Preparation for practice. In end-of-year surveys, CIC students felt less well prepared than their peers to practice in the hospital setting, but more prepared to practice in the ambulatory setting. They felt better prepared than their peers in understanding how the health care system works, having the knowledge base necessary to be competent practitioners, knowing their strengths and limitations, dealing with ambiguity, and engaging in self-reflection. They also felt better prepared to understand how the social context affects patient care and to work with patients from diverse backgrounds and at different stages of the life cycle. There were no significant differences in the feelings of the two groups about their ability to practice evidence-based medicine. See Table 3 for specific details about these findings.
Career choice. CIC students’ expectations for future career choices (as expressed in time spent in practice, research, and education) were not significantly different from the comparison students either at the beginning or at the end of the clerkship year. Students’ reports of future career goals revealed no systematic differences from their traditional peers, with most CIC students seeking specialty, academic, and research career paths. CIC students have been successful in matching in the residency programs of their choice, with all students reporting having received their first or second choice of program—the vast majority their first choice.
In its design, the CIC adhered to principles derived from the learning sciences with the goals of improving students’ learning, professional development, and satisfaction.16,17,25–34 The program’s structural pillars support an environment in which continuity of care and supervision drive student learning.11,12 These “continuities” support a highly relational learning model that relies on patient–student, faculty–student, student–student, and student–society relationships to facilitate professional growth.11–16 This educational lattice of effective student engagements has been termed “symbiotic.”35,36 The CIC appears to be both effective in reaching these goals and feasible for more widespread implementation.
Traditional clerkships provide students with limited opportunities to participate in establishing a preliminary diagnosis and following diagnostic and therapeutic plans or to know patients as people or as part of a family or community. Seeing “undifferentiated” patients prior to admission to the hospital and following them after discharge provides just this opportunity. By following patients across care venues, CIC students observe the natural history of illness and the results of therapeutic interventions.
Previous research demonstrates that longitudinal experiences generate rich benefits for learning.17,37 Continuity of care also provides the opportunity for reflection on the primacy of the doctor–patient relationship. It is surely not coincidental that 100% of the CIC students in three successive cohorts reported that they were often or very often able to establish meaningful relationships with their patients, a rate almost twice that of their peers in traditional clerkships. It is likewise noteworthy that CIC students reported significantly more frequently than their peers that they had made a real difference in the health or well-being of patients.
Students in traditional clerkships also have limited opportunities to develop meaningful relationships with faculty preceptors. We intentionally created an educational structure to support a functional “community of practice” wherein students learn by directly comanaging patients with faculty and other members of the interprofessional team.16,28 Students have multiple iterative interactions with experienced practitioners and receive serial, developmentally aligned coaching and assessment.16,17,28,33 Enhanced role modeling and mentoring authenticate the students’ participation.16,26–28,33 We designed the CIC specifically with these considerations in mind. Compared with their peers, CIC students receive far more of their supervision and mentoring from faculty preceptors, and CIC students rate the quality of feedback higher than students in traditional clerkships.
CIC students describe their clerkship experience very differently, characterizing it as more humanizing (even transformational) and less marginalizing than do their peers in more traditional clerkships. Strikingly, these strongly positive perceptions exist in the face of an experience that is described as both more hectic and more stressful than the traditional clerkship. The CIC’s relatively flexible structure requires that students organize their schedules and negotiate more competing duties than peers in traditional clerkships. It is also possible that students’ daily demands feel more “real” and urgent as they attempt to satisfy patients’ expectations of them. In essence, CIC students must be able to organize their learning tasks simultaneously with the immediacy of being real caregivers and colleagues—goals reasonably described as being both satisfying and transformative and hectic and stressful.
CIC students also view themselves as better prepared than their peers in many important elements of professional identity formation: to be truly caring in dealing with patients, to be able to deal with ethical dilemmas, to involve patients and families in decision making, to relate well to a diverse patient population, to relate to people at different stages of the life cycle, and to see how the social context affects patients and their problems.
Although this study does not address the underlying reasons for these differences, it is likely that the central emphases of the CIC on patients’ welfare and on the learning environment are important factors. Although not different at the beginning, by the end of the clerkship CIC students scored higher than their peers on a validated instrument for assessing patient-centeredness. In addition, in terms of faculty role modeling, observation, and support of patient-centered behavior, CIC students felt less exposed to the negative effects of the hidden curriculum than their peers.22–24 Thus, rather than experiencing the “ethical erosion” so typical of traditional clerkships,13,18,38–40 the CIC seems to reinforce students’ humanistic patient-centered values.
