Lessons from across the pond: Student perspectives on the Internal Medicine clerkship experience at an Irish and Canadian medical school

This article was migrated. The article was marked as recommended. There is an increasing number of Canadians studying medicine outside of Canada, with a large cohort studying in Ireland. Studying abroad often means different foci in medical training which may make transitioning to residency in a different system more challenging. Students often enter North American elective rotations with little knowledge of student roles and responsibilities. This paper provides insight into the differences in learning objectives and student experiences in an Internal Medicine clerkship at a medical school in Canada and Ireland. Learning objectives are similar between systems; but there is an experiential discordance. In Ireland, clerks see many different patients, gaining exposure to a breadth of topics and clinical signs, but medical student presentations rarely inform decisions around patient care. In Canada, clerks have more direct patient responsibilities, performing physical examinations, reviewing investigations, writing progress notes, and devising management plans as part of their professional development. Overall, the Irish system places emphasis on the mastery of core clinical skills and maximizing breadth of patient exposure whereas the Canadian clerkship is more focused on graduated responsibility and formulating management plans, at the expense of some breadth of exposure. Such discrepancies may not affect the quality of residents, but are important considerations for Canadians studying abroad when repatriating for electives and residencies.


Introduction
As residency beckons, international medical students intent on returning to Canada question how their training compares to Canadian-trained students.There are over 3500 Canadians studying medicine abroad at 80 different medical schools in 30 different countries, with the majority studying in Australia and Europe (within which Ireland hosts the largest portion) (CaRMS, 2010;Barer et al., 2014).Upon completion of core rotations in Ireland, several of the authors completed clerkship rotations in Canada.We didn't know what to expect.Irish-trained students commonly rely on vague informal commentary from far-removed 'doctor friends' and urban legends of repatriated alumni.North American electives are critically important for residency matching.Students are evaluated on their performance and relationships made in this short time are integral to securing a residency position.A post hoc comparison has limited utility for students aiming to prove their readiness upon arrival at these early career-defining rotations.In this paper, we outline a comparison of Internal Medicine Learning Objectives of an Irish medical school (University College Cork) and CanMEDs Clerkship Curriculum Objectives for a Canadian medical school (University of Toronto) for the specialty of Internal Medicine (Table 1).We subsequently provide a subjective experiential comparison by way of personal observation.We hope this narrative may interest our student successors in Ireland and International Medical Graduates (IMGs) hoping to pursue residency in Canada.

Comparison of Learning Objectives
Upon review of Learning Objectives, major differences were not identified in curricula for pathophysiology, clinical medicine, and physical examination skills (Table 1) (University College Cork School of Medicine, 2018; University of Toronto Faculty of Medicine, 2018).The majority of identifiable differences were in areas relating to law, epidemiology, and public health.Irish trainees do not receive training on Canadian health policy or risk factors unique to Canadian populations.Some examples include: differences in responsibility for end-of-life decision-making and code status (these decisions are made by the patient or substitute decision maker in Canada, but by the most responsible physician in Ireland) (Medical Council of Ireland, 2017), epidemiological differences in disease prevalence (e.g.high rates of celiac disease and cystic fibrosis in Ireland) (Johnston et al., 1997;Farrell, 2008), and other socio-medical issues such as healthcare access for specific populations including the First Nations, Inuit, and Métis peoples in Canada and Travelling Community in Ireland (Harfield et al., 2015;O'Donnell et al., 2016).

Experiential Comparison Clerkship in Ireland
A clerkship day in Ireland typically includes: 1-2 group-based tutorials, 1 hour of bedside teaching, a team ward round, and histories/physical examinations on 2-3 patients.Patient interactions are commonly limited to patients familiar to the attending physicians or junior doctors.Clerks are expected to present structured histories and examination findings, but these presentations rarely inform decisions around patient care.Constructive criticism and questions about the pathophysiology and management of relevant conditions commonly follow.Each day, clerks see different patients for practice, learning about a breadth of topics and seeing many clinical signs.There is a strong emphasis on bedside teaching where a consultant takes a group of students to patients with known diagnoses.Irish clerks routinely perform basic procedural skills such as phlebotomy and intravenous cannulation, as this is a fundamental function of the junior doctor within the Irish healthcare system.Overnight call is not a requirement, though students can elect to be on-call with their assigned teams.

