National Survey Reveals How the Internal Medicine Clerkship Survived the Pandemic Era

The core internal medicine clerkship has long been considered the backbone of clinical education in American medical schools, the place where students first learn to think like physicians while managing acutely ill patients on hospital wards. Yet the precise shape of this foundational rotation has been surprisingly opaque. The last comprehensive national portrait of the clerkship’s structure was published in 2017, and much has changed since then. The COVID-19 pandemic forced clerkship directors to dismantle and rebuild their curricula almost overnight, while broader shifts in medical education, including the move of the USMLE Step 1 examination to pass/fail scoring and growing attention to competency-based assessment, have reshaped the environment in which students learn. A new nationally representative survey, published in the Journal of General Internal Medicine, now offers the most complete picture to date of how the internal medicine clerkship is actually organized in the post-pandemic era, and the findings reveal both remarkable stability and quiet erosion at the margins.

The study, led by Ryan Nall of the University of Florida College of Medicine with colleagues from institutions across the country and the Alliance for Academic Internal Medicine, surveyed clerkship directors at U.S. medical schools who hold membership in Clerkship Directors in Internal Medicine, the national organization that represents the faculty responsible for running the core rotation. Of 141 clerkship directors invited to participate, 114 completed the survey, an exceptionally strong response rate of 80.9 percent that lends considerable weight to the results. The cross-sectional instrument collected descriptive data on the fundamental architecture of the clerkship: how long it lasts, which educational models it employs, what students experience on inpatient wards and in outpatient clinics, and how all of this has shifted relative to the period before the pandemic. Because the survey captured a nationally representative sample, the findings can reasonably be generalized to the vast majority of MD-granting schools in the United States.

The headline structural finding is one of continuity. Nearly nine in ten clerkships, 87.7 percent, still use the traditional block model, in which students are immersed in internal medicine for a concentrated period rather than weaving the specialty through an entire academic year as in longitudinal integrated clerkships. The median clerkship length stands at eight weeks, a figure that has remained remarkably consistent across successive national surveys. This persistence is notable given that longitudinal models have attracted substantial enthusiasm in the education literature for more than a decade. Studies of longitudinal integrated clerkships have documented benefits for continuity of relationships between students, preceptors, and patients, and prior surveys of clerkship directors explored the diffusion of these innovations. Yet the block model endures as the dominant format, likely reflecting institutional inertia, scheduling complexity, faculty capacity, and the logistical costs of restructuring an entire clinical curriculum around a minority model.

Beneath that stability, however, the survey documented measurable post-pandemic compression. Compared with the pre-pandemic period, 34.2 percent of clerkships reported an increase in the number of students assigned per rotation, while 19.3 percent reported a decrease in overall clerkship length. These two trends point in the same direction: more learners passing through less protected time. The authors characterize this as clerkship directors navigating increasing complexity in the learning environment, alongside structural, institutional, and system-level challenges. Rising student density on teaching services has been a recurring concern in the hospital medicine literature, where studies of direct-care teaching services have examined how many learners can be accommodated without diluting the educational experience or compromising patient care. A clerkship that simultaneously absorbs more students per rotation and shortens its duration faces a compounding challenge to the apprenticeship model at its core.

Ambulatory training emerged as one of the most striking weak points in the current landscape. Only 49.6 percent of clerkships require an internal medicine-specific ambulatory experience, meaning that roughly half of American medical students complete the core internal medicine rotation without a mandatory outpatient component in the discipline. This is a paradoxical finding for a specialty that defines itself around comprehensive, longitudinal care of adults, and it echoes longstanding critiques that undergraduate medical education underweights chronic disease and outpatient management relative to acute hospital care. The ambulatory half of internal medicine, where hypertension, diabetes, and preventive care are actually managed, remains an optional experience for a substantial share of students. As physician workforce projections raise alarms about the adequacy of the future physician supply and the distribution of generalist physicians, the marginal status of outpatient training within the flagship generalist clerkship is a detail with potentially outsized consequences.

