Longitudinal Integrated Clerkship Students Research Articles

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.

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.

Block versus longitudinal integrated clerkships: students' views of rural clinical supervision.

Medical students undertaking longitudinal integrated clerkships (LICs) train in multiple disciplines concurrently, compared with students in block rotations who typically address one medical discipline at a time. Current research suggests that LICs afford students increased access to patients and continuity of clinical supervision. However, these factors are less of an issue in rural placements where there are fewer learners. The aim of this study was to compare rural LIC and rural block rotation students' reported experiences of clinical supervision. De-identified data from the 2015 version of the Australian national rural clinical schools (RCSs) exit survey was used to compare students in LICs with those in block rotations in relation to how they evaluate their clinical supervisors and how they rate their own clinical competence. Multivariate general linear modelling showed no association between placement type (LIC versus Block) and reported clinical supervision. The single independent predictor of positive perception of clinical supervisors was choosing an RCS as a first preference. There was also no association between placement type (LIC versus Block) and self-rated clinical competence. Instead, the clinical supervision score and male gender predicted more positive self-ratings of clinical competence. The quality of clinical supervision in block placements and LIC programmes in rural Australian settings was reported by students as equivalent.

Teaching Medical Students in a New Rural Longitudinal Clerkship: Opportunities and Constraints.

Background:Medical schools in Africa are responding to the call to increase numbers of medical graduates by up-scaling decentralized clinical training. One approach to decentralized clinical training is the longitudinal integrated clerkship (LIC), where students benefit from continuity of setting and supervision. The ability of family physician supervisors to take responsibility for the clinical training of medical students over a longer period than the usual, in addition to managing their extensive role on the district health platform, is central to the success of such training.Objective:This study investigated the teaching experiences of family physicians as clinical supervisors in a newly introduced LIC model in a rural sub-district in the Western Cape, South Africa.Method:Nine semi-structured interviews were conducted with six family physicians as part of the Stellenbosch University Rural Medical Education Partnership Initiative (SURMEPI) five-year longitudinal study. Code lists were developed inductively using Atlas.ti v7, they were compared, integrated, and categories were identified. Emerging common themes were developed.Findings:Three overarching themes emerged from the data, each containing subthemes. The rural platform was seen to be an enabling learning space for the LIC students. The family physicians’ experienced their new teaching role in the LIC as empowering, but also challenging. Lack of time for teaching and the unstructured nature of the work emerged as constraints. Despite being uncertain about the new LIC model, the family physicians felt that it was easier to manage than anticipated.Conclusion:The centrality of the rural context framed the teaching experiences of the family physicians in the new LIC, forming the pivot around which constraints and opportunities for teaching arose. The African family physician is well positioned to make an important contribution to the upscaling of decentralized medical training, but would need to be supported by academic institutions and health service managers in their teaching role.

Comparing a longitudinal integrated clerkship with traditional hospital-based rotations in a rural setting

Context: Longitudinal integrated clerkships (LIC) are widely used as an educational method, particularly in rural areas. They are good for facilitating hands-on learning and deep relationships between student, patients, and supervisors.Objectives: This study sought to examine and compare learning experience of third-year rural medical students studying specialties (women’s health, aged care, child and adolescent heath, mental health, general practice) by either a traditional hospital-based rotation or a LIC in a rural general practice setting.Methods: Data was collected from two groups of rural students (LIC; traditional hospital-based) over two academic years, utilizing focus groups to investigate general experiences of living and learning rurally, within the different educational models.Results: Results reaffirmed that there was no perceived academic disadvantage to studying medicine rurally. Studying medicine in a rural area provides increased access to patients, more hands-on experience, and close relationships with patients and colleagues. LIC students reported increased confidence in clinical skills, felt better prepared for internship, however experienced more social isolation than students in hospital-based rotations.Conclusions: Students undergoing a rural LIC feel more confident in their clinical skills and preparedness for practice than other rural students. This study supports the use of LICs as a powerful educational tool.

