Pharmacy Rotations vs. Medical School Clerkships: What's the Difference?

As a future physician pharmacist, you are probably wondering how your pharmacy rotation experiences compare to the medical school equivalent. This article will teach you how to survive medical school clerkship and contrast them to your pharmacy education experiences. At the end we will tally up the "Wins and Losses" and see which opportunities are better!

When do medical students start clinical rotations?

As you know, medical school takes 4 years to complete and it's traditionally split into a didactic phase and a clinical phase. Students are expected to complete 1.5-2 years of didactic "in-house" coursework along with achieving a passing score on USMLE STEP 1 prior to starting clinical rotations. Now there are exceptions to this rule as some students all allowed to start their clerkships prior to passing Step 1 however, we won't discuss them today. Once this initial phase is complete, students spend 2-2.5 years working with patients in an immersive/hands on environment. In contrast, pharmacy school students only receive 1 singular year of rotations in their last part of pharmacy school. Whether this is better or worse can be left to your interpretation. I personally prefer hands-on opportunities and think its way easier to learn new skills when participating rather than reading about them in a textbook.

Score: Medical School ✅; Pharmacy School ❌; because of the extra time in clinical roles, and less time in the classroom.

How are clinical rotations structured?

Just like pharmacy, there are certain mandatory rotations that need to be completed in order to graduate medical school. Every medical school has slightly different rotation requirements but I have listed my own 3rd year schedule below for your reference.

• 3 Months of Surgery (Inpatient, Preceptorship, Elective)

• 1.5 Months of Family Medicine (Outpatient > Inpatient)

• 1.5 Months of OB/GYN (L&D, Surgical, Outpatient)

• 1.5 Months of Pediatrics (Inpatient = Outpatient)

• 1.5 Months of Psychiatry

• 3 Months of Internal Medicine (Inpatient, Preceptorship, Elective)

Just like pharmacy, most rotations are back to back with one ending on a Friday, and the next starting on the following Monday. One major difference is that 3rd year medical students don't get any off-blocks or time off (outside of University sanctioned holidays - ie. Christmas). Not having time-away from school really drags out the process and contributes to burnout! Your 3rd year of medical school is often referred as the most challenging. This is typically due to your lack of knowledge, long hours, and little time away from rotations!

Keep your head up though, as 4th year is arguably the best year by most accounts due to the easier schedule (post-residency applications) and expanded comfort in clinical scenarios. You are usually expected to complete a Neurology block as well as an Advanced Medicine rotation. The rest is often reserved for Sub-Internships (Sub-I's), Away Rotations, and of course, bogus electives to ride out the last few months of medical school!

Score: Medical School ❌; Pharmacy School ✅; because of the lack of off-blocks and time-away from school.

Shelf Exams:

Contributing to the burnout I just mentioned are the National Clerkship "Shelf" exams which are required to be taken at the conclusion of every rotation. Shelfs are standardized exams created to ensure competency in specialty focused topics across the nation in the setting of highly variable clinical site experiences. These are massive 110 question exams that require large scale preparation over months of time to perform well which unfortunately clashes with your sacred personal time. Another reason 4th year is so much better than 3rd year is the lack of Shelf Exams you need to take (Neurology being one of the only ones)!

To put this in perspective, I'll share my life on surgery clerkship, or lack-thereof. When I was working on the Trauma Surgery Service as my first rotation of 3rd year, I was required to work 12 hour days at a minimum for 6 days a week. For the "mathematicians," that's 72 hours a week minimum. For those who have worked in retail pharmacy know, it's almost a guarantee that the last few hours of your night are filled with straggler customers or those who have a prescription "emergency." The same principal applies in medicine which ultimately results in far longer hours than you desire. Sure there is a "80 hour cap" on hours but that just an average of your hours over a period of a month. So my 95 hour week is ok since I only did 72 hours the past 2 weeks! Ok, I'm not complaining as the stuff we get to do is pretty cool however, finding the motivation to study for the shelf exams after a long shift is almost impossible. Any days off turn into work days as you struggle to catch up on study material.

Contrast this to pharmacy school where your rotations very rarely keep you longer than 8 hours. Additionally, your only challenges you faced outside of your scheduled shift time involved tedious written reflections or rotation requirement paperwork, most of which was reserved for the final week at the site. This isn't to say that pharmacy rotations are easy! In fact, they can be quite hard if you are interested in a competitive pharmacy residency or get stuck with a challenging preceptor. I personally recall working very long shifts at The Cleveland Clinic and with The Johns Hopkins Hospital Pharmacy Teams. Despite these points, most of my pharmacy rotations had me taking very little extra work home and never had anything equivalent to a "Shelf exam."

Score: Medical School ❌; Pharmacy School ✅; because of the lesser load of "take-home" work and absence of tedious Shelf Exams.

Grades:

One upside of sitting for Shelf exams throughout your medical school training is that you are forced to prepare for your USMLE Step 2 Exam that is taken at the end of 3rd year of medical school. This is the most important exam you will take in your training and will determine your competitiveness for residency. As a minor-league procrastinator, I appreciate the oversight as I would be much further behind academically. When I was studying for my NAPLEX, I certainly should have started during rotations but had very little enthusiasm to get started!