Some argue that the lack of discipline-based immersion in longitudinal integrated clerkships could impair knowledge accrual; however, when compared with traditionally trained peers at Harvard Medical School, CIC students perform as well or better on measures of content knowledge and clinical skills. Moreover, the experience seems to strengthen skills critical for lifelong learning and safe and effective clinical practice, as CIC students felt better prepared to be self-reflective, to know their own strengths and limitations, and to deal with ambiguity.
In summary, CIC students are at least as well prepared as, and in several important ways better prepared than, their peers to enter advanced clerkships and electives. At the very least, we believe that CIC students bring with them a richer perspective on the course of illness, more insight into the social determinants of illness and recovery, and an increased commitment to patients that will motivate ongoing learning and patient advocacy.37
The limitations of this study include its small size, relatively short time frame during which formal comparisons could be made, and its testing at a single institution. In addition, even though we found no discernible differences between CIC students and the comparison group at baseline, the potential exists that the study cohort somehow differed on other unmeasured characteristics. In response, we can only emphasize that our results were consistent across multiple cohorts and multiple measures over time. In addition, we note that the CIC is ongoing, now about to begin its ninth year, and has continued to fully meet its programmatic goals.
Another limitation is that reports of beliefs and abilities are not objective assessments of competency and that students’ self-assessments may not ultimately predict their actual behaviors in residency or independent practice. However, it is reassuring that all graduates of the program reported receiving their first or second choice of residency program and that anecdotal reports are highly affirming and have not revealed any problems. Although some published data suggest that students in longitudinal integrated clerkships develop greater retention of content knowledge,1,41 it remains unknown whether graduates of the program sustain the changes described.
In this study, we did not address which features of the CIC most influence students’ development. The longitudinal, integrated design makes it impossible to separate the influences of patients and teachers. Indeed, we believe that both sets of relationships are crucial for appropriate professional identity formation. Independent effects ascribable to the context and nature of the Cambridge Health Alliance, where our students spend the year, might also have an important influence. It is possible that an environment permeated by social advocacy has a seminal influence on professional identify formation. Perhaps so, but if this is the case, these data invite the need to rethink the kinds of environments to which we expose learners.
Longitudinal clerkships with similar features to the CIC have existed worldwide for 40 years, and the number of such programs is growing rapidly.1,42–52 Longitudinal integrated clerkships are succeeding in large tertiary hospitals50–52 and at schools with primary care missions.42–48,51 The model has proved feasible in urban settings1,49–52 and in rural and remote settings.42–48,51 Some institutions have demonstrated that an entire class can participate.48 The model has importantly influenced The Future of Medical Education in Canada: A Collective Vision for MD Education53 and the Carnegie Foundation’s Educating Physicians: A Call for Reform of Medical School and Residency.54 To support the growth of the model and advance scholarship, medical education leaders have formed the International Consortium of Longitudinal Integrated Clerkships, which has met—and grown in size—annually since 2007.43,51
Despite these successes, resistance to more widespread adoption of longitudinal, integrated clerkship models continues. We believe this article begins to fill this gap, if only with short-term outcome metrics. Further study is needed to ascertain whether students’ attitudes and skills are so powerfully ingrained as to be maintained in postgraduate training and beyond. To address this question, we are currently studying graduates of the program, and the initial data look promising.
Another consideration is cost. Given that the CIC relies on faculty educators rather than residents, how financially realistic is this model? At Harvard Medical School, the CIC receives the same per-student reimbursement as more traditional clerkship sites, and the program’s cost is at the lower end of the range described in the literature.55 Nonetheless, it remains to be determined whether faculty-intensive models of this type can support the education of a class of hundreds at schools now relying largely on tertiary care hospitals for clinical training and (subsidized) residents for medical student teaching.
For large classes, students might be apportioned into functional units (e.g., “pods” of 8–12 learners) to improve ease of scheduling while still reaping the benefits of the model: small-group student “learning communities” with close faculty oversight, a developmental approach to curriculum and assessment, and relationship-centered learning.16 Mechanisms to schedule and track longitudinal patients are robust,56 but methods to develop and reward faculty merit more innovation. Nonetheless, even as institutions possess the resources to support this model, ingrained culture may prove to be the greatest hurdle to overcome.
