“Every system is perfectly designed to get the results it gets.”1 This oft-quoted adage accurately applies to 21st-century medical education. Traditional medical school curricula emphasize department-specific knowledge acquisition in transient, physician-centered learning environments.2 These models may contribute to a loss of patient-centered attitudes and reduced empathy, possibly by exposing students to fragmented care.3 While this curricular structure produces clinicians effective at providing acute care, it may not develop the optimal skills needed to practice in the team-based, patient-centered systems necessary for managing a population increasingly burdened by chronic illness.4,5
Introducing continuity with patients into medical school curricula may foster these skills.2 Continuity of care promotes professional identity growth and enables students to experience the “heroism of incremental care.”6–8 Students who have continuity experiences are more involved in patient care, perceive a greater sense of pride in their work, and identify themselves as health educators.9,10 While negative aspects of the hidden curriculum may lead to depersonalization,11,12 longitudinal experiences may preserve patient-centered attitudes and ensure that patient preferences, needs, and values guide clinical decisions.13–15 Transient, chaotic learning environments may result in a loss of professional efficacy.16,17 Having an “educational home” may enable students to feel more grounded and experience a greater sense of accomplishment in a more supportive learning environment.18–21 Importantly, studies of medical school continuity experiences have to date only reported observational data involving subsets of students.13,22–25
The Education Centered Medical Home (ECMH) at Northwestern University Feinberg School of Medicine (FSM) is a 4-year, longitudinal primary care clerkship (PCC) emphasizing continuity with patients, preceptors, and peers.25 While other longitudinal models integrate students in a single clerkship for a discrete time period,26 the ECMH enables students to have a continuity clinic alongside their other clinical and academic responsibilities. Our prior study of this model demonstrated that students who self-selected the ECMH reported significantly more satisfaction with their primary care training compared with students in a traditional curriculum,25 though these findings were limited by potential volunteer bias. To better evaluate the ECMH’s curricular effectiveness, we designed a randomized, controlled, medical education trial. We organized our hypotheses using Kirkpatrick’s framework.27 Specifically, we hypothesized the ECMH model, when compared with an enhanced individual preceptorship (IP) control group, would result in the following: improved primary care experiences and higher satisfaction with the learning environment (level 1: reactions and learning environment), higher patient-centered and team-oriented attitudes with comparable medical knowledge acquisition (level 2: attitudes, perceptions, and knowledge), and higher professional efficacy and more therapeutic relationships with patients (level 3: behavioral outcomes).
In the years preceding this trial, students at FSM were given a choice of 2 models for primary care training: the ECMH or the IP (Table 1).28
The ECMH is a 4-year, team-based, longitudinal PCC emphasizing continuity with patients, peers, and preceptors.23 In each ECMH, 16 students (4 from each class) are embedded in existing primary care clinics. Students attend clinic bimonthly throughout the 4 years of medical school (M1, M2, M3, M4). During each clinic, pairs of students (e.g., a junior M1/M2 paired with a senior M3/M4) see patients with preceptor oversight. To promote continuity, preceptors attempt to recruit a consistent panel of medically complex, high-risk patients who return to the ECMH regularly. Peer teaching plays a central role; M3/M4 students review clinical concepts, scientific principles, and physical examination skills with their M1/M2 peers before, during, and after encounters. Students track the quality of care they deliver and act as health coaches to potentially add value to patient care.29,30
The IP is a 2-year, 1:1 preceptor apprenticeship model. IP students attend clinic bimonthly for their first 2 years, seeing and presenting patients at the preceptor’s discretion. IP students may see some patients for follow-up encounters during their 2-year experience, though this occurs more by happenstance than deliberate educational design. This model is typical for early clinical immersion in medical school.31 In both models, faculty preceptors oversee clinical care, model professional behavior, and provide feedback.
During the first 2 years, both ECMH and IP students attend clinical skills sessions with standardized patients on alternate weeks. Curricular content and weekly learning objectives during these sessions are identical between groups. In the third year, all IP students enroll in a 4-week PCC where they attend at least 26 clinic sessions. In contrast, ECMH students attend their ECMH clinic at least 26 times during their M3/M4 years. Some ECMH students choose to enroll in the PCC in addition to their ECMH and receive 4 weeks of elective credit. All students complete the National Board of Medical Examiners (NBME) Ambulatory Medicine Subject Examination.
