Letters to the Editor
We certainly agree with Dwyer Brooks and her colleagues about the importance of longitudinal clerkships and applaud the long history of longitudinal clinical education of the Minnesota Rural Physician Associate Program (RPAP). There are several questions, however, that are interesting to consider. First, why do the RPAP students not talk about feeling challenged by issues of professional boundaries, while the students in our longitudinal clerkship definitely do? Do they not have the challenges because of differences in patient selection or because of different faculty expectations of students' involvement? Our students' patients are selected from among the most ill and complex in their preceptors' panels, and preceptors expect students to develop strong therapeutic alliances with their patients over time.
Second, and perhaps even more interesting, is the question: Is it better for students to feel challenged or not? If these challenges represent the development of a sense of responsibility toward the patient, is it better for them to be postponed until residency or to remain under the surface during student clinical rotations? We believe it is critical, as the literature suggests, to “unmask” the hidden curriculum and make it explicit. To address this need, over the past six years, we have developed orientation and reflective exercises specifically designed to prepare our students for boundary and role challenges,1 and we have measured students' perceptions by surveys. Over this time, our students report decreased perceptions of “having more responsibility than they can comfortably handle,” without leaving them, as many traditional students report, “having less responsibility than they feel they can handle.” We believe these boundary challenges, along with other challenges to their understanding of their emerging roles as physicians, provide students much-needed opportunities for professional and moral development and are best addressed under the supervision of experienced preceptors. Clearly, more research needs to be done to find what is the best educational mix of students' genuine responsibility for patients with supervisors' guidance.
Barbara Ogur, MD
Cofounder and codirector, Harvard Medical School–Cambridge Integrated Clerkship, and associate professor of medicine, Harvard Medical School, Boston, Massachusetts; firstname.lastname@example.org.
David Hirsh, MD
Cofounder and codirector, Harvard Medical School–Cambridge Integrated Clerkship, and instructor in medicine, Harvard Medical School, Boston, Massachusetts.
1 Gaufberg E, Shtasel D, Hirsh D, et al. The Harvard Medical School Cambridge Integrated Clerkship: Challenges of longitudinal integrated training. Clin Teach. 2008;5:78–82.