Following a Patient's Care Over Many Months Enriches Clerkship Training

The longitudinal integrated clerkship model allows students to follow a patient’s care over time and learn the value of care continuity and developing meaningful relationships with patients.
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When Jessica Porcelan started her clerkship year at The Commonwealth Medical College (TCMC), she found the daily routine challenging.

The college’s months-long longitudinal integrated clerkship (LIC) curriculum meant she was switching gears from internal medicine to pediatrics or from psychiatry to family medicine in a single day. But after a few weeks of acclimation, the benefits of following the same patients over a longer period of time were clear, she said.

“I think it really helped my ability to be adaptive no matter what situation I’m walking into,” said Porcelan, now a fourth-year medical student at the Scranton, Pa., college. “And the LIC really sets you up to be a patient-centered physician. It allowed me to develop more meaningful relationships with patients and develop a better understanding of continuity of care.”

TCMC was the first medical school in the nation to standardize the LIC model for all third-year students. Unlike the more traditional block clerkship in which medical students spend weeks-long blocks in one specialty at a time, the LIC model lets students split their time among many specialties during a typical week.

“If your curricular goal is to give students an appreciation of patient-centered care and the course of illness, then there’s no question that the LIC is the way to go.”

Steven Scheinman, MD
The Commonwealth Medical College

According to the AAMC Curriculum Inventory and Reports, the LIC model is growing in popularity, increasing from 29 schools during the 2010–2011 academic year to 44 in 2014–2015. The advantage of the LIC is that students have a chance to follow a patient’s care over time and between medical settings. In addition, this model facilitates richer relationships between learners and preceptors.

At TCMC, third-year medical students spend half of the year in traditional inpatient block rotations and the other half in an outpatient LIC. During the LIC, students participate in six clerkships simultaneously. A typical week might include one half-day each in psychiatry, internal medicine, pediatrics, obstetrics/gynecology, family medicine, and surgery, with students developing a cohort of “continuity patients” who they follow over the six-month LIC period. During the LIC, the students also have three half days each week of “white space” when they are encouraged to explore other specialties and follow up on continuity patients.

Five classes have completed the LIC to date, and the results are promising, said Steven Scheinman, MD, TCMC president and dean. In surveys of residency program directors, TCMC graduates tend to score particularly high in patient communication, the ability to empathize and understand a patient’s social context, and the ability to work in teams.

“If your curricular goal is to give students an appreciation of patient-centered care and the course of illness, then there’s no question that the LIC is the way to go,” Scheinman said.

A more holistic understanding of patient care

A number of studies have found that students who complete LICs score as well or better on measures of clinical knowledge and skills, among other benefits.

A study published in Academic Medicine, in 2012 reported that students who participated in the Harvard Medical School–Cambridge integrated clerkship experienced greater satisfaction with the learning environment than students in traditional clerkships. Another 2012 Academic Medicine-published study found that LIC students were more likely to experience collaborative interactions with their teachers, and a 2012 study in Medical Education found that LIC students commonly served in a “doctor-like” role, whereas block clerkship students rarely did. 

“Continuity is the key word with LICs,” said Lori Hansen, MD, who coauthored the latter two studies and serves as dean of the University of South Dakota Sanford School of Medicine at the Yankton Campus, where students take part in a year-long ambulatory LIC.

The Yankton Campus was one of the country’s first medical schools to adopt the LIC model in 1991 in an effort to mimic the realities of practicing medicine more closely. While she and her colleagues have documented many educational benefits of LICs, Hansen noted that implementing the model can introduce challenges as well.

On a practical level, Hansen said it’s tricky to schedule simultaneous clerkships and notify students when their patients show up at emergency rooms or in clinic. There’s also the issue of getting consent from preceptors who are used to the block model.  

“It can be a long process of introducing this change and then showing faculty the evidence that this does work,” she said. “But it’s really less burdensome for faculty because they’re not orienting new students every eight weeks. By the end of the LIC, students are actually very skilled, know their continuity patients very well, and can help the attending in the evaluation of patients.”

The Yankton model was so successful that the Sanford School of Medicine is now implementing the LIC across all of its campuses, said Mark Beard, MD, MHA, assistant dean for medical student education. Beard noted that in comparing medical students among Sanford’s four campuses, Yankton students typically reported less burnout and greater satisfaction with the curriculum.

LICs and underserved communities 

The University of North Carolina (UNC) School of Medicine introduced the LIC in 2009 at its Asheville campus to give students more “authentic clinical experiences” and help them develop into physicians ready to serve and learn during residency, said Julie Byerley, MD, MPH, vice dean for education and chief education officer. Since then, LICs have expanded in some form to all of the school’s campuses.

In Asheville, the nine-month LIC includes six half days a week in core specialties, one half-day for didactic learning, and three half days for self-directed learning. An LIC stretched out over many months provides the seasonal variation that allows for “a deeper experience with more breadth,” Byerley explained.  A student in a block-style pediatrics clerkship in early summer, for instance, would have a very different experience if that block took place in winter when pediatric offices are filled with upper respiratory infections, she said.

In addition to providing continuity of care experiences, LICs that take place in rural communities can attract students to return to practice in underserved, provider-shortage areas, said Robyn Latessa, MD, assistant dean and director of the Asheville campus. A 2014 study in Rural and Remote Health that surveyed rural physicians in Maine about LICs documented this observation as well.

Since 2013, UNC School of Medicine Charlotte Campus has been offering a six-month LIC in which students work closely with Carolinas HealthCare System patients. Students rotate through clinics at the Charlotte VA Health Care Center and urban clinics for non- or underinsured patients, as well as community practices with larger insured populations. Similar to the Asheville students, some Charlotte students have expressed interest in returning to work with Latinos and other underserved communities they treated during their experience. 

Mary Hall, MD, chief academic officer of Carolinas HealthCare System said that the LIC model is about students building relationships with patients, preceptors, the community, and with each other. “Our hope is that if students spend six months in the community they will understand the value of, for example, watching a kid grow from two months to six months, or working with a woman with diabetes as she makes significant life style changes. We hope that students will understand patients better; that’s what the LIC brings to medical education,” she said.

Rebecca Flint, a UNC Charlotte student who followed a patient with recurrent breast cancer and accompanied her to chemotherapy, spoke to that point. “I feel like learning this side of medicine is something that many students do not get the opportunity to experience,” she said.

For Joshua Onyango, a third-year UNC medical student, the LIC’s emphasis on relationship building with preceptors and patients has been especially fulfilling.

“It really did give me an opportunity to see different dimensions of a patient’s life and how the different parts of the health care system affect them,” he said. “It’s turned my perspective around from looking at patients as avenues for practicing medicine to seeing medicine as an avenue to helping people.”
 

Rebecca Greenberg contributed to this article.