Longitudinal Integrated Clerkship Research Articles

College of Medicine, University of Saskatchewan.

College of Medicine, University of Saskatchewan.

Penn State College of Medicine.

Penn State College of Medicine.

Validating an Obstetrics and Gynaecology Longitudinal Integrated Clerkship Curriculum at the University of Toronto: A Four-Year Review.

The University of Toronto launched a longitudinal integrated clerkship (LIC) pilot project in 2014. Our aim was to evaluate LIC student outcomes in obstetrics and gynaecology compared with those of traditional block students. LIC and block students underwent identical evaluations, including written and oral exams, as well as clinical assessments from the ward. LIC student scores in each domain were compared with those of the traditional block students over 4 years. There were no differences in overall pass/fail status between LIC and block students. Thus, our LIC design could be appropriately modeled at other teaching institutions contemplating introducing an LIC stream.

The hidden curriculum and its marginalisation of Longitudinal Integrated Clerkships

ABSTRACT Longitudinal Integrated Clerkships (LICs) have a growing presence as a model of educational delivery on the stage of UK medical education, where they are most frequently based within primary care. Yet, despite both local and internationally reported benefits, significant challenges to programme implementation and student engagement remain. Although perhaps initially challenges could be explained by the novelty of LICs, UK LICs have aged, yet challenges remain, leading to the marginalisation of LICs within UK medical schools. This leading article suggests institutional hidden curricula may be an important vehicle for this marginalisation and explores how the dominant fact-based paradigm of UK medical education could act to dissuade student engagement with LICs. So long as the hidden curricula messages we transmit to early-stage medical students revolve around the disproportionate importance of cognitive knowledge acquisition, UK-based LICs are unlikely to realise their full impact or benefit, in comparison to successfully running LICs internationally. Alternatively, refocusing early medical education on patient interaction, encouraging students to take an active role in their care, would send a different hidden curricula message more aligned with the ethos of LICs, and so would likely increase uptake to later stage comprehensive programmes.

Medical Students Can Learn Surgery Effectively in a Rural Longitudinal Integrated Clerkship

At Deakin University School of Medicine, compulsory formal teaching in Surgery occurs in year 3. This may occur as part of a rural longitudinal integrated clerkship (LIC), or in a traditional teaching hospital block rotation (BR). The purpose of this study was to compare these groups' exposure to surgical common conditions and their academic outcomes. Part I: This was a survey of students' encounters with patients with common surgical conditions between 2016 and 2018. Self-reported data were collected describing the nature of the encounters and their clinical settings. Part II: All third year Surgery MCQ and OSCE results from 2011 to 2017 were analyzed. Students were deidentified and grouped according to whether they were in the LIC or BR programme. Part I: Thirty-eight third year students (20 LIC, 18 BR) submitted data for a total of 188 clinical encounters. Both groups encountered all nominated common surgical conditions, but the settings in which this occurred were different. BR students saw most patients as hospital inpatients whereas LIC student encounters were distributed across multiple clinical sites. Part II: A total of 942 (121 [26%] LIC and 821 [74%] BR) students' assessment results were analyzed. The groups performed similarly in the MCQ (p = 0.21) and OSCE (p = 0.16) examinations. Students who were taught surgery in a LIC program performed similarly to on their final exams to their peers in traditional clerkships, with self-reported student data indicating both groups encountered a similar range of conditions.

It Takes a Village: Utilizing a Community-based Longitudinal Integrated Clerkship Model at a Regional Medical Campus to Provide the Core Emergency Medicine Clerkship Experience.