Students' experiences of role, relationships and learning in two clerkship models.

An increasing number of medical schools around the world are implementing longitudinal integrated clerkships (LICs). The University of Alberta's third-year LIC admits a small group of each class. Those not in the LIC undertake a rotation-based clerkship (RBC). All students have a fourth-year RBC. Meaningful participation in patient care and guidance have been identified as affordances for work-based learning. This qualitative study is part of an ongoing research programme conducted in a hermeneutic phenomenological frame. The overarching research question is: What is the lived experience of integrated community clerkship (ICC) students in their clerkships? This paper focuses on an emic question, that is, one arising from the analysis, which was: What was the experience of ICC students in their transitioning to the fourth year? One-to-one reflective conversations with LIC students when they were at the end of their fourth year were the source of the material analysed. Transcripts were first analysed by each researcher and then co-analysed with an emphasis on overall meaning. Results are from conversations with 33 students from the first five LIC cohorts. Socio-cultural learning theory was used as an interpretive framework. This study identifies that the length and nature of placements led to continuity relationships for students with patients and teachers and meaningful participation in patient care. These are an interwoven set of affordances that facilitate learning in the ICC. Participants described the loss of these affordances in the RBC, resulting in diminished confidence, disruption of the learning trajectory and a re-forming of identity. It is important for all medical schools with LICs followed by RBCs to consider the differences between these two clerkships as experienced by students in order to determine how best to support students as they navigate through both. Medical educators need to examine all of their clerkships to identify the affordances that support learning.

A typology of longitudinal integrated clerkships.

Longitudinal integrated clerkships (LICs) represent a model of the structural redesign of clinical education that is growing in the USA, Canada, Australia and South Africa. By contrast with time-limited traditional block rotations, medical students in LICs provide comprehensive care of patients and populations in continuing learning relationships over time and across disciplines and venues. The evidence base for LICs reveals transformational professional and workforce outcomes derived from a number of small institution-specific studies. This study is the first from an international collaborative formed to study the processes and outcomes of LICs across multiple institutions in different countries. It aims to establish a baseline reference typology to inform further research in this field. Data on all LIC and LIC-like programmes known to the members of the international Consortium of Longitudinal Integrated Clerkships were collected using a survey tool developed through a Delphi process and subsequently analysed. Data were collected from 54 programmes, 44 medical schools, seven countries and over 15000 student-years of LIC-like curricula. Wide variation in programme length, student numbers, health care settings and principal supervision was found. Three distinct typological programme clusters were identified and named according to programme length and discipline coverage: Comprehensive LICs; Blended LICs, and LIC-like Amalgamative Clerkships. Two major approaches emerged in terms of the sizes of communities and types of clinical supervision. These referred to programmes based in smaller communities with mainly family physicians or general practitioners as clinical supervisors, and those in more urban settings in which subspecialists were more prevalent. Three distinct LIC clusters are classified. These provide a foundational reference point for future studies on the processes and outcomes of LICs. The study also exemplifies a collaborative approach to medical education research that focuses on typology rather than on individual programme or context.

Preceptor teaching tips in longitudinal clerkships.

In longitudinal integrated clerkships (LICs), the continuous preceptor and student relationship over time creates opportunities for more in-depth teaching approaches than shorter preceptorships allow. We identify student perceptions of the most effective teaching practices and develop tips for LIC preceptors. The first four third-year medical student classes completing the Asheville LIC of the University of North Carolina School of Medicine (UNCSOM) formed the subject group. Between June and August2013, a trained research assistant (AS) conducted semi-structured interviews with all 27 UNCSOM Asheville LIC students. Interviews were transcribed and coded by thematic analysis. All 27 (100%) students participated in the interviews. We identified seven main themes of successful precepting practices: enhance teaching; create bring-backs (learning topics to bring back to preceptors); support patient ownership; structure clinic; improve feedback; engage learners; and develop a relationship. These themes were condensed into nine preceptor tips for teaching in LICs. The longitudinal relationship of preceptor and student in LIC models affords specific, important opportunities for teaching and learning. The concise list of LIC preceptor tips can be used by preceptors to further optimise their teaching in the LIC setting. We identify student perceptions ofthe most effective teaching practices and develop tips for LIC preceptors.

