-Title: JURSI Challenges Report Summary

Author: Josh Butcher1

Affiliations: University of Saskatchewan College of Medicine1

Introduction

At the University of Saskatchewan (U of S), the SMSS (Student Medical Society of Saskatchewan) acts as a representative body for all College of Medicine students in all four years. At the U of S, clerkship students are identified as JURSI’s (Junior Undergraduate Rotating Student Internship students). The SMSS recognizes that JURSI’s face different challenges and barriers than pre-clerkship students. They also work on different time and geographic schedules than pre-clerkship students. For these reasons, JURSI’s are under-represented on the SMSS, as many positions often require a heavy time commitment that is incompatible with JURSI schedules. As a result, communication between JURSI’s and the SMSS has been less than ideal. In an effort to identify areas in which the SMSS can help advocate for change to support our JURSI’s, we created a survey.

Methods

In order to gain a general idea of some of the issues our JURSI’s have been facing, we consulted current and past year 3 and year 4 class reps, along with past SMSS presidents. Due to their busy schedules, we were unable to receive feedback from them all, however the feedback that we did receive seemed to be consistent with what we have heard issues about. We also asked for any issues that were brought up in the ‘bear pit’ sessions that hadn’t been addressed. ‘Bear Pit’ sessions are hosted by members of the UGME office and course coordinators and are an opportunity for students to voice their concerns about the curriculum. Once we received all feedback, we compiled together a list of issues and separated everything into issues that were specific to year 4, or that applied to all JURSI students. Additionally, some questions were left to be answered by year 4 students only, because at the time the survey was sent out, the year 3 students had only been in JURSI for about 1-2 months and had less experience. As well, since the College of Medicine has satellite sites in Regina and Prince Albert, some issues were specific to certain sites.

Next, we began to develop the survey using Fluid Surveys as a platform. We used a variety of question types including multiple choice, checkboxes, sliders, and text responses. However, all questions had an associated text box for any comments or further explanation that they wish to add. The survey was split into 2 pages; all participants answered the first page. Upon completion of the first page, all year 4

students were redirected to the second page for questions that were specific to their year or level of experience.

Once the initial development of the survey was complete, it was distributed to relevant faculty to proofread and provide feedback or make any additional changes. The majority of faculty generally seemed to find the survey unnecessary, as there are already measures in place (such as bear pit sessions) where they acquire feedback from students. As well they pointed out the number of surveys that students are responsible for filling out, and were concerned about survey fatigue. We certainly understood these concerns from faculty. However we chose to continue with the survey because we wanted to be sure that issues being presented in bear pit sessions were being met. As well, in the event that students don’t feel comfortable in coming out with their issues to administration and faculty, we wanted to give them another option to have their voices heard. In regards to survey fatigue, we tried to keep the survey relatively brief and easy to fill out.

After the additions and changes that were advised from faculty were made, the survey was sent to the current and past year 3 and year 4 class reps, along with past SMSS presidents for further feedback. Once this was received, we made any necessary revisions and finalized our survey. It was then sent out to the year 3 and 4 class reps who distributed it to their classmates.

Survey Questions

Page 1 (to be answered by all JURSI’s) consisted of 16 questions, which will be specified below. All questions had an associated text box for any comments or further explanation.

Question 1: What is your site placement?o Saskatoono Reginao Prince Alberto Other, please specify: _____

Question 2: When at RUH (Royal University Hospital), do you have a locker in the JURSI locker room?

o Yes, I have my own lockero Yes, but I’m sharing a lockero Noo N/Ao Other, please specify: _____

Question 3: When at RGH (Regina General Hospital), do you have a locker in the JURSI locker room?

o Yes, I have my own lockero Yes, but I’m sharing a locker

o Noo N/Ao Other, please specify: _____

Question 4: Have you experienced pressure from physicians/residents to work past maximum hours or past when you’re supposed to go home?

o Yes (please specify the rotation this occurred in the comment box below)

o Noo Other, please explain:

Question 5: Have you ever experienced learner mistreatment?o Yes (please specify the type of mistreatment, and in what context, in

the comment box below)o Noo Other, please explain:

Question 6: If you did not report your learner mistreatment, why? (Choose all that apply)

o I have not experienced learner mistreatmento I didn’t have timeo I didn’t feel it was significant enough to reporto Fear of repercussions (negative evaluations, conflict with admin, etc.)o Other, please explain:

Question 7: During rotations away from home (electives or rural family med rotations etc.), have you struggled with feelings of isolation?

o Yeso Noo I haven’t been on a rotation away from homeo Other, please explain:

Question 8: How did you find the transition from Pre-clerkship to Clerkship?o Sliding scale from 1-5. 1=difficult, 5=easy.

