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Time to Trust: Longitudinal Integrated Clerkships and Entrustable Professional Activities

Hirsh, David A. MD; Holmboe, Eric S. MD; ten Cate, Olle PhD

doi: 10.1097/ACM.0000000000000111

Medical education shaped by the learning sciences can better serve medical students, residents, faculty, health care institutions, and patients. With increasing innovation in undergraduate and graduate medical education and more focused attention on educational principles and how people learn, this era of educational transformation offers promise. Principles manifest in “educational continuity” are informing changes in educational structures and venues and are enriching new discourse in educational pedagogy, assessment, and scholarship.

The articles by Myhre and colleagues and Woloschuk and colleagues in this issue, along with mounting evidence preceding these works, should reassure that principle-driven innovation in medical education is not only possible but can be achieved safely. In this commentary, the authors draw from these works and the wider literature on longitudinal integrated educational design. They suggest that the confluences of movements for longitudinal integrated clerkships and entrustable professional activities open new possibilities for other educational and practice advancements in quality and safety.

With the advent of competency-based education, explicit milestones, and improved assessment regimens, overseers will increasingly evaluate students, trainees, and other learners on their ability rather than relying solely on time spent in an activity. The authors suggest that, for such oversight to have the most value, assessors and learners need adequate oversight time, and redesign of educational models will serve this operational imperative. As education leaders are reassessing old medical school and training models, rotational blocks, and other barriers to progress, the authors explore the dynamic interplay between longitudinal integrated learning models and entrustment.

Dr. Hirsh is associate professor in medicine and cofounder and director, Cambridge Integrated Clerkship, Harvard Medical School, Boston, Massachusetts.

Dr. Holmboe is chief medical officer and senior vice president, American Board of Internal Medicine, Philadelphia, Pennsylvania.

Dr. ten Cate is professor of medical education and director, Center for Research and Development of Education, University Medical Center Utrecht, Utrecht, Netherlands.

The authors have informed the journal that they agree that both Dr. Hirsh and Dr. Holmboe completed the intellectual and other work typical of the first author.

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: Dr. Holmboe receives royalties from Mosby-Elsevier for a textbook on assessment and also serves on the boards of the National Board of Medical Examiners and the American Board of Family Medicine. Dr. Hirsh is the cofounder and director of the Cambridge Integrated Clerkship at Harvard Medical School.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Hirsh, Department of Medicine, Macht 4th Floor, Cambridge Health Alliance, 1493 Cambridge St., Cambridge, MA 02139; telephone: (617) 665-3132; fax: (617) 665-3164; e-mail:

© 2014 by the Association of American Medical Colleges