Welcome to Rounds. In this edition, we'll explore the dynamic world of 'new' models designed to improve clinical education. As a profession, we do a good job of teaching the biologic and physical sciences as the basis for the practice of medicine in the core disciplines of Medicine, Surgery, Psychiatry, Ob-Gyn, Pediatrics, Family Medicine, and Neurology. Medical education has not done as well incorporating other fields into our teaching, such as systems management (quality and safety), population health, and social determinants of health, community engagement, patient-centered care, and professionalism.
Over the last 30 years, the work of most health professionals has shifted from episodic acute care in hospitals to managing chronic diseases over time in the outpatient setting. Yet, clinical education in many medical schools still focuses only on hospital-based care taught in 4-to-12-week rotations known as traditional clerkships.
Longitudinal Integrated Clerkship
UNLV School of Medicine's clinical education will use the Longitudinal Integrated Clerkship model, where students have regular, recurrent placement in the same outpatient setting with the same preceptor (and thus with access to the same patient base). Students will learn from and manage patients over a year, develop continuing learning relationships with clinicians, and meet the majority of the clinical competencies across multiple disciplines simultaneously.
This model started in 1971 at the University of Minnesota to foster rural care. In the early 1990s, Harvard and the University of California, San Francisco developed urban longitudinal integrated clerkships. It soon became clear that the benefits of this model extended beyond improving the primary care workforce.
Compared to students in traditional clerkships, students in longitudinal clerkships perform as well or better in clinical knowledge exams. Studies suggest that longitudinal students demonstrate better retention of clinical knowledge. Harvard students in the longitudinal clerkship demonstrate better outcomes in overall testing at year's end in the Comprehensive Clinical Science Self-Assessment, a multidisciplinary exam, compared to Harvard students in traditional clerkships.
More important, students in longitudinal clerkships demonstrate higher sustained patient-centered attitudes, receive more formative feedback from faculty and perceive it as more valid, and have progressively higher levels of patient care responsibility. This also results in higher student satisfaction with the curriculum.
In both clerkship types, patients' benefit from the support medical students provide through empathetic listening and by their effort to compensate for shortcomings in the health care system. In longitudinal clerkships, patients perceive they have greater access to care from students, that they are easier to reach and they take the time to answer questions. Patients also report students improved the quality of their care through education about the disease and therapy. The model helps medical students and patients to foster long-term relationships and trust, mutual respect, and greater engagement. Patients reported increased respect for their doctors based on observing them help medical students learn their profession.
Clinical physician benefits
Doctors experience tension between the demands of clinical service and the commitment to teaching medical students. The cost and time pressure experienced as a consequence of this tension are identified in the hospital and outpatient care settings. This pressure is reduced in longitudinal clerkships where clinicians and
students build collaborative working relationships with progressive contribution of students to the work of the clinical team.
Doctors involved in longitudinal clerkship programs describe finding their professional lives as clinical teachers more satisfying than being solely a clinician. In longitudinal clerkships, patient care and student teaching are no longer seen as competing activities, but each contributes to the performance of the other. As the student-preceptor relationship develops, clinicians value the contribution of medical students, report high levels of satisfaction with precepting and take increased ownership in student learning. Preceptors also appreciate the opportunity to come together with other interested colleagues as a community of practice in clinical teaching, and increase their interest in interprofessional learning within hospital settings.
Physicians who engage in the work of social justice and health advocacy can be a powerful force for change that improves communities. At follow-up 4 to 6 years after their clerkships, twice as many longitudinal clerkship graduates report participating in social justice and health advocacy (50 percent) compared to their traditional clerkship graduate peers.
The UNLV School of Medicine's longitudinal clerkship will be a key part of achieving the goal of "Student-centered education for patient-centered care."