Third-Year Curriculum Overview

At the start of third year, all students participate in the two-week Transition to Clerkships Course (T2C2) course that provides support and skills in moving toward a clinical workplace teaching environment.

Third-year students then have an educational experience as clerkships in the core areas of medicine, surgery, family medicine, pediatrics, obstetrics-gynecology, psychiatry, neurology, and emergency medicine at ambulatory clinics and hospitals in Inland Southern California. They also have the opportunity to take three 2-week electives and participate in a 2-week community-based experience course. Several curricular threads may continue into year 3 and 4.

At the end of year 3, students present a capstone LACE health systems science project and have their clinical skills assessed as part of the California Clinical Performance Examination (CPX). Students take USMLE Step 2CK at the end of third year or beginning of fourth year.

Block Schedule

Third Year Roles and Responsibilities

Third-year medical students serve as members of the health care team and share responsibility for patients’ well-being. Students provide patient care in a structured environment under the direct supervision of an attending physician or resident. Students often function as caregivers of patients presenting with undifferentiated medical complaints. Each patient that students encounter will receive a directed evaluation in a timely fashion by faculty and/or residents.

Physicians must successfully combine the personal qualities of compassion and commitment (duty) with an ever-evolving knowledge base to complement sharpened academic and clinical skills (expertise). The M.D. degree confers great responsibility and implies that graduates who have earned it can function with some independence in the care of patients. Clerkships provide students with an intense opportunity to improve their current fund of knowledge, basic history-taking and diagnostic skills, and to apply these to multiple situations and settings. Although observing staff physicians and house officers at work is beneficial, experiential learning is more effective. For students, most clinical situations will be new, and it is understandable to feel uncertain. During the clerkship rotations, students find that having a willingness to challenge themselves with new experiences will be a vital aspect of their education. This is a new and more participatory learning process for students to develop their skills as a physician in training.

Medical students must know their own team’s patients in necessary detail and follow these patients as if they were totally responsible for them. Students with supervision should play a proactive role in patient care. They should not remain a bystander or simply report facts. During clerkships, students must make a transition from beyond the role of a “reporter” to demonstrating some evidence of beginning to function as a reasonable “interpreter.” Students should demonstrate an understanding of the medical conditions affecting their patients which is the best way to show their faculty and residents that they are learning. Working with other medical students, interns, residents, and skilled staff physicians can be challenging but is an important process for students’ professional growth as physicians in training. Patients and medical team members expect students to be available and actively thinking all the time. 

Courses, Clerkships and Electives

Transition to Clerkships Course (T2C2)

This initial two-week course introduces students to clerkships, including onboarding, safety, tips for success, and policies and procedures. Students will be introduced to the clinical workplace, interprofessional roles and relationships, and common third-year student tasks. This course also explores professional identity growth and approaches to maintaining well-being.

Internal Medicine

The internal medicine clerkship is an eight-week rotation designed to immerse the students in the specialty of internal medicine. Major emphasis is placed on using pathophysiology of disease and other concepts introduced during the first two years of medical school in the clinical setting, as well as conducting a hypothesis-driven history and physical examination. The great majority of the clerkship is spent in the inpatient setting, with the rest in outpatient or specialty services. 

All the clinical sites are important resources for the Inland Empire and at the same time referral centers for the wider region. Exposure to diverse pathologies and patient populations is offered at these clinical partners. Students work closely with the residents and faculty, participate in all educational activities sponsored by the school’s Graduate Medical Education (GME) partners, such as morning reports, noon conferences, and grand rounds. Additionally, student specific lectures or other educational activities are organized by the clerkship or site faculty. 

Surgery

The eight-week surgery clerkship is structured to give students a rich exposure to general surgery practice in academic as well as community surgical settings. Students are an integral part of the surgical teams with attending faculty, residents, and mid-level providers.

Students learn and acquire clinical skills in all phases of surgical patient care (pre-operative, intra-operative and post-operative). In the pre-operative phase, students assess surgical patients by taking history and physical for a wide variety of surgical pathologies, including acute abdomen, surgical oncology, and biliary disease. Students also learn pre-operative cardiac and pulmonary risk factors for surgery. In the intraoperative care, students scrub and assist in wide variety of operations, including laparoscopic and open surgery. The intra-operative care is an excellent opportunity for students to acquire basic surgical skills such as knot tying and skin closure. Students’ understanding of surgical anatomy during the operation is also part of this phase. Patient safety in the operating room is also taught by faculty, such as sterile techniques, time out, and decreasing fire risk in the operating room. In post-operative teaching phase, students learn common post-operative complications, such as wound infection, post-op deep venous thrombosis and its prophylaxis.