The objective was to evaluate the efficacy of a required emergency medicine (EM) experience embedded in a new community-based longitudinal integrated clerkship (LIC) for participating students and faculty. We developed and implemented a community-based LIC EM experience. The experience included 10 clinical shifts, one emergency medical services prehospital care shift, four didactic sessions, one reflection, and an emergency medicine simulation session. Students' outcomes were assessed using end-of-year surveys, focus groups, an emergency medicine subject examination, simulation performance, and clinical evaluations of the students by faculty. Faculty were recruited, underwent faculty development, and were evaluated by students. Faculty perceptions were gathered from a focus group and faculty retention rates were collected. Three cohorts of LIC students (total N=61) have completed their core emergency medicine experience in our community-based LIC. Among students, 76% to 95% rated the overall quality of teaching as very good or excellent and 66% to 100% rated the quality of learning in their community-based setting as very good or excellent. All students who passed the EM subject examination achieved the clinical competencies of the experience based on clinical evaluations. Among faculty, we have retained greater than 95% each year and they have reflected positively on their precepting experience. Implementing a required EM experience within a community-based LIC model can be an effective learning experience for students and perceived positively by community-based faculty. This model may offer an opportunity to expand clinical learning experiences in EM.

Same but Different: Exploring Mechanisms of Learning in a Longitudinal Integrated Clerkship.

Longitudinal integrated clerkships (LICs) are a widely used method of delivering clerkship curricula. Although there is evidence that LICs work and core components of LIC training have been identified, there is insufficient understanding of which components are integral to why they work. To address this question, this research explored how students experienced the first year of an LIC program. The aim was to use participants' understanding of their learning experiences to identify potential mechanisms of the LIC curriculum model. Thirty-two interviews were conducted with 13 University of Toronto students, 7 LIC and 6 block rotation students from the same site, from October 2014 to September 2015. A thematic analysis was performed iteratively to explore participants' understanding of their key learning experiences and outcomes. Participants in both cohorts described their key learning outcome as integration and application of knowledge during patient care. Experiences supporting this outcome were articulated as longitudinal variable practice and continuity of relationships with preceptors and patients. Critically, these experiences manifested differently for the 2 cohorts. For block students, these learning experiences appeared to reflect the informal curriculum, whereas for LIC students, learning experiences were better supported by the LIC formal curriculum. The results illustrate the importance of learning experiences that support longitudinality and continuity. By also emphasizing variability and knowledge integration, they align with literature on expert development. Notably, many of the learning experiences identified resulted from informal learning and thus support going beyond the formal curriculum when evaluating the effectiveness of curricula.

Clerkship Roles and Responsibilities in a Rapidly Changing Landscape: a National Survey of Internal Medicine Clerkship Directors.

In the rapidly changing landscape of undergraduate medical education (UME), the roles and responsibilities of clerkship directors (CDs) are not clear. To describe the current roles and responsibilities of Internal Medicine CDs. National annual Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. One hundred twenty-nine clerkship directors at all Liaison Committee on Medical Education accredited US medical schools with CDIM membership as of September 1, 2017. Responsibilities of core CDs, including oversight of other faculty, and resources available to CDs including financial support and dedicated time. The survey response rate was 83% (107/129). Ninety-four percent of the respondents oversaw the core clerkship inpatient experience, while 47.7% (n = 51) and 5.6% (n = 6) oversaw the outpatient and longitudinal integrated clerkships respectively. In addition to oversight, CDs were responsible for curriculum development, evaluation and grades, remediation, scheduling, student mentoring, and faculty development. Less than one-third of CDs (n = 33) received the recommended 0.5 full-time equivalent (FTE) support for their roles, and 15% (n = 16) had less than 20% FTE support. An average 0.41 FTE (SD .2) was spent in clinical work and 0.20 FTE (SD .21) in administrative duties. Eighty-three percent worked with other faculty who assisted in the oversight of departmental UME experiences, with FTE support varying by role and institution. Thirty-five percent of CDs (n = 38) had a dedicated budget for managing their clerkship. The responsibilities of CDs have increased in both number and complexity since the dissemination of previous guidelines for expectations of and for CDs in 2003. However, resources available to them have not substantially changed.

Establishing a Patient-centered Longitudinal Integrated Clerkship: Early Results from a Single Institution.

