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A Radical Proposal for an Integrated Junior–Senior-Year Clerkship

Hays, Richard PhD, MD; Harding, Alexander MBBS, MEd; Alston, Sebastian MD

doi: 10.1097/ACM.0b013e3181b17d56
Letters to the Editor

Head of school, Keele University School of Medicine, Keele, Newcastle-under-Lyme, United Kingdom; ( (Hays)

Sub-dean, Peninsula Medical School, Exeter, United Kingdom. (Harding)

Associate dean, Florida State University College of Medicine, Tallahassee, Florida. (Alston)

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To the Editor:

Medical education is under pressure to produce more graduates to meet health care and workforce needs, but current models of training may be too expensive and too long to achieve these aims. A viable alternative may be to redesign medical education processes to produce well-trained graduates faster and at lower cost by borrowing business concepts from other industries where quality and price controls have produced innovation.1

With this concept in mind, we, as members of a clinical reform group at a recent Harvard–Macy program, propose a model that extends current thinking: an intensive, longitudinal, and integrated 18-month clinical clerkship, spanning junior and senior clinical clerkships, with a unidirectional sequence of blocks that reflect mastery of progressively more complex clinical roles rather than of specific specialties. For example, students would commence by consolidating clinical skills with real patients and finish in practice immersions, combining knowledge, skills, and attitudes to manage patients at close to graduate level. Rather than hoping that random service routines bring relevant patients to medical students, the clinical education office would allocate students to patients who match curriculum objectives, drawing from all specialties in primary, secondary, and tertiary care. Each patient would be the focus of intensive learning and feedback, involving faculty released from routine clinical service to concentrate on teaching. Frequent and intensive longitudinal assessment of students would ensure that competencies were achieved by the completion of each block.2 As the clerkship progressed, there would be increased individual monitoring, problem solving, and flexibility for teachers and learners, and time allocated to remediate deficiencies. New medical graduates could be released every two months, decreasing the service impact problems of commencing each year with all new graduates at the same time.

While longitudinal integrated models already exist,3,4 this one goes further by realigning learning opportunities and resources to support the intensive education process—a difficult task, as education and clinical service budgets and practices are entwined. The model also challenges many aspects of accepted medical education practice, but it may provoke debate that facilitates further innovation and piloting.

Richard Hays, PhD, MD

Head of school, Keele University School of Medicine, Keele, Newcastle-under-Lyme, United Kingdom; (

Alexander Harding, MBBS, MEd

Sub-dean, Peninsula Medical School, Exeter, United Kingdom.

Sebastian Alston, MD

Associate dean, Florida State University College of Medicine, Tallahassee, Florida.

The other members of the clinical reform group: Vesna Degoricija, PhD, MD; Mark Flomenbaum, PhD, MD; Mary Beth Gordon, MD; Myra Hurt, PhD; and Roger Strasser, MBBS, MCISc.

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1 Armstrong EG, Mackey M, Spear SJ. Medical education as a process management problem. Acad Med. 2004;79:721–728.
2 Prescott-Clements L, van der Vleuten CP, Schuwirth LW, Hirst Y, Rennie JS. Evidence for validity within workplace assessment: The Longitudinal Evaluation of Performance (LEP). Med Educ. 2008;42:488–495.
3 Bell SK, Krupat E, Fazio SB, Roberts DH, Schwartzstein RM. Longitudinal pedagogy: A successful response to the fragmentation of the third-year medical student clerkship experience. Acad Med. 2008;83:467–475.
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.
© 2009 Association of American Medical Colleges