Didactic conferences and bedside teaching are also conducted regularly during the rotation. Examples are morbidity/mortality weekly meetings, journal club, and grand rounds. Simulation lab teaching for basic skills of knot tying and skin closure is also conducted.

Psychiatry

The four-week psychiatry clerkship consists of two weeks in inpatient service and two weeks in outpatient service. Students will be exposed to a variety of mental disorders ranging from milder cases to individuals who suffer from severe mental illnesses. Students will be instructed in the diagnosis and management of major syndromes. Each student will have a broad experience in better understanding the treatment of a patient utilizing the psychobiosocial model that not only focuses on pharmacology, but also utilizes other therapeutic modalities.

Students also participate in didactics by psychiatry faculty, ranging from treatment with different therapeutic modalities including therapy and psychopharmacology, as well as an understanding of diagnosing challenging mental illnesses. In addition, each student is assigned to a preceptor who oversees their experience and monitors the development of their educational and professional skills during the clerkship experience. The student evaluation is based upon the shelf exam at the end of the rotation as well as an evaluation completed by each student’s preceptor.

Neurology

The neurology clerkship is a two-week rotation which consists of one week of inpatient neurology and one week of outpatient neurology. Third-year medical students will evaluate patients in both settings under the supervision of neurology faculty and residents.

Medical students will be exposed to various neurological conditions during this hybrid inpatient and outpatient clinical experience. They will take history, examine patients, and generate a discussion, a differential diagnosis, and a plan on each of their patients. They will present their cases to the supervising faculty and/or residents and will write up at least two of these history and physical exams (H&P) as a documentation exercise. They will additionally observe clinical neurological evaluations, encounters, and procedures performed by other clinical providers.

Medical students will also participate in the clinical learning activity called “Residents as Teachers,” a group activity with a resident being the teacher under the supervision of neurology faculty. This exercise involves discussion of clinical neurological vignettes or seeing a patient.

Students will have one educational day per week free from clinical duties dedicated for them to read and research different neurological topics, and to prepare and deliver a required presentation. Presentations cover innovations of a neurological topic which they will select from a list. Additionally, they will attend a series of neurological didactics and conferences.

During the neurology clinical rotation, third-year medical students will learn and exercise the clinical skills of neurological-history taking, pertinent to the chief complaint and will learn to perform a neurological examination including the components of mental status exam, cranial nerve examination, motor and sensory examinations, and gait and cerebellar examinations. They will be able to recognize and analyze the key elements in the neurological history and exam, recognize the objective findings, practice and learn how to localize the neurological problem at hand, and generate a thoughtful assessment and differential diagnosis with a corresponding appropriate plan of management. In addition to expanding the neurological knowledge and clinical neurologic skills, this rotation will help the medical students build an understanding of the connection between neurological manifestations and systemic disease.

Pediatrics

Pediatrics is a six-week clerkship that introduces medical students to wholistic and patient-centered care of children in both ambulatory and inpatient settings. During the outpatient rotation, students learn about normal growth and development, preventive care and child health maintenance, examination and care of the newborn, and evaluation of sick children. During the inpatient rotation, students are exposed to the care of pediatric patients ranging from the neonatal period through adolescence. Students work closely with the house staff. They are expected to do complete histories and physicals and to follow and document the progress of patients. They are given opportunities to present patients on attending rounds and preceptor rounds.

Over the course of the clerkship, a series of core lectures and case-based learning sessions are given to students covering growth and development, examination of the pediatric patient, and management of commonly encountered pediatric problems. Students participate in team presentations addressing pediatric health disparities, disability, and chronic medical conditions. Daily teaching conferences for medical students and house staff are scheduled at each affiliated pediatric teaching site.

At the end of the rotation, students will have acquired the skills necessary to perform culturally sensitive, effective, age-oriented interviews and physical examinations on newborns, children, and adolescents from diverse ethnic, social, and racial backgrounds. They will interpret clinical information to form an intelligent differential diagnosis and plan for patient management. In addition, students will recognize common pediatric complaints and have an approach for treatment and develop an understanding of children’s and families’ perspectives of health care experiences through observation, inquiry, and reflection.

Obstetrics and Gynecology

The obstetrics and gynecology clerkship is a six-week clinical rotation that introduces medical students to patient-centered, culturally sensitive care of pregnant (obstetric) patients, non-pregnant patients with gynecologic conditions, and patients requiring preventative healthcare specific to obstetrics and gynecology. Medical students will see and care for patients in the outpatient clinic, labor and delivery, and gynecologic operating room. Clinical sites include UCR Health Silver Oaks Clinic/Riverside Community Hospital, Riverside University Health System, and Kaiser Permanente.