Clerkship in Canada
In Canada, the clerkship format is different in many ways.Observations are primarily drawn from Clinical Teaching Units (CTUs) and select Internal Medicine subspecialty rotations.A clerkship day in Canada typically includes: 1-2 groupbased tutorials, 1-2 hours of structured bedside teaching per week, reviewing active patient issues with the team, direct responsibility for 2-6 patients (numbers vary based on patient volumes and level of training), seeing new undifferentiated patient consultations, and overnight call.Clerks are responsible for following up active patient issues, performing physical exams, reviewing investigations, writing progress notes, and creating management plans, which are reviewed by the team.This format challenges clerks to apply clinical skills, follow the same patients each day, observe the effects of their management, and prompt adjustments as necessary.Overnight call is an expectation of Canadian clerkship where medical students see new consultations from the emergency department and manage overnight issues for their admitted ward patients, overseen by a senior medical resident (PGY2 or PGY3).

Discussion
While the Medical Councils of both Canada and Ireland have similar expectations for the core competencies of their students and trainees, there are unique aspects of each program.In Ireland, there is a greater focus on the mastery of core skills (including basic procedures) and maximizing breadth of exposure by seeing different patients every day, at the expense of direct patient responsibility.Canadian clerkship is more focused on graduated responsibility through

Communicator
Demonstrate effective communication skills in all areas including interaction with patients, families and their environment.
Communicate effectively with patients, their families and the community through verbal, written, and other non-verbal means of communication.

Demonstrate competence in presenting a complete history
Present a case summary orally in a clear, logical, and focused manner.
Collaborator Adopt a multidisciplinary approach to clinical practice.
Participate in interdisciplinary team discussions, demonstrating the ability to accept, consider, and respect the opinions of other team members, while contributing an appropriate level of expertise to patient care.

Manager/ Leader
Exhibit professional behaviour by meeting all scholarly requirements in a professional and timely manner During the clerkship in internal medicine, the medical student will deepen his/her understanding of the appropriate use of health care resources in the internal medicine context and contribute to a culture that promotes patient safety.Students are also expected to manage their own time in an efficient manner.

Demonstrate competence in health promotion and disease prevention in adults
Recognize important determinants of health and principles of disease prevention pertinent to internal medicine.
Act as an advocate on behalf of patients assigned to their care, when interacting with other members of the health care team.

Scholar
Self-directed learning is a significant part of the curriculum, with a list of learning objectives that students must cover however there is not a specific learning objective in the curriculum outline to this topic.
Demonstrate the ability to engage in selfdirected learning.This involves identifying personal learning objectives, and then finding and using a variety of resources to address learning needs, and to use self-reflection to assist their own learning.
individual patient interactions, formulating management plans, and a greater role on a healthcare team, at the expense of some breadth of exposure.
As globalization continues to universalize the supply of medical graduates, greater emphasis should be placed on understanding transatlantic differences in clerkship curriculums both in terms of education and patient-care responsibilities.Publicizing these differences may also better allow preceptors to evaluate students in the context of their training.Awareness of these differences may allow students and preceptors to better align expectation frameworks, making for an even more positive elective experience for all.
There are many possible explanations for differences in Irish and Canadian clerkship experiences ranging from cultural to practical.The Irish and Canadian medical systems evolved in different ways and developed different medical traditions including the delegation of patient care responsibilities.Canada abolished the rotating internship in the early 1990s whereas the Internship year remains a mandatory component of medical training in Ireland.There is no rush for medical students to assume patient care responsibilities in Ireland as Internship serves as a foundational year, allowing learners to achieve graduated responsibility in patient care.Irish residency programs are also on average longer than their Canadian counterparts.Differences in patient volumes may also account for some differences, but no direct comparisons exist in the literature.Noted differences are unlikely to be specific to Internal Medicine.A more thorough comparison amongst a broader range of specialties is warranted to outline roles and responsibilities for incoming international elective students.

