Where did you learn this?
Determining learner attributions for the
sources of learning in a clerkship
Divy Ravindranath MD MS and Tamara Gay MD
Department of Psychiatry, University of Michigan School of Medicine
Third year medical students at the University of Michigan are required to
complete a 6 week clerkship in psychiatry. During this clerkship, students
learn in a variety of settings. They see psychiatric patients, receive
supervision from psychiatry residents and attending physicians, participate in
weekly didactic sessions with each didactic session covering one topic area in
psychiatry, and study on their own. As is the case at many other medical
schools,1 students also complete a USMLE “Shelf” Examination at the end of
the clerkship.
68% of questions were answered by knowledge gained from self-study. 18%
were answered by knowledge gained from conversations with
residents/faculty. 12% were answered by knowledge gained from the didactic
series. 6% were answered by knowledge gained from patient encounters.
These data were statistically different from random responses (chi-squared
value = 1115.554, p < 0.0001; Figure 1). Combining data for self-study and
didactic series and comparing against pooled data for the other responses
continued to show statistical significance (chi-squared value = 364, p <
0.0001). Moreover, attributions for correct responses did not vary from
attributions for incorrect responses (chi-squared value = 3.67, p = 0.299;
Figure 2).
Figure 1: Learner Attributions for Sources of Learning (Percentages)
1) Conversations
2) Didactic Series
3) Experience with
a patient (6%)
4) Self-study
We hypothesized that students see learning for the shelf examination as an
independent process from learning during delivery of clinical care during the
clerkship. If so, then students would report that they learned material to
answer shelf examination style questions from self-study and the didactic
series, rather than from other activities in the clerkship.
To test this hypothesis, we designed a survey that paired nine shelf
examination-style questions with a question asking students where they
acquired the knowledge to answer the shelf-style question. The shelf-style
questions were drawn from the nine topic areas covered in the didactic
sessions. The attribution question was phrased as a forced choice between one
of the four setting for learning identified above. The survey was administered
immediately before the examination for each clerkship block in the 2007-2008
academic year.
Chi-squared value = 1115.554, d.f. = 3, p < 0.0001
Figure 2: Learner Attributions Separated by Correct vs. Incorrect Answer (Percentages)
1. Which of the following is a defining characteristic of delirium?
a. Concomitant infection
b. Gradual onset
c. Psychotic symptoms
d. Waxing/waning attentiveness
Correctly Answered
Which of the following were most useful in helping you answer the above
1) Conversations with residents/faculty
2) Didactic Series
3) Experience with a patient
4) Self-study
These data support the hypothesis that students see learning for answering
shelf-style questions as independent from delivery of clinical care. When
asked to identify the mechanism of knowledge acquisition most useful in
answering a Shelf examination-style multiple choice question, students
overwhelmingly selected self study. Using a different survey methodology,
Briscoe et al found that students primarily used books to prepare for their end
of clerkship examinations.2 Given that the medical school admissions
process selects for students who have developed techniques for success on
multiple choice tests, it is not surprising that students see test preparation as
independent from the “work” of the clerkship.
Briscoe et al also found that students asked for “more time to read/study” in
order to get ready for the clerkship-end examination. However, more time to
study may not result in better test scores.3 Given that time spent reading may
trade off with clinical experiences during a clerkship and that these clerkship
experiences form the basis for development of professional identity, one
could question the value of heavily weighting the Shelf exam in a student’s
final clerkship grade. Indeed, schools that use the Shelf examination score
assign a median fractional weight of 25% to the examination score.1
There are many limitations to generalization of the present study. The most
significant limitation is that the survey was administered immediately before
the clerkship end examination, which is a time when students are
theoretically steeped in preparation for the test. As such, there may have been
a recency effect modulating the students’ survey answers. Moreover, the
survey has not been formally validated and the data only represent one class
of students at one medical school.
1) Conversati ons wi th resi dents/facul ty
2) Di dacti c Seri es
3) Experi ence wi th a pati ent
4) Sel f-study
Chi-squared value = 3.67, d.f. = 3, p = 0.299
1. Levine RE, Carlson DL, Rosenthal RH, et al. Academic Psychiatry. Spring 2005; 29:1, 52-57.
2. Briscoe GW, Fore-Arcand L, Levine RE, et al. Academic Psychiatry. March-April 2009; 33:2, 120-124.
3. Gerhardt JD, Filipi CJ, Watson P, et al. American Journal of Surgery. February 1999; 177, 132-135.
Results were analyzed using chi-squared tests of independence.
Acknowledgments: Thanks to our medical students for their participation, University of Michigan Residency
This project was determined to be exempt by the University of Michigan IRB.
Research/Clinical Scholars Track colleagues for input into this project, and Beth Weihe for administrative support.

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