Student Continuity with Patients: A System Delivery Innovation to Benefit Patient Care and Learning (Continuity Patient Benefit).

Medical education is continuing to evolve to meet the healthcare needs of the future. The longitudinal integrated clerkship (LIC) model is an important innovation in medical education. It has in its vision and structure “patient- and learner-centered education”, using longitudinal relationships between patients and students as a foundational element in its design. LIC students have shown more patient-centered attitudes and behaviors that persist after medical school. They remain connected with the patient experience of care, which supports empathy and student moral development. The time that LIC students spend acting independently with patients also supports the development of higher order clinical and cognitive skills and professional identity formation. Student participation in a more meaningful way in the care of their patients promotes patient wellbeing, and helps patients with transitions of care, communication and preventative care. Patients report feeling empowered to be more active agents in their own care and feel an accountability and pleasure in the training of new physicians. Focusing on the patient/student relationship as a foundational element of clinical education has meaningful benefits to the patient and student with the potential to improve patient care directly and in the future, as these students become physicians.

Who should choose a rural LIC: A qualitative study of perceptions of students who have completed a rural longitudinal integrated clerkship

Purpose: Evidence from many longitudinal integrated clerkships (LICs) has shown that students in LICs do as well as those in rotation-based clerkships (RBCs). Researchers now are turning to questions of how and why LICs work and for whom. This study explores the question: “Who should choose the University of Alberta’s Rural LIC?”Methods: Reflective conversations were held with former LIC students at the end of their fourth year of the MD program. The 5-year study began in a hermeneutic phenomenological frame evolving to an iterative process of collection and analysis in the tradition of grounded theory.Results: Students’ perceptions coalesced around four themes: (1) approach to learning, (2) personality, (3) attitudes and (4) career goals. The ability to adapt one’s own structure for learning, a preference for learning by doing and self-directedness were all important factors.Conclusion: Prospective students should be flexible, adaptable, comfortable being uncomfortable, adventuresome and embrace both the program and rural community life in order to benefit maximally from the experience. Rural LICs can be a choice for anyone, but students who have completed a rural LIC identify reasons why it may or may not be the best choice for everyone.

Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships

Background: Hidden curriculum literature suggests that different learning environments and curricular designs reinforce disparate values and behaviors.Aim: This study explores potential differences in learning environments afforded by two clerkship models through perceptions of the ideal student.Methods: In this qualitative study, research assistants interviewed 48 third-year students and 26 clinical supervisors from three US medical schools. Students and supervisors participated in longitudinal integrated clerkships (LICs) or block clerkships. Students and supervisors described the ideal student in their clerkship. Using phenomenographic techniques, authors identified five ideal student profiles and coded students’ and supervisors’ descriptions for alignment with one or more profiles.Results: Most students in both models described an ideal student who matched a learner profile (proactive and self-directed). More LIC students described an ideal student who fit a caregiver profile (engaging with and advocating for patients) and more block students described performer (appearing knowledgeable and competent) and team-player (working well with others) profiles. Supervisors’ descriptions paralleled students’ descriptions but with less emphasis on caregiving.Conclusions: Ideal student descriptions in LIC and block models may reflect different learning experiences and values emphasized in each model. These findings suggest implications for students’ construction of professional identities that warrant further exploration.

