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Medical students discern ‘hidden’ lessons during family medicine clerkships


Identifying challenges could lead to more residents entering primary care.

Family medicine has “hidden” lessons that become clear to medical students when they have clerkships in the field.

And addressing challenges in practice of family medicine could lead to more medical students choosing it as a specialty later on.

Researchers found medical students picked up on specified learning objectives and at least four traits that were not part of their course plans, according to the study, “Revealing the Hidden Clerkship Curriculum: A Qualitative Analysis,” published this year in the journal Family Medicine. Researchers Molly Cohen-Osher, MD, MmedEd, Amy L. Lee, MD, and Deborah Erlich, MD, MmedED, analyzed 668 written reflections from medical students at Boston University Chobanian & Avedisian School of Medicine and Tufts University School of Medicine.

After required six-week family medicine clerkships, the budding doctors were asked to list their top five take home points about the specialty. The researchers classified 13 broad categories, nine that matched the stated learning objectives, and four topics “that could be considered part of the hidden curriculum.”They were:

  • Traits of a family doctor, such as empathy, efficiency, and flexibility.
  • Challenges in family medicine, such as payment issues, time constraints, and patient complexity.
  • Personal impacts on students’ future careers.
  • Life skills and tips to carry through their careers.

“Three of the four categories of the hidden curriculum were not counter to the overall goals of the rotation, but one signifies a topic that we could more explicitly address: the challenges of family medicine as a profession,” Cohen-Osher said in a news release. Cohen-Osher is assistant dean of medical education for curriculum and instructional design, and previously was the family medicine clerkship director.

“Acknowledgment of the difficulties of primary care practice and solution-focused education could potentially impact how we address why students may not choose family medicine as a career,” Cohen-Osher said. The study acknowledged the goal of the 25X2030 initiative of the American Academy of Family Physicians (AAFP), which aims to draw 25% of medical students to the specialty by 2030.

This month, the National Resident Matching Program posted a record number of filled primary care slots, though family medicine was left with 577 unfilled positions, while internal medicine had 380 unfilled openings. Despite the unfilled posts, AAFP’s leader said the numbers were both good news and a reminder of the need for more primary care physicians, and 57% of doctor of osteopathic medicine students matching into primary care slots.

As for the “hidden” curriculum study, medical students listed lessons dealing with:

  • Scope of practice, with prevention as a subcategory.
  • Health care systems.
  • The role of family medicine in the health care system.
  • Traits of a family doctor.
  • Values of family medicine, with subcategories: doctor-patient relationships; continuity of care; and team-based care.
  • Cultural competency/social justice.
  • Challenges of family medicine care.
  • Evidence-based medicine.
  • Clinical skills for students.
  • Personal impact.
  • Life skills and tips.
  • Patient centeredness.
  • Clinical pearls.

The authors noted limitations of the study, including data from two private medical schools in the same city without a primary care mission and with average or below average match rates into family medicine. There was not a causal relationship between the students’ written observations and the clerkships.

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