GraysAnatomyWhat was your first clinical clerkship rotation?

Oddly, I started my third year with a sub-internship rotation on the Burn/Plastics service as my first rotation. Not sure how that happened… I managed my own patients like a 4th year student, did lots of wound care, and even got to harvest a few skin grafts. It was trial by fire.

In a recent JAMA article, 3rd year medical students who started their clinical experiences in an Internal Medicine rotation overall did better on overall clerkship grades, when compared those who started their rotations on the Ob/Gyn, Psychiatry, or Family Medicine service.

These 3rd year medical students were spread across four distinct sites at the University of Illinois (Chicago, Peoria, Rockford, Urbana). An analysis of covariance was used to test for differences between groups. In this case, differences in the first clerkship rotation were compared with respect to:

  • NBME shelf exam scores (score range 0-100)
  • Student clinical performance ratings (score range 12-30)
  • Overall 3rd year clerkship grades (score range 12-30)
  • USMLE Step 2 exam scores


Interestingly, students who began their 3rd year clerkships with Internal Medicine fared better on the NBME exams (p<0.001) and clerkship grades (p=0.02) during their entire 3rd year.

Specifically, they performed better than students who began their rotations with such specialties, such as Ob/Gyn, Psychiatry, and Family Medicine. Clinical performance ratings and USMLE Step 2 scores, however, were not associated with the the student’s first clinical clerkship. 

It seems that the Internal Medicine rotation provides a crucial foundation in preparing for other clerkships. It is the best first clerkship for students just starting their clinical rotations. 

Hmm, I wonder…

There has been a lot of talk about significantly reorganizing in the U.S. medical school curriculum. Much hype has focused on incorporating more clinical experiences as early as the 1st year of medical school. This study seems to suggest that students should all start with Internal Medicine as their first clinical experience. This, however, is logistically impossible because of limited space on the Internal Medicine teams.

This begs the question – Why DO students have to start medical school at the same time each year? Why can’t medical schools enroll students on a rolling basis, such as on the 1st day of each month? This would allow a more equivalent clinical clerkship experience, because students can now follow the same sequence of clerkships. Everyone could start with Internal Medicine.

Kies SM, Roth V, & Rowland M (2010). Association of third-year medical students’ first clerkship with overall clerkship performance and examination scores. JAMA : the journal of the American Medical Association, 304 (11), 1220-6 PMID: 20841536.


Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD