longitudinal integrated clerkships Into the future: patient-centredness endures in longitudinal integrated clerkship graduates Elizabeth Gaufberg,1,2,* David Hirsh,1,2,* Edward Krupat,1 Barbara Ogur,1,2 Stephen Pelletier,1 Deborah Reiff2 & David Bor1,2
OBJECTIVES This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time. METHODS The authors’ earlier work compared the 27 graduates in the first three cohorts of students undertaking the CIC with a comparison group of 45 traditionally trained HMS students; CIC graduates emerged from their clerkship year with a higher degree of patient-centredness and felt more prepared to deal with numerous domains of patient care. Between April and July 2011, at 4–6 years post-clerkship, the authors asked these original study cohorts to complete an electronic survey which included measures used in the original study. The authors also reviewed data from the National Residency Match Program to compare career paths in the two groups.
RESULTS The response rate was 62% (42/68). The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time (p < 0.035). Reflecting retrospectively on their clerkship experiences, CIC graduates continued to report that their clerkship year had better prepared them in a wide variety of domains. Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work. Both groups chose a wide range of residency programmes. Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship. CONCLUSIONS This paper indicates that benefits of longitudinal integrated clerkship training are sustained over time across multiple domains.
Medical Education 2014; 48: 572–582 doi: 10.1111/medu.12413 Discuss ideas arising from the article at “www.mededuc.com discuss”
1 2
Harvard Medical School, Boston, Massachusetts, USA Cambridge Health Alliance, Cambridge, Massachusetts, USA
*These authors share joint first authorship of this paper.
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Correspondence: Dr Elizabeth Gaufberg, Department of Medicine and Psychiatry, The Cambridge Health Alliance, 1493 Cambridge St, Cambridge, Massachusetts 02139, USA. Tel: +1 617 665 3101; E-mail: [email protected]
ª 2014 John Wiley & Sons Ltd. MEDICAL EDUCATION 2014; 48: 572–582
Longitudinal integrated clerkships and patient-centredness
INTRODUCTION
Longitudinal integrated clerkship (LIC) models of clinical medical education are proliferating worldwide.1,2 Three principles define these relationship-centred clinical curricula: medical students participate in the comprehensive care of patients over time; students establish continuing learning relationships with these patients’ clinicians, and students meet the majority of the year’s core clinical competencies across multiple disciplines simultaneously.2,3 Some institutions adapt the LIC design to address workforce deficiencies or expand options for clinical training sites.4 Others posit that LICs may serve to improve the quality and safety of care, and to train leaders in health system redesign.5 Harvard Medical School (HMS) designed the Cambridge Integrated Clerkship (CIC) to improve the learning and retention of science and clinical medicine and to foster humanism and patient-centredness.1,6–11 To date, nearly 60 published studies demonstrate short-term successes of these models.12 Our study of the first three cohorts of CIC graduates shows that in comparison with traditionally trained HMS students, CIC students performed at least as well or better on measures of medical knowledge and clinical skills, reported higher satisfaction with their learning environment and greater confidence in dealing with numerous domains of patient care, and emerged from their clerkship year with a higher degree of patientcentredness.10 Patient-centredness is a central professional value.13 The literature demonstrates that patientcentredness is associated with satisfaction with care, patient adherence to medical advice and a variety of objectively measured health outcomes.14–18 Our previous investigations demonstrated that patient-centred values, as assessed by the Patient– Practitioner Orientation Scale (PPOS), increased over the course of the integrated clerkship experience but declined among those who followed a traditional course of study.10 Thus, the typical pattern of ‘ethical erosion’19–25 – an expression used in the literature to denote the erosion of ethicsrelated sensibilities, empathy and patient-centredness during clinical training – appears to be reversed in the CIC cohort. We sought to discover whether these differences would be sustained or whether they would disappear with exposure to a traditional Year 4 curriculum, residency and practice.
This paper reports the results of a follow-up of CIC graduates at 4–6 years after completion of the programme and compares outcomes in this group with those in the traditionally trained student group from our initial 3-year trial. We assess the attitudes and perceptions of the CIC graduates and their counterparts, as well as their postgraduate activities. We compare the cohorts longitudinally and conduct between-group, cross-sectional comparisons at the time of data collection. In particular, we address three questions: (i) Do clerkship graduates maintain their patient-centred beliefs 4–6 years after completing their clerkship? (ii) Do clerkship graduates maintain their perceptions about their clerkship experience? (iii) What residency specialties do clerkship graduates choose and in which post-clerkship professional activities do they engage? This is the first paper to compare the patient-centredness of LIC and traditionally trained graduates, along with characteristics in the other domains, over an extended period. We discuss our findings in light of three educational principles: relational learning, reflection on practice, and advocacy as a professional duty.
METHODS
Participants During its first 3 years of operation (2004–2005, 2005–2006 and 2006–2007), the CIC represented an educational pilot undertaken by a total of 27 students over the 3 years. For each of those years, we recruited a comparison (COM) group of HMS students (total: n = 45), who rotated through traditional discipline-based clerkships among our major teaching hospitals. As has been described previously,7,10 more students identified the CIC as their first preference than could be accommodated; the HMS registrar randomly selected students to enter the CIC from the pool of volunteers who had requested to participate in the CIC. The COM group comprised students who were not selected but had volunteered for the CIC. These were supplemented by other third-year volunteers on traditional clerkships. As an incentive, the COM group received credit for the equivalent of a 2-week elective. There were no significant between-group differences (CIC group versus COM group) on a variety of baseline measures prior to the beginning of the clerkship year, including Medical College Admission Test (MCAT) scores, US Medical Licensing Examination (USMLE) Step I scores, HMS Year 2
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E Gaufberg et al objective structured clinical examination (OSCE) scores, plans for future practice, and patient-centred beliefs assessed using the PPOS, a well-validated instrument.25,26 Whereas previous papers have reported on the endof-clerkship differences between the CIC and COM groups,7,10 this paper compares the two groups’ responses at 4–6 years after respondents had completed their principal clinical year. We collected these follow-up data between April and July 2011. For this study, we identified and contacted the three original CIC and COM cohorts by e-mail and requested that participants complete an online survey. We were unable to obtain contact information for four students (all in the COM group). The institutional review boards of HMS and the Cambridge Health Alliance considered this study exempt from requirements for formal ethical approval. Data collection The electronic survey instrument requested basic demographic information and asked about participants’ attitudes, perceptions and current activities. In order to make data comparable over time, wherever possible, questions were identical to those that had been asked of participants when they were students and which have been reported in past papers.7,10
and accomplishments in areas such as research, publications, awards, scholarships, graduate degrees, fellowships or other areas of activity or accomplishment. Lack of response on free-text questions was assumed to represent non-involvement in the given area. Finally, we obtained residency matching data for all of the students who had been in the original CIC and COM groups from National Residency Match Program (NRMP) reports to determine the career paths they had taken. Data analysis The data reported here represent mean scores and frequencies for the three follow-up cohorts of CIC students in combination and the three follow-up cohorts of COM students in combination. For all parametric data, we conducted independent t-tests and calculated effect sizes to compare the two follow-up cohorts. In addition, in instances in which we had asked identical questions, we compared the responses of each current group at follow-up with the responses they had provided during their third year using repeated-measures t-tests. The number of CIC respondents totalled 20 and that of COM respondents amounted to 22, but in our analysis the cohorts were as small as 19 and 21, respectively, as a result of missing data.
RESULTS
The respondents completed the PPOS,25,26 the instrument to which they had responded at the beginning and end of their clerkship year. In addition, using a 6-point Likert scale, graduates were asked to indicate how well they currently believed that their clerkship experiences had prepared them to practise in 18 different domains central to doctoring (e.g. dealing with ethical dilemmas; involving patients in decision making; knowing one’s own strengths and weaknesses), 16 of which were identical to those in the original items. In a parallel vein, respondents also made nine ratings (on a 6-point scale) indicating the extent to which various adjectives or phrases characterised their clerkship learning environment, six of which were identical to the original items (e.g. how stressful, satisfying or confidence building they found the environment to be), and then made the same ratings in reference to the graduate medical training programmes they were in or had been in. To assess a global reaction to their former programmes, we asked respondents which form of Year 3 programme they would choose in retrospect. Respondents also reported in free-text write-in format on their post-clerkship experiences
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Of the original 45 students who participated in the COM group, we were able to locate contact information for 41. Twenty-two of the 41 individuals to whom the survey was sent responded, giving a COM response rate of 54%. We were able to locate contact information for all 27 CIC graduates and 20 (74%) responded. The overall response rate to our survey was therefore 62% (42/68). At the time of follow-up, at 4–6 years after completion of the clerkship year, all respondents had completed medical school and most were in residency or had completed residency. As match data derive from publicly available information, data for all COM and CIC students were included, regardless of whether they were surveyed or responded at follow-up. In order to determine whether the responding sample was representative of the original clerkship participants, and whether the follow-up groups were themselves still similar (as they had been at the preclerkship baseline), we tested for differences in age, gender, year of clerkship completion, and current level of training, as well as for the original baseline
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Longitudinal integrated clerkships and patient-centredness variables (MCAT, USMLE Step I scores, HMS Year 2 OSCE scores, plans for future practice and PPOS scores). No significant between-groups (CIC versus COM at the current time) or within-groups (COM baseline versus COM current, and CIC baseline versus CIC current) differences were found on any of these variables. Maintenance of patient-centred beliefs As previously reported,10 the CIC students’ level of patient-centredness (as measured by the PPOS) showed no statistically significant difference with that of the COM group at the beginning of the clerkship year. At the end of the clerkship year, CIC students’ scores had increased and traditionally trained students’ scores decreased, with the result that CIC students were significantly more patientcentred.10 As Fig. 1 shows, our follow-up data indicate that levels of patient-centredness in both the CIC and COM groups remained constant over time so that the difference between the groups remained significant (p = 0.035; effect size = 0.33). Maintenance of perceptions about clerkship experiences Table 1 contains the previously published10 end-ofclerkship mean responses on perceived preparedness, with standard deviations and effect sizes, alongside the corresponding values for the CIC and COM cohorts at follow-up. On all 13 items
6.00
on which significant differences had been detected immediately post-clerkship, the findings remained significant at follow-up; 12 of these ratings indicated greater perceived preparedness on the part of the CIC students (the one exception referred to preparedness ‘…to practise in a hospital setting’). Whereas we found no differences in perceived preparedness to integrate basic science and clinical practice at the end of the clerkship year, follow-up ratings from CIC students indicated that they felt they had been significantly better prepared. Two items added to the follow-up survey, about understanding the role of the patient’s family and being the patient’s advocate, also showed significantly greater perceived preparedness on the part of CIC students. Ratings of the clerkship learning environment at follow-up are also consistent with findings at the end of the clerkship year (Table 2). Graduates of the CIC recalled their clerkship experience as more satisfying, more confidence-building, more humanising, and more transformational than did the COM group. By contrast with the earlier findings, although the CIC experience was described as significantly more stressful immediately post-clerkship, this difference disappeared in the retrospective reports, and, whereas COM graduates had reported their experience as more marginalising immediately post-clerkship, this difference was not found in the retrospective data. In questions added to the followup survey, CIC and COM graduates did not differ
CIC COM
5.00
5.10
5.11
5.00 4.87
4.78
4.78
4.00
3.00 Pre-clerkship
Post-clerkship
Follow-up
Figure 1 Comparison of pre- and post-clerkship mean scores of 27 Harvard Medical School–Cambridge Integrated Clerkship (CIC) students and 40 traditionally trained comparison group (COM) students on the Patient–Practitioner Orientation Scale (PPOS), which measures patient-centredness on a 6-point scale. All study participants engaged in their clerkship year at Harvard Medical School during 2004–2007. The graph is extended to compare PPOS scores of 19 CIC and 21 COM students 4–6 years later. For scores pre-clerkship, p = 0.239; for scores immediately post-clerkship, p = 0.011; for follow-up scores 4–6 years later, p = 0.035.
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Table 1 Graduates’ self-assessments of their clerkship’s influence upon their preparation for practice: Harvard Medical School (HMS) student participants in the 2004–2007 Cambridge Integrated Clerkship (CIC) and traditionally trained HMS students in a comparison group (COM) were surveyed immediately post-clerkship and at 4–6 years later
Perceptions of clerkship experiences
Perceptions of clerkship experiences at
immediately post-clerkship
4–6 years follow-up†
Topical areas of students’
CIC group
COM group
p-value,
CIC group
COM group
p-value,
perceived preparedness*
Mean SD
Mean SD
t-test (ES)
Mean SD
Mean SD
t-test (ES)
Readiness for practice Practice in the hospital setting
4.63 0.883
5.07 0.764
< 0.05 (0.533)
4.42 1.170
5.19 0.928
< 0.05 (0.729)
Practice in the ambulatory setting
5.89 0.320
4.22 1.074
< 0.001 (2.107)
5.74 0.452
3.95 1.284
< 0.001 (1.860)
Have the knowledge base
5.11 0.847
4.47 0.751
< 0.005 (0.799)
5.42 0.692
4.81 1.078
< 0.05 (0.673)
4.30 1.137
4.57 1.035
0.303 (0.248)
5.47 0.612
4.81 0.873
< 0.01 (0.876)
4.89 1.121
4.97 0.974
0.739 (0.076)
5.05 1.026
5.05 0.973
0.987 (0)
necessary to be a competent practitioner Integrate basic science and clinical practice‡ Practise evidence-based medicine Self-awareness and reflective practice Be a self-reflective practitioner
5.70 0.609
4.62 1.213
< 0.001 (1.125)
5.79 0.535
4.90 1.261
< 0.01 (0.919)
Deal with ethical dilemmas
5.33 0.734
4.17 1.375
< 0.001 (1.052)
5.68 0.478
4.43 1.248
< 0.001 (1.323)
Know your strengths and
5.44 0.801
4.85 1.001
< 0.05 (0.651)
5.42 0.961
4.62 1.244
< 0.05 (0.720)
5.48 0.643
4.55 1.108
< 0.001 (1.027)
5.63 0.597
4.67 1.138
< 0.005 (0.987)
5.93 0.267
5.07 1.163
< 0.001 (1.109)
5.89 0.315
5.14 1.108
< 0.01 (0.920)
Involve patients in decision making
5.59 0.694
4.55 1.131
< 0.001 (1.108)
5.63 0.597
4.81 1.078
< 0.01 (0.941)
Relate well to a diverse patient
5.96 0.192
4.72 1.086
< 0.001 (1.590)
5.84 0.375
5.05 0.973
< 0.005 (1.071)
5.74 0.526
5.07 0.859
< 0.005 (0.941)
5.79 0.419
5.09 0.700
< 0.001 (1.213)
Not asked
Not asked
–
5.58 0.692
4.86 1.062
< 0.05 (0.803)
5.52 0.643
5.47 0.847
0.88 (0.066)
5.53 0.697
5.24 0.700
0.20 (0.415)
limitations Deal with patient problems that do not have clear answers Relational skills Be truly caring in dealing with patients
population Relate to people at different stages of the lifecycle Understand the role of the patient’s family in their care Work successfully with other health professionals as a team member Context and advocacy Be the patient’s advocate
Not asked
Not asked
5.89 0.459
5.05 0.921
< 0.001 (1.154)
Understand how the health care
5.26 0.859
4.07 1.328
< 0.001 (1.064)
–
5.00 1.00
4.00 1.673
< 0.05 (0.725)
5.89 0.320
4.67 1.022
< 0.001 (1.610)
5.89 0.315
4.76 1.179
< 0.001 (1.309)
system works See how the social context affects patients and their problems
*‘At this point, how well do you believe that your third-year medical school experience helped you to…?’. (1 = it prepared me very poorly; 6 = it prepared me very well). †Immediately post-clerkship, the total number of CIC respondents is 27 and COM respondents is 40. In follow-up, the total number of CIC respondents is 20 and COM respondents is 22, but numbers may fall to as low as 19 in the CIC group and 21 in the COM groups as a result of missing data. ‡This domain showed the only statistically significant change over time using 2 9 2 analysis of variance. SD = standard deviation; ES = effect size.
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Longitudinal integrated clerkships and patient-centredness
Table 2 Graduates’ descriptions of their medical school clerkships’ and residency programmes’ learning environments: Harvard Medical School student participants in the 2004–2007 Cambridge Integrated Clerkship (CIC) and a comparison group (COM) were surveyed immediately post-clerkship and 4–6 years later
Perceptions of clerkship experience at end of
Perceptions of clerkship experience at
Perceptions of graduate medical education/
clerkship
follow-up*
training experience†
Descriptions of
CIC group
COM group
p-value,
CIC group
COM group
p-value,
CIC group
COM GROUP
p-value,
clerkship
Mean SD
Mean SD
t-test (ES)
Mean SD
Mean SD
t-test (ES)
Mean SD
MEAN SD
t-test (ES)
Confidence-building
4.96 1.055
3.87 1.471
< 0.005 (0.851)
5.21 0.855
4.52 1.123
< 0.05 (0.691)
4.83 1.150
4.86 1.153
0.949 (0.026)
Humanising
5.44 0.698
3.88 1.223
< 0.001 (1.566)
5.68 0.583
4.52 1.631
< 0.005 (0.947)
3.67 1.328
3.81 1.861
0.782 (0.086)
Stressful
5.26 0.764
4.62 0.952
< 0.005 (0.741)
4.16 1.214
4.19 1.078
0.929 (0.026)
5.11 0.900
4.71 0.956
0.193 (0.430)
Satisfying
5.41 0.888
4.67 0.917
< 0.005 (0.819)
5.50 0.707
4.71 1.270
Marginalising
1.89 1.251
3.43 1.394
< 0.001 (1.163)
1.89 1.370
2.62 1.322
Transformational
5.44 0.847
4.62 1.390
< 0.01 (0.712)
5.00 1.054
4.24 1.338
Good preparation
Not asked
Not asked
–
4.16 1.537
4.86 1.062
Not asked
Not asked
–
5.68 0.582
4.71 1.231
Not asked
Not asked
–
5.53 0.612
4.76 1.513
< 0.05 (0.768) 0.097 (0.542) < 0.05 (0.631)
4.44 1.149
4.76 1.136
0.392 (0.280)
2.56 1.338
2.19 1.167
0.369 (0.295)
4.72 1.364
4.57 1.248
0.721 (0.115)
Not asked
Not asked
–
< 0.005 (1.01)
5.06 1.056
4.95 1.359
0.795 (0.090)
< 0.05 (0.667)
5.17 0.857
5.00 1.183
0.623 (0.165)
0.100 (0.529)
for internship Good preparation for doctoring Valuable in informing my future career choice
*Describing the learning environment: ‘At this point, how well would you say that the following adjectives describe your third-year medical school experience?’ (1 = describes it not at all; 6 = describes it extremely well). †Describing the learning environment: ‘At this point, how well would you say that the following adjectives describe your internship and residency experiences?’ (1 = describes it not at all; 6 = describes it extremely well). SD = standard deviation; ES = effect size.
on whether their experience represented ‘good preparation for internship’. However, CIC graduates believed more strongly than the COM group that the clerkship experience provided good preparation for doctoring and was valuable for informing future career choice.
enough information to answer. A total of 85% (n = 17) of the CIC graduates indicated that they would choose an LIC programme again, 15% (n = 3) indicated that they did not have enough information to answer, and none indicated that they would choose a traditional programme.
By contrast with the differences found in their ratings of their undergraduate clerkship experiences, there were no significant differences between CIC and COM graduates’ ratings on any of the eight descriptors referring to residency programmes.
Post-clerkship professional activities
When asked what kind of programme they would choose if they had the opportunity to do so again, 50% (n = 11) of the COM graduates reported that they would choose a traditional clerkship programme again, 27% (n = 6) that they would choose a longitudinal integrated programme, and the remainder (n = 5) indicated that they did not have
At follow-up, 50% (n = 10) of the CIC graduates indicated that they had been involved in social justice or health advocacy work, compared with 23% (n = 5) of the COM group (p = 0.03). For both CIC and COM graduates, their involvement occurred both within and outwith opportunities provided by their residency programmes. There were no statistically significant differences between the two groups in the percentage of students indicating involvement in research, publications, awards, scholarships, graduate degrees, fellowships or other areas of activity or accomplishment.
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E Gaufberg et al Match data indicated that graduates of both groups chose a wide range of residency training programmes, in both surgical and non-surgical specialties, and that there were no statistically significant differences between the groups for any individual choice (Table 3). When we combined several primary care-oriented residency programmes (family medicine and primary care tracks in internal medicine and paediatrics), we found that 26% (n = 7) of the 27 CIC graduates and 7% (n = 3) of the 45 COM graduates were matched in these programmes (p = 0.01). Students’ pre-clerkship preferences and the incidence of switching specialties after the initial match choice could not be assessed.
DISCUSSION
There appear to be differences and benefits of the CIC that continue into residency and practice. We organise our discussion to address three domains: the maintenance of patient-centred beliefs, perceptions about the clerkship experience, and post-clerkship activities.
Maintenance of patient-centred beliefs: relationships, reflection and advocacy Our PPOS data demonstrate consistency from the immediate end of the clerkship year to the measurement of attitudes 4–6 years later, with almost identical mean scores for each group over time, a significant between-groups difference at follow-up, and moderate effect size. Although we cannot be certain that the higher mean scores on the PPOS of CIC graduates reflect a clinical difference, several studies have demonstrated that differences in PPOS scores are associated with differences in patient-related behaviour.27,28 Regardless, the fact that the pattern is maintained at 4–6 years later seems noteworthy. These data may address concerns that the impact of the third year might diminish or disappear after the CIC students were thrust back into the ‘real world’. We hypothesise that CIC graduates’ clerkship experiences may help to ‘immunise’ them against the adverse influences of advanced graduate and postgraduate training. We propose that three factors in
Table 3 Specialty choices of 27 Harvard Medical School (HMS) Cambridge Integrated Clerkship graduates (CIC) and a comparison group (COM) of 45 traditionally trained HMS students from National Residency Match Program data
Specialty
578
CIC group (n = 27)
COM group (n = 45)
p-value, t-test
Anaesthesiology
0
4 (8.9%)
0.145
Dermatology
1 (3.7%)
0
0.397
Emergency medicine
4 (14.8%)
1 (2.2%)
0.059
Family medicine
2 (7.4%)
0
0.133
Internal medicine, primary care
3 (11.1%)
3 (6.7%)
0.417
Internal medicine, categorical
2 (7.4%)
9 (20.0%)
0.136
Neurology
1 (3.7%)
0
0.397
Obstetrics and gynaecology
1 (3.7%)
4 (8.9%)
0.359
Ophthalmology
0
1 (2.2%)
0.394
Orthopaedic surgery
0
3 (6.7%)
0.221
Otolaryngology
0
1 (2.2%)
0.394
Paediatrics, primary care
2 (7.4%)
0
0.133
Paediatrics, categorical
2 (7.4%)
7 (15.6%)
0.258
Physical medicine/rehab
1 (3.7%)
0
0.397
Psychiatry
4 (14.8%)
2 (4.4%)
0.133
Radiation oncology
0
1 (2.2%)
0.394
Radiation diagnostic
2 (7.4%)
2 (4.4%)
0.496
Surgery
1 (3.7%)
1 (2.2%)
0.356
Internal medicine, paediatrics
0
1 (2.2%)
0.394
Other/not yet matched
1 (3.7%)
5 (11.1%)
0.255
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Longitudinal integrated clerkships and patient-centredness their clerkship experiences may contribute to the sustained patient-centredness: (i) relational learning; (ii) reflection on practice; and (iii) advocacy as a professional duty. Relational learning The CIC is structured around students’ longitudinal relationships with patients and their family members, with faculty mentors and their practice environments, with student peers, and with the local community.6 This ‘educational continuity’6,7 allows for and upholds a relationship-centred curriculum, an educational structure intentionally designed to motivate students’ patient-centredness and to create patient-centred roles for students as a way to foster the learning and retention of science and clinical medicine. The longitudinal integrated design affords CIC students authentic and meaningful roles in patient care7,10,29–32 and students report that their motivation to learn derives in large part from their sense of duty and connection to their patients.8,10,32 This internal motivation,31–33 which is aligned with their values, stands in contrast with other common external motivators such as grades or fear of humiliation on rounds.34,35 Longitudinal iterative feedback within the CIC reinforces relational skill development and collaborative teamwork, both of which are central goals of students’ clinical learning. Reflection on practice Patient-centredness depends upon self-awareness and the ability to make connections between values and actions. CIC graduates regarded their clerkship experience as more effective in conveying these skills of ‘reflective practice’ than their colleagues in traditional programmes and the differences were found to remain years later. A core CIC curricular element that supports these attributes is a year-long, developmentally progressive reflective practice curriculum designed to connect closely to students’ workplace learning needs rather than merely functioning as a separately maintained safe space. The CIC intentionally supports the practice of reflection over the course of a year in clinical and non-clinical (reflective space) venues and hence the daily work and the overarching patient-centred ‘themes’ are confluent and mutually reinforcing. In the CIC, reflection is learned and practised as a core clinical skill. We speculate that the CIC structure’s pervasive support of these habits of reflection sustains and even fosters patient-centredness.
Advocacy as a professional duty Graduates of the CIC were found to be more often involved in social justice and health advocacy activities than their traditionally trained counterparts and to feel that the clerkship prepared them for success in this domain. During the CIC year, students gain intimate knowledge of patient–system interactions and the social determinants of patient health and illness. This first-hand experience draws them naturally to the role of advocate.8,10,30,32 To refine and support the students’ emerging advocacy skills, the CIC delivers a health advocacy curriculum led by doctor role models engaged in this work. The programme, faculty and institution also encourage CIC students to openly identify disconnects between formal and hidden curricular messages, and support students to be agents of positive cultural change in their learning community. Our data imply that in this era of health system redesign, the CIC may foster the development of well-trained and motivated graduates who seek to drive health care system change.5,11,32 Maintenance of perceptions about the clerkship experience At 4–6 years post-clerkship, CIC graduates continue to describe their experiences affirmatively, expressing a more positive sense of their clerkship’s contribution to their future preparedness than their traditionally trained counterparts. The results are not only statistically significant, but the effect sizes are generally in the range considered moderate to large. In fact, both groups’ recollections of the learning environment and its influence on their preparedness for medical practice are remarkably consistent with their impressions at the end of their third year. Although it might be possible to ask whether the perceptions of CIC students at year-end may have been unrealistically positive, the positivity of their perceptions remains remarkably strong when viewed in light of subsequent clinical experience. Moreover, the possibility of accounting for this finding by citing the ‘Pollyanna effect’36 (the tendency to demonstrate a generally positive response bias), is made unlikely by our findings of the graduate medical programme ratings; CIC graduates were no different – neither more positive nor more negative – in their ratings of their residency training programmes. Interestingly, with hindsight, CIC graduates recall their clerkship experience as less stressful than they had at the end of the year, and COM graduates
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E Gaufberg et al recall theirs as less marginalising than they did immediately post-clerkship. Perhaps these earlier negative perceptions were extinguished by subsequent experiences in residency training. Post-clerkship professional activities: what they do and how they do it A critical test of a clerkship experience is the degree to which it sets a pathway toward career success. Compared with their traditionally trained peers, CIC graduates retrospectively report that their clerkship experience was more valuable in informing career choice. We sought to know more about the paths they took following the programme. Graduates of the CIC report achievements in traditionally valued realms, such as in the receipt of awards and fellowships, and the authoring of scholarly publications, as often as their traditionally trained peers do. Like their COM counterparts, CIC graduates choose a wide variety of careers, with some preferring fields considered to be more relational, and at the same time CIC students report a significantly greater sense of preparedness to integrate clinical practice with its basic science underpinnings. Although there are no significant differences in the fields chosen at graduation, data combined post hoc suggest more CIC students matched initially in primary care specialties (family medicine, and primary care tracks in internal medicine and paediatrics). However, these initial match data do not include students who switched fields, and we do not yet know about ultimate practice or subsequent specialisation. It would be premature to draw conclusions as to whether CIC graduates enter the primary care workforce in greater or lesser proportion than their non-longitudinally trained peers. Optimistically, we believe that these results may indicate that CIC training might very well represent the best of both worlds, providing solid preparation for a variety of specialties and allowing the patient-centred ethos of the graduates to permeate their work. Limitations Limitations temper the generalisability of our findings. This was a study of small cohorts at a single institution with a follow-up period of only 4–6 years. We could not enlarge the cohorts by extending the study through additional years of observation because HMS adopted aspects of longitudinality throughout its curriculum after the third year of this innovation and thus no equivalent control groups could be recruited. We hope to follow subsequent CIC cohorts
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over time and track their perceptions and career paths to enlarge the sample size. In all 3 years in which CIC and COM data were collected, there were no discernible baseline differences between the groups across a range of relevant measures. We cannot exclude the possibility that other unmeasured and undetected differences might exist between the two groups and account for differences found in our outcome measures. Although we found no differences between respondents and non-respondents in either group, there remains the possibility of self-selection bias among those who consented to respond to the survey. Additionally, we cannot isolate the role of the curriculum per se from the influences of the culture of the public hospital in which the CIC functions. Nonetheless, if venue is so powerful and effective, educators should remain open to the potential advantages to be derived by situating training outside traditional settings. Finally, we cannot know whether these findings are predictive of these doctors’ values, behaviours or practice choices even further into the future.
CONCLUSIONS
Longitudinal integrated clerkships are rapidly growing in size, number and diversity nationally and internationally. Evidence exists that LICs advance our profession’s social accountability mission and can address workforce distribution.37 Our findings contribute to the evidence that LICs stimulate learners to become the humanistic doctors and agents of change our society demands and deserves.5 This study stands alongside those reporting the benefits of LICs in the realms of learning and professional development.7,10–12,27,30–32,38 It is the first to demonstrate that those benefits are sustained over time.
Contributors: EG, DH and DB contributed to the study conception and design, the design of the survey tool and the interpretation of data. EK contributed to the study conception and design, particularly of the methods, and to the analysis and interpretation of data. BO contributed to the study conception and design, and the interpretation of data. SP contributed to the analysis, interpretation and presentation of data. DBR contributed to the acquisition and analysis of data. EG, DH and DB led the drafting and revision of the article, in which all authors participated. All authors approved the final manuscript for submission. Acknowledgements: the authors thank the Arnold P Gold Foundation. In particular, EG is grateful for an Arnold P Gold Foundation professorship. The authors also wish to
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Longitudinal integrated clerkships and patient-centredness acknowledge the Cambridge Health Alliance, Harvard Medical School, and the Consortium of Longitudinal Integrated Clerkships for their support. Funding: none. Conflicts of interest: none. Ethical approval: this study was considered exempt from requirements for ethics approval by the institutional review boards of the Cambridge Health Alliance and Harvard Medical School.
REFERENCES 1 Strasser R, Hirsh D. Longitudinal integrated clerkships: transforming medical education worldwide? Med Educ 2011;45:436–7. 2 Poncelet A, Hirsh D, chapter editors. Longitudinal integrated clerkships. In: Morgenstern BZ, ed. Guidebook for Clerkship Directors. Alliance for Clinical Education, 4th edn. North Syracuse, NY: Gegensatz 2012;173–224. 3 Hirsh D, Walters L, Poncelet AN. Better Learning, Better Doctors, Better Delivery System: Possibilities from a case study of longitudinal integrated clerkships. Med Teach 2012;34 (7):548–54. 4 Worley P, Silagy C, Prideaux D, Newble D, Jones A. The Parallel Rural Community Curriculum: an integrated clinical curriculum based in rural general practice. Med Educ 2000;34:558–65. 5 Berwick DM, Finkelstein JA. Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new ‘public interest’. Acad Med 2010;85 (Suppl):56–65. 6 Hirsh DA, Ogur B, Thibault GE, Cox M. ‘Continuity’ as an organising principle for clinical education reform. N Engl J Med 2007;356 (8):858–66. 7 Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School–Cambridge Integrated Clerkship: an innovative model of clinical education. Acad Med 2007;82 (4):397–404. 8 Gaufberg E, Shtasel D, Hirsh D, Ogur B, Bor D. The Harvard Medical School–Cambridge Integrated Clerkship: challenges of longitudinal integrated training. Clin Teach 2008;5:78–82. 9 Cohen P. Training for expertise: the Harvard Medical School–Cambridge Integrated Clerkship tutorial. Clin Teach 2009;6:28–33. 10 Hirsh D, Gaufberg E, Ogur B, Cohen P, Krupat E, Cox M, Pelletier S, Bor D. Educational outcomes of the Harvard Medical School–Cambridge Integrated Clerkship: a way forward for medical education. Acad Med 2012;87 (5):643–50. 11 Hirsh D, Walters L, Poncelet AN. Better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships. Med Teach 2012;34 (7):548–54. 12 Walters L, Greenhill J, Richards J, Ward H, Campbell N, Ash J, Schuwirth LWT. Outcomes of longitudinal
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integrated clinical placements for students, clinicians and society. Med Educ 2012;46:1028–41. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: IoM 2001. http://iom.edu/Reports/2001/Crossingthe-Quality-Chasm-A-New-Health-System-for-the21st-Century.aspx. [Accessed 4 January 2014.] Stewart M, Brown JB, Donner A et al. The impact of patient-centred care on outcomes. J Fam Pract 2000;49 (9):796–804. Rao JK, Anderson LA, Inui TS, Frankel RM. Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care 2007;45 (4):340–9. Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centred care and evidence-based medicine. Health Serv Res 2010;45 (5 Pt 1):1188–204. Epstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centred health care. Health Aff (Millwood) 2010;29 (8):1489–95. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centred care and adherence: definitions and applications to improve outcomes. J Am Acad Nurse Pract 2008;20 (12):600–7. Christakis DA, Feudtner C. Temporary matters: the ethical consequences of transient social relationships in medical training. JAMA 1997;278:739–43. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med 1994;69:670–9. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993;68:249–54. Feudtner C, Christakis DA. Making the rounds. The ethical development of medical students in the context of clinical rotations. Hastings Cent Rep 1994;24: 6–12. Hojat M, Vergare MJ, Maxwell K et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med 2009;84 (9): 1182–91. Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Acad Med 2008;83 (3):244–9. Haidet P, Dains JE, Paterniti DA, Hechtel L, Chang T, Tseng E, Rogers JC. Medical student attitudes toward the doctor–patient relationship. Med Educ 2002;36:568–74. Krupat E, Hiam CM, Fleming MZ, Freeman P. Patient-centredness and its correlates among firstyear medical students. Int J Psychiatry Med 1999;29:347–56. Street RL Jr, Krupat E, Bell RA, Kravitz RL, Haidet P. Beliefs about control in the physician–patient
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relationship: effect on communication in medical encounters. J Gen Intern Med 2003;18:609–16. Shaw WS, Woiszwillo MJ, Krupat E. Further validation of the Patient–Practitioner Orientation Scale (PPOS) from recorded visits for back pain. Patient Educ Couns 2012;89:288–91. O’Brien BC, Poncelet AN, Hansen L, Hirsh DA, Ogur B, Alexander EK, Krupat E, Hauer KE. Students’ workplace learning in two clerkship models: a multisite observational study. Med Educ 2012;46:613–24. Hauer KE, Hirsh D, Ma I, Hansen L, Ogur B, Poncelet AN, Alexander EK, O’Brien BC. The role of role: learning in longitudinal integrated and traditional block clerkships. Med Educ 2012;46:698–710. Hauer KE, O’Brien BC, Hansen LA, Hirsh D, Ma IH, Ogur B, Poncelet AN, Alexander EK, Teherani A. More is better: students describe successful and unsuccessful experiences with teachers differently in brief and longitudinal relationships. Acad Med 2012; 87 (10):1389–96. Ogur B, Hirsh D. Learning through longitudinal care – narratives from the Harvard Medical School– Cambridge Integrated Clerkship. Acad Med 2009;84: 844–50.
33 Deci EL, Vallerand RJ, Pelletier LG, Ryan RM. Motivation and education: the self-determination perspective. Educ Psychol 1991;4:325–46. 34 Wilkinson T, Gill D, Fitzjohn J, Palmer C, Mulder R. The impact on students of adverse experiences during medical school. Med Teach 2006;28 (2):129–35. 35 Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students’ perceptions of teaching. BMJ 2004; 329 (7469):770–3. 36 Matlin MW, Gawron VJ. Individual differences in Pollyannaism. J Pers Assess 1979;43 (4):411–12. 37 Worley P, Martin A, Prideaux D, Woodman R, Worley E, Lowe M. Vocational career paths of graduate entry medical students at Flinders University: a comparison of rural, remote and tertiary tracks. Med J Aust 2008; 188 (3):177–8. 38 Teherani A, Irby DM, Loeser H. Outcomes of different clerkship models: longitudinal integrated, hybrid, and block. Acad Med 2013;88:1–9. Received 11 September 2013; editorial comments to author 5 November 2013, accepted for publication 29 November 2013
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OBJECTIVES This study was intended to determine if previously identified educational benefits of the Harvard Medical School (HMS) Cambridge Integrated Clerkship (CIC) endure over time. METHODS The authors’ earlier work compared the 27 graduates in the first three cohorts of students undertaking the CIC with a comparison group of 45 traditionally trained HMS students; CIC graduates emerged from their clerkship year with a higher degree of patient-centredness and felt more prepared to deal with numerous domains of patient care. Between April and July 2011, at 4–6 years post-clerkship, the authors asked these original study cohorts to complete an electronic survey which included measures used in the original study. The authors also reviewed data from the National Residency Match Program to compare career paths in the two groups.
RESULTS The response rate was 62% (42/68). The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time (p < 0.035). Reflecting retrospectively on their clerkship experiences, CIC graduates continued to report that their clerkship year had better prepared them in a wide variety of domains. Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work. Both groups chose a wide range of residency programmes. Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship. CONCLUSIONS This paper indicates that benefits of longitudinal integrated clerkship training are sustained over time across multiple domains.
Medical Education 2014; 48: 572–582 doi: 10.1111/medu.12413 Discuss ideas arising from the article at “www.mededuc.com discuss”
1 2
Harvard Medical School, Boston, Massachusetts, USA Cambridge Health Alliance, Cambridge, Massachusetts, USA
*These authors share joint first authorship of this paper.
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Correspondence: Dr Elizabeth Gaufberg, Department of Medicine and Psychiatry, The Cambridge Health Alliance, 1493 Cambridge St, Cambridge, Massachusetts 02139, USA. Tel: +1 617 665 3101; E-mail: [email protected]
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Longitudinal integrated clerkships and patient-centredness
INTRODUCTION
Longitudinal integrated clerkship (LIC) models of clinical medical education are proliferating worldwide.1,2 Three principles define these relationship-centred clinical curricula: medical students participate in the comprehensive care of patients over time; students establish continuing learning relationships with these patients’ clinicians, and students meet the majority of the year’s core clinical competencies across multiple disciplines simultaneously.2,3 Some institutions adapt the LIC design to address workforce deficiencies or expand options for clinical training sites.4 Others posit that LICs may serve to improve the quality and safety of care, and to train leaders in health system redesign.5 Harvard Medical School (HMS) designed the Cambridge Integrated Clerkship (CIC) to improve the learning and retention of science and clinical medicine and to foster humanism and patient-centredness.1,6–11 To date, nearly 60 published studies demonstrate short-term successes of these models.12 Our study of the first three cohorts of CIC graduates shows that in comparison with traditionally trained HMS students, CIC students performed at least as well or better on measures of medical knowledge and clinical skills, reported higher satisfaction with their learning environment and greater confidence in dealing with numerous domains of patient care, and emerged from their clerkship year with a higher degree of patientcentredness.10 Patient-centredness is a central professional value.13 The literature demonstrates that patientcentredness is associated with satisfaction with care, patient adherence to medical advice and a variety of objectively measured health outcomes.14–18 Our previous investigations demonstrated that patient-centred values, as assessed by the Patient– Practitioner Orientation Scale (PPOS), increased over the course of the integrated clerkship experience but declined among those who followed a traditional course of study.10 Thus, the typical pattern of ‘ethical erosion’19–25 – an expression used in the literature to denote the erosion of ethicsrelated sensibilities, empathy and patient-centredness during clinical training – appears to be reversed in the CIC cohort. We sought to discover whether these differences would be sustained or whether they would disappear with exposure to a traditional Year 4 curriculum, residency and practice.
This paper reports the results of a follow-up of CIC graduates at 4–6 years after completion of the programme and compares outcomes in this group with those in the traditionally trained student group from our initial 3-year trial. We assess the attitudes and perceptions of the CIC graduates and their counterparts, as well as their postgraduate activities. We compare the cohorts longitudinally and conduct between-group, cross-sectional comparisons at the time of data collection. In particular, we address three questions: (i) Do clerkship graduates maintain their patient-centred beliefs 4–6 years after completing their clerkship? (ii) Do clerkship graduates maintain their perceptions about their clerkship experience? (iii) What residency specialties do clerkship graduates choose and in which post-clerkship professional activities do they engage? This is the first paper to compare the patient-centredness of LIC and traditionally trained graduates, along with characteristics in the other domains, over an extended period. We discuss our findings in light of three educational principles: relational learning, reflection on practice, and advocacy as a professional duty.
METHODS
Participants During its first 3 years of operation (2004–2005, 2005–2006 and 2006–2007), the CIC represented an educational pilot undertaken by a total of 27 students over the 3 years. For each of those years, we recruited a comparison (COM) group of HMS students (total: n = 45), who rotated through traditional discipline-based clerkships among our major teaching hospitals. As has been described previously,7,10 more students identified the CIC as their first preference than could be accommodated; the HMS registrar randomly selected students to enter the CIC from the pool of volunteers who had requested to participate in the CIC. The COM group comprised students who were not selected but had volunteered for the CIC. These were supplemented by other third-year volunteers on traditional clerkships. As an incentive, the COM group received credit for the equivalent of a 2-week elective. There were no significant between-group differences (CIC group versus COM group) on a variety of baseline measures prior to the beginning of the clerkship year, including Medical College Admission Test (MCAT) scores, US Medical Licensing Examination (USMLE) Step I scores, HMS Year 2
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E Gaufberg et al objective structured clinical examination (OSCE) scores, plans for future practice, and patient-centred beliefs assessed using the PPOS, a well-validated instrument.25,26 Whereas previous papers have reported on the endof-clerkship differences between the CIC and COM groups,7,10 this paper compares the two groups’ responses at 4–6 years after respondents had completed their principal clinical year. We collected these follow-up data between April and July 2011. For this study, we identified and contacted the three original CIC and COM cohorts by e-mail and requested that participants complete an online survey. We were unable to obtain contact information for four students (all in the COM group). The institutional review boards of HMS and the Cambridge Health Alliance considered this study exempt from requirements for formal ethical approval. Data collection The electronic survey instrument requested basic demographic information and asked about participants’ attitudes, perceptions and current activities. In order to make data comparable over time, wherever possible, questions were identical to those that had been asked of participants when they were students and which have been reported in past papers.7,10
and accomplishments in areas such as research, publications, awards, scholarships, graduate degrees, fellowships or other areas of activity or accomplishment. Lack of response on free-text questions was assumed to represent non-involvement in the given area. Finally, we obtained residency matching data for all of the students who had been in the original CIC and COM groups from National Residency Match Program (NRMP) reports to determine the career paths they had taken. Data analysis The data reported here represent mean scores and frequencies for the three follow-up cohorts of CIC students in combination and the three follow-up cohorts of COM students in combination. For all parametric data, we conducted independent t-tests and calculated effect sizes to compare the two follow-up cohorts. In addition, in instances in which we had asked identical questions, we compared the responses of each current group at follow-up with the responses they had provided during their third year using repeated-measures t-tests. The number of CIC respondents totalled 20 and that of COM respondents amounted to 22, but in our analysis the cohorts were as small as 19 and 21, respectively, as a result of missing data.
RESULTS
The respondents completed the PPOS,25,26 the instrument to which they had responded at the beginning and end of their clerkship year. In addition, using a 6-point Likert scale, graduates were asked to indicate how well they currently believed that their clerkship experiences had prepared them to practise in 18 different domains central to doctoring (e.g. dealing with ethical dilemmas; involving patients in decision making; knowing one’s own strengths and weaknesses), 16 of which were identical to those in the original items. In a parallel vein, respondents also made nine ratings (on a 6-point scale) indicating the extent to which various adjectives or phrases characterised their clerkship learning environment, six of which were identical to the original items (e.g. how stressful, satisfying or confidence building they found the environment to be), and then made the same ratings in reference to the graduate medical training programmes they were in or had been in. To assess a global reaction to their former programmes, we asked respondents which form of Year 3 programme they would choose in retrospect. Respondents also reported in free-text write-in format on their post-clerkship experiences
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Of the original 45 students who participated in the COM group, we were able to locate contact information for 41. Twenty-two of the 41 individuals to whom the survey was sent responded, giving a COM response rate of 54%. We were able to locate contact information for all 27 CIC graduates and 20 (74%) responded. The overall response rate to our survey was therefore 62% (42/68). At the time of follow-up, at 4–6 years after completion of the clerkship year, all respondents had completed medical school and most were in residency or had completed residency. As match data derive from publicly available information, data for all COM and CIC students were included, regardless of whether they were surveyed or responded at follow-up. In order to determine whether the responding sample was representative of the original clerkship participants, and whether the follow-up groups were themselves still similar (as they had been at the preclerkship baseline), we tested for differences in age, gender, year of clerkship completion, and current level of training, as well as for the original baseline
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Longitudinal integrated clerkships and patient-centredness variables (MCAT, USMLE Step I scores, HMS Year 2 OSCE scores, plans for future practice and PPOS scores). No significant between-groups (CIC versus COM at the current time) or within-groups (COM baseline versus COM current, and CIC baseline versus CIC current) differences were found on any of these variables. Maintenance of patient-centred beliefs As previously reported,10 the CIC students’ level of patient-centredness (as measured by the PPOS) showed no statistically significant difference with that of the COM group at the beginning of the clerkship year. At the end of the clerkship year, CIC students’ scores had increased and traditionally trained students’ scores decreased, with the result that CIC students were significantly more patientcentred.10 As Fig. 1 shows, our follow-up data indicate that levels of patient-centredness in both the CIC and COM groups remained constant over time so that the difference between the groups remained significant (p = 0.035; effect size = 0.33). Maintenance of perceptions about clerkship experiences Table 1 contains the previously published10 end-ofclerkship mean responses on perceived preparedness, with standard deviations and effect sizes, alongside the corresponding values for the CIC and COM cohorts at follow-up. On all 13 items
6.00
on which significant differences had been detected immediately post-clerkship, the findings remained significant at follow-up; 12 of these ratings indicated greater perceived preparedness on the part of the CIC students (the one exception referred to preparedness ‘…to practise in a hospital setting’). Whereas we found no differences in perceived preparedness to integrate basic science and clinical practice at the end of the clerkship year, follow-up ratings from CIC students indicated that they felt they had been significantly better prepared. Two items added to the follow-up survey, about understanding the role of the patient’s family and being the patient’s advocate, also showed significantly greater perceived preparedness on the part of CIC students. Ratings of the clerkship learning environment at follow-up are also consistent with findings at the end of the clerkship year (Table 2). Graduates of the CIC recalled their clerkship experience as more satisfying, more confidence-building, more humanising, and more transformational than did the COM group. By contrast with the earlier findings, although the CIC experience was described as significantly more stressful immediately post-clerkship, this difference disappeared in the retrospective reports, and, whereas COM graduates had reported their experience as more marginalising immediately post-clerkship, this difference was not found in the retrospective data. In questions added to the followup survey, CIC and COM graduates did not differ
CIC COM
5.00
5.10
5.11
5.00 4.87
4.78
4.78
4.00
3.00 Pre-clerkship
Post-clerkship
Follow-up
Figure 1 Comparison of pre- and post-clerkship mean scores of 27 Harvard Medical School–Cambridge Integrated Clerkship (CIC) students and 40 traditionally trained comparison group (COM) students on the Patient–Practitioner Orientation Scale (PPOS), which measures patient-centredness on a 6-point scale. All study participants engaged in their clerkship year at Harvard Medical School during 2004–2007. The graph is extended to compare PPOS scores of 19 CIC and 21 COM students 4–6 years later. For scores pre-clerkship, p = 0.239; for scores immediately post-clerkship, p = 0.011; for follow-up scores 4–6 years later, p = 0.035.
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Table 1 Graduates’ self-assessments of their clerkship’s influence upon their preparation for practice: Harvard Medical School (HMS) student participants in the 2004–2007 Cambridge Integrated Clerkship (CIC) and traditionally trained HMS students in a comparison group (COM) were surveyed immediately post-clerkship and at 4–6 years later
Perceptions of clerkship experiences
Perceptions of clerkship experiences at
immediately post-clerkship
4–6 years follow-up†
Topical areas of students’
CIC group
COM group
p-value,
CIC group
COM group
p-value,
perceived preparedness*
Mean SD
Mean SD
t-test (ES)
Mean SD
Mean SD
t-test (ES)
Readiness for practice Practice in the hospital setting
4.63 0.883
5.07 0.764
< 0.05 (0.533)
4.42 1.170
5.19 0.928
< 0.05 (0.729)
Practice in the ambulatory setting
5.89 0.320
4.22 1.074
< 0.001 (2.107)
5.74 0.452
3.95 1.284
< 0.001 (1.860)
Have the knowledge base
5.11 0.847
4.47 0.751
< 0.005 (0.799)
5.42 0.692
4.81 1.078
< 0.05 (0.673)
4.30 1.137
4.57 1.035
0.303 (0.248)
5.47 0.612
4.81 0.873
< 0.01 (0.876)
4.89 1.121
4.97 0.974
0.739 (0.076)
5.05 1.026
5.05 0.973
0.987 (0)
necessary to be a competent practitioner Integrate basic science and clinical practice‡ Practise evidence-based medicine Self-awareness and reflective practice Be a self-reflective practitioner
5.70 0.609
4.62 1.213
< 0.001 (1.125)
5.79 0.535
4.90 1.261
< 0.01 (0.919)
Deal with ethical dilemmas
5.33 0.734
4.17 1.375
< 0.001 (1.052)
5.68 0.478
4.43 1.248
< 0.001 (1.323)
Know your strengths and
5.44 0.801
4.85 1.001
< 0.05 (0.651)
5.42 0.961
4.62 1.244
< 0.05 (0.720)
5.48 0.643
4.55 1.108
< 0.001 (1.027)
5.63 0.597
4.67 1.138
< 0.005 (0.987)
5.93 0.267
5.07 1.163
< 0.001 (1.109)
5.89 0.315
5.14 1.108
< 0.01 (0.920)
Involve patients in decision making
5.59 0.694
4.55 1.131
< 0.001 (1.108)
5.63 0.597
4.81 1.078
< 0.01 (0.941)
Relate well to a diverse patient
5.96 0.192
4.72 1.086
< 0.001 (1.590)
5.84 0.375
5.05 0.973
< 0.005 (1.071)
5.74 0.526
5.07 0.859
< 0.005 (0.941)
5.79 0.419
5.09 0.700
< 0.001 (1.213)
Not asked
Not asked
–
5.58 0.692
4.86 1.062
< 0.05 (0.803)
5.52 0.643
5.47 0.847
0.88 (0.066)
5.53 0.697
5.24 0.700
0.20 (0.415)
limitations Deal with patient problems that do not have clear answers Relational skills Be truly caring in dealing with patients
population Relate to people at different stages of the lifecycle Understand the role of the patient’s family in their care Work successfully with other health professionals as a team member Context and advocacy Be the patient’s advocate
Not asked
Not asked
5.89 0.459
5.05 0.921
< 0.001 (1.154)
Understand how the health care
5.26 0.859
4.07 1.328
< 0.001 (1.064)
–
5.00 1.00
4.00 1.673
< 0.05 (0.725)
5.89 0.320
4.67 1.022
< 0.001 (1.610)
5.89 0.315
4.76 1.179
< 0.001 (1.309)
system works See how the social context affects patients and their problems
*‘At this point, how well do you believe that your third-year medical school experience helped you to…?’. (1 = it prepared me very poorly; 6 = it prepared me very well). †Immediately post-clerkship, the total number of CIC respondents is 27 and COM respondents is 40. In follow-up, the total number of CIC respondents is 20 and COM respondents is 22, but numbers may fall to as low as 19 in the CIC group and 21 in the COM groups as a result of missing data. ‡This domain showed the only statistically significant change over time using 2 9 2 analysis of variance. SD = standard deviation; ES = effect size.
576
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Longitudinal integrated clerkships and patient-centredness
Table 2 Graduates’ descriptions of their medical school clerkships’ and residency programmes’ learning environments: Harvard Medical School student participants in the 2004–2007 Cambridge Integrated Clerkship (CIC) and a comparison group (COM) were surveyed immediately post-clerkship and 4–6 years later
Perceptions of clerkship experience at end of
Perceptions of clerkship experience at
Perceptions of graduate medical education/
clerkship
follow-up*
training experience†
Descriptions of
CIC group
COM group
p-value,
CIC group
COM group
p-value,
CIC group
COM GROUP
p-value,
clerkship
Mean SD
Mean SD
t-test (ES)
Mean SD
Mean SD
t-test (ES)
Mean SD
MEAN SD
t-test (ES)
Confidence-building
4.96 1.055
3.87 1.471
< 0.005 (0.851)
5.21 0.855
4.52 1.123
< 0.05 (0.691)
4.83 1.150
4.86 1.153
0.949 (0.026)
Humanising
5.44 0.698
3.88 1.223
< 0.001 (1.566)
5.68 0.583
4.52 1.631
< 0.005 (0.947)
3.67 1.328
3.81 1.861
0.782 (0.086)
Stressful
5.26 0.764
4.62 0.952
< 0.005 (0.741)
4.16 1.214
4.19 1.078
0.929 (0.026)
5.11 0.900
4.71 0.956
0.193 (0.430)
Satisfying
5.41 0.888
4.67 0.917
< 0.005 (0.819)
5.50 0.707
4.71 1.270
Marginalising
1.89 1.251
3.43 1.394
< 0.001 (1.163)
1.89 1.370
2.62 1.322
Transformational
5.44 0.847
4.62 1.390
< 0.01 (0.712)
5.00 1.054
4.24 1.338
Good preparation
Not asked
Not asked
–
4.16 1.537
4.86 1.062
Not asked
Not asked
–
5.68 0.582
4.71 1.231
Not asked
Not asked
–
5.53 0.612
4.76 1.513
< 0.05 (0.768) 0.097 (0.542) < 0.05 (0.631)
4.44 1.149
4.76 1.136
0.392 (0.280)
2.56 1.338
2.19 1.167
0.369 (0.295)
4.72 1.364
4.57 1.248
0.721 (0.115)
Not asked
Not asked
–
< 0.005 (1.01)
5.06 1.056
4.95 1.359
0.795 (0.090)
< 0.05 (0.667)
5.17 0.857
5.00 1.183
0.623 (0.165)
0.100 (0.529)
for internship Good preparation for doctoring Valuable in informing my future career choice
*Describing the learning environment: ‘At this point, how well would you say that the following adjectives describe your third-year medical school experience?’ (1 = describes it not at all; 6 = describes it extremely well). †Describing the learning environment: ‘At this point, how well would you say that the following adjectives describe your internship and residency experiences?’ (1 = describes it not at all; 6 = describes it extremely well). SD = standard deviation; ES = effect size.
on whether their experience represented ‘good preparation for internship’. However, CIC graduates believed more strongly than the COM group that the clerkship experience provided good preparation for doctoring and was valuable for informing future career choice.
enough information to answer. A total of 85% (n = 17) of the CIC graduates indicated that they would choose an LIC programme again, 15% (n = 3) indicated that they did not have enough information to answer, and none indicated that they would choose a traditional programme.
By contrast with the differences found in their ratings of their undergraduate clerkship experiences, there were no significant differences between CIC and COM graduates’ ratings on any of the eight descriptors referring to residency programmes.
