Extra Practice for Transition to Application Phase (xTAP): A Clinical Refresher for MD-PhD and Leave-of-Absence Students Reentering Medical School

by N. Loren Oh, University of North Carolina at Chapel Hill School of Medicine, and Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill; Kelly L. Smith, MD*; Kimberley R. Nichols, MD*, Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill

* Indicates co-senior author



MD-PhD students and leave of absence (LOA) students remove themselves from formal medical training to pursue research, other professional development, or fulfillment of personal needs and goals. This leave of absence can last for multiple years, especially for PhD studies, with little formal clinical training during this period. Transitioning back to medical school, therefore, can be stressful,1,2 with feelings of inadequacy compared to peers.3 Struggles around this transition can translate into lower performance on metrics used to grade clinical students.1,4,5 Transition courses or reimmersion programs seem to mitigate the adverse effects on the medical school performance of students who have taken an extended leave from medical school training.4,6 Bolstered by evidence for improved clinical performance with transition courses, we implemented a transition course at the University of North Carolina School of Medicine for MD-PhD students and LOA students. Our aim was to determine how a transition course would affect students’ comfort levels with their clinical skills prior to reentering medical school. 



We implemented a 3-day transition course that reintroduced clinical skills to MD-PhD and LOA students. This course started with an introductory Objective Structured Clinical Examination (OSCE) at the stimulation center. Students then had (1) a half-day session that reviewed the history, (2) a half-day session that reviewed and practiced the physical exam, and (3) a half-day session on giving oral presentations and writing notes. On the final day, students participated in several OSCEs, giving oral presentations on the patients. Given the COVID-19 pandemic, our transition course in March 2021 took place virtually. In June 2021, students completed an in-person transition course with the necessary precautions (eg, wearing masks, social distancing).


To assess the transition course, students completed a presurvey and postsurvey where we quantified comfort level with history and physical exam using a 4-point scale. We also included open-ended responses for students to explain their choices of comfort levels. To help finalize the survey for data collection, we implemented two rounds of data collection with pilot surveys for the transition courses in February 2020 and June 2020. This study was considered exempt human subjects research by the University of North Carolina at Chapel Hill Institutional Review Board.



We conducted two iterations of the transition course in February 2021 and June 2021. A total of 21 students participated, with 12 students in February 2021 and nine students in June 2021. Of those 21 students, eight were MD-PhD students, and 13 were LOA students. We received 19 completed presurveys for a response rate of 90.5% and 16 completed postsurveys for a response rate of 76.2%.


The transition course increased students’ comfort levels with the history and physical exam (Table 1). Compared to an average of 1.5 on the presurvey, postsurveys showed an average of 2.3 in history-taking skills, with more students at the “comfortable” and “very comfortable” level. Regarding the physical exam, compared to an average of 1.2 in presurveys, postsurveys averaged 1.8, with more students in the “comfortable” and “very comfortable” level. For both history and physical exam, students cited that the review and practice from the course was the primary reason for their comfort levels on the postsurvey.

Table 1: Pre- and Postsurvey Results in Comfort Level of History and Physical Exam




n (persons)





Mean comfort level



Comfort levels


     Not comfortable



     Somewhat comfortable








     Very comfortable





Physical Exam


Mean comfort level





Comfort levels


     Not comfortable



     Somewhat comfortable










     Very comfortable



Note: 4-point scale constructed as 0 “Not comfortable,” 1 “Somewhat comfortable,” 2 “Comfortable,” and 3 “Very comfortable”


Our results suggest that the transition course was effective in increasing the comfort levels of students in their clinical skills, with higher average scores and a distribution of more students indicating “comfortable” or “very comfortable” after the course. For future iterations, we plan to include a half day on the wards, with students working with faculty preceptors to see patients and a series of clinical review sessions on differential diagnoses for common chief complaints.



  1. Dyrbye LN, Rohren C, Tiegs R. An MD-PhD re-entry curriculum. Med Educ. 2004;38(5):548-549. doi:10.1111/j.1365-2929.2004.01854.x
  2. Surmon L, Bialocerkowski A, Hu W. Perceptions of preparedness for the first medical clerkship: a systematic review and synthesis. BMC Med Educ. 2016;16(1):89. doi:10.1186/s12909-016-0615-3
  3. Chakraverty D, Jeffe DB, Tai RH. Transition Experiences in MD-PhD Programs. CBE Life Sci Educ. 2018;17(3):ar41. doi:10.1187/cbe.17-08-0187
  4. Bills JL, Davidson M, Dermody TS. Effectiveness of a clinical intervention for MD/PhD students re-entering medical school. Teach Learn Med. 2013;25(1):77-83. doi:10.1080/10401334.2012.741539
  5. Goldberg C, Insel PA. Preparing MD-PhD students for clinical rotations: navigating the interface between PhD and MD training. Acad Med. 2013;88(6):745-747. doi:10.1097/ACM.0b013e31828ffeeb
  6. Swartz TH, Lin JJ. A clinical refresher course for medical scientist trainees. Med Teach. 2014;36(6):475-479. doi:10.3109/0142159X.2014.886767

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