Longitudinal, integrated clerkship education has been receiving increased attention in the past few years as an innovation that can “fix” what is perceived to be broken about medical education and engender in students and teachers a newfound sense of commitment.1–3 We should ensure students’ sense of belonging, commitment, and ownership of patients during medical school to prepare them for their next developmental step. But is longitudinal clerkship education the best way to do it?
This issue of Academic Medicine provides an opportunity to review what is known about longitudinal clerkship education. Although not the first such program, the integrated clerkship program at Harvard Medical School is frequently cited.4 In this program, eight selected volunteer students worked with handpicked faculty known to be outstanding teachers and whose time, effort, and resources were supported by the institution.4 Early data showed that the eight volunteer students did not perform any worse than students in the “usual care” clerkship model in terms of traditional academic measures. Ogur and Hirsh5 report a positive attitudinal impact of the clerkship in this issue of Academic Medicine through affecting stories from the cohort of 16 students in the program thus far. However, are we to believe that such stories of the sense of belonging and involvement with patients are unique to longitudinal models and absent among students in traditional clerkship models?
The costs, financial and otherwise, for the shift to a longitudinal curriculum have not been well detailed in these articles, nor do we know the longer-term outcomes (e.g., career choice, residency performance, practice satisfaction).6 Furthermore, it is a daunting challenge to expand such a longitudinal curriculum to an entire medical school class, notwithstanding efforts to increase class size and add new medical schools and the ongoing competition for teachers among medical schools. Certainly, not every student would get to work with the most gifted, senior teachers—there simply aren’t enough to go around even in current models—and thus, would any preliminary gains cited about student attitudes be evident with this larger group of “lesser” teachers? In the pilot studies, the teachers’ time for hosting a student was financially supported, but this would be nearly impossible for an entire class of students. Without being able to offer compensation for the required extra commitment, could we recruit enough teachers for year-round teaching? Further, teaching would necessarily have to extend beyond a single institution to multiple teaching sites in both academic and community-based settings. The task for clerkship directors of simultaneously monitoring an integrated, longitudinal clerkship program for an entire class across multiple sites would be momentous.
Today’s predominant clerkship model with single clerkships for specified periods of time allows students to be immersed within a discipline, able to focus their efforts through deliberate practice while working with multiple content experts simultaneously or sequentially. In addition, it is a model that is more grounded in the reality of current career practice than is the multidisciplinary model that has students simultaneously performing multiple practices—a model that is inherently student-centered and, ironically, one that more fully embraces apprenticeship than does the current model (for which it is criticized).
Implicit in the discussions about longitudinal clerkship models is that by showing students longitudinal, relationship-centered care, we can influence them to embrace primary care as a career choice. However, there remains one inescapable fact about the clinical education of medical students in the United States, no matter the model employed. It is, and will be for the foreseeable future, embedded in an environment that values procedures over personal relationships, it rewards doing rather than thinking, and it seems well designed to allow the E-ROAD (Emergency Medicine, Radiology, Ophthalmology, Anesthesiology, Dermatology) to e-rode principal care career choices. Such forces have a powerful role in shaping student and teacher views (and career choices), and, frankly, it would be naïve to believe that the “hidden curriculum,” system dysfunction, or demands on teachers for clinical productivity over teaching will not be formidable barriers to wider implementation of the longitudinal clerkship model beyond a few select students. 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. Culture will always trump strategy.
The authors of this issue’s reports of longitudinal clerkship education should be commended for trying to determine measures of “success,” and they offer important lessons about helping students become professionals. However, excitement must be tempered by a reasoned recognition that long-term benefits or consequences of longitudinal clerkships are unknown, and, just as in clinical research and patient care, we must be concerned about the broad application of the results of preliminary studies.
Paul Hemmer, MD, MPH
Dr. Hemmer is professor and vice-chair for education, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland.
1 Hirsh DA, Ogur B, Thibault GE, Cox M. “Continuity” as an organizing principle for clinical education reform. N Engl J Med. 2007;22356:858–866.
2 Irby DM. Educational continuity in clinical clerkships. N Engl J Med. 2007;356:856–857.
3 Whitcomb ME. The April issue: Required reading. Acad Med. 2007;82:319–320.
4 Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School–Cambridge integrated clerkship: An innovative model of clinical education. Acad Med. 2007;82:397–404.
5 Ogur B, Hirsh D. Learning through longitudinal patient care—Narratives from the Harvard Medical School–Cambridge integrated clerkship. Acad Med. 2009;84:844–850.
6 Norris TE, Schaad DC, DeWitt D, Ogur B, Hunt DD; Members of the Consortium 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.