Norris, Thomas E. MD; Schaad, Douglas C. PhD; DeWitt, Dawn MD, MSc; Ogur, Barbara MD; Hunt, D Daniel MD, MBA; members of the Consortium of Longitudinal Integrated Clerkships
There is general agreement that the primary goal of undergraduate medical education (UME) is to create a doctor who is broadly educated across the key competencies of medicine and who has the knowledge and clinical skills to enter graduate training.1–3 According to medical education experts, it is difficult to accomplish this goal in traditional fragmented and highly specialized clinical environments in which medical student education competes with resident education, clinical productivity, and research.1,4,5 Additional key goals for UME include preparing graduates who exhibit high levels of professionalism including compassion, altruism, integrity, and a patient-centered orientation.4–6
In almost all medical schools, the traditional “first clinical year” consists of a sequence of short clerkships or rotations through specialty areas that usually include, at a minimum, medicine, obstetrics-gynecology, surgery, psychiatry, family medicine, and pediatrics. These basic clinical clerkships are usually based in tertiary, urban teaching hospitals. Shortened inpatient stays and the shift toward ambulatory diagnosis and management have had a negative impact on student learning, leading medical educators to suggest that the traditional specialty-based clerkship in the traditional hospital setting may not be the optimal way to conduct basic clinical education.7,8 Thus, a new model for the curricular structure of the clinical clerkship is emerging.
This new model, the longitudinal integrated clerkship, built on the concept of continuity, may offer the patient- and learner-centeredness that are sometimes missing in the traditional curricular structure of the clinical clerkship.1 Traditional rotational scheduling, with frequent changes in disciplines, limits patient and teacher continuity and prevents logical educational development. The traditional curricular structure requires students to rotate to a new clinical clerkship, often in a different hospital, every six to eight weeks. Continuity-based, clinical medical education requires that the student stay in one place, with one set of faculty members and one group of patients, for an extended period of time. Such continuity also allows the implementation of a developmentally progressive curriculum: a rationally progressive organization of learning, with the ordering of educational tasks in sequentially increasing complexity, and a focus on the individual pace and learning styles of the student by experienced clinician-educators. To provide for the medical students’ needs for clinically diverse patient-care experiences, integration of multiple clinical services into the continuity experience is both expedient and educationally desirable. The model of a longitudinal integrated clerkship is one way of achieving continuity-based education.
An example of how a learner-centered, continuity-based, longitudinal integrated clerkship might work with a developmentally progressive curriculum is as follows:
During the first several weeks of a six-month or longer longitudinal integrated clerkship, the student is assigned to evaluate patients who have simple medical problems that are not superimposed on one or more chronic conditions. By the end of the six month (or longer) clerkship, with mentoring from an experienced clinician-educator, a student’s capability of managing complexity has increased to the point that evaluating complex patients with multiple comorbidities is feasible and nonthreatening.
Although this type of clerkship is relatively uncommon, several examples have been described in the medical education literature.9–17 Considering the relatively new concept of “continuity” as an organizing principle for clinical education, we sought to answer the following research questions in this study:
* What are the characteristics of the existing integrated clerkships?
* What educational experience have they had to date?
* Has the “continuity” principle, in combination with an integrated clerkship experience, been successful?
The Integrated Clerkship Workshop
In August 2006, the new Northern Ontario School of Medicine (NOSM), whose entire first class was scheduled to complete a yearlong, integrated clerkship in August 2008, convened a meeting in Thunder Bay, Ontario, aimed at sharing experiences gained from longitudinal integrated clinical clerkships. The purpose of the gathering was to inform NOSM leadership about this educational approach, prior to implementation of longitudinal integrated clerkships as their primary clinical education modality. The Integrated Clerkship Workshop was designed to bring together the directors of programs that were known to the NOSM leadership as sites using longitudinal integrated clerkships. The following schools with longitudinal integrated clerkships sent a total of 11 representatives to the meeting: the University of Minnesota Medical School (UMMS), the University of British Columbia Faculty of Medicine, Harvard Medical School (HMS), the University of Washington School of Medicine (UWSOM), the Sanford School of Medicine of the University of South Dakota, and the University of Wollongong Graduate School of Medicine. During the meeting and with follow-up e-mails, a more complete list of schools known to be using longitudinal integrated clerkships was developed. The Integrated Clerkship Workshop participants were enthusiastic about continued information sharing and began planning the creation of a consortium.
