Stevens, Carl D. MD, MPH; Wilkerson, LuAnn EdD; Uijtdehaage, Sebastian PhD
Dr. Stevens is health sciences clinical professor and director of curriculum development, David Geffen School of Medicine, University of California, Los Angeles (UCLA), Los Angeles, California, and director of quality and process improvement, Department of Emergency Medicine, Harbor–UCLA Medical Center, Torrance, California.
Dr. Wilkerson is senior associate dean for medical education, David Geffen School of Medicine, UCLA, Los Angeles, California.
Dr. Uijtdehaage is director of research, Center for Educational Development and Research, David Geffen School of Medicine, UCLA, Los Angeles, California.
Editor’s Note: This is a commentary on Myhre DL, Woloschuk W, Jackson W, McLaughlin K. Academic performance of longitudinal integrated clerkship versus rotation-based clerkship students: a matched-cohort study. Acad Med. 2014;89:292–295; and Woloschuk W, Myhre D, Jackson W, McLaughlin K, Wright B. Comparing the performance in family medicine residencies of graduates from longitudinal integrated clerkships and rotation-based clerkships. Acad Med. 2014;89:296–300.
Funding/Support: None reported.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Correspondence should be addressed to Dr. Stevens, Dean’s Office, Center for Educational Development and Research, David Geffen School of Medicine at UCLA, Box 951722, 60-051 CHS, Los Angeles, CA 90095-1722; telephone: (310) 825-6928; e-mail: CarlStevens@mednet.ucla.edu.
For several years, educators have proposed longitudinal “continuity” clinical experiences as enhancements to existing medical school curriculuma, with some authors even hailing continuity as a new organizing principle for medical education at large.1,2 In this issue of Academic Medicine, educators from the University of Calgary compare the educational outcomes of students in a longitudinal, integrated rural clerkship with classmates in the more traditional rotation-based core clerkship year. They found similar academic performance results during medical school,3 and somewhat higher ratings of overall performance by residency program directors, for those graduates completing the first year of residency training in family medicine.4 As is generally the case, the Calgary longitudinal experience differed from the rotation-based program in several ways beyond simply locating the students at a single geographic site. Among the differences, students in the longitudinal clerkship had a single designated faculty mentor for the duration of their six-month experience. Faculty, staff, and work routines of the various clinical departments in the longitudinal setting likely also differed substantially from the same services and staff in the more traditional academic health center.
The growing literature on integrated, multidisciplinary and “continuity” experiences during the core clinical years raises interesting questions about how these programs compare to more traditional department-based rotations in their effect on educational outcomes and, if important differences do exist, which of the many elements that distinguish a longitudinal continuity experience from department-based rotations have the greatest impact. In a narrative review of studies of continuity clerkships published between 1996 and 2012, Walters and colleagues5 identify six outcomes: academic performance; clinical performance; values and ethics; learning experience qualities; clinical supervision; and impact on career intentions. With the exception of academic performance, which has largely been demonstrated to be equivalent (as demonstrated by Myhre and colleagues3 in this issue), most of these studies have demonstrated positive or improved outcomes favoring continuity. The study by Woloschuk and colleagues4 in this issue is the first to document differences in outcomes beyond graduation—that is, higher performance ratings for graduates of the longitudinal clerkship by residency program directors in family medicine.
Perhaps a statement of the problem being addressed by these innovations offers one path for wading into the growing and varied continuity literature. The core clerkship component remains pivotal in U.S. and Canadian medical schools, transforming bright, motivated basic science students into medical professionals, albeit on the bottom rung of a long, steep training ladder. Over the past several decades, however, several fundamental changes that have taken place in typical academic health centers have created “discontinuity,” disconnecting medical students from faculty, residents, peers, staff, and learning environments for this crucial year of medical education. The changes—largely driven by economic forces in the health care delivery environment—have occurred gradually, but their cumulative effects on students’ core clerkship experience are profound. The managed care revolution that, like a bout of rheumatic fever, gripped the U.S. health care system with dramatic intensity for the entire decade of the 1990s and then faded away,6 left in its wake serious sequellae that are only now becoming fully apparent in their impact on education.
First, prospective payment and other reimbursement models drove average hospital length of stay from nearly 6 to 4.6 days, where it has remained.7 The lost day and a half was often devoted to activities in which medical students on clerkships were intimately involved, such as the preoperative workup of surgical patients, who were admitted the day before surgery and underwent a thorough medical history followed by a head-to-toe physical examination (often consuming more than an hour of both patient and student time), which the resident reviewed before writing preoperative orders. Now, with rare exceptions, surgical patients see their office-based primary care physician for preoperative clearance and come to the hospital on the day of the scheduled procedure. Once admitted, a multidisciplinary team of providers, often following strict, standardized clinical pathway protocols, works to ensure the shortest possible inpatient stay, followed by rapid discharge with additional home health services if needed. Students have trouble breaking into these teams as full participants, and the truncated hospitalizations have squeezed out key learning opportunities for early-stage trainees.
Previously, on services like internal medicine and neurology, patients who were seriously but not critically ill but presented diagnostic challenges—for example, those with a newly detected mass lesion, or evidence of occult or frank bleeding from the respiratory or gastrointestinal tracts—were often hospitalized for diagnosis. Now, strict criteria dictate that such patients receive outpatient workups unless they are demonstrably unstable. Another important student role, the coordination and gathering of diagnostic studies for the team to consider on these complex patients, has been lost to the outpatient setting, where students have less involvement in their care. In effect, society has traded short-term cost savings by reducing hospital stays to the bare minimum for the longer-term costs of a less well-prepared physician workforce.