Question 9: How well did the College prepare you for planning electives in JURSI?

o Sliding scale from 1-5. 1=very poor, 5=excellent Question 10: By finishing all their core rotations in 3rd year, do you believe

future JURSI’s will be more informed to plan their electives in 4th year?o Yeso Noo Unsureo Other, please explain:

Question 11: Do you find it difficult to participate in student groups, SMSS, or other student-run events due to differing schedules with the pre-clerks?

o Yeso Noo Did not participate in these activities

Question 12: Do you believe that Academic Half-days should be MANDATORY?

o Yeso Noo Unsureo Other, please explain:

Question 13: Have you ever received your call schedule past the specified amount of notice that was stated in the syllabus?

o Yeso Noo Other, please explain:

Question 14: Is there any information that you feel you were not adequately taught prior to clerkship? If so, please specify:

Question 15: Are there any other challenges that you have experienced throughout JURSI that you would like to bring up?

Question 16: What is your graduating class?o 2016o 2017

Page 2 (to be answered by year 4 students) consisted of 7 questions, which will be specified below. All questions had an associated text box for any comments or further explanation.

Question 17: Relative to your peers from other medical schools, how would you compare your pharmacology knowledge?

o Sliding scale from 1-5. 1=Lacking, 5=Superior. Question 18: Do you feel like you have been adequately prepared for

residency in terms of clinical skills/reasoning?o Sliding scale from 1-5. 1=No, 5=Yes.

Question 19: Do you feel like you have been adequately prepared for the LMCC compared to your peers at other schools?

o Sliding scale from 1-5. 1=No, 5=Yes. Question 20: Do you feel that preparing for the NBME’s have helped you

prepare for the LMCC?o Sliding scale from 1-5. 1=No, 5=Yes.

Question 21: Do you feel that your JURSI academic half-days have helped you prepare for the LMCC?

o Sliding scale from 1-5. 1=No, 5=Yes. Question 22: Do you feel that you had the resources and preparation

necessary for you to be successful in the CaRMS match?o Yeso Noo Other, please explain:

Question 23: What could be done in the future to help students be more prepared for CaRMS? (Choose all that apply)

o Nothing, we have been provided with an adequate amount of appropriate resources

o CVo Personal letterso Interview Preparationo Time off to work on applicationso Other, please specify:

Results

The survey was left open for 1 week due to time constraints. We were hoping to receive at least 30 responses, and we achieved 37 in total. 32.4% of the responses came from year 4 students, while 67.6% came from year 3 students. 70.3% of the responses came from Saskatoon-based students, while 29.7% came from Regina-based students. In regards to lockers available at RUH, only 54.1% of students had their own locker, while 2.7% were sharing a locker. 16.2% of students did not have a locker. In regards to lockers in Regina, only 2.7% of students (1 response) did not have their own locker.

35.1% of students said that they did experience pressure from physicians/residents to work past maximum hours or past when they’re supposed to go home. Specific comments were made about Psychiatry, Pediatrics, Internal Medicine, Surgery, Obstetrics/Gynecology, Infectious Disease, and Neurology. Comments can be seen below:

18.9% of students said that they had experienced learner mistreatment and left their personal accounts in the comments including threats of physical violence and verbal harassment.

27.8% of responses said they failed to report learner mistreatment because they didn’t feel the mistreatment was significant enough, or for the fear of repercussions and lack of anonymity. 5.6% of students reported that they didn’t have time to report the event. 1 student actually did report their mistreatment. Note: the number of students giving reasons for not reporting their learner mistreatment in this question exceeds the number of students who reported experiencing learner mistreatment in the previous question.

During rotations away from home, 62.2% of students reported struggling with feelings of isolation. 1 student left a comment about sometimes feeling unwelcomed, as well as a lack of patience from staff since there is always a short adjustment period when entering a new environment and ‘learning the ropes’.

When asked about the transition from pre-clerkship to clerkship, we received a normal distribution of responses from 1 (difficult) to 5 (easy).

We asked the students how well they felt the college had prepared them for planning electives. We found a skewed distribution and that on a scale of 1 (very poor) to 5 (excellent), most students felt the college had prepared them poorly.

