequate supervision [23]. In the current medical environment, where expectations for quality medical services are growing, student participation is likely to face skepticism [24, 25]. To prevent students from experiencing severe negative experiences in clerkship, professors should intervene appropriately to ensure patients accommodate students and help form a constructive learning community [26,27,28].

Another noteworthy observation is the students’ tendency to solve problems through discussions with colleagues rather than seeking help from professors. They valued having a common, agreed-upon solution as much as knowing the correct answer, and they perceived asking supervisors for help as something to avoid. We can discuss this behavior from a cultural perspective.

In Asian cultures, relationships play a significant role in influencing behavior [29]. Combined with the hierarchical and closed nature of medical groups, students may fear that making an unfavorable impression on a professor could adversely affect their future [30]. This hierarchical relationship extends beyond the university into their professional careers, emphasizing the importance of reputation management as perceived through the professor’s eyes [31, 32]. As a result, students often felt burdened to maintain a professional appearance and were highly conscious of their evaluator-evaluatee relationship with their professors. Their perception of asking questions as annoying likely stemmed from this hesitation [3, 8, 33]. Consequently, this structure may deter students from interacting directly with professors, leading them to rely more on peer support.

While peer interactions can strengthen their relationships, there is a risk of students acquiring inaccurate information due to their lack of expertise and difficulty in discerning the validity and usefulness of medical evidence [34]. This can hinder the development of expertise and skills, ultimately impacting their professional identity as physicians [19, 28]. Therefore, fostering an environment where students can actively communicate and challenge rigid cultural norms is crucial for effective medical education [10, 35].

Students’ developmental features through transition

Students grew up balancing clerkship and life, adapting to the hospital environment, and developing efficient and professional clinical competencies during the transition to clerkship education. These developments improve students’ adaptability, which is an important factor in their effective performance as future healthcare professionals [1, 4, 11]. To date, research has focused on increasing readiness by exploring gaps in pre- and post-clinical practice training [10, 11]. However, our work focuses on examining students’ features during the transition to clerkship education and discussing the implications.

First, personal development demonstrates how students constantly strive to balance practice and life during clinical practice. With the recent emphasis on the concept of work-life balance [36], students recognize clerkship as a kind of work and seek to flexibly cope with stress and improve their quality of life [37]. They use their leisure time and reduced time spent preparing for clerkship to recharge or meet friends, and they develop resilience to maintain psychological stability. This is crucial because healthcare settings frequently expose not only students but also medical staff to the risk of physical and mental fatigue and burnout [7, 8, 24]. Therefore, practicing self-management, such as time management and flexible coping with stress during the clerkship education, can also greatly benefit professional socialization [10].

Second, with regard to social development, the participants recognized adaptation to the hospital environment as a crucial factor for the transition to clerkship education. The participants gained confidence as members of the hospital by becoming acquainted with facilities and locations of the hospital. This result differs from those of previous studies that reported the lack of clinical knowledge and skills as the cause of difficult conversion [38,39,40]. Until now, the preparatory curriculum for the transition primarily focused on basic clinical skills, communication, physical examination, and other topics related to the national examination, resulting in relatively limited awareness and information about the hospital’s work environment [41]. It could have made the students feel that clinical practice education was a difficult process [9, 10]. However, it is necessary to review the content composition of the transition course, as students require useful and practical tips for clinical practice training, such as detailed job descriptions, in addition to clinical knowledge [13].

Furthermore, the participants felt the professors were more humane and accessible, although they were still difficult, which reduced the psychological distance between them. This contributed to creating an environment where students can reduce tension in the hospital and move around without being overly conscious of their surroundings. For example, there were many students who were nervous to be polite when meeting professors, but the tension decreased as the psychological distance decreased. This allowed students to move confidently within the hospital, get the necessary information more easily, and adapt faster to the hospital’s facilities and environment.

Finally, students achieved professional development through the cultivation of clinical competencies with a focus on efficiency. Specifically, their professional development mainly consisted of clinical competencies that could be objectively identified. Some participants mentioned that they were able to reflect on the characteristics of a good doctor as perceived by patients, but many others mentioned the reduction in patient consultation time as a key factor in a successful transition. Participants, who initially focused on patients’ emotions such as pain, gradually came to understand symptoms through concise questions. They developed an attitude that was unaffected by patients’ emotions and experienced a sense of bonding with doctors as a result of these changes. The overly skill-centered clerkship education may have led the participants to adopt a doctor-centered attitude instead of a patient-centered one [42, 43]. However, patient-centered healthcare is important because it not only contributes to improving patients’ health outcomes, increasing patient satisfaction, and strengthening the trust relationship between patients and their healthcare providers, but also enhances doctor’s the job satisfaction [44]. Therefore, clerkship education should be improved to cultivate doctors who can not only develop the capacity to objectively identify diseases but also empathize with patients and have a subjective perspective on diseases [5].

Implications for medical education

Based on the results of this study, we derive several practical implications for improving clerkship education.

Firstly, we suggest implementing a faculty development program that offers guidance on conducting clerkship education. Guiding students through the transition process and sharing their difficulties will help professors reflect on how to manage a clerkship and adopt a learner-centered perspective. These efforts will provide opportunities for students to experience clinical practice in a constructive environment with appropriate supervision.

Second, we propose changing the content of the transition course before students enter clerkship education. Providing practical information about the clerkship, including the hospital’s structure and system, as well as lectures related to medical knowledge or skills, will be helpful for a successful transition [9, 10]. Additionally, similar to the faculty development program, including information on what students will experience after entering clerkship education will help reduce their initial confusion and increase their adaptability.

Finally, we suggest creating a clerkship environment that fosters patient-centered attitudes. To achieve this, involving patients as active partners or mentors can be considered. Patients’ active participation in education can enhance students’ understanding of diseases and patient experiences, as well as provide insights into the professional values expected by society from doctors [45, 46]. Furthermore, it can be a useful strategy, as involving patients who explicitly agreed to participate in student education can reduce the student’s feelings of rejection and increase the patient’s satisfaction with their treatment [26].

Limitation and avenues for future research

The limitations of this study and suggestions for future studies are as follows: First, we observed that the participants reached the transition to clerkship education at varying speeds, but we did not analyze the specific causes and types in detail. Therefore, to further understand the factors affecting the transition and the steps involved, we propose a follow-up study to verify the causes and types by conducting additional interviews. Second, this study limited its scope to experiences in block-type clinical practice and did not investigate students’ experiences in longitudinal integrated clerkship or mixed clerkship education. Longitudinal integrated clerkship provides a unique learning environment in which students develop clinical competencies by establishing a longitudinal relationship with patients; therefore, block-type clinical practice and conversion experiences may differ [47]. Accordingly, examining students’ conversion experiences in various clinical practice education models can contribute significantly to improving the overall clerkship education. Nevertheless, this study is significant because it presents the process of students’ transition to clerkship education as well as the meaning of the features that develop through this transition.