The Consortium of Longitudinal Integrated Clerkships
Representatives from many of the institutions that participated in the Integrated Clerkship Workshop formed the Consortium of Longitudinal Integrated Clerkships with plans for ongoing collaboration and research. The consortium is open to individuals from schools that have or are considering creating integrated clinical clerkship experiences. List 1 provides the individuals and the institutions who served on consortium at the time this study was written. At a November 2007 meeting in Cambridge, Massachusetts, the consortium proposed that a longitudinal integrated clerkship is characterized by being the central element of clinical education whereby medical students (1) participate in the comprehensive care of patients over time, (2) participate in continuing learning relationships with these patients’ clinicians, and (3) meet the majority of the year’s core clinical competencies, across multiple disciplines simultaneously, through these experiences. The student may need to log all clinical experiences to ensure that all core competencies are met. Some members of the consortium felt that an additional characteristic is the opportunity to develop a connection between the student and the clerkship host community.
During the 2007 meeting in Cambridge, the consortium developed a set of proposed survey questions designed to address the research questions. The survey questions were validated by having an educator from each of the 11 medical schools represented at the NOSM Integrated Clerkship Workshop respond to the survey. After the schools attending the NOSM workshop responded, the survey was sent to the other institutions where, to our knowledge, longitudinal integrated clerkships were in use. Surveys were sent to 17 total medical schools identified by the NOSM workshop participants as either having or developing longitudinal integrated clerkship programs. The 17 schools included those that participated in the workshop and the first round of the survey. Unresponsive schools were contacted several times with e-mails sent to their program directors. Surveys were sent by e-mail, and responses were collected in free-text. Follow-up discussions regarding survey responses were not held.
We received reports from 16 institutions that were planning, or had implemented, longitudinal, integrated clinical clerkships, with a resulting response rate of 94%. One school did not respond, and one school that did respond (NOSM) had not implemented its program. The information presented here will detail the findings from the 15 responding schools that have implemented their longitudinal integrated clinical clerkship programs.
Elective or required experience
Only 5 out of the 15 institutions implemented their clerkships prior to 2000, though one dates back to 1971 (UMMS). Thirteen of the fifteen institutions that have implemented their programs indicated that their programs were elective experiences for subsets of each class of medical students; only two (13%) survey respondents, the University of Melbourne Faculty of Medicine, Dentistry, and Health Sciences School of Rural Health and the University of Wollongong Graduate School of Medicine, currently require the experience for all students. As NOSM implements its program, all students will be required to participate.
Application and screening process
All schools require the students to be in good academic standing, and seven (47%) schools indicated that a formal application process and interview were required before acceptance. Two (13%) institutions (Flinders University School of Medicine [FUSOM] and UMMS) require a separate screening of student applicants for admissibility to the integrated clerkship. FUSOM screens for students from a rural background, and UMMS screens according to interest in rural and primary care. UMMS and UWSOM also require preparatory inpatient rotations prior to the continuity experience. Three out of the 16 institutions who responded to the survey (FUSOM, UMMS, and UWSOM) have collected data on the origins of their applicants: A majority of students come from rural backgrounds.
Content of an integrated clerkship
Core clinical content areas include medicine, surgery, pediatrics, and obstetrics-gynecology within each of the 15 institutions with active programs. Beyond that core content, each program reported specialty training dependent on the community resources available and the requirements of the medical school. Psychiatry, family medicine, and orthopedics are common to a number of the integrated clerkship experiences.
Duration and location of clerkship
The duration of the longitudinal integrated clerkships surveyed ranges from 5.5 months in one program (UWSOM) to a full calendar year (HMS; Sanford School of Medicine of the University of South Dakota; University of California, San Francisco, School of Medicine), with a median duration of 40 weeks. Seven programs range between 10 and 12 months. Ten schools (66% of those with active programs) report that the majority of the training occurs in ambulatory settings, with only one program (University of Melbourne Faculty of Medicine, Dentistry, and Health Sciences School of Rural Health) reporting that the majority of the training occurs in the inpatient setting. Three (20%) programs are based in urban settings, but the majority (n = 13, 87%) are rural programs. In 10 (66%) programs, students are dispersed in small training sites across a wide geographic area.
Feedback on the integrated clerkship experience
Eleven (73%) of the active programs have collected extensive student feedback on their elective or optional integrated clerkships, which is consistently supportive of the experience. Feedback information from both students and physician faculty has been collected using a variety of methods including individual interviews, focus groups, and written evaluations. One program (University of Melbourne Faculty of Medicine, Dentistry, and Health Sciences School of Rural Health) with a compulsory experience reported that students appreciate the opportunity, and the attending physicians who teach the students after their integrated clinical experience feel that the students are well prepared for graduate training. Two (13%) programs indicated that while faculty members were initially reticent about participation and concerned about the quality of education and efficacy, most participating faculty are now quite enthusiastic and feel much more comfortable in documenting student performance.