Academic outcomes of a community-based longitudinal integrated clerkships program

Background: Longitudinal integrated clerkships (LICs) receive recognition internationally as effective, innovative alternatives to traditional block rotations (TBRs) in undergraduate medical education. No studies of LICs in the USA have assessed how students perform on all the standardized exams.Aim: To compare performance on standardized tests of students in the first four years of LICs at the University of North Carolina School of Medicine–Asheville (UNC SOM–Asheville) with students from UNC SOM’s Chapel Hill main campus in TBRs.Methods: LIC and TBR students’ previous academic performance was considered using Medical College Admissions Test (MCAT) and United States Medical Licensing Examination (USMLE) Step 1 scores. Step 1 exam tests students’ pre-clinical, basic science knowledge. Outcome measures included all eight standardized National Board of Medical Examiners (NBME) Subject Shelf Examinations and USMLE Step 2 Clinical Knowledge (CK) examinations, which are used widely in the US to assess students’ progress and as prerequisites to eventual licensure. TBR students were selected using propensity scores to match LIC students. Groups were also compared on the required core clinical conditions documented, and on residency specialty choice.Results: Asheville LIC students earned higher scores on the Step 2 CK examination and the six shelf examinations linked to longitudinal clerkships than the matched TBR students (Step 2 CK exam, Family Medicine and Ambulatory Medicine shelf exams reached statistical significance). LIC students logged greater percentages of core conditions than TBR students and more often chose primary care residencies.Conclusions: UNC School of Medicine medical students participating in a longitudinal integrated curriculum in a community setting outperformed fellow students who completed a more TBR curriculum within the school’s academic medical center. Differences were found in performance on standard tests of clinical knowledge (six NBME exams and Step 2 CK exam), documented breadth of clinical experiences, and likelihood of choosing primary care residency programs.

Academic Performance of Longitudinal Integrated Clerkship Versus Rotation-Based Clerkship Students

Prior studies suggest that students on a longitudinal integrated clerkship (LIC) have comparable academic performance to those on a rotation-based clerkship (RBC); however, most of these studies did not adjust for preclerkship academic performance. The objective of this study was to compare the academic performance of LIC and RBC students matched on prior academic performance over a three-year period. Each LIC student in the University of Calgary classes of 2009, 2010, and 2011 (n = 34) was matched with four RBC students (n = 136) of similar prior academic performance. Knowledge and clinical skills performance between the streams was compared. Knowledge was evaluated by internal summative examinations and the Medical Council of Canada Part 1 licensing exam. Clinical skills were evaluated via in-training evaluation report (ITERs) and performance on the clerkship objective structured clinical examination (OSCE). Meta-analysis was used to compare knowledge evaluations and clinical performance for all core clerkship disciplines, and pooled effect sizes from the fixed-effect models were reported. Meta-analyses showed no statistically significant heterogeneity. There were no differences between LIC and RBC students on knowledge evaluations (pooled effect size 0.019; 95% confidence interval [-0.155, 0.152], P = .8), ITERs (pooled effect size -0.015 [-0.157, 0.127], P = .8), or mean OSCE ratings (67.9 [SD = 4.6] versus 68.6 [SD = 5.8], P = .5). After matching on prior academic performance, LIC and RBC students at one school had comparable performance on summative evaluations of knowledge, clinical performance, and clinical skills over three years.

Comparing the Performance in Family Medicine Residencies of Graduates From Longitudinal Integrated Clerkships and Rotation-Based Clerkships

In 2008, the University of Calgary implemented a longitudinal integrated clerkship (LIC) called the Rural Integrated Community Clerkship (RICC), which places students in a rural community for 32 weeks. Research indicates that LIC students perform academically as well as or better than students completing rotation-based clerkships (RBCs). However, little is known about how LIC graduates perform in residency. This study compared residency program director ratings of RICC and RBC graduates. The performance of RICC and RBC graduates (2009-2011) was assessed using a rating form mailed to family medicine residency program directors at the end of graduates' first postgraduate year. Because of sample size and confounding effects of discipline, only the performance of graduates training in family medicine was examined. Data were analyzed using factor analysis, ANOVA, and chi-square. Three hundred sixteen of 399 (80.8%) rating forms were returned. The instrument contained two factors (clinical acumen and human sensitivity) of acceptable reliability (≥ 0.90) plus an overall rating of performance. Of 124 (31.7%) students who matched to family medicine, 101 (81.5%) rating forms (RICC = 22/25; RBC = 79/99) were returned. Program directors rated the performance of RICC graduates to be at least equivalent to their RBC peers on both dimensions. On overall performance, 16/22 (72.7%) RICC graduates and 43/79 (54.4%) RBC graduates were rated as "stronger" or "much stronger" than most residents in the program, P = .30. The performance of RICC graduates was at least equivalent to the performance of their RBC peers.