BackgroundLongitudinal integrated clerkships (LICs) have been adopted by medical schools to overcome the limitations of traditional block clerkship rotations and to promote continuity of care. In 2018, Seoul National University College of Medicine introduced a patient-centered LIC program as part of a new curriculum in parallel with traditional block rotation clerkships. The purpose of this study was to present the patient-centered LIC program and to investigate its educational effects.MethodsIn 2018 and 2019, a total of 298 third-year medical students participated in the LIC program. We divided the students into groups of eight, which were organized into corresponding discussion classes. Throughout the academic year, students followed up patients by interviewing them at the hospital or reviewing their electric medical records. Discussion classes on set topics were held seven times per year with facilitators and clinical faculites. Students completed a course evaluation questionnaire at the end of the academic year. The questionnaire included 22 items measured on a 5-point scale and two open-ended questions asking about the benefits and limitations of the program. The items covered three domains: student experience, satisfaction, and self-assessment. Final reflective essays were collected as both student assessments and data for qualitative analysis.ResultsDuring the study period, the overall experience of the students improved. We increased the number of faculty members and patients and decreased the number of students in each discussion class. We also provided additional feedback through an e-portfolio. Students' satisfaction changed positively. Compared to the rotational clerkship, students answered that the LIC provided additional help in learning the two core competencies. During the first 2 years of the program, the percentage of students who answered that the program was more helpful than the rotational clerkship increased from 23.7% to 46.4% for continuity of care (P < 0.001), and from 20.5% to 50.7% for patient-centered care (P < 0.001).ConclusionOur patient-centered LIC, in parallel with traditional block rotation clerkships, had a positive effect on students' experience of continuity of care and patient-centered care.

Feasibility of Peer-Led Didactics in the Core Clinical Year on a Regional Medical Campus

Purpose&#x0D; The best methods for learning outside of the clinical setting in the core clinical year, especially at Regional Medical Campuses with limited full-time academic faculty, are unknown.&#x0D; Methods&#x0D; We developed and implemented a peer-led didactic program to complement our longitudinal integrated clerkship (LIC) for students at our new regional medical campus (RMC) to achieve the same goals, objectives, and competencies as students at our main campus. These didactic sessions were developed and led by students for their peers with the assistance of community faculty members. Student scores on USMLE Step exams and National Board of Medical Examiner (NBME) subject exams for the core specialties were compared among the intervention group at the Regional Medical Campus, the main campus, and the national average. Finally, a student focus group provided qualitative data about student perceptions of these sessions.&#x0D; &#x0D; Results&#x0D; Among participating students, ninety-five percent reported that the student-led didactics were relevant to their clinical work and eighty percent reported that these sessions enhanced their knowledge and the content was provided at the right pace and level. Students ranked preparing to teach student-led didactics as one of the most valuable learning experiences and “worth the time it took to prepare.” Students scored comparably to their main campus peers on all seven NBME subject exams and the Step 2 CK exam.&#x0D; Conclusion&#x0D; Utilizing peer-led didactics as a part of a longitudinal integrated clerkship is feasible and effective in helping students achieve the goals, objectives, and competencies of the core clinical year. This educational method should be considered at other LIC-based programs.&#x0D; The authors do not have any conflicts of interest to disclose. This project received no funding. As all data were completely anonymized thought the internet survey and no patients were involved, this was not reviewed by an ethics board.

Team-Based Learning in a Longitudinal Integrated Clerkship: an Opportunity for Integrated Multidisciplinary Learning and Curricular Focus on the Underserved.

Team-based learning (TBL) offers opportunities to tailor curricula to match specific aims and modalities of innovative medical education models. This paper describes a TBL curriculum developed for a longitudinal integrated clerkship (LIC) at an urban safety-net hospital. Similar to our LIC students' clinical training experience, which includes simultaneously meeting core competencies across specialties in an underserved setting, our TBL curriculum is multidisciplinary and integrates topics related to caring for vulnerable patients. TBL within our LIC avoids the limitations of teaching content in specialty specific silos, creating a cohesive didactic and clinical education model which is highly rated by our students.

