Getting Real: Embracing the Conditions of the Third-Year Clerkship and Reimagining the Curriculum to Enable Deliberate Practice.

There are many calls in the literature for changes in how medical students are educated. Although many curricular innovations have been attempted, a look at the theory behind how complex skills are learned provides useful information to guide new curriculum developments. The requirement of deliberate practice as the road map for success in the learning of clinical skills suggests that perhaps the current clinical milieu is not an optimal place for medical students to learn. The idiosyncrasy inherent in the dramatically changed medical landscape of the last 20 years makes it difficult for such practice to occur; the apprentice model of legitimate peripheral participation in a community of practice as it used to exist does no longer. Indeed, current workplace environments are at odds with the needs of medical students. Overwhelming numbers of goals and objectives in existing third-year clerkships serve as wish lists of what students should learn. They should be replaced by a systematic, longitudinal curriculum in which all students can be guaranteed to have encountered the core clinical competencies as defined. Moving the goals and objectives of the current clerkships to a longitudinal, spiral curricular format frees up clinical time in the third year to be used for students to find their future specialty and socialize into medicine. Doing so allows for an opportunity for students to spend extended time in areas of their interest. Moving to such a new curriculum format maximizes and optimizes learning while embracing the reality of current clinical workplace environments.