How Do Graduates of Longitudinal Integrated Clerkships Fare on the Medical Council of Canada Qualifying Exam Part ll?

The longitudinal integrated clerkship (LIC) model has recently become a popular educational model for training clinical clerks. LICs permit students to train in multiple disciplines concurrently and typically in rural practice sites. Because little is known about how graduates of LIC programs fare in residency, the purpose of this study was to compare the clinical performance of residents who graduated from rural longitudinal integrated and urban rotation-based clerkships on the Medical Council of Canada Qualifying Exam Part ll (MCCQE Part ll) taken 16 months into residency. Participants included medical school graduates from the classes of 2009, 2010 and 2011 at the University of Calgary. Each of the 34 LIC students were prospectively matched (first on Medical Skills ll course performance, then grade point average) with 4 students from the traditional rotation-based (RB) stream to serve as controls (n = 136). A dataset containing 170 graduates was forwarded to the Medical Council of Canada (MCC) who subsequently supplied MCCQE Part ll pass/ fail status and total score for each resident, and returned the dataset for our analysis. Data were analyzed using chi-square and analysis of variance. The final dataset for analysis consisted of 30 (88%) LIC graduates and 115 (85%) RB graduates. Analysis revealed a similar MCCQE Part ll pass rate for LIC (28/30; 93.3%) and RB (107/115; 93.0%) graduates, p > 0.05. The MCCQE Part ll mean total score for the LIC graduates (M = 527.4; SD = 64.3) did not differ from the mean total score (M = 529.9; SD = 61.4) reported by the RB graduates, F = 0.04, p = 0.85. Completing the majority of clerkship in a rural community over an extended period allowed LIC graduates to perform as well as their peers on a measure of clinical skills taken 16 months into residency.

Using tablets to support self-regulated learning in a longitudinal integrated clerkship

IntroductionThe need to train physicians committed to learning throughout their careers has prompted medical schools to encourage the development and practice of self-regulated learning by students. Longitudinal integrated clerkships (LICs) require students to exercise self-regulated learning skills. As mobile tools, tablets can potentially support self-regulation among LIC students.MethodsWe provided 15 LIC students with tablet computers with access to the electronic health record (EHR), to track their patient cohort, and a multiplatform online notebook, to support documentation and retrieval of self-identified clinical learning issues. Students received a 1-hour workshop on the relevant features of the tablet and online notebook. Two focus groups with the students were used to evaluate the program, one early and one late in the year and were coded by two raters.ResultsStudents used the tablet to support their self-regulated learning in ways that were unique to their learning styles and increased access to resources and utilization of down-time. Students who used the tablet to self-monitor and target learning demonstrated the utility of tablets as learning tools.ConclusionsLICs are environments rich in opportunity for self-regulated learning. Tablets can enhance students’ ability to develop and employ self-regulatory skills in a clinical context.

Profiles of rural longitudinal integrated clerkship students: A descriptive study of six consecutive student cohorts

Background: Medical schools worldwide are challenged to address the rural primary care workforce shortage by creating community-engaged curricula to nurture student interest in rural practice.Aim: To examine the personal characteristics of six consecutive rural longitudinal integrated clerkship student cohorts to understand whom the programs attract and select and thus inform the development of such programs.Method: A cross-sectional cohort design was used. Six cohorts (2007–2012) completed a survey on demographics and factors that influenced their choice of rural primary care. The Temperament and Character Inventory was used to measure personality. Analysis was mainly descriptive. Where appropriate univariate analysis compared variables between groups.Results: Sample size was 205 with the majority female (61%), between 25 and 29 years (64%), single (60%) and lived longest in rural communities with populations less than 20,000 (60%).Rural lifestyle, background and desire to work in underserved areas were noted to impact rural medicine interest. Professional satisfaction, personal and professional goals and family needs had the highest impact on career decisions, and financial concerns lowest.Conclusion: The stability of students’ personal characteristics across cohorts and the workforce outcomes of this program suggest the recruitment process successfully nurtures students who will fit well into future rural practice.