Some have suggested that the model requires highly self-motivated, well-organized student learners and “may not be for everyone.” Naturally, this question invites consideration as to whether the traditional model is “for everyone” or whether any model could be. More important, this critique encourages us to consider what attributes of learners we seek to engage when creating educational structures. In this case, do we not wish for medical students to be highly self-motivated, well organized, and able to integrate complex themes from multiple perspectives in real time?17,34,37
In addition, our experience is that our students receive more direct oversight and guidance than students in the traditional model, and we have been successful in identifying and assisting students who have had learning and other issues that merited identification and assistance. Areas of further study will be to determine which facets of the program make it stressful and hectic and to what degree these impede or facilitate students’ learning and development. Similarly, we have yet to determine which factors most support learning and development and how we might best enhance these features.
In conclusion, we reflect on the century since Abraham Flexner’s review of the medical schools of the United States and Canada. With regard to clinical training of medical students, the basic structure of the CIC reveals nothing more than a return to the first two key principles that Flexner57 espoused:
To sample a school on its clinical side, one makes in the first place straight for its medical clinic, seeking to learn the number of patients available for teaching, the variety of conditions that they illustrate, and the hospital regulations in so far, at least, as they determine (1) continuity of service on the part of the teachers of medicine, (2) the closeness that the student may follow the individual patients….
The need to idealize the training of medical students remains as critical now as it was then. The CIC is a model of medical education deliberately designed to place the patient continuously at the center of the student’s interest and the student and the patient together continuously at the center of the teacher’s interest. Educational structures in which the core student experience derives from following cohorts of patients longitudinally and cooperatively with faculty are feasible and conform well to Hippocratic, Flexnerian, and other sacred traditions of medicine. The model of longitudinal integrated education also closely adheres to core principles described in diverse academic literatures making up the learning sciences. Our data demonstrate that the CIC serves to foster students’ learning, to advance students’ professionalism, to harness the hidden curriculum, and to stem ethical erosion. It may, in fact, transform learners and teachers, the systems in which they work, and, ultimately, the care of their patients.58 Through “educational continuity”11 and meaningful relationships with patients and preceptors, this model may also inspire students’ idealism about the future of the profession.
Acknowledgments: The authors wish to thank the following individuals for their wise teaching and advice, their outstanding work in creating and advancing the CIC, and for inspiration that led to this report: Ronald Arky, MD, Elizabeth Armstrong, PhD, Kirsten Austad, Jeremiah Barondess, MD, Maren Batalden, MD, MPH, Carolyn Bernstein, MD, Jack Burke, Jr, MD, MPH, Jeanette Callahan, MD, Steve Carter, MBA, Allison Cook, EdM, MA, Molly Cooke, MD, Jules Dienstag, MD, Jeffrey Flier, MD, Martha Garcia, MD, Arundhati Ghosh, MD, James Gordon, MD, Wendy Gutterson, MS, Frederic Hafferty, PhD, Kathleen Harney, MD, Carol Hulka, MD, David Irby, PhD, Dennis Keefe, MBA, Robert Kegan, PhD, Judy Klickstein, MS, Kathy Kosinski, MD, David Link, MD, Bridget O’Brien, PhD, Joseph Martin, MD, PhD, Robert Meyer, MD, Stephen Schwaitzberg, MD, Gary Setnick, MD, Kitt Shaffer, MD, PhD, Derri Shtasel, MD, MPH, William Silen, MD, Art Spector, MD, George Thibault, MD, Todd Thompson, MD, Joseph Velletri, Ronald Weintraub, MD, and Michael Whitcomb, MD. Indeed, the authors thank all the students, faculty, and administrators of the CIC. The authors also thank the Cambridge Health Alliance and the Harvard Medical School Academy of Educators for their financial support.
Funding/Support: Association of American Medical Colleges, New York Academy of Medicine, Macy Foundation Grant (#281918) from 2004 to 2006.
Other disclosures: David Hirsh and Barbara Ogur were the cocreators and codirectors of the program at the time of this study. Pieter Cohen and Elizabeth Gaufberg held other leadership roles. David Hirsh, Barbara Ogur, Elizabeth Gaufberg, Pieter Cohen, and David Bor have received honoraria and/or support for travel to discuss the CIC, new models of clinical education, and medical education reform more generally. They have also been teachers in the CIC. Malcolm Cox was the dean of medical education of Harvard Medical School at the time of the initiation of the program and this study.
Ethical approval: The institutional review boards of Harvard Medical School and Cambridge Health Alliance considered this study exempt.
Previous presentations: Some of this material, in a variety of formats, has been presented at medical-school-based conferences, at the Gold Foundation Biennial Meeting in Chicago, Illinois, in 2008, and at the Association of American Medical Colleges annual meeting in Denver, Colorado, in 2011. Some of the preliminary data accompanied the original program description, published in Academic Medicine in 2007.
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