Setting and participants
The study was approved by the Northwestern University Institutional Review Board (STU#00200764, approved 6/30/15). The study period was August 2015 to August 2018.
At matriculation in July 2015 and July 2016, we randomly assigned all first-year students to the ECMH or IP. As in a prior comparative effectiveness study,32 we used a modified constrained randomization approach across 2 randomization waves.33 Because of a predetermined need for Spanish language skills at several ECMH clinics, randomization occurred within blocks of students stratified by Spanish proficiency. For each incoming class, we simulated 20,000 randomization schemes and then examined balance across the following covariates: sex, MD/PhD program matriculation, race/ethnicity (non-Hispanic white vs other), and interest in pediatrics (to ensure adequate enrollment in pediatric ECMH clinics). After identifying randomization schemes that were balanced across all covariates of interest, we randomly selected one balanced randomization scheme. We obtained individual written informed consent from matriculated students to survey them longitudinally and to allow access to academic records.
The number of available spaces for ECMH students was smaller (256) than the total number of students (650). Over the 3-year study period, 4 ECMH clinics were added. Interested students were allowed to switch as space became available or if a switch was appropriate for a student’s academic needs. If space was available for crossover, students were randomly selected from a wait list. We analyzed data using an intent-to-treat approach. Students were analyzed according to their original group assignment regardless of crossover.
We distributed surveys to all consenting students at 4 timepoints: baseline, end of first year, end of second year, and end of third year. For Kirkpatrick level 1 outcomes (reactions and learning environment), we included previously published questions about FSM-specific experiences and students’ likelihood to recommend ECMH to an incoming medical student. For level 2 outcomes (attitudes, perceptions, and knowledge), we included the Attitudes Toward Health Care Teams (ATHCT) scale, which measures perceptions of team-based care34; the Patient–Practitioner Orientation Scale (PPOS), which measures patient-centered attitudes35; the Communication, Curriculum, and Culture (C3) survey, assessing perceptions of the hidden curriculum, that is, the set of unwritten behaviors that influence the learning climate36; and questions regarding career choice. We evaluated effects on level 3 behavioral outcomes using the Maslach Burnout Inventory–General Survey (MBI-GS), which contains 3 subscales: emotional exhaustion, cynicism, and professional efficacy.37 Additionally, we asked questions regarding students’ achievement of continuity of care during clerkships. Instruments used in this study were administered to medical students in comparable settings in prior research.13,17,34–36,38,39 Baseline surveys contained items that could be asked before the start of clinical experiences; follow-up surveys were identical to each other. The majority of surveys were administered during in-person sessions using Research Electronic Data Capture (REDCap) online tools hosted at Northwestern University FSM.40 One initial survey was collected using SurveyMonkey (SurveyMonkey Inc., San Mateo, California). We emailed individual survey links to students who were absent or who had not completed surveys.
Power and statistical analysis
Statistical power estimates were extrapolated from results of a prior observational study focusing on PPOS scores, which measures perceptions of patient-centered attitudes on a scale where a higher score indicates greater patient-centeredness.25 We hypothesized that IP students’ PPOS scores would remain flat at 4.3, while ECMH scores would increase gradually over 4 years from 4.3 to 4.8. Using a repeated measures ANOVA with α = 0.05 and within-student correlation of 0.7 between annual PPOS measures, a sample size of 329 students provided 82% power to detect such a hypothetical difference between the groups.
Analyses were conducted in Stata statistical software, version 14.2 (StataCorp LLC, College Station, Texas). We estimated regression models with generalized estimating equations (GEEs), which accounted for longitudinal data clustered at the student level using an independent working correlation matrix and robust variance estimates. For continuous outcomes, we estimated models using an identity link and normal family. Intention-to-treat analysis investigated the intervention effect over the entire follow-up period, with the beta coefficient of interest in each regression model representing a constant ECMH effect across 3 years. All regression models adjusted for baseline characteristics above, as well as Spanish language proficiency, baseline interest in primary care, and year of matriculation. We obtained predictive margins using Stata’s “margins” command, with group-level scores adjusted across the sample’s covariate distribution. We explored effect modification in the trial’s final year (a potential dose–response effect) by separately estimating models with an ECMH-by-year 3 interaction. We elected not to impute missing data. GEE regression models assumed data were missing at random.41
In total, 329 students were randomized; 316 (96%) consented to academic data collection and surveys. We finished the study with an 88% response rate across 1,264 potential follow-up survey opportunities (100% baseline, 85% year 1, 94% year 2, and 85% year 3). Figure 1 illustrates participant flow, and Table 2 displays demographic characteristics.42 In accordance with our randomization approach,33 the 2 trial arms were highly balanced with regard to randomization covariates (P ≥ .71 for sex, MD/PhD program enrollment, race/ethnicity, and interest in pediatrics). Eighteen students (9.9%) initially assigned to IP crossed over to ECMH, while 5 students (3.7%) originally assigned to ECMH crossed over to IP. Preceptor retention during the study was > 90% in both groups.
