The idealized medical system of the 21st century, with the promise of integrated, comprehensive, high-quality, equitable, and affordable care, requires a revised medical curriculum emphasizing a new set of skills.1–3 More than simply the acquisition of biomedical knowledge, today’s medical education must be designed to develop skills needed to coordinate care across a vast, interdependent network; track and improve quality; and practice proactive, patient-centered, value-conscious medicine.4–7 Longitudinal clerkships that emphasize continuity have the potential to address these needs by providing authentic experiences in patient engagement, teamwork, mentorship, and feedback.8–12 Preliminary studies have shown that medical students in longitudinal clerkships can play a meaningful role in clinical care through patient advocacy even in the early stages of training, a concept known as “value-added medical education.”4,8,13–15 These early successes have led medical education experts to call for further study and expansion of the model.5,6,8
Longitudinal clerkships have been implemented in a variety of settings, predominantly with third-year students.16–21 Evidence suggests that they are well received, improve patient centeredness, and mitigate the depersonalization that occurs during traditional clinical clerkships.18,19,22–25 In spite of these proven benefits, longitudinal clerkships currently exist at a minority of U.S. medical schools and usually include only a small percentage of their students because of logistic and financial barriers.26 New models are required in order to expand the benefits of longitudinal patient care education models to a larger population of students. As part of a comprehensive curriculum renewal process, Northwestern University Feinberg School of Medicine piloted a novel longitudinal outpatient clerkship in 2011 called the Education-Centered Medical Home (ECMH). In prior work, we demonstrated that the ECMH model is feasible, as students from all four classes were successfully embedded into primary care environments to provide collaborative care for panels of medically complex patients.27 Early short-term results suggest that this model creates valuable experiences in continuity, peer education, and quality improvement.27,28 Building on the experience of other longitudinal clerkships,29 we hypothesized that the ECMH model may also improve patient centeredness and the overall quality of primary care education in medical school. Additionally, few data exist on patient outcomes when students are incorporated into longitudinal care models. We hypothesized that students may add value to patient care by improving outreach and focusing on prevention and chronic disease control. The aim of this study is to assess the four-year educational and clinical impact of the longitudinal ECMH curriculum by comparing outcomes between graduating students who participated in the ECMH and those who completed a traditional primary care curriculum.
Method
Setting
Northwestern University Feinberg School of Medicine is an urban medical school located in Chicago, Illinois. Students have the majority of their clinical experiences at Northwestern Memorial Hospital, Ann & Robert H. Lurie Children’s Hospital of Chicago, the Rehabilitation Institute of Chicago, and the Jesse Brown Veterans Affairs Medical Center. The ECMH longitudinal clerkship was piloted in academic year 2011–2012 across 4 clinic sites with 56 students (14 from each class) randomly selected from a pool of volunteers. In subsequent years, additional ECMH clinics were added with students selected in the same fashion; the program has grown to 18 total sites and 290 students in academic year 2014–2015, with 72 students in the M4 graduating class out of 172 (approximately 40% of the class).
Intervention
The ECMH is a longitudinal, immersive primary care clerkship that spans the length of the undergraduate medical curriculum, as described previously.27 Teams of 16 students, 4 from each class, are embedded into existing primary care clinics under the direction of a single faculty preceptor. Half of ECMH students are currently at clinics principally caring for underserved populations including nine Federal Qualified Health Centers (FQHCs). With their preceptor’s oversight, students care for a panel of medically complex patients, defined as any patient requiring three or more annual office visits, having one or more chronic condition, or at risk for hospitalization or deterioration. Patients are enrolled from the preceptor’s existing patient pool or from students’ other clerkships, as students are encouraged to offer follow-up to amenable patients who lack a primary care provider. Clinics attempt to schedule all follow-up appointments during ECMH sessions, although patients are able to schedule appointments with the preceptor for acute problems as needed. Students attend ECMH clinic for four hours every other week and see patients in pairs (an M3/M4 student paired with an M1/M2 student); they also serve as peer educators by investigating clinical questions in real time, and as health coaches by contacting patients for follow-up on laboratory or radiology studies, consultations, and clinical status. A pair of students (as defined above) reviews each scheduled patient’s recommended screening and chronic disease control guidelines with the care team. Students also act as quality managers by compiling quality-of-care report cards and targeting areas of clinical care for improvement as part of an annual ECMH team quality improvement project.
