Academic Workload and Self-Directed Learning for Courses in the Preclerkship and Post-PCE Curriculum
The HMS curriculum comprises three phases of developmental progression: a preclerkship phase (either in the Pathways or the HST curriculum); the Principal Clinical Experience or PCE (the clerkship year); and the post-PCE phase, which consists of advanced courses, clinical experiences, and other educational opportunities. This policy applies to all courses (both preclerkship and post-PCE); a related but separate workload policy for the clinical clerkships, required subinternships and clinical electives is included below (see Medical Student Workload on Core and Elective Clinical Rotations).
The pedagogy of most preclerkship and post-PCE courses at HMS is based on fundamental interactions between self-directed learning, didactic teaching, critical thinking, and problem solving facilitated by expert faculty. As a matter of educational philosophy, the School emphasizes the promotion of self-directed learning and the recognition of our students as mature adult learners who need to have the latitude to pursue their academic, clinical, research, and personal interests.
- In Pathways, a “flipped-classroom” model predominates in the preclerkship curriculum, where students study preparatory materials in advance, self-assess their readiness, and then participate actively in case-based discussions guided by expert faculty. Courses feature specific self-directed learning exercises, and students therefore need to be provided enough outside time in their weekly schedule to pursue such independent activities. Advanced Integrated Science Courses (AISCs) and Essentials of the Profession II in the post-PCE phase also feature multiple pedagogical elements, including classroom discussions, specialized clinical experiences, and both independent and group projects that require self-directed time outside the in-class sessions.
- In HST, courses emphasize interactive problem-solving based on a quantitative understanding of biological systems, incorporating hands-on laboratories, exploration of the primary scientific literature, and small group interactions highlighting the boundaries of current knowledge while also providing core didactic material. As a central element of this approach to learning medicine, HST students are required to do significant longitudinal research; they therefore require sufficient outside time to pursue this independent work.
The success of learning methods in all of these courses requires not only sufficient time in the classroom with faculty, but also sufficient time in individual preparation, study, and exploration. At the same time, medical student wellness is improved when the amount of time spent in required activities (including both in-class sessions and outside preparation) is not excessive. This policy was developed after careful consideration of 1) these underlying principles; 2) the natural variations in curricular structure that exist throughout each course and across the phases of the curriculum; 3) actual student survey data on time spent on required activities; and 4) benchmark information from peer medical schools.
Several complicating factors are evident in the development of such a policy. First, different students spend different amounts of time completing the same required work outside of the classroom. The actual amount of time spent, even on an average basis, may be different from what was envisioned by the course faculty in designing the work. It may in fact be appropriate for the academic workload to vary from week to week or month to month, depending on scheduling of assessments, for example. Finally, it may be difficult to enforce a maximum limit on time to be spent on outside preparation, since that is completed individually by learners in an unsupervised manner.
Taking all of the above principles and factors into account, the Educational Policy and Curriculum Committee has approved the following policy for academic workload in HMS courses:
- Required educational activities will be designed by the course directors with the explicit intention of allowing for adequate self-directed learning time. In both the Pathways and HST preclerkship curricula and in post-PCE courses such as AISCs, required activities (totaling in-class sessions plus required outside preparation) will be designed so they never exceed 68 hours per week. This time falls well below the guidelines followed by HMS clinical clerkships (80 hours total per week), and the 68-hour-per-week limit represents an absolute maximum rather than a targeted workload.
- Each course will acquire data regarding the actual amount of time spent by students on required work outside of in-class sessions. This may occur through real-time surveys; readiness assessment questions; direct feedback from the medical education student representatives; and/or questions on the end-of-course evaluation.
- These data will be reviewed by each course director as they become available and will be used to guide the assignment of required work in the course, if appropriate.
- The relevant curricular subcommittees will review these data across all courses at least annually, and will implement curriculum phase-wide changes as needed, as part of its continuous quality improvement processes.
- Students will be encouraged to contact course faculty and their society advisors if their own personal workload feels excessive or is not in line with the intended goal of the course directors as outlined above; course directors and curricular subcommittees will review this feedback and may implement changes at any time, including mid-course, above and beyond the usual yearly review.
- Students will be encouraged to maintain self-care and monitor other goals for personal wellness (e.g., getting adequate sleep each night) irrespective of the total amount of hours spent on educational activities.
- This policy will be presented annually to students during their first-year orientation.
Medical Student Workload on Clinical Rotations
Medical student workloads on clinical clerkships in Harvard-affiliated clinical institutions must support students’ learning while maintaining an appropriate level of engagement with the clinical environment. The specific details of these expectations will vary somewhat with the clinical specialty or rotation, but must:
- Ensure that educational priorities outweigh the service needs of the clinical setting;
- Take into account the impact of fatigue on learning; and
- Reinforce the fact that Clinical Experience and Education Work Hours restrictions, like other compliance requirements for physicians, are consistent with the necessity of meeting professional standards.