During the outpatient rotation, students learn about obstetric and gynecologic care across the reproductive lifespan, which may include the care of:

• Patients who are pregnant (routine and high-risk)
• Patients with gynecologic cancer
• Patients with infertility
• Patients with incontinence and prolapse
• Patients who require transgender care
• Patients who need routine preventive care

In the outpatient clinic, medical students collect and communicate a clinical history from the patient to the preceptor and perform supervised breast and pelvic examinations. Students may also participate in office procedures. While in the labor and delivery unit, students follow patients in the various stages of labor and participate in both vaginal deliveries and c-sections. In the gynecologic operating room, students prepare adequately for the surgeries of the day, understand the principles of sterile technique, and may participate in various intraoperative tasks, such as speculum placement, foley catheter insertion, and suturing.

Over the course of the clerkship, students attend and participate in weekly didactic lectures covering a variety of gynecologic and obstetric topics. Students also prepare a required topic summary on an ob/gyn topic of their choice to prepare for their final subject examination. 

At the end of the rotation, medical students will have acquired the skills necessary to perform culturally sensitive and trauma-informed interviews and physical examinations on both obstetric and gynecologic patients. They will be able to interpret clinical information to form a reasonable differential diagnosis and plan for patient management. In addition, students will recognize when patients require referral to an obstetrician or gynecologist.

Family Medicine

The family medicine clerkship is an introduction to the outpatient primary care medicine. Students care for patients in every stage of life from pregnancy, infancy, and childhood through adult and senior groups. Medical students see patients for routine health maintenance, management of chronic medical conditions, care of acutely urgent issues, and everything in between. Students will interact with people from a wide variety of communities and learn to approach their clinical issues utilizing the biopsychosocial model – all in the outpatient office setting. There is no category of individual patient or clinical situation that does not fall into the spectrum of family medicine. Additionally, students gain an appreciation for two of the hallmarks of the family medicine specialty: the broad variety of clinical presentations and diagnosis, and the ability to provide continuity and multi-generational care.

For four weeks, students will be welcomed into a local outpatient clinic. They will see the see the same variety of patients that attendings and residents treat.  

There are no inpatient responsibilities in the third-year Family Medicine Clerkship. One afternoon a week, students have protected time to come together as a group for lectures and active learning sessions. This time is set aside to discuss common topics in family medicine, share experiences in the clinic, and explore issues related to healthcare disparities, social determinants of health, and the delivery of healthcare in the community. In summary, medical students have the opportunity to live the vast breadth of clinical and social experience that is family medicine.

Emergency Medicine

The UCR School of Medicine is among a few schools offering emergency medicine as a core clerkship for third-year medical students. This two-week clerkship places students in one of several surrounding emergency departments where students get to experience patient care in the acute setting. This clerkship will involve direct patient care and supervised procedures and can be very intense but has been known to be among one of the most rewarding clerkships of the third-year experience.

Longitudinal Ambulatory Care Experience 3 (LACE 3)

The mission of the Longitudinal Ambulatory Care Experience (LACE) is to develop innovative community-based physician leaders and advocates for the Inland Empire. LACE 3 is the culmination of the three-year longitudinal clerkship, with weekly ambulatory sessions focused on applied clinical reasoning and professional identity formation. Students also complete their Practice Improvement Projects and share their health care impact at the annual Quality Improvement Conference at the School of Medicine. 

MS3 Electives

Elective experiences in the third year offer students a wide variety of two-week clinical rotations where students can explore and begin to narrow down their specialty of interest. Students can choose from electives in nearly every field and can even submit a new elective subject to approval from the elective director. The electives are chosen by a lottery system and are subject to availability and capacity.

Community-based Experience (CBE)

The community-based experience (CBE) is a unique rotation for medical students. The goal of CBE is to help students understand the context and community where they care for patients in the Inland Empire. CBE is a two-week rotation offering a multidisciplinary approach for the students to engage with the local community. The two weeks will be comprised of visiting two different CBE sites, chosen by a lottery system, OSCEs focusing on cultural competency, reflections/presentations, and health equity social justice and anti-racism modules.

Clinical Teaching Sites 

Third-year medical students train within a broad network of community hospitals and regional medical centers. These include the public safety net hospitals in Riverside County and San Bernardino County, private general acute care medical centers, community hospitals, a non-profit integrated health plan, two behavioral health centers, a Veterans Administration facility, and a state-operated forensic psychiatric hospital. This ensures that students will have educational experiences with the diverse patient populations of the Inland Southern California region.

Third-year students also continue with their preceptors in the Longitudinal Ambulatory Care Experience (LACE 3). Preceptors include physicians in such primary care settings as community clinics, multi-specialty practice groups, and medical center-based outpatient clinics.