The pandemic’s imprint on teaching methods is also visible in the data, though in a way that suggests partial reversal rather than permanent transformation. A full 92.0 percent of clerkships have returned to in-person didactics since the pandemic, indicating that the wholesale shift to remote learning that defined 2020 and 2021 has largely been unwound for the core rotation’s classroom teaching. This finding aligns with systematic reviews comparing blended and traditional learning in medical education, which have shown that digital formats can match traditional instruction on some outcomes but rarely replicate the tacit learning of the clinical workplace. The rapid return to in-person teaching suggests that clerkship directors, having experimented with virtual didactics under duress, judged face-to-face instruction essential to the clerkship’s mission even as many institutions retain hybrid elements elsewhere in their curricula.

Perhaps the most sobering results concern the challenges clerkship directors themselves identify as most pressing. The most common difficulties reported were ensuring that students receive formative feedback, recruiting enough faculty preceptors, and delivering faculty development. Each of these points to a structural vulnerability in clinical education. Formative feedback, the low-stakes coaching that allows students to correct errors before high-stakes assessment, depends on preceptors having time and skill to observe and critique performance. Preceptor recruitment is strained by the same workforce pressures documented in recent analyses of the physician pipeline, as clinical productivity demands compete with teaching obligations. Faculty development, meanwhile, requires institutional investment in clinicians as educators, an investment that is easy to defer when clinical volumes surge. That these three challenges top the list suggests the clerkship’s most serious problems are not curricular but human: too few trained teachers, with too little time, for a growing cohort of learners.

The survey arrives at a moment of unusual flux in how clinical performance is measured. The transition of USMLE Step 1 to pass/fail scoring has shifted weight toward clerkship evaluations and away from a single numerical score, intensifying scrutiny of assessment practices within rotations. Commentators have described a shadow economy of effort emerging around pass/fail grading, with unintended consequences for how students engage with clinical work, and others have called for rebuilding clerkship assessment around objectivity and equity. Against this backdrop, the survey’s finding that clerkship directors struggle to guarantee formative feedback takes on added significance: if national licensing examinations no longer differentiate students numerically, the quality of day-to-day feedback and evaluation within the clerkship becomes the load-bearing element of the assessment system, and it is precisely that element directors report as most fragile.

There is also a genuinely reassuring thread running through the data. Despite the pressures of increased student numbers, shortened rotations, and strained preceptor pools, the authors report that clerkship directors have maintained stable learner density on rotations and preserved ambulatory training within the clerkship overall. The median eight-week duration and the dominant block structure have held. In other words, the system has bent without breaking. The pandemic prompted clerkship directors to reevaluate their curricula and educational strategies, and the resilience they demonstrated, restoring in-person teaching and holding core structures in place, represents a quiet institutional achievement that rarely makes headlines but directly shapes the competence of every graduating physician who passes through an internal medicine ward.

What the survey ultimately provides is a baseline for the decisions ahead. Medical schools continue to multiply, with recent counts documenting steady growth in MD-granting institutions and enrollment, which will only intensify the competition for teaching patients, teaching beds, and teaching faculty. Workforce analyses published in leading journals warn of mounting challenges to sustaining a robust physician pipeline, making the internal medicine clerkship, the specialty’s principal recruitment and training vehicle, a strategic asset rather than a curricular formality. Whether the field responds by protecting clerkship length, capping learner density, mandating ambulatory experiences, and investing in preceptor development will determine whether the next national survey documents recovery or continued erosion. For now, the picture is clear: the traditional clerkship endures, but the margins are thinning, and the educators who run it know exactly where the strain is greatest.

Subject of Research: National survey of the structure of the internal medicine clerkship in U.S. medical schools

Article Title: Current Landscape of the Internal Medicine Clerkship: A National Survey

Article References: Nall, R., Pincavage, A., Ratcliffe, T. A., Williams, W., Mullick, D. T., Duca, N. S., Kisielewski, M., Eadie, E., Weinstein, A. R., & Lai, C. J. (2026). Current Landscape of the Internal Medicine Clerkship: A National Survey. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10718-7

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10718-7

Keywords: internal medicine, clerkship, medical education, clerkship directors, COVID-19, ambulatory training, block rotation, formative feedback, preceptors, undergraduate medical education, national survey, Journal of General Internal Medicine