Medical education trends for future physicians in the era of advanced technology and artificial intelligence: an integrative review

BackgroundMedical education must adapt to different health care contexts, including digitalized health care systems and a digital generation of students in a hyper-connected world. The aims of this study are to identify and synthesize the values that medical educators need to implement in the curricula and to introduce representative educational programs.MethodsAn integrative review was conducted to combine data from various research designs. We searched for articles on PubMed, Scopus, Web of Science, and EBSCO ERIC between 2011 and 2017. Key search terms were “undergraduate medical education,” “future,” “twenty-first century,” “millennium,” “curriculum,” “teaching,” “learning,” and “assessment.” We screened and extracted them according to inclusion and exclusion criteria from titles and abstracts. All authors read the full texts and discussed them to reach a consensus about the themes and subthemes. Data appraisal was performed using a modified Hawker ‘s evaluation form.ResultsAmong the 7616 abstracts initially identified, 28 full-text articles were selected to reflect medical education trends and suggest suitable educational programs. The integrative themes and subthemes of future medical education are as follows: 1) a humanistic approach to patient safety that involves encouraging humanistic doctors and facilitating collaboration; 2) early experience and longitudinal integration by early exposure to patient-oriented integration and longitudinal integrated clerkships; 3) going beyond hospitals toward society by responding to changing community needs and showing respect for diversity; and 4) student-driven learning with advanced technology through active learning with individualization, social interaction, and resource accessibility.ConclusionsThis review integrated the trends in undergraduate medical education in readiness for the anticipated changes in medical environments. The detailed programs introduced in this study could be useful for medical educators in the development of curricula. Further research is required to integrate the educational trends into graduate and continuing medical education, and to investigate the status or effects of innovative educational programs in each medical school or environment.

Physician Preceptor Satisfaction and Productivity Across Curricula: A Comparison Between Longitudinal Integrated Clerkships And Traditional Block Rotations

Phenomenon: Physicians are under intense pressure to improve clinical productivity. High clinical load, limited availability, and decreased clinical efficiency are well-documented barriers to precepting medical students and threaten clinical productivity. In an era of increasing medical student enrollment, these barriers have already led to a decreased availability of clinical teachers and training sites across the United States. Improved preceptor satisfaction could have a great impact on recruitment and retention of medical student preceptors and is likely linked to changes in productivity. Curriculum structure could impact both preceptor productivity and satisfaction. Comparing productivity and satisfaction of physician preceptors teaching in longitudinal integrated clerkships (LICs) to those teaching in traditional block rotations (TBRs), or in both settings (LIC-TBR), could lead to a better understanding of the impact of curriculum structure on preceptor productivity and satisfaction. Approach: Data were collected through a quantitative cross-sectional survey of outpatient physician preceptors in North Carolina in 2017. Preceptor satisfaction and student influence on productivity-related aspects of practice were analyzed with bivariate chi-square statistics and multivariate logistic regression. Findings: Analyses included 338 physician preceptors: 79 LIC (23%), 50 LIC-TBR (15%), and 209 TBR preceptors (62%). LIC preceptors were more likely to indicate being “very satisfied” with precepting than either their LIC-TBR or TBR counterparts. There were no differences in perceived productivity-related aspects of practice across the different curricula, such as patient flow, income, or physician working hours. Logistic regressions controlling for potential confounding variables suggested that those teaching in LICs were almost 3 times more likely to be “very satisfied” relative to those teaching in LIC-TBR and TBR settings and that the negative influence of students on patient flow and physician working hours had an adverse effect on preceptor satisfaction. Insights: Preceptor satisfaction was high overall, though satisfaction was significantly higher among preceptors who teach in LICs. The perceived impact of students on clinical productivity was stable across the different curricula. In an era of increasing need for physician preceptors, the higher satisfaction of those who teach in LICs should be considered in curricular design and for preceptor recruitment and retention.