In the comments, students stated that: “there was virtually no guidance”, “there was no planning whatsoever that I was aware of/involved in”, “I found that we got no career planning, and if we did it was too little and too late”. Another student made the comment that we should have someone to teach us how to use the portal system that more schools are becoming part of. They found that the college had very little experience using the portal and couldn’t answer any questions regarding it. Some students noted that they didn’t think the college could have done much more to prepare us, and they found talking to upper year students to be the most useful.

83.8% of responses reported that they do believe that future JURSI’s will be more informed to plan their electives by finishing all core rotations in 3rd year.

89.2% of responses reported that they find it difficult to participate in student groups, SMSS, or other student-run events due to differing schedules with the pre-clerks. Comments on this question yielded that it is difficult to participate, but not impossible. As well, it was stated that this is to be expected when switching to clerkship as your focus changes. SMSS, student groups, and student-run events take a lower priority on your list of things you need and want to do.

In regards to academic half-days, 24.3% believed they should be mandatory while 62.2% believed they should not. A variety of comments were left on this issue. One person felt that they should be mandatory out of respect for the lecturers who find poor attendance to be frustrating. Some felt that the half-days are hit and miss, as some are interesting and useful while other are the exact opposite. Most comments seemed to find that the topics had limited value since they are usually not relevant to the rotation that you are on (unless you get lucky). Several felt that the presentations were poor and little was learned and that the morning would be better served with independent study time. It was also stated that some flexibility would be appreciated so that the time could be used to attend lecture, do their own reading, or go to appointments to take care of themselves, as it’s difficult to get time off for self-care appointments. It was also argued that we are independent learners and not everyone learns from lectures, just like in pre-clerkship. It was also stated that the content of the lectures should be geared more towards clinical approaches to presentations. It was suggested that the time for academic half-days in the last 2 weeks of each rotation should be allotted for independent study time so students can use it to study for the rotations they’re currently on.

32.4% of students reported receiving their call schedule past the specified amount of notice listed in the syllabus. 4 out of the 5 comments left on this question stated that this occurred frequently within the internal medicine block. The last comment said that they received their call schedule for obstetrics 1 week before the rotation started.

We also asked for feedback on anything that students felt they were not adequately taught prior to JURSI. The comments could be grouped into the following categories:

When asked about any other challenges or difficulties that were experienced throughout JURSI, students’ reported difficulties in the following categories:

The remaining questions in the survey were answered by the year 4 students only. We had a total of 11 year 4 students complete the survey (32.4% of the responses).

We asked students how they felt their pharmacology knowledge was compared to students from other schools. On a scale from 1 (lacking) to 5 (superior), no students selected an answer higher than 3.

As well, in the comments, 1 student felt that this issue would be fixed by the new 2+2 curriculum that is being implemented in the College of Medicine. 1 other student felt that “Pharmacology should be taught by physicians that use those drugs everyday, not by research pharmacologists”.

We asked students if they felt they have been adequately prepared for residency in terms of clinical skills/reasoning. We received a fairly positive response on this question. On a scale from 1 (no) to 5 (yes), most students selected a 3 or higher.

In the comments section, 1 student “felt that we needed to be taught in a more general approach to form differentials. We also need more imaging knowledge”. Another student commented that “being able to write medication orders would have helped my learning a lot”.

We asked students if they felt like they had been adequately prepared for the LMCC compared to their peers at other schools. On a scale from 1 (no) to 5 (yes), most students selected a 3 or lower.

When students were asked if they felt that preparing for the NBME’s helped in preparing for the LMCC, we received a mostly positive response. On a scale from 1 (no) to 5 (yes), most students selected a 3 or higher.

In addition, 3 comments were left that all leaned towards the NBME’s being helpful for the LMCC. However, they also stated that the NBME’s would be better if they were Canadian.

When we asked students if they felt that academic half-days were useful in preparing for the LMCC, we received a mostly negative response. On a scale from 1 (no) to 5 (yes), most students selected a 3 or lower.

We also asked students if they felt that they were given the resources and preparation necessary to be successful in the CaRMS match. 90.9% of the students selected yes, while 9.1% (1 student) selected no. It should also be noted that this survey was filled out before students found out their CaRMS match results.

Lastly, we asked students what they think the college could provide in the future to better prepare students for CaRMS. 72.7% of students felt that time off to work on applications would be of great benefit. As well, guidance on CV and personal letters was supported by 45% of students each. 27.3% felt that they would have benefitted from more interview prep, and another 27.3% felt that they did receive an adequate amount of appropriate resources.