Figure 2 displays the effect size of each outcome using regression modeling as described above. Data in tables represent the adjusted mean outcomes of participants based on these effect sizes.
Level 1: Reactions and learning environment
Across 3 years of follow-up, the ECMH model improved learner reactions across several measures (Table 3). ECMH students reported higher scores on survey items about looking forward to going to clinic, feeling involved in clinical care, achieving continuity with patients, and developing rapport with patients in clinic (P < .001 for all). ECMH students reported higher satisfaction with their learning environment. ECMH students reported higher satisfaction with the atmosphere for learning during primary care training, higher quality of mentoring/feedback from all sources, and higher overall quality of primary care training (P < .001 for all). Regarding likelihood to recommend, 70.1% of all respondents recommended the ECMH model to a hypothetical incoming M1 student, 9.8% recommended the IP, and 20.1% were undecided. ECMH participation was associated with 59% increased odds of recommending the ECMH (95% confidence interval [CI] 1.19, 1.98; P < .001).
Level 2: Attitudes, perceptions, and knowledge
ECMH participants’ ATHCT were significantly more positive across all years (P = .007) than IP participants, while patient-centered attitudes were comparably high in both ECMH and IP groups (Table 3). On the C3 hidden curriculum survey, ECMH participants reported greater perceived support from their peers and preceptors when conducting patient-centered tasks (P < .001). Regarding medical knowledge acquisition, there were no significant differences in United States Medical Licensing Examination Step 1 scores (ECMH 241.2 [95% CI 238.6, 243.9] vs IP 241.0 [95% CI 238.7, 243.3], P = .90) or NBME Ambulatory Medicine Subject Examination scores (ECMH 80.9 [95% CI 79.3, 82.5] vs IP 80.7 [95% CI 79.5, 82.0], P = .87).
Participants in both groups reported similar levels of interest in primary care as a career (Table 3, P = .34). ECMH students were more likely to report increased interest in a primary care career as a result of their training experience (P < .001).
Level 3: Behavioral outcomes
Participants in the ECMH reported actively following 2.2 patients, on average, compared with 0.3 in the IP (Table 3, P < .001). ECMH participants also reported establishing more patient relationships and more active involvement in patient care than IP participants (Table 3, P < .001 on all measures). Regarding wellness and burnout, the ECMH experience significantly increased professional efficacy (Table 3, P = .02). Participants’ levels of emotional exhaustion and cynicism were similar over the course of the study.
Effect modification analysis
In an exploratory analysis, we investigated whether the ECMH had a different effect during the clerkship year (M3) compared with the preclinical years (Table 4). All level 1 outcomes remained significant for M3 participants, other than ability to balance clerkship responsibilities which remained nonsignificant (P = .90). Among level 2 outcomes, the ECMH was associated with a greater effect on the hidden curriculum in M3, particularly in preceptor role modeling and support for patient-centered behaviors (Table 4). Level 3 outcomes related to continuity of care were significant across all years. Finally, ECMH effects on MBI professional efficacy scores were greater for M3 participants, while cynicism and exhaustion subscales remained unchanged (Table 4).
In this randomized, controlled medical education trial, the ECMH—a team-based, longitudinal PCC—outperformed a traditional primary care education model across a broad range of outcomes. The ECMH conferred positive effects on students’ perceptions of the learning environment, improved attitudes toward team-based care, and reduced exposure to negative aspects of the hidden curriculum. These findings suggest that ECMH students are better prepared to practice in the team-based, collaborative, patient-centered settings needed in the modern health care system.4 Students in both groups recommended the ECMH to incoming students, demonstrating the popularity of the model and replicating high satisfaction found in prior studies.25 Finally, ECMH students demonstrated comparable medical knowledge acquisition, improved continuity of care with patients, and significantly improved professional efficacy—one of the 3 defining components of burnout.20 Effects on the hidden curriculum and on professional efficacy accelerated during the third year, suggesting a dose–response relationship and potentially additive effects when layering a longitudinal ambulatory experience onto an existing discipline-based block clerkship curriculum.