Reflective Writing as a Window on Medical Students’ Professional Identity Development in a Longitudinal Integrated Clerkship

Phenomenon: Integral to the formation of a professional identity is the concept of professional identity construction, an essential part of becoming a competent physician. In this framework, identity is dynamic and shaped by experiences and relationships. Minimal work has addressed the impact that clinical care settings and relationships with patients have in the construction of professional identity for medical students. This study explores how patient interactions and intentional curriculum design support professional identity construction in students participating in a longitudinal integrated clerkship focused on care for the underserved. Approach: This qualitative analysis investigated students’ professional identity construction as detailed in 45 reflective essays from 15 students while enrolled in an 11-month longitudinal integrated clerkship (LIC) in a safety-net hospital system. Researchers used an inductive analytic approach. Findings: Students provided rich and complex descriptions of their experiences. Six themes emerged: care for the underserved; therapeutic alliance; humility and gratitude; altruism; resilience; and aspirations. Insights: Professional identity construction was observable through students’ reflective essays. Student interactions with patients provided rich material for professional identity construction, and role models in patient care enhanced this process. This study suggests that clinical learning in a safety-net hospital system, coupled with an LIC curriculum that prioritizes continuity with vulnerable patients, faculty role models, and ongoing reflection, supported the professional identity construction of students as patient-centered caregivers providing equitable care and advocacy for the underserved, described here as an Equity Identity.

Alliance, Trust, and Loss: Experiences of Patients Cared for by Students in a Longitudinal Integrated Clerkship.

The longitudinal integrated clerkship (LIC) model, which allows medical students to participate in comprehensive care of a panel of patients over time, is rapidly expanding because of recognized benefits to students and faculty. This study aimed to determine how LIC student contact affected patients' experiences and self-described health outcomes. This qualitative case study used semistructured patient interviews to understand the impact of LIC learners at the University of Colorado School of Medicine on patients at Denver Health. Patients with at least 3 encounters with an LIC student and over age 18 were selected. Thirty patients were invited to participate in 2016-2017; 14 (47%) completed interviews before the thematic analysis reached saturation. Four researchers independently analyzed interview transcripts and reached consensus on emergent categories and themes. Six broad themes were identified: beginnings of a relationship, caring demonstrated by student, growing to trust student, reaching a therapeutic alliance, improvement of patient outcomes due to student involvement, and a sense of loss after students completed the LIC program. Patients deeply valued the therapeutic alliances built with LIC students involved in their care over time. These alliances led to improved patient experience, mitigation of perceived health system failures, and subjective improvement in health outcomes. Patients described a sense of loss at the end of the LIC when students were no longer involved in their care. Curricula that support students building longitudinal therapeutic relationships with their patients are an opportunity to improve patient experience while promoting students' professional development.

The role of vertically integrated learning in a rural longitudinal integrated clerkship

BackgroundDeakin’s Rural Community Clinical School (RCCS) is a Longitudinal Integrated Clerkship (LIC) program in Western Victoria. Students undertake a year-long placement in a rural General Practice, many of which also host General Practice Registrars. There is a lack of evidence addressing the role and impact of Vertically Integrated Learning (VI) in practices hosting both LIC medical students and General Practice Registrars.The objective of the study was to establish how VI is perceived in the LIC context and the impact that it has on both learners and practices, in order to consider how to potentiate the role it can play in facilitating learning.MethodsSemi-structured, in-depth, qualitative interviews were undertaken, with 15 participants located in RCCS General Practices. Emergent themes were identified by thematic analysis.ResultsFive main interconnected themes were identified; (i) understanding and structure, (ii) planning and evaluation, (iii) benefits, (iv) facilitators, and (v) barriers.ConclusionVI in a rural LIC is not clearly understood, even by participants. VI structure and methodology varied considerably between practices. Benefits included satisfying and efficient sharing of knowledge between learners at different levels. VI was facilitated by the supportive and collegiate environment identified as being present in a rural LIC context. Resources for VI are needed to guide content and expectations across the continuum of medical training and evaluate its role. The financial impact of VI in a rural LIC warrants further exploration.

UK longitudinal integrated clerkships: where are we now?