In the comments, students echoed the need for time off to work on applications, as well as giving the students the choice in when to take that time (as is done for holidays). They also mentioned that students would benefit from earlier career planning. They suggested as early as first or second year as specialties are becoming increasingly competitive.

Discussion

The purpose of this survey was to identify areas in which the SMSS can better advocate for our clerkship students in the future. While we did find things that can be improved on, it is also important to note that the college is constantly working to improve the curriculum and improve the experience for our JURSI’s. If future projects do arise from the findings of this report, they should be discussed with the college to see if the issue is being dealt with or has been brought to their attention.

It has been the goal of the college to ensure that every JURSI student has their own locker in the JURSI locker room. As you saw from the survey this was not the case. We are pleased to know that this issue has since been dealt with, and there are now a full 120 lockers in the JURSI locker room at RUH, so every student can have their own. This has not seemed to be an issue in Regina.

It seems that a sizeable amount of students have been having issues with preceptors keeping them late. For example, students being kept late post-call or on off-call days; and then being scolded for speaking up. This may be an issue the SMSS, alongside the wellness committee, could bring up to the college and see if there is anyone enforcing when students should be going home. As well, if these incidents seem to be isolated to certain rotations, maybe we should be addressing the faculty of these rotations directly. There will always be times when students may want to stay late to show their interest to preceptors for a certain rotation; but this should be seen as voluntary and at the will of the student, not required by the preceptor. Independent study time is important, and the later a student stays, the more independent study time they lose.

According to the survey, learner mistreatment still seems to be an issue. One thing that should either be reviewed or better explained to the students is what mistreatment is, what is considered as mistreatment, what is allowed, and what is not. Once this is done, students should be able to differentiate between

mistreatment and other minor incidents that may not be. Although, they should still be encouraged to report incidents if they feel they are significant. As well, incident reports should be relatively quick and easy, as the clerkship students are very busy and will often dismiss these events for the sake of saving time for other things. Also, students need to be ensured that a system is in place to maintain anonymity of these reports and to minimize repercussions from staff. Staff should be explained to the point of understanding why what they did was wrong to minimize antagonistic emotions towards the student.

While away from home on rotations or electives, a significant amount of students have reported difficulty with feelings of isolation. This is something that the wellness committee and possibly the Office of Student and Resident Affairs should be made aware about. We can see if we currently have any services to offer these students while they’re away from home, or if something needs to be put in place.

In reference to planning electives, most students felt that the college had underserved them. This is something that should likely be presented to students early on in year 3, when they will start applying for electives. Students need to be given strategies and understanding as to why it is important to do a certain number of electives in certain specialties, where they should be doing their electives, etc. As well, students should also receive a presentation on how to use the AFMC (Association of Faculties of Medicine of Canada) student portal for visiting electives. Previously, students have had no introduction on how to use this portal, so students would greatly benefit from this. These should be discussed with the Career Development and Mentoring office. As well, some students have mentioned that they would have benefitted from career planning earlier on in their medical career. Students that end up wanting some of the more competitive specialties may wind up behind because they didn’t plan for this earlier on in their medical school. This is something that should also be discussed with the Career Development and Mentoring office. All of this being said, some changes have already occurred and clerkship students believe it will help. The new 2+2 curriculum that has been implemented by the College of Medicine sees the JURSI’s completing all of their core rotations in 3rd year, before starting electives in 4th year. The majority of clerkship students believe that this will help the 3rd years be more informed for planning electives in 4th year.

The majority of students did report finding increased difficulty participating in SMSS, student groups, and other student-run events while in JURSI. However, this may not be such an issue because once in JURSI, these are things that typically decrease in priority as time is often better spent on other things such as studying and developing clinical skills. In understanding these groups/events may still be important to students, they will likely have to understand that you won’t be able to make them all the time.

Academic half-days seem to be another issue among JURSI students. The majority of students seem to be frustrated with these days. Currently, all students are required to attend academic half-days, which are run for the entire class at the same time every week. Currently, if students are not present, they are subject to penalties. These half-days are an issue because students are all on different rotations throughout the year. This makes the half-days relatively useless for the majority of students who aren’t on a rotation that deals with the specific topic that is being presented on. When a student is on a specific rotation, it makes more sense for them to study topics related to that rotation, as they will be writing an exam at the end of it. In addition, this survey found that the majority of students didn’t find academic half-days helpful in preparing for the LMCC. Since it is obviously not possible to coordinate half-days to be relevant to all students on different rotations, a possible solution would be to have the academic half-days be coordinated by each individual rotation to serve all year 3 and year 4 students that are on that rotation for that block. As well, to allow for some flexibility for students so they can have some independent study time or to attend health appointments, students could be required to attend 4/6 half-day sessions throughout a block. This could also assist with the argument for students who don’t learn as well in a lecture setting, and would benefit more from independent study time. This is a great source of frustration for JURSI students, and it would be a worthwhile endeavor to start a conversation with UGME staff for a possible solution to this issue.