Take Home Messages
There is an increasing number of Canadian's travelling abroad to complete their medical education.
The learning objectives for clerkship rotations in Canada and Ireland are very similar.
Clerkship in Canada focuses on graduated responsibility and patient management.
Clerkship in Ireland focuses on mastery of core skills and breadth of exposure.This review has been migrated.The reviewer awarded 3 stars out of 5

Notes On Contributors
An interesting paper written to demonstrate that what we often take for granted is not always what happens in real-time.We frequently assume that equity exists between two curricula , especially from schools of similar disposition and resource.The frequent travel between countries and schools that we now see among both undergraduate and postgraduate students causes curriculum planners and programme developers to assume too much, as this paper proposes.The paper was a little short on how this dichotomy of outcomes could be resolved and whether the outcomes were standard or reflected the needs of the country-this I think would make it a more rounded paper that was useful to all readers..I would still however recommend the paper to curriculum planners for their discourse on the subject.

Table 1 .
Direct comparison of the Internal Medicine Learning Objectives from University College Cork (Cork, Ireland) with the Internal Medicine Learning Outcomes from the University of Toronto (Toronto, Canada), grouped by CanMEDs roles of a medical student.
Ryan Taylor Sless -Ryan Sless is a final year medical student at University College Cork in Cork, Ireland who plans to pursue a career in Internal Medicine.In addition, he has a Master's of Science in Cardiovascular Exercise Physiology from the University of Toronto and a special interest in Simulation and Medical Education.ORCID ID: https://orcid.org/0000-0001-5086-426XNathanielEdward Hayward -Nathaniel is a Canadian medical student currently studying at University College Cork School of Medicine in Cork, Ireland.He is completing his final year of study and plans to pursue a residency in pediatrics.In his spare time, he is an avid distance runner, coffee connoisseur, and music lover.ORCID ID: https://orcid.org/0000-0001-9085-981XPaulMacDaraghRyan -Paul MacDaragh Ryan is a final year medical student at University College Cork and an Evidence Synthesis Ireland Fellow within the Grimshaw group in University of Ottawa.Paul holds a PhD in gut microbiome research and continues projects in the field within the Centre for Research in Vascular Biology.ORCID ID: https://orcid.org/0000-0001-7251-6725AdamKovacs-Litman-Adam Kovacs-Litman is an Internal Medicine resident at the University of Toronto.He obtained his medical degree from Western University and undergraduate from Queen's University.He has an interest in Quality Improvement with ongoing research using covert and electronic monitoring to quantity hand hygiene rates and implications for patient care.Umberin Najeeb -Dr.Najeeb is staff internist at Sunnybrook Health Sciences Centre and an Assistant Professor of Medicine at University of Toronto.She is the Faculty-Lead for International Medical Graduates [IMGs] mentorship program and the Co-Director of Department of Medicine's Master Teachers Program at UofT.ORCID ID: https://orcid.org/0000-0002-1652-9959DeclarationsTheauthor has declared that there are no conflicts of interest.Exploring levers and barriers to accessing primary care for marginalised groups and identifying their priorities for primary care provision: a participatory learning and action research study.Int J Equity Health.15(1), p.19. Reference Source University College Cork School of Medicine (2018) CP4006 Fundamentals of Adult Disease -Handbook 2018/19.Cork, Ireland.University of Toronto Faculty of Medicine (2018) Internal Medicine Clerkship Curriculum Outline.Toronto, Canada.