ABSTRACTIn this article, we discuss whether it is possible for UK institutions to influence the international longitudinal integrated clerkship (LIC) narrative, in the context of supplying future clinicians to a fragmented health service that is battling a General Practice recruitment crisis. Perhaps more importantly, we will discuss whether the ‘LIC model’ fits the UK undergraduate framework. We intend to present some emerging evidence of LICs in the UK, informed by a UK-wide survey and observations from a 2019 UK LIC think tank and then discuss whether the global CLIC definition applies to the UK context with possible ways forward.

It takes a community to train a future physician: social support experienced by medical students during a community-engaged longitudinal integrated clerkship

Social support may be beneficial for medical students who must develop adaptive strategies to respond to the demands and challenges during third-year clerkship. We provide a detailed description of the supportive behaviours experienced by third-year students during a longitudinal integrated clerkship (LIC) in the context of rural family medicine. Informed by a social constructivist research paradigm, we undertook a qualitative study to understand from the students' perspectives the presence and characteristics of social support available during a LIC. Data were collected from conversational interviews at three points during the eight-month clerkship year, pre-, during, and post-clerkship, to explore how 12 medical students experienced social support. We employed an innovative methodological approach, the guided walk method, to gain the students' stories in the contexts where they were taking place. The participants described the relationships they developed with various sources of social support such as (a) preceptors, (b) peers, (c) family, (d) health professionals, and (e) community members. Various individuals representing communities of practice such as the medical profession and community members were intimately related to the longitudinal aspects of the students' experiences. The findings lend credence to the view that it really does take a community to train a future physician.

Faculty Entrustment of Students in the Core Clerkships: A Comparison between the Longitudinal Integrated Clerkship and the Block Clerkship

INTRODUCTION: Entrustable Professional Activities (EPAs) have been proposed for use in undergraduate medical education. The ability of faculty to entrust students with EPAs may differ between Longitudinal Integrated Clerkships (LICs) and traditional block clerkships. METHODS: Participants were core clerkship faculty, 64 in a LIC and 31 in a sequential block clerkship. We administered a web-based survey at the end of the core clerkship year to measure preceptors’ typical entrustment (on a scale of 0–10) in students for the 13 American Association of Medical Colleges Core EPAs. We compared entrustment between LIC and block faculty using a Mann-Whitney test. RESULTS:LIC faculty were more entrusting of students than block faculty in 12 out of 13 Core EPAs (p DISCUSSION: LIC faculty were more likely than block clerkship faculty to entrust core clerkship students with performance of most EPAs. This finding is likely the result of LIC faculty having increased familiarity with student abilities because of the continuity of supervision and education inherent to LIC. More research is needed to ascertain the specific features of longitudinal clerkships that increase faculty entrustment of students. CONCLUSIONS: Longitudinal educational experiences may facilitate the assessment of medical students with EPAs.

The personalities of most medical students are suited to rural practice: Implications for rural education program recruitment

Introduction: The success of rural longitudinal integrated clerkship (LIC) programs has contributed to our understanding of selecting and training students for rural practice. Studies have explored the personality traits of students who participate in rural LICs although few have compared them with classmates who have not. The purpose is to compare personalities of four successive cohorts of students in the LIC Rural Physician Associate Program (RPAP) with their non-RPAP classmates.Methods: In a longitudinal cross-sectional design, medical students RPAP and non-RPAP, from 2013 to 2017 completed identical questionnaires comprising measures of personality, perfectionism, ambiguity tolerance, and resilience. T-tests, ANOVA, and post-hoc tests compared groups. K-means cluster analysis identified profiles of traits.Results: Total sample 286; RPAP = 128; non-RPAP = 158. Gender and age proportions were not different between groups. RPAP students were significantly lower in levels of perfectionism and higher in cooperativeness compared to non-RPAP classmates. Similar proportions of both groups were distributed across three personality profiles detected.Conclusions: Lower perfectionism implies advantages for rural practice. Nevertheless, similarities between groups suggest that most students would be successful in rural practice. More encouragement to all students may improve uptake of rural LICs. Greater attention to issues that affect decisions to explore rural medical education, particularly for our next generation of students, is required.