TurtleScaredsmDo you remember the sheer terror you felt, when you first started your medical school clinical rotations? Your first two years were probably spent in classrooms and small-group labs discussing anatomy, pharmacology, pathology, etc.

Then BAM! You are thrown into the deep end of the pool. You are now on a clinical team of medical professionals taking care of actual patients!

Some students fare better than others during this abrupt transition period. This commentary in Academic Medicine provides a framework to help students adapt to this change, by understanding adult learning literature. Specifically, the authors review the concept of Kolb’s learning cycle.


Kolb initially proposed that learning occurs in a 4-stage cycle. This consists of:

  1. Concrete Experience (experiencing an event)
  2. Reflective Observation (reflection on that concrete experience)
  3. Abstract Conceptualization (generation of new approach or style based on reflection)
  4. Active Experimentation (test the new approach or style in reality)

The authors of this article propose a 5-stage modified Kolb cycle to adapt to the new challenges of the clinical years of medical school:

1. Preparing for the Clinical Setting

  • As a student, identify what your roles and responsibilities are on the team. The clerkship director should tell you this, but if not, seek out the answer. What should your presentations be like for new and established patients? Do you write notes in the chart, and if so, what is the format preferred?
  • Remember to do no harm. As a student, be sure not to give definitive answers to patients or families if you are not sure of the answers. Tell them that you will find out the answer. Also, do not perform procedures with which you are unfamiliar. Let the resident or attending know that you are uncomfortable with the new procedure and would like to observe at this time.

2. Experiencing the Clinical Setting

  • Keep a log of patient encounters, framed within goals and objectives in the medical school curriculum. Such objectives might include: communication with a consultant, dealing with a difficult patient, practicing cost-effective medicine when deciding on prescribing discharge medications.
  • Learning should be driven by the student. Read more about conditions or symptoms from your patient encounters. For me personally, I retain information more when it’s contextually based.
  • Share what you have learned by teaching your fellow team members. Teaching reinforces what you’ve learned.
  • Move beyond “reporter” status. Medical students are traditionally perceived as data gatherers. Go one step further and think about a broad differential diagnosis list, based on your gathered data, without prompting from your resident or attending.
  • Build collaborative relationships with your team members. In team-based clinical work, it is crucial to understand the importance of collaboration. Unit secretaries, mid-level providers, nurses, and other professionals in the health care system are all part of the greater team.
  • Set a high professionalism standard. Sometimes students may witness unprofessional behavior. Think about how you would have handled the scenario differently, so that you don’t fall into that trap in the future. Emulate those who exhibit humanistic behavior towards their patients and colleagues.
  • Develop habits that promote mental health and physical and social well-being.

3. Reflecting on Experience

  • A critical component in the “learning cycle” is the reflective piece. For self-reflection to improve your learning, seek out frequent feedback on how you are performing from residents and faculty. Be specific in what you are seeking feedback on — “Can you tell me how I did in taking this patient’s history?” or “Any feedback about my venipuncture procedure?”
  • During your reflection of your clerkship experiences, think about what you like and don’t like about that specialty. Start developing a pros/cons list of factors which will play into your decision-making about selecting a career choice. Clearly, the specialty of Emergency Medicine is the best, but I suppose I’ll let you come to that decision yourself.

4 and 5. Conceptualizing and Testing New Approaches

  • Based on self-reflection, think of how you might improve upon yourself or what you are doing. This might be how you approach a difficult patient, how you ask sensitive questions, troubleshooting a procedure, or present your differential diagnosis list.
  • Test your new approaches.
  • Repeat as new experiences arise.

Greenberg L, & Blatt B (2010). Perspective: successfully negotiating the clerkship years of medical school: a guide for medical students, implications for residents and faculty. Academic medicine : journal of the Association of American Medical Colleges, 85 (4), 706-9 PMID: 20354392



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 https://t.co/50EapJORCa Bio: https://t.co/7v7cgJqNEn
Michelle Lin, MD