Non-ECMH students participate in the “traditional curriculum” (TC), which consists of a biweekly individual preceptorship with an ambulatory care attending during their second year and a four-week outpatient primary care clerkship during their third year with a different primary care preceptor. All students (ECMH and TC groups) participate in biweekly clinical skills and communication skills classroom sessions with standardized patients during their first two years. All students are required to pass the National Board of Medical Examiners (NBME) ambulatory medicine subject exam and a primary care objective structured clinical examination developed by the medical school.
Procedure
To obtain long-term academic and student-centered outcomes of the ECMH, we asked students graduating in May 2015 to consent to review of their deidentified medical school application characteristics (undergraduate grades, score on Medical College Admission Test [MCAT]) and medical school academic performance (examination scores, United States Medical Licensing Examination [USMLE] Step scores, and clerkship grades) and participate in a two-part survey as described below. Surveys were distributed via SurveyMonkey (surveymonkey.com) and designed to take a total of 20 minutes to complete. We sent a total of four reminder e-mails to students to maximize response rate.
Educational outcomes
The first part of the survey, containing questions regarding student perceptions of their primary care educational experiences, was developed using an iterative process.30 We conducted a review of relevant literature regarding surveys of students in longitudinal clerkships19,22 and developed a set of survey items intended to address students’ perceptions of primary care experiences, adequacy of preparation for future training, quality of mentorship, career choice, and self-perceived competency regarding primary care medical home objectives. Survey items were developed by study authors (J.B., D.B.W., J.X.T., and D.E.) and reviewed for content and clarity by a group of primary care educators.
The second part of the instrument contained survey tools derived from prior published studies.31–34 Each tool has been previously evaluated in a medical student population. These included items regarding student attitudes about longitudinal clerkships and exposure to the “hidden curriculum,” including the C3 survey instrument.22,31 We assessed perceived patient centeredness using the Patient–Practitioner Orientation Scale (PPOS) survey instrument.32 Students self-assessed their quality improvement skills using a previously developed Quality Improvement Self-Assessment Tool (QISAT).33,34
Clinical outcomes
To assess the impact of the intervention on clinical care quality and patient engagement, we abstracted medical records of ECMH patients at a single site. We selected this clinic because it was one of the original ECMH sites, had the longest time to accrue patients, and was part of an accessible electronic record system making chart review feasible. This clinic is located at an academic general internal medicine practice serving a diverse adult patient population. Its patients are representative of an ECMH patient pool and met the criteria described above. As students were randomly assigned to clinics, the students at this site are likely representative of all ECMH sites. We collected demographic data, frequency of clinic contacts (including patient visits, telephone calls, and secure electronic medical record messages), and measures of selected cancer screening, secondary markers of chronic disease control, and yearly influenza vaccination. These variables were selected as proactive care measures that are clinically meaningful as well as reflective of patient engagement with their clinic and with their ECMH student coaches. For each patient, data were collected for the first year after starting the ECMH clinic; data from one year prior to their enrollment in ECMH served as a historical control.
Statistical analysis
We compared ECMH and TC groups using means and standard deviations (SDs). For surveys we chose to display results as percentages responding positively to each survey item, as opposed to survey means, to provide more meaningful comparisons between groups. All data were analyzed using Stata 12.0 (Statacorp, College Station, Texas); academic outcomes and clinical data were compared using Student t tests while survey data were compared using Wilcoxon rank–sum and Kruskal–Wallis tests where appropriate.
This study was approved by the Northwestern University institutional review board.
Results
One hundred eighty-one students were eligible to participate, and 137 (75.7%) consented to participate in the study (84% of ECMH students and 69% of TC students). As shown in Table 1, student attributes were similar between groups, including academic baseline performance (undergraduate grades, MCAT scores), performance on standardized examinations (USMLE Step 1 and 2 scores and NBME clinical subject examination scores), and clerkship grades. We observed no difference in students’ self-reported career paths, although there was a slight nonsignificant trend toward more ECMH students choosing careers leading to potential primary care specialties rather than surgical careers.