Clinical Experience and Education Work Hours
The directors of each core clerkship, subinternship and clinical elective determine how best to accomplish the educational goals and objectives for students and, on that basis, design the experience to provide the best opportunity for student learning and to achieve a balance that favors learning over service. While time spent during regular working hours may suffice for most learning experiences, overnight call or participation in early morning work rounds with the medical or surgical team may be necessary to accomplish other clerkship goals (e.g., delivering babies during overnight call in OB/GYN; the unique learning experience a student shares with an on-call intern during overnight call; experience in surgical trauma; review of patients with the team at the beginning of the day, etc.).
Student work hours in Harvard Medical School core and elective clerkships should follow the ACGME standard that limits work hours to not more than 80 hours per week, averaged over a four-week period, inclusive of all in-house call activities, with the following caveats:
- Adequate time for rest and personal activities must be provided. Optimally, this should be a 10-hour time period provided between all daily duty periods and after in-house call.
- Students must have at least 14 hours free of clinical work and education after 24 hours of in-house call.
- The time medical students spend delivering patient care services of marginal or no educational value should be minimized.
- If a student believes that they are being asked to remain on duty beyond the work hour limits, the student should immediately consult with the Clerkship Director and/or the PCE Director.
- Religious holidays* must be respected. Students requesting time off for religious observances must notify supervising faculty in advance and assure appropriate clinical coverage by another student, resident or faculty member. Students may be required to make up any missed academic or clinical work at the discretion of the clerkship director.
Limiting required work hours does not imply that medical students must cease providing essential patient care services at arbitrary cut-off times. Priority must always be given to patient safety and well-being and to avoiding transferring patient care responsibilities to others at inappropriate times in the continuum of care (e.g., during an operative procedure or in the midst of a rapidly evolving clinical event). A tired medical student who is intimately familiar with a sick patient is often better able to provide quality care than is a fully rested medical student who is unfamiliar with the details of the case.
Like residents, however, students are expected to respect and operate within HMS work hour policy limits. Working longer than 80 hours/week leads to fatigue that can both degrade a student’s ability to learn and put patients at risk; therefore, violation of work hour limits represents a lapse in professional responsibility. Residencies do not expect students to take, and actually discourage students from taking, the responsibility of bridging between rotating teams of residents, and students should avoid the temptation to violate work hours in order to do so. Worth reiterating, it is a matter of professionalism and a responsibility to patients for students to monitor their own hours to assure that voluntary violations of work hours limits do not occur.
Adapted from: AAMC Policy Guidance on Graduate Medical Education- Assuring Quality Patient Care and Quality Education and from ACGME's Approach to Limit Resident Duty Hours 12 Months after Implementation.
Monitoring of these guidelines is the responsibility of the Clerkship Director, the PCE Director, and the Dean for Medical Education. The Program in Medical Education surveys Core Clerkship Directors annually regarding the amount of time medical students spend in required activities, including the total number of hours medical students are required to spend in clinical and educational activities during clinical clerkships. PCE Directors and the PCE Executive Committee review duty hours by clerkship at each site quarterly.
Students are also required to respond to a question about work hours in the PCE log (Class of 2018) or the OASIS Requirement Checklists (Class of 2019 and subsequent classes) at the mid-point and the end of each clerkship, as indicated below. Responses will be reviewed by the clerkship director and PCE mentor to insure that students are not exceeding the 80-hour limit and to remedy the situation if the limit is being exceeded. Students who continue to exceed the 80-hour limit will be cited for unprofessional behavior in their clerkship evaluation.
Please follow the guidelines below in responding to the work-hours survey:
During a typical week in this clerkship, do you spend more than 80 hours on duty, physically present at the hospital/clinic?
Response options: Yes or No
Guidelines for calculating work hours during a typical week:
- DO INCLUDE all clinical and academic activities during which you were physically present in the hospital or clinic—hours of scheduled clerkship activities (rounding, seeing patients, completing medical records, ordering and reviewing lab tests, etc.); time spent sleeping in the hospital when you are on-call (but not when you are not on-call); time in scheduled didactic sessions; and time in required longitudinal experiences, including the Primary Care Clerkship, PCE sessions and Patient-Doctor tutorials.
- DO NOT INCLUDE time spent commuting; reading, studying, or preparing academically at home or away from the patient care unit, such as preparing for presentations or conferences and studying for exams; or on hospital premises for activities that are not scheduled as part of your clerkship.
*Harvard University Policy on Religious Holidays (Section 7.01)
In accordance with Massachusetts State law, any student in an educational institution who is unable, because of his/her religious beliefs, to attend classes or to participate in any examination, study, or work requirement on a particular day shall be excused from any such examination, study, or work requirement. The student shall be provided with an opportunity to make up such examination, study or work requirement, which he or she may have missed because of such absence on any particular day, provided that such makeup examination or work does not create an unreasonable burden upon the School. No fees of any kind shall be charged by the institution for making available to the said student such opportunity. No adverse or prejudicial effects shall result to any student because of his/her availing himself or herself of the provisions of this section. See also HMS Student Handbook Section 2.02: Attendance for further details regarding attendance surrounding religious holidays.Last updated 8/1/18