Selected inpatient training affiliates include:

• Riverside Community Hospital, offering a variety of specialty resources including a Comprehensive Stroke Center and Level I Trauma Center
• Riverside University Health System (RUHS) Medical Center, a 439-bed facility with more than 60 hospital-based primary care and specialty care clinics
• Kaiser Permanente medical centers in Riverside, Fontana, Ontario, Moreno Valley, and Anaheim
• Eisenhower Medical Center, a 463-bed hospital that is part of not-for-profit Eisenhower Health system in the Coachella Valley
• Pacific Grove Hospital, a Riverside-based adult treatment center with services for psychiatric illnesses, substance use disorders, and co-occurring disorders.
• Patton State Hospital, a 1,500-bed hospital providing treatment to forensically and civilly committed patients
• St. Bernardine Medical Center, a 342-bed acute care, nonprofit hospital in San Bernardino
• Corona Regional Medical Center, a 238-bed hospital network including a 160-bed acute care hospital and 78-bed rehabilitation campus

Students are expected to travel to all clinically affiliated UCR SOM clerkship sites as assigned. Students rotating on required third-year clerkships in Palm Springs and the Coachella Valley are provided housing during their training at those sites.

Clerkship Requisites

Formative Feedback to Students 

Faculty and residents involved with medical student education are expected to provide timely feedback to medical students regarding their clinical and academic performance. By definition, "formative" assessment is feedback designed to help students improve their performance and is not to be used to determine students’ grades or to influence decisions about academic progress or promotions. Toward the midpoint of each clinical clerkship, every UCR third-year medical student is scheduled for a one-to-one meeting with the clerkship director or designated faculty member for a mid-rotation feedback discussion. 

Required Clinical Encounter (RCE) Logs

All students are required to document patient encounters, diagnosis, and procedures using an online logging system. This mandatory requirement enables students to standardize their clinical experiences at every clinical site within a clerkship. The clerkship faculty review the RCE logs with each student at the mid-clerkship feedback session to assure that clinical expectations are being met.

Observed Clinical Encounter (OCE)

The educational objective of a required formal OCE in every clerkship is for faculty to directly observe and gather information on students’ clinical performances in history taking, physical exam, and communication skills with patients in workplace settings. Another important purpose of the OCE is to provide formative feedback to students for performance improvements and professional growth.

Clerkship Grading 

Grading in all third-year clerkships is comprised of the same three components with the same weighting: knowledge (35% of the final grade), clinical performance (45% of the final grade) and professionalism (20% of the final grade). Each clerkship determines the appropriate assessment methods for each of the three components. For clerkships an NBME shelf exam assesses the knowledge component.

Students may receive an Honors grade for exceptional work, High Pass for above average work and Pass for average work in third year clerkships, the third year of LACE, and third-year electives. The Community-Based Learning Experience (CBE) is not graded. Students are also provided a written summative assessment of their clinical performance on all clerkships.

Objective Structured Clinical Examinations (OSCEs) in Third Year

Students will be required to perform two comprehensive formative Objective Structured Clinical Examinations (OSCE) during the fall and spring of the academic year. These exams are designed to test clinical skill performance and competence in areas such as history taking, physical examination, communication and interpersonal skills, differential diagnosis, and work-up. The purpose of the formative examinations is to provide skills assessment and feedback to students in preparation for the end of year Clinical Performance Exam (CPX).

Both fall and spring OSCEs consist of four patient encounters followed by patient note writing exercises. Although scoring will not affect clerkship grades, students will be provided with a color-coded performance indicator as follows:

• Red = Total OSCE score < 70%
• Yellow= Total OSCE score 70-80%
• Green= Total OSCE score > 80%

Those in Red are highly recommended to meet with a faculty mentor to review UCR School of Medicine Clinical Skills Standards and their examination performance. Those in Yellow are cautioned to review the UCR SOM Clinical Skills Standards and may consider meeting with a faculty mentor to review their examination. Those in Green are on track to pass the end of the year CPX.

The CPX is designed by a consortium of clinicians and medical educators from 10 California medical schools to assess clinical skills essential to the practice of medicine regardless of specialty. More than 1,000 students take this exam each year. During the exam, students will see eight patients with a broad range of ambulatory problems. Similar to the formative OSCE, students will be expected to communicate their thinking and preliminary plans to the patient. Students also complete interstation exercises or note writing focused on clinical reasoning for each encounter.

The exam is designed to be taken at the end of third year. All students must pass the CPX before graduation. Students who do not achieve a passing score on the CPX will be notified. Students will be required to complete the following:

• Meeting with a faculty mentor and participating in a clinical skills workshop.
• Take and pass the CPX Retest exam.

By completing the workshop and the CPX Retest, students will successfully complete the CPX requirement and will have the same language in their MSPE as students who pass on the first attempt.