In a second major change during the 1990s, many clinical faculty members at non-government-sponsored teaching hospitals faced pressure to maximize their volume and intensity of patient visits and procedures, to maintain both their personal incomes as well as hospital and clinic revenues. Equally destructive to education, the penurious reimbursement practices of the 1990s were followed by the “gold rush” of the first decade of this century, when the end of managed care refocused academic health centers as enormous juggernauts of profit from organ transplants, high-end cancer care, and orthopedic and neurosurgery, pushing medical students—the ultimate “cost center”—to the periphery of daily operations of profitable clinical enterprises. Additional regulatory, documentation, and administrative duties lessened or eliminated faculty time previously available for teaching medical students. This difference became most extreme in capitated, provider-at-risk settings, but has persisted after the return to discounted fee-for-service reimbursement, and will likely further intensify under the next generation of health reforms, which once again spread financial risk of caring for populations to providers.
Finally, dramatic reductions in resident duty hours without corresponding decreases in the house staff’s workloads have threatened the essential bond between core clerkship students and the residents on the clinical service, who must now complete their many tasks and responsibilities in stringently enforced shifts. Residents must steal time from their work to teach students, and only the most dedicated and most talented succeed in sharing their reasoning strategies, knowledge, and procedural skills with students. As a result, our students can show up at a clinical training site and risk remaining anonymous outsiders to the daily workings of the clinical team unless they are very outgoing self-starters or are lucky enough to be paired with a resident or faculty member who still incorporates students as full members of the clinical team. Curriculum leaders must take specific steps to minimize this risk.
Until 2010, students at the David Geffen School of Medicine at the University of California, Los Angeles, took their third-year core clerkships at as many as six sites that were dispersed across Los Angeles County. Consequently, by the time students were familiar with the idiosyncrasies of each health system and could effectively participate in health care teams, it was time to move on to the next rotation located elsewhere in Los Angeles. In 2010, we created a continuity experience where students could take several clerkships at one site for up to 24 weeks. They were also paired with one clinical coach who mentored them without grading them through the entire continuity period. We determined the impact of this continuity experience by comparing a range of educational outcomes with historic controls. Contrary to the findings reported here by the University of Calgary, we found that all clerkship subject shelf exam scores improved—some as much as 0.4 standard deviations—as did performance on components of a comprehensive clinical performance examination at the end of the core clerkship year. Moreover, when compared with noncontinuity controls, students reported a stronger sense of ownership of and an ability to more effectively participate in patient care. They felt more skillful in core clinical tasks, such as writing patient notes, conducting aspects of the physical exam, and using the electronic medical record system. They more frequently followed patients longitudinally through entire illness episodes or from primary to specialty care (as documented in patient logs) and reported greater knowledge of health care system parameters and how these features affect patient outcome. As one student summarized in his course evaluation,
It was really nice to start with Ob/Gyn care and literally follow some of the patients’ babies over into my pediatric rotation. I also felt like getting to know the [electronic medical record] system was beneficial in my ability to integrate myself into the team. I really knew how everything worked in the hospital so it was nice to perform like a [subintern].
Having just one clinical coach during the entire continuity experience was seen as beneficial:
Having the flexibility to use the mentor relationship to best suit my needs as a student was extremely helpful. I used the experience more for career development than history and physical exam skills and appreciated the opportunity to do so, as this kind of mentoring is more difficult to achieve in rotations in general.
Continuity experiences represent one strategy for combating the aforementioned trends that together have resulted in many clinical services losing their “receptors” for rotating medical students, producing nameless third-year clerks who have no specific job to do, and who have become peripheral to clinical teams and their daily work. With multiple months at the same site, faculty, residents, and staff begin to know the students by name, and vice versa. Longitudinal, integrated experiences and other continuity initiatives may constitute a strategy for restoring some of the historical learning conditions in both inpatient and clinic-based services that prevailed from Osler and Flexner’s time until the managed care revolution of the 1990s fundamentally disrupted the U.S. health care delivery system. And with the imminent transition to “accountable” care, the stakes and challenges for teachers and learners get even higher. As educators, our duty to the public surely includes pointing out the trade-offs inherent in the evolving delivery and reimbursement systems, and protecting or restoring the time, personal relationships, and attention that transform learners into doctors. An expert physician workforce must remain central to the planning and implementation of delivery system reforms.
1. Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;356:858–866
2. Norris TE, Schaad DC, DeWitt D, Ogur B, Hunt DDConsortium of Longitudinal Integrated Clerkships. . Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med. 2009;84:902–907
3. Myhre DL, Woloschuk W, Jackson W, McLaughlin K. Academic performance of longitudinal integrated clerkship versus rotation-based clerkship students: a matched-cohort study. Acad Med. 2014;2:292–295
4. Woloschuk W, Myhre D, Jackson W, McLaughlin K, Wright B. Comparing the performance in family medicine residencies of graduates from longitudinal integrated clerkships and rotation-based clerkships. Acad Med. 2014;2:296–300
5. Walters L, Greenhill J, Richards J, et al. Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ. 2012;46:1028–1041
6. Robinson JC. The end of managed care. JAMA. 2001;285:2622–2628