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Table 1: Demographics, Academic Outcomes, and Career Choices of Graduating Medical Students (n = 137) in the Traditional Curriculum (TC) and Education-Centered Medical Home (ECMH)
As shown in Table 2, we found significant differences between groups with regard to primary care self-efficacy and training experiences. ECMH students were able to see their patients for follow-up visits more frequently, derived greater satisfaction out of their primary care learning environment, and reported establishing more meaningful relationships with primary care patients. ECMH students perceived their primary care clinics as more patient-centered, effective, and safe than those experienced by TC students. Importantly, ECMH students expressed more satisfaction with the quality of feedback they received, as well as the quality of their primary care training overall. Over 90% of ECMH students and over 50% of TC students recommended the ECMH curricular pathway to incoming medical students.
Table 2: Perceptions of Primary Care Training Experience Among Graduating Medical Students (n = 137) in the Traditional Curriculum (TC) and Education-Centered Medical Home (ECMH)
We found major differences between ECMH and TC student responses related to patient-centered behaviors. As shown in Table 3, ECMH students more frequently observed their preceptors performing such behaviors, including encouraging patients’ participation in their own care, exploring emotional aspects of illness, and communicating concern. As assessed by a previously published tool, ECMH students demonstrated more patient-centered attitudes than TC students, with the difference approaching statistical significance. Students who participated in the ECMH for three or four years had the most patient-centered responses (PPOS mean 4.8 [SD 0.5], versus 4.5 [0.6] for one to two years of participation and 4.3 [0.8] for TC, P = .023). ECMH students also felt more encouraged to develop rapport and understand their patients as unique persons. Finally, ECMH students scored statistically significantly higher on the QISAT, an assessment of comfort with quality improvement principles such as writing a problem statement, identifying whether a change leads to an improvement in your skills, and using the Plan, Do, Study, Act model.
Table 3: Responses to Previously Published Surveys Regarding Longitudinal Clerkships Among Graduating Medical Students (n = 137) in the Traditional Curriculum (TC) and Education-Centered Medical Home (ECMH)
To assess the impact of the ECMH on patient outcomes, we abstracted charts of patients empaneled and seen for a continuity visit by an ECMH team at one site (n = 81). As shown in Table 4, patients were 60 years old and had 5.8 chronic conditions on average (SD = 1.7). Eight patients died during the study period, and one moved away. Markers of patient engagement in clinic, such as the rate of clinic visits, telephone contacts, and electronic messages, increased significantly compared with baseline. There was no change in the rates of no-shows or cancellations; there were nonsignificant trends toward a reduced number of study hospital emergency department visits and inpatient admissions. Glycemic control for diabetics trended lower, though this was not statistically significant. Rates of breast, cervical, and colorectal cancer screenings rose significantly during the first ECMH year for patients eligible for those measures at baseline, as did yearly influenza vaccination. Only patients who qualified for screening on the basis of demographics and comorbidities were included.
Table 4: Utilization, Chronic Disease Management, and Preventive Screening Among Education-Centered Medical Home (ECMH)-Enrolled Patients (n = 81) at One Site
Discussion
This study reports four-year outcomes of the ECMH, a longitudinal team-based primary care clerkship designed to promote continuity between patients, preceptors, and peers. This model enables medical students to create meaningful therapeutic relationships with patients and take ownership for the quality of care provided to patient panels at their curricular sites. This patient-centered ethos of learning ideally permeates the entirety of their medical education, and our results show that participating in the ECMH had powerful effects on medical students’ experiences and attitudes. ECMH students reported that their years working with the same peer and preceptor team led to more authentic, rewarding, and effective primary care experiences as evidenced by higher satisfaction scores than TC students. The ECMH also provided students with opportunities for iterative feedback, interclass collaboration, and role modeling. Because this study is the longest follow-up of the largest group of medical students to participate in a longitudinal clerkship, these findings add to the growing body of knowledge supporting the longitudinal model of medical education.
We found that traditional measures of academic performance were similar between groups at baseline and throughout the four years. This is not surprising as the ECMH accounts for less than 10% of total student curricular hours. It is possible that ECMH students were likely more interested in primary care careers at the beginning of medical school and were thus more likely to volunteer; this interest persisted as shown by the trend toward EMCH students applying for internal medicine, family medicine, and pediatric residency positions, although there was no statistical difference in specialty choice between the groups. Longer-term follow-up is needed to identify the percentage of ECMH students who ultimately choose primary care careers.