None of the respondents documented significant differences in scores on nationally normed exams between students completing the integrated clerkships and those who elected not to participate. However, two of the programs surveyed had collected and reported data on the professional development of students in longitudinal integrated clerkships. These professional development ratings suggest that students are more likely to maintain high levels of humanism and patient-centeredness and are less likely to undergo the “ethical erosion” so often described as a feature of the first clinical year of medical education.18 Analysis of students’ perceptions revealed that they feel themselves to be better prepared for such professional tasks as responding to patients humanistically, reacting to ethical challenges, and dealing with problems that do not have clear answers. In interviews conducted with the students to assess the impact of the programs, they noted their sense of being valued by patients and preceptors as part of the team, acknowledging that their sense of “symbiosis” with the university, the health care system, and the community allowed them to learn “how to mesh their own values with their professional expectations.”19
Longitudinal integrated clinical clerkships are being adopted by an increasing number of medical schools, and more medical students are participating—from a slow start of 2 programs established prior to 1995, there are now 13 programs that have been started or planned since then. Integrated clerkships consistently include at least three of the core clinical areas usually seen in the first clinical year of medical education and are typically 6 to 12 months in length. Students have rated them highly, and initial faculty concerns about educational quality, in at least two programs we surveyed, have abated with continued participation. Faculty concerns about the clinical time it takes to teach in this format have also been addressed.20 Standardized testing of the students who participate in these integrated clerkships has not demonstrated any significant difference from the traditional clerkships. However, data from the Parallel Rural Community Curriculum program at FUSOM in South Australia (1998-2002) reveal that students who experience the longitudinal integrated rural clinical placements are ranked higher in the cohort, at the common end of course assessments following the longitudinal year.21
Logistical management of these programs is complex, requiring frequent communications with medical school administration and site visitations for faculty development and training. Active participation by site faculty in the selection of students reduces the likelihood of a poor learner-environment fit. Although the programs require more logistical support than is needed for traditional on-site rotations at a medical school’s own teaching hospital, they do seem to offer significant benefits that may outweigh the increased complexity and need for support. A significant benefit is the capacity for “the entire learning community to nurture and maintain a spirit of idealism.”1 Our study also suggests that graduates of those programs with a mission to train primary care physicians are more likely to enter primary care practice in a rural setting.22
Longitudinal integrated clerkships represent an innovation in medical education. One of the definitions of innovation is the introduction of a new idea or method, and another definition is change. Consideration of the descriptive terms longitudinal and integrated will clarify the new idea and the change represented by these clerkships. Traditional clinical clerkships in medical school are usually 6 to 12 weeks in duration. The longitudinal clinical clerkships described in this article have a median duration of 40 weeks. Advantages associated with longer clerkships include an increased opportunity for faculty and students to become well acquainted with each other as well as a much greater opportunity for students to participate in the continuity of patient care. The development of a closer relationship between faculty and students increases the likelihood of a mentoring relationship and may provide practical lessons in professionalism. Hirsh and colleagues1 have noted that the continuity-based intergenerational relationships between faculty and students can result in a “learning community [that] nurtures and maintains a spirit of idealism—idealism that will surely be translated into enhanced learning, greater patient satisfaction, and more efficient and effective medical care.” As we see more patients with chronic diseases, an improved student understanding of continuity of care will probably be beneficial.