I also find it useful that medical school rotations count towards your overall grade in school (or class rank). This may not sound like a major benefit but as an aspiring pharmacist physician we can capitalize on good personalized evaluations. This feature is highly school specific but generally your rotation performance is evaluated on a scale of "Honors, High Satisfactory, Satisfactory, and Insufficient." Whatever numerical value they corelate with is unknown to me, however the fact that they can benefit a student is nice to hear. Those with a Pharmacist education will have a natural leg up when it comes to clinical rotations due to our advanced practice training and comfort with patients. The bar is very low for 3rd year medical students and having just a little pharmaceutical knowledge has been very well received by preceptors. In comparison, my pharmacy rotation grades where pass-fail and were of no consequence to my overall GPA. While this may not matter to me now, it would have helped to have a higher overall GPA to further my post-graduation ambitions.

Score: Medical School ✅; Pharmacy School ❌; because it helps thwart procrastinator tendencies and I believe working hard on rotations should receive recognition.

Hours in the "Office":

I have already alluded to this concept and it probably goes without saying that pharmacy rotations have far better work hours and overall work-life-balance. I mean, I shouldn't complain because this is just an expectation in medicine and many people choose pharmacy because of the attractive work hours.

Score: Medical School ❌; Pharmacy School ✅; because having a life outside of medicine is very important!

Extent of Exposure:

A nice feature about medical school clerkships is that you will receive a very large exposure to different specialties and styles of practice. While this can be achieved in pharmacy (ambulatory practice settings, nuclear pharmacy, fellowship routes, etc.), it still only touches the surface of what is actually going on. Allow me to explain. In just my few months on clerkships I have learned how to perform hands-on skills, utilize diagnostic interpretation, and then make clinical decisions for management in a variety of practice settings. I can interpret an ECG reading, I can analyze fetal contractions with Decelerations, I can throw knots, very poorly single hand tie when closing surgical cases, roughly read CT scans, and confidently analyze X-rays. These features offer a unique educational experience that obviously extends beyond medication specialization.

I've said it before but pharmacy focuses primarily on optimizing medical care (and they do a great job with this) however, not much consideration goes beyond the original provided diagnosis. I know this because I am a pharmacist and I have rarely questioned it myself (ok, I know the clinical pharmacists are screaming internally here but you get my point). Medical training makes you question every diagnosis whereas pharmacy does not. When I see "Hypertension" on the cart, in the back of my head I'm thinking about all the "unicorn" diagnoses that could be hidden (some of which I've actually seen in practice). I'm thinking about the possibility of a pheochromocytoma, Cushing Syndrome, Primary Hyperaldosteronism, Renal Artery Stenosis, Congenital Adrenal Hyperplasia, Geller Syndrome and more!

The main idea is that medical students get to see a whole lot on their rotations including a diversity of medications. One day I may be closing up a gunshot victim case in the OR during a trauma surgery shift, delivering a baby on obstetrics, or hiding in a corner of the hospital interpreting radiographic images. The overall exposure was far wider than my pharmacy rotations and I believe those who take this path would agree!

Score: Medical School ✅; Pharmacy School ❌; because "your practice is molded by experience" and you get a lot of it in medical school.

Overnight Rotations:

I already mentioned overnights but I can say this is rather unique compared to traditional pharmacy rotations. I am sure there are exceptions but most pharmacy students do not have the opportunity to practice overnight. My medical school overnight shifts where long (14 hours kind of "long") but it was very interesting to see how things work with a skeleton crew. More importantly, as a student you are given far more opportunities to get involved if you so choose. The team actually depends on you to get work done and see patients which I think really contributed to my development.

I've had friends who have worked in the hospital pharmacy overnight and also agree that night-shifts every now and then are quite stimulating. Instead of having a full-pharmacy staff to back you up when things get crazy, you are forced to figure out solutions and get things done. This Sink-or-Swim philosophy can actually be a rather prudent way of making someone resourceful (geez I already sound like a hospital administrator). All jokes aside, I think pharmacy students miss-out on this opportunity!

Score: Medical School ✅; Pharmacy School ❌; because nights are cool 😎.

Responsibilities:

Medical students are expected to get involved with patients immediately, write notes on day 1 of a rotation, and apply clinical knowledge off the cuff in every situation. I feel as though we are often tossed into the system and expected to apply the classical "see one, do one, teach one" mantra that medicine is notoriously associated with.

I think this is also a major contrast to pharmacy school rotations which often had a more casual introductory phase. I wasn't expected to consult the medical team with my recommendations on rounds during my first day. Rather, I would gradually work my way up to larger challenges and more involved patient care (medication counseling) as the rotation progressed. I also recognize that this is highly dependent on having a relaxed preceptor which may not be the case for every pharmacy student. However, there is an obvious difference in having to delivery a child on your second day of Labor and Delivery versus completing a medication reconciliation for a few patients on the floor!

You could look at this reality as being favorable in both ways by recognizing that it's a great way to gain experience (similar to my previous argument) or that pharmacy's less aggressive approach helps facilitate a more welcoming experience for newer students. For that I think they both deserve a "thumbs-up."

Score: Medical School ✅; Pharmacy School ✅; because added responsibility can promote development, yet gradual starts can help students develop comfort in the practice setting.

Review:

Medical School Takes Home the Gold!

To wrap things up, many of you are probably wondering "which one is technically harder?" If I haven't made my case already, I think medical school rotations are much harder than pharmacy school rotations. I'm definitely not saying that pharmacy rotations are easy, however the risk of fatigue, academic burnout, and overall expectations are greater on medical school clerkships. Keep in mind, I still hold the position that the first 2 years of didactic medical school curriculum is comparable to pharmacy school! The only difference is having slightly more volume of content in medical school. Not bad for the pharmacy profession in my opinion! We really are a well-trained and proud community of healthcare professionals.

Thanks for reading and comment below if you agree with me, disagree, or have additional questions!

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