Students who enrolled in the ECMH clerkship participated in more continuity relationships with patients and believed they made a difference in the lives of their patients more often. They also describe a greater sense of safety and efficacy in the primary care clinics in which they worked. We believe that these attitudes reflect the fact that when provided with meaningful opportunities to take ownership, students take advantage, become invested, and nurture a sense of patient centeredness. Similar to prior studies of longitudinal education models,22,23 ECMH students were perceived to exhibit more patient-centered attitudes, greater satisfaction with their primary care experience, and a greater degree of self-efficacy. Those with more experience in the ECMH responded the most positively, suggesting a dose–response relationship. On the basis of these results, we believe that it is possible that exposure to authentic clinical environments early in medical school can mitigate some of the “hidden curriculum’s” dehumanizing effects on medical student attitudes toward patients.
In addition to the benefits shown to student education, our study suggests that medical students acting as health coaches can improve chronic disease management for high-risk primary care patients. When empaneled in the ECMH, as opposed to the year prior, patients were more engaged in clinic, had a trend toward fewer hospital and emergency room visits and improved glycemic control, and had improved rates of cancer screening and influenza vaccination. Because chronic care measures and preventive health opportunities may be overlooked by a single provider seeing medically complex patients under time constraints, adding students who focus on these issues may increase rates of preventive screening without adding extra time to a provider’s schedule.
Whereas prior studies of longitudinal clerkships have demonstrated their educational impact, ours is one of the first to show that medical students can improve care and add value to a primary care setting.13,15 Our results also suggest the possibility of evaluating longitudinal clerkships on the basis of patient-level outcomes rather than traditional metrics such as student satisfaction and attitudes. Further examination of patient outcomes using concurrent controls and multiple clinic sites to confirm these findings is under way.
This study has several limitations. First, our results reflect student and patient outcomes over a relatively short time period from one institution. Second, there is a potential for volunteer bias. Although ECMH students were selected at random from all who volunteered, and the TC cohort contained some students who volunteered but were not chosen, the possibility exists that differences in behaviors and attitudes about primary care are driven by ECMH students’ enthusiasm for contributing to a novel educational intervention and a new primary care experience. However, we believe that the statistically similar baseline academic performance, medical school academic performance, and final career choices between groups likely minimize this bias. Third, although student perceptions and attitudes are important metrics used to assess the quality of medical education, we acknowledge that we do not yet have objective evidence of enhanced learning or clinical skill development in ECMH students. Although differences in primary care attitudes and exposure to the hidden curriculum may be due to a preceptor effect rather than from the ECMH itself, we believe that this effect would be minimal as preceptors in each group are derived from the same faculty pool. Fourth, we only sampled patient outcomes at a single ECMH site. The sample clinic’s population is likely similar to that at other sites, but there may be heterogeneity inherent in using a diverse cohort of ECMH clinics in various settings including FQHCs. Using historical controls also limits our ability to draw conclusions and requires further study at multiple sites using a concurrent control group. Finally, we have yet to link participation in the ECMH to retention of enhanced attitudes and perceptions in residency and beyond. Further study is needed to assess the long-term impact of the ECMH on student attitudes and perceptions of longitudinal care objectives.
In conclusion, four-year outcomes of the ECMH show that it is a promising model for medical education. The ECMH builds on the prior success of longitudinal clerkships, fosters authentic patient care encounters which allow for “value-added” learning as early as the first year,8,13 and emphasizes educational principles of the patient-centered medical home as recommended by primary care physician leaders.35 Incorporating student teams longitudinally into primary care clinics is rated positively by students and yields comparable academic performance, improved continuity, improved learning climate, and higher patient centeredness. Preliminary data suggest that student health coaches add value and improve patient outcomes at the clinics where they train. Further study will involve confirming these findings on a larger sample of students and testing the ECMH model at additional institutions.
Acknowledgments: The authors wish to thank the physicians and administrative staff who participated in the Education-Centered Medical Home (ECMH), as well as the organizations that have graciously served as ECMH sites, including PCC Community Wellness Center, Erie Family Health Center, Community Health Clinic of Chicago, Near North Health Service Corporation, and Northwestern Medical Group.
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