The integration of disciplines into a student’s clerkship is accomplished in two ways—by using either an integrated schedule of discipline-based experiences or by having the student see the widely diverse types of patients seen in a primary care physician’s workday. In some programs using the multiple disciplines approach, this is accomplished by an integrated weekly program; for example, integration can be achieved by scheduling half-day sessions of medicine clinics, intermixed with inpatient care of pediatric patients and time spent at a community mental health center. In other programs, the mixed practice content of primary care physicians provides the integrated clinical experience. In these situations the primary care physician might see, within the course of a single day, older patients with complex medical problems, infants and children for preventive care, adolescents with behavioral concerns, prenatal patients, and so on. Integrating clinical experiences in at least medicine, surgery, pediatrics, and obstetrics-gynecology, but often also family medicine and psychiatry, has many educational advantages. One of the key advantages is the opportunity to view the complexities of individual patients with multiple medical problems through a holistic, rather than discipline-focused, lens. Other advantages include more opportunities to view the patient through an entire illness process, more teaching from faculty than house officers, and exposure to a wider breadth of clinical problems.18
For students with an interest in primary care, the mixed clinical exposure offers an educational model that is more similar to what they will see in their future practices than the traditional, single-discipline-based model. Many of these programs serve areas that are rural in nature and that have primary care workforce shortages. Thus, the fact that six schools we surveyed provided specialty choice data noting increases in primary care choices among these students is quite significant. As previously mentioned, the two challenges associated with longitudinal integrated clerkships are their logistical complexity and their cost. The challenge of logistic complexity has been addressed by developing procedures and staff to manage the site visits, faculty development, student transportation, and other logistical issues associated with these programs. Reliable data on the cost of these programs are not available. Increased costs may be associated with increased student travel, faculty travel, faculty development, additional staff needed to handle the increased logistical complexity, and other factors. For the schools that have instituted them, the benefits outweigh the challenges, and the schools have absorbed the increased costs.
Given the short history of these longitudinal integrated clerkships, very few programs have long-term outcome data. The existing data come from programs (FUSOM, UMMS, University of North Dakota School of Medicine and Health Sciences) whose missions were to train primary care and rural physicians. These schools have tracked graduate medical education choices and practice sites for graduates of their programs, and these data confirm that a higher proportion of students enter primary care practice and that a higher portion of students enter rural practice. However, these conclusions cannot yet be generalized, given the preselection bias in these programs.
We have described longitudinal integrated clerkships as an innovation in medical education. In a recent editorial in Academic Medicine, Kanter challenges us to provide better descriptions of innovations, including a delineation of the array of potential solutions and details of why a particular solution was selected.23 We sought to find an “array of potential solutions” to the problems of fragmentation and discontinuity in clinical clerkships; however, we were unable to identify reports of alternative approaches, and therefore we were unable to compare them with the longitudinal integrated clerkship. Indeed, in a recent editorial in the New England Journal of Medicine, Irby24 states that “Continuity in medical-student clerkships is becoming a thing of the past”; he notes, “Discontinuity creates an inefficient and disjunctive system that produces great frustration and anxiety in learners and great challenges for teachers.” Irby closes by citing several of the programs that we have described, and he notes that “new models of longitudinal clerkships are required to make clinical education more effective and efficient.”
This study has several limitations. First, this paper describes a convenience sample—although it includes all of the schools with longitudinal integrated clerkships that members of our consortium were aware of, there may be other schools with these programs that were not surveyed. Second, because there has not been a standardized evaluation system in place for these programs, it is difficult to compare experiences between schools. Another drawback of the current collaboration between schools that have established integrated clinical clerkships is that we were unable to gather and compare financial data on the costs of these programs. It has been suggested that longitudinal integrated clerkships may be more expensive than traditional educational curricular formats, but the authors did not have the data to affirm or refute that suggestion. We hypothesize that site visits and distance implementation of curriculum, including faculty development costs and travel costs (if these are more commonly required in sites distant from traditional teaching hospitals) will be significant costs. One must also consider that the placement of the integrated clerkship students in nontraditional sites might result in substantial savings in costs at the traditional teaching hospitals where they previously would have been placed. This is an area that should be studied in the future.
Based on the experiences of the schools that participated in this survey, there are several lessons that may be useful to medical schools considering development of a longitudinal integrated clerkship. Of special note, careful site selection, vigorous faculty development, and close attention to logistical detail must be included in the planning process.
The study reported here adds to the literature by compiling the experiences of a number of medical schools from different countries with longitudinal integrated clerkships. As more medical schools, both in the United States and internationally, adopt innovative longitudinal, continuity-based, integrated clinical clerkships, ongoing evaluation will be required to ascertain whether the suggested benefits endure and whether the suggested added costs (if real) are justified.
It is too early to speculate about the long-term impact of longitudinal integrated clerkships on medical education, but with a substantial number of these programs functioning in medical schools across the world, we have the opportunity to consider the question. Outcome studies are needed to help us understand the role of continuity, integration, and longitudinal clerkships on learners, teachers, patients, communities, and medical schools.
In describing the education of medical students, Sir William Osler stated, “Medicine is learned by the bedside and not in the classroom.” If this is true, then it seems logical that medicine is best learned by the bedside (or in the clinic) with a patient known by the medical student because of repeated encounters and having the student assisted by a teacher with intimate knowledge of the student gained through months of continuity-based interaction.
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