To the Editor:
We wish to share our responses to three recent articles1–3 in Academic Medicine that discussed longitudinal clerkships in light of our own experience with such a clerkship. Each year since 1971, the University of Minnesota's Rural Physician Associate Program (RPAP) has educated 35 to 40 third-year students in a nine-month longitudinal rural clerkship. They experience continuity with a primary preceptor, health care team, and patient population. An organizing principle is to follow the course of a patient's care in his or her primary care physician's panel, learning from primary and specialty clinicians.
In their Academic Medicine article, Ogur and Hirsh1 noted in their analysis of students' narratives a broader understanding of all aspects of illness: the patient's experience, the physician's professional roles, and a systems approach to care. In our research on the RPAP clerkship, we found similar themes, with students describing a deep connection with patients.4 However, they did not report being challenged by difficulties in establishing appropriate professional boundaries. Perhaps this is because the RPAP model does not create a specific patient panel for students; rather, they join the health care team.
Lyss-Lerman et al2 discussed the importance of distinguishing workplace learning from school: “Workplace learning occurs when new knowledge is integrated with everyday activities, under the guidance of a coach, and supported by formal didactics.” We agree: In RPAP, students are immersed in the rural medical workplace and comment on trusting, coaching relationships with members of the health care team that allow for progressive learning throughout nine months.4
Finally, Hemmer comments that “it may be shortsighted to focus only on altering education to encourage primary care careers when it is the practice environment that should be the focus.”3 We agree with his view of the practice environment, but we think that “altering education” via solid longitudinal clerkships should also be a focus. For example, RPAP students are successfully taught and coached by community physicians and university faculty. To date, 82% of over 1,175 graduates chose primary care specialties, and 68% selected family medicine.5 Because the medical school has committed resources to this longitudinal program for 39 years, RPAP has successfully achieved its mission to educate future rural primary care providers.
Kathleen Dwyer Brooks, MD, MBA, MPA
Director, Rural Physician Associate Program, assistant professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota; firstname.lastname@example.org.
Gwen Wagstrom Halaas, MD, MBA
Associate dean for academic and faculty affairs, associate professor, Family and Community Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, North Dakota.
Therese Zink, MD, MPH
Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota.
1 Ogur B, Hirsh D. Learning through longitudinal patient care-narratives from the Harvard Medical School–Cambridge Integrated Clerkship. Acad Med. 2009;84:844–850.
2 Lyss-Lerman P, Teherani A, Aagard E, Loeser H, Cooke M, Harper G. What training is needed in the fourth year of medical school? Views of residency program directors. Acad Med. 2009;84:823–829.
3 Hemmer P. Longitudinal, integrated clerkship education: Is different better? Acad Med. 2009;84:822.
4 Zink T, Halaas GW, Finstad D, Brooks KD. The Rural Physician Associate Program: The value of immersion learning for third-year medical students. J Rural Health. 2008;4:353–359.
5 Halaas GW, Zink T, Finstad D, Bolin K, Center B. Recruitment and retention of rural physicians: Outcomes from the Rural Physician Associate Program of Minnesota. J Rural Health. 2008;4:345–352.