This study of longitudinal clerkships compared with traditional models is unique for several reasons. Randomized, controlled medical education studies are rare due to difficulties in recruitment, varying institutional structures, logistical constraints preventing multicenter collaboration, and small sample sizes limiting statistical power.43–46 In this study, we compared 2 primary care curricular models using a prospective randomized design with inclusion of 96% of eligible subjects, high survey response rates (88%), and 3 years of follow-up. Previous observational studies of longitudinal clerkship models have demonstrated improved education outcomes,13,22–24 and various curricular and extracurricular activities to promote student wellness have been implemented at U.S. medical schools.47 However, to our knowledge, our study is the first to use a randomized design to demonstrate improved outcomes in both education and well-being, sustained over 3 years.
The ECMH model promotes rewarding aspects of patient care including building relationships with patients and working with peers in a supportive environment.10 In qualitative interviews, ECMH students describe themselves as advocates, health educators, and care managers, rather than simply passive learners or shadowers.10 Working in this active, team-based environment prompts students to try new roles earlier in their training, accelerating their professional development.9 When asked whether they were making real differences in the lives of their patients, ECMH students reported that they were doing so more than once a month. As they enter the often-chaotic, fragmented world of clinical clerkships, these experiences may better prepare ECMH students to withstand potential negative forces in the hidden curriculum. Promoting active clinical roles may help students build resiliency to overcome the challenges of clinical clerkships and form a greater sense of professional efficacy.48 We postulate that adding a longitudinal ambulatory clerkship alongside existing discipline-based clerkships allows students to return iteratively to a safe harbor and feel a sense of growth over time. Although our findings show promising effects on professional efficacy, further work is clearly needed to reduce other aspects of burnout, notably the persistent high levels of exhaustion and cynicism.17 As the ECMH and IP were small portions of a student’s overall medical curriculum, other factors, such as demanding duty hours, loss of autonomy, and stress regarding evaluations, may be greater contributors to emotional exhaustion and cynicism. Further research may help optimize longitudinal curricula to best address this phenomenon.
Our study has several limitations. It was conducted at a single institution. There was crossover between groups; however, if this produced any impact, it would bias our findings toward the null. We attempted to minimize bias in outcome assessment to the extent possible; though results were not blinded, survey data were collected online so there were no data collectors who could have introduced bias in the outcome assessment process. Additionally, the data analyst had no contact with students and thus could not bias responses. We did not perform a Bonferroni correction on the data; though we had multiple outcomes, we did not have sufficient statistical power due to real-world sample size constraints. However, out of 25 observed outcomes, 17 were in favor of the ECMH; 8 showed no difference; and 0 favored the IP, a pattern unlikely to be due to chance. More research may be needed to confirm our observed effects where P is closer to .05. More ECMH clinics were located in Federally-Qualified Health Centers or community sites; however, this was driven by clinical site availability rather than trial design and reflects the reality of conducting a randomized medical education study. ECMH preceptors received a stipend to offset productivity losses. Many of the IP preceptors were in compensation plans that gave ~10% effort credit for teaching, scholarship or citizenship and, while IP preceptors’ time demand was overall substantially less, they had more one-on-one time with students. Finally, the ECMH model of team-based care does not reflect current primary care practice models. However, the key features of ECMH—continuity with patients, near-peer education, and longitudinal preceptors—are achievable in other settings and could be used to inform future practice models. Importantly, the ECMH structure may reflect the team-based care models in which our students will eventually practice.49
In conclusion, our findings provide convincing evidence that the ECMH results in superior educational outcomes across multiple Kirkpatrick levels of evaluation.50 Further studies may shed light on the ECMH effect on Kirkpatrick level 4 outcomes (effects on the system), including patient-level effects. Overall, this study validates the efficacy of the ECMH as a new paradigm for primary care education. Continuity with patients, peers, and preceptors is achievable for medical students—and results in superior primary care training.
The authors thank Raymond Curry, MD, John X. Thomas, PhD, and Marianne Green, MD, for their support for the ECMH and assistance in project implementation. The authors also thank the organizations that have 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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