Exposure and attitudes toward interprofessional teams: a three-year prospective study of longitudinal integrated clerkship versus rotation-based clerkship students

This study explored exposure to, and attitudes toward, interprofessional (IP) teams between third-year longitudinal integrated clerkship (LIC) and traditional rotation-based clerkship (RBC) students at the University of Calgary medical school. Students completed a survey pre-post 32-week LIC or 6-week rural, regional or urban RBC family medicine rotations. Pre and post rotation surveys were completed by 213 (48%) students (LIC = 33/34; rural = 76/152; regional = 24/46; urban = 80/208). More LIC students (76%) reported participating on six or more IP teams than RBC students (rural = 38%; regional = 25%; urban = 21%). At pre rotation, the mean attitude to IP teams score of LIC and rural RBC students was high and did not differ. At post rotation, the mean attitude score of LIC students was significantly greater than the mean reported by rural RBC students. Only LIC students reported a significant pre-post rotation increase in attitude. Exposure to IP teams, possibly facilitated by a longer duration of rotation, appears to be an important factor in affecting attitude to IP teams.

Patient views of continuity relationships with medical students

Introduction: Continuity relationships between students and patients, that occur in a longitudinal integrated clerkship (LIC), enrich medical students’ opportunities to learn from patients and provide patient-centered care. Patient preferences for continuity with a primary provider are well-documented, but little is known about patients’ experiences of continuity with students. This study examines patients’ perception of continuity with and care received by students.Methods: This qualitative study uses data from semi-structured interviews with 32 patients of LIC students at an academic medical center. Data were analyzed for themes about continuity and experiences of care provided by students.Results: Patients valued relationships with students over time and across settings. Students’ contributions to their care included enhanced access to and coordination of care, communication, patient education and wellbeing. Patients with substantial continuity and/or who were moderately or severely ill described their student in a physician-like role more frequently than other patients. Patients appreciated patient-centered attitudes and behaviors in their students.Conclusion: Patients value continuity relationships with students, akin to that described between patients and their physicians. Patients described a variety of ways in which students enhanced their care and assumed a physician-like role. These patient perceptions support the concept of mutually beneficial relationships between students and patients.

Outcomes of Different Clerkship Models

To examine student perceptions and learning outcomes of three different third-year clerkship models: a yearlong, longitudinal, integrated clerkship (LIC); six-month clerkships with continuity (hybrid); and traditional, discipline-specific block clerkships (BCs). The authors compared the perceptions regarding the clerkship year and the hidden curriculum, as well as the pre- and postclerkship academic performance, of third-year medical students participating in LIC, hybrid, and BC models between 2006 and 2010. Generally, LIC students rated the following clerkship experiences higher than did the hybrid and BC students: faculty teaching, faculty observation of clinical skills, feedback, and the clerkship overall. Students in the LIC observed more positive role-modeling behaviors and had more patient-centered experiences than BC students. All students preferred to see patients more than once, work within a consistent site or system, and work with a stable group of peers and faculty mentors over time. Whereas students in both the LIC and the hybrid models outperformed their BC counterparts in clinical skills, student performance on the U.S. Medical Licensing Exam Step 2 (clinical knowledge) was equivalent across models. Key differences in student experiences and outcomes between the continuity clerkship models (LIC and hybrid) and BCs reinforce the literature and the educational framework for continuity in clinical learning. The benefits to student outcomes seem to increase with greater opportunities for continuity.