To the Editor:
The increased prevalence of chronic illness has highlighted the need for enhanced medical student training in ambulatory care. In recent years, many medical schools have moved from a traditional month-long ambulatory care block to a longitudinal rotation that places students in clinic over multiple months.1 In the longitudinal model, students build a relationship with patients over multiple months and, with preceptor oversight, care for a small panel of patients. This model was designed to enhance exposure to longitudinal patient relationships.1 Despite the benefits, we worry that this approach constrains medical student exposure to the diverse nature of ambulatory care for chronic illness.
Chronic disease management requires an understanding of how patients oscillate between stable and active disease states. Developing this understanding requires seeing patients that present in a stable condition, where focus is on health care maintenance and pharmacologic adjustments. But it also requires seeing patients in times of acute destabilization and those nearing the end of life, where focus is directed toward evaluating symptoms, determining prognosis, and deciding to escalate or de-escalate interventions. We feel that longitudinal clerkships place a premium on the former, at the expense of the latter.
Chronic disease trajectories are defined by prolonged periods of stability punctuated with intermittent periods of decompensation. In the longitudinal ambulatory model, there is an increased probability for discordance between a student’s time in clinic and the patient’s disease activity. In the setting of a longitudinal ambulatory care experience, where students only attend clinic weekly or biweekly, it is possible for students to miss critical windows of care where patients present in dynamic states of instability. We are concerned that longitudinal rotations may be exposing students to predominantly stable chronic disease management, while missing opportunities to better understand acute on chronic disease exacerbations.
Without adequate exposure to the diagnostic dilemmas and care escalations in chronic disease management, the field risks being misrepresented to students actively making choices about clinical careers. Anecdotally, many of our peers left their ambulatory clerkship with an impression that ambulatory chronic care was little more than nutrition counseling and titrating antihypertensives. Clinical training is always constrained by the stochastic presentation of patients, but clerkship models should look to optimize a diversity of patient presentations for a more challenging and engaging experience.
Jordan D. Anderson, MPhil
Fourth-year medical student, Harvard Medical School, Boston, Massachusetts; Jordan_anderson@hms.harvard.edu.
Brian W. Powers, MD, MBA
First-year resident physician, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts.
1. Ogrinc G, Mutha S, Irby DM. Evidence for longitudinal ambulatory care rotations: A review of the literature. Acad Med. 2002;77:688693.