Students also reported issues of receiving their call schedules past the required amount of notice specified in the syllabus. While students understand that their schedules are very busy and will be comprised mostly of school, they have to be able to take care of themselves, which includes health appointments. Students have made these appointments but then found they needed to cancel because they’ve received a schedule late. This is something that should be brought up to the UGME and hopefully dealt with. Based on the comments we received, it seems that the majority of this issue is coming from the internal medicine block.

As far as curriculum prior to clerkship, students felt that they were not adequately educated in certain areas by the time they got to clerkship. These areas include clinical microbiology, pharmacology, radiology, procedural skills, simulations, dictations, and how to do a consult. With the change in the curriculum to the new 2+2, pharmacology has become a lot better taught as it is coordinated with the system that is being taught at the time. Microbiology is something that still seems to be an issue, as even with new curriculum, most microbiology teaching is squished into the 1st semester of year 1. There is currently a push to get more radiology involved in the curriculum, and I believe some students have already started working on this. Students seem to love procedural skills along with the simulation labs and the fantastic teaching they get while there. While we are exposed to some procedural skills and simulations, it seems that students would like to see them incorporated further into our curriculum. Student group skills nights (ex. Emergency Interest Group skills nights) seem to provide a lot of the procedural skills and simulations that our students do. Dictations and how-to-do a consult are

two things that could hopefully be included in the “Success in Medical School” course that is part of orientation at the start of clerkship (if they are not already).

Students have also had issues with their being too many learners on the floor at one time, making teaching difficult. Unfortunately, this might just be the reality of medical school in Saskatchewan. When the college expanded to 400 students, the number of learners increased without a real increase in infrastructure. This is something that the college has been working to correct over the years.

The majority of students seem to be satisfied with their preparation for residency in terms of clinical skills and reasoning. However, the majority of students also felt they had not been adequately prepared for the LMCC. This will likely improve with the oncoming of the 2+2 curriculum. Towards the end of year 4, students will take part in a capstone course to help them prepare for the LMCC examination. In addition to this, the NBME’s have shown to be a valuable tool for students in helping to prepare for the LMCC’s. However, this exam is being phased out in favor of Canadian departmental exams that will be developed over the next few years. This is because of the difficulties encountered on this exam by Canadian medical students (i.e. American units).

In regards to CaRMS, the majority of students did feel that they had been given the appropriate amount of resources and preparation to be successful in the match. However, this survey was filled out before they received their responses, and we had a higher number of people going unmatched this year compared to other years. So whether they actually did receive enough resources and preparation time may be up for questioning. The students did feel there are some things that could be done to further assist them in being successful with CaRMS. The most popular idea was receiving time off to work on their applications, along with further assistance on CV’s and personal letters. Some students also mentioned that interview preparation would be helpful. The office of Career Development and Mentoring has been doing some work with providing presentations on these topics. While these presentations are useful, students maybe looking for some more hands-on help with some of these aspects of their applications. There may be an opportunity for the SMSS to get involved and work with the Career Development and Mentoring office to develop more appropriate assistance for the JURSI’s. As well, the SMSS, could advocate for some time off for students to work on their CaRMS applications.

Conclusion

As you can see, there is lots of opportunity for the SMSS to get involved in advocating for our clerkship students. The best part about getting involved in some of these issues is you are potentially making a difference that you will see and benefit from one day when you are in JURSI. This is your opportunity to create change that could make your life a whole lot easier down the line.

I’d like to thank the following people who I consulted throughout the project:

o Jessica Suchorab (Year 3 Class Rep)o Maple Liu (Year 3 Class Rep)o Kristin Black (Year 4 Class Rep)o Mowad Benguzzi (Year 4 Class Rep)o Sarah Stewart (Year 4 Class Rep)o Larissa Padayachee (Past SMSS President)o Lena Xiao (Past SMSS President)o Krista Trinder (Research Coordinator)o Dr. Schaana Van De Kamp (Year 2 Chair)o Dr. Meredith McKague (Assistant Dean, Academic)