Post-clerkship professional activities
When asked what kind of programme they would choose if they had the opportunity to do so again, 50% (n = 11) of the COM graduates reported that they would choose a traditional clerkship programme again, 27% (n = 6) that they would choose a longitudinal integrated programme, and the remainder (n = 5) indicated that they did not have
At follow-up, 50% (n = 10) of the CIC graduates indicated that they had been involved in social justice or health advocacy work, compared with 23% (n = 5) of the COM group (p = 0.03). For both CIC and COM graduates, their involvement occurred both within and outwith opportunities provided by their residency programmes. There were no statistically significant differences between the two groups in the percentage of students indicating involvement in research, publications, awards, scholarships, graduate degrees, fellowships or other areas of activity or accomplishment.
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E Gaufberg et al Match data indicated that graduates of both groups chose a wide range of residency training programmes, in both surgical and non-surgical specialties, and that there were no statistically significant differences between the groups for any individual choice (Table 3). When we combined several primary care-oriented residency programmes (family medicine and primary care tracks in internal medicine and paediatrics), we found that 26% (n = 7) of the 27 CIC graduates and 7% (n = 3) of the 45 COM graduates were matched in these programmes (p = 0.01). Students’ pre-clerkship preferences and the incidence of switching specialties after the initial match choice could not be assessed.
DISCUSSION
There appear to be differences and benefits of the CIC that continue into residency and practice. We organise our discussion to address three domains: the maintenance of patient-centred beliefs, perceptions about the clerkship experience, and post-clerkship activities.
Maintenance of patient-centred beliefs: relationships, reflection and advocacy Our PPOS data demonstrate consistency from the immediate end of the clerkship year to the measurement of attitudes 4–6 years later, with almost identical mean scores for each group over time, a significant between-groups difference at follow-up, and moderate effect size. Although we cannot be certain that the higher mean scores on the PPOS of CIC graduates reflect a clinical difference, several studies have demonstrated that differences in PPOS scores are associated with differences in patient-related behaviour.27,28 Regardless, the fact that the pattern is maintained at 4–6 years later seems noteworthy. These data may address concerns that the impact of the third year might diminish or disappear after the CIC students were thrust back into the ‘real world’. We hypothesise that CIC graduates’ clerkship experiences may help to ‘immunise’ them against the adverse influences of advanced graduate and postgraduate training. We propose that three factors in
Table 3 Specialty choices of 27 Harvard Medical School (HMS) Cambridge Integrated Clerkship graduates (CIC) and a comparison group (COM) of 45 traditionally trained HMS students from National Residency Match Program data
Specialty
578
CIC group (n = 27)
COM group (n = 45)
p-value, t-test
Anaesthesiology
0
4 (8.9%)
0.145
Dermatology
1 (3.7%)
0
0.397
Emergency medicine
4 (14.8%)
1 (2.2%)
0.059
Family medicine
2 (7.4%)
0
0.133
Internal medicine, primary care
3 (11.1%)
3 (6.7%)
0.417
Internal medicine, categorical
2 (7.4%)
9 (20.0%)
0.136
Neurology
1 (3.7%)
0
0.397
Obstetrics and gynaecology
1 (3.7%)
4 (8.9%)
0.359
Ophthalmology
0
1 (2.2%)
0.394
Orthopaedic surgery
0
3 (6.7%)
0.221
Otolaryngology
0
1 (2.2%)
0.394
Paediatrics, primary care
2 (7.4%)
0
0.133
Paediatrics, categorical
2 (7.4%)
7 (15.6%)
0.258
Physical medicine/rehab
1 (3.7%)
0
0.397
Psychiatry
4 (14.8%)
2 (4.4%)
0.133
Radiation oncology
0
1 (2.2%)
0.394
Radiation diagnostic
2 (7.4%)
2 (4.4%)
0.496
Surgery
1 (3.7%)
1 (2.2%)
0.356
Internal medicine, paediatrics
0
1 (2.2%)
0.394
Other/not yet matched
1 (3.7%)
5 (11.1%)
0.255
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Longitudinal integrated clerkships and patient-centredness their clerkship experiences may contribute to the sustained patient-centredness: (i) relational learning; (ii) reflection on practice; and (iii) advocacy as a professional duty. Relational learning The CIC is structured around students’ longitudinal relationships with patients and their family members, with faculty mentors and their practice environments, with student peers, and with the local community.6 This ‘educational continuity’6,7 allows for and upholds a relationship-centred curriculum, an educational structure intentionally designed to motivate students’ patient-centredness and to create patient-centred roles for students as a way to foster the learning and retention of science and clinical medicine. The longitudinal integrated design affords CIC students authentic and meaningful roles in patient care7,10,29–32 and students report that their motivation to learn derives in large part from their sense of duty and connection to their patients.8,10,32 This internal motivation,31–33 which is aligned with their values, stands in contrast with other common external motivators such as grades or fear of humiliation on rounds.34,35 Longitudinal iterative feedback within the CIC reinforces relational skill development and collaborative teamwork, both of which are central goals of students’ clinical learning. Reflection on practice Patient-centredness depends upon self-awareness and the ability to make connections between values and actions. CIC graduates regarded their clerkship experience as more effective in conveying these skills of ‘reflective practice’ than their colleagues in traditional programmes and the differences were found to remain years later. A core CIC curricular element that supports these attributes is a year-long, developmentally progressive reflective practice curriculum designed to connect closely to students’ workplace learning needs rather than merely functioning as a separately maintained safe space. The CIC intentionally supports the practice of reflection over the course of a year in clinical and non-clinical (reflective space) venues and hence the daily work and the overarching patient-centred ‘themes’ are confluent and mutually reinforcing. In the CIC, reflection is learned and practised as a core clinical skill. We speculate that the CIC structure’s pervasive support of these habits of reflection sustains and even fosters patient-centredness.
Advocacy as a professional duty Graduates of the CIC were found to be more often involved in social justice and health advocacy activities than their traditionally trained counterparts and to feel that the clerkship prepared them for success in this domain. During the CIC year, students gain intimate knowledge of patient–system interactions and the social determinants of patient health and illness. This first-hand experience draws them naturally to the role of advocate.8,10,30,32 To refine and support the students’ emerging advocacy skills, the CIC delivers a health advocacy curriculum led by doctor role models engaged in this work. The programme, faculty and institution also encourage CIC students to openly identify disconnects between formal and hidden curricular messages, and support students to be agents of positive cultural change in their learning community. Our data imply that in this era of health system redesign, the CIC may foster the development of well-trained and motivated graduates who seek to drive health care system change.5,11,32 Maintenance of perceptions about the clerkship experience At 4–6 years post-clerkship, CIC graduates continue to describe their experiences affirmatively, expressing a more positive sense of their clerkship’s contribution to their future preparedness than their traditionally trained counterparts. The results are not only statistically significant, but the effect sizes are generally in the range considered moderate to large. In fact, both groups’ recollections of the learning environment and its influence on their preparedness for medical practice are remarkably consistent with their impressions at the end of their third year. Although it might be possible to ask whether the perceptions of CIC students at year-end may have been unrealistically positive, the positivity of their perceptions remains remarkably strong when viewed in light of subsequent clinical experience. Moreover, the possibility of accounting for this finding by citing the ‘Pollyanna effect’36 (the tendency to demonstrate a generally positive response bias), is made unlikely by our findings of the graduate medical programme ratings; CIC graduates were no different – neither more positive nor more negative – in their ratings of their residency training programmes. Interestingly, with hindsight, CIC graduates recall their clerkship experience as less stressful than they had at the end of the year, and COM graduates
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E Gaufberg et al recall theirs as less marginalising than they did immediately post-clerkship. Perhaps these earlier negative perceptions were extinguished by subsequent experiences in residency training. Post-clerkship professional activities: what they do and how they do it A critical test of a clerkship experience is the degree to which it sets a pathway toward career success. Compared with their traditionally trained peers, CIC graduates retrospectively report that their clerkship experience was more valuable in informing career choice. We sought to know more about the paths they took following the programme. Graduates of the CIC report achievements in traditionally valued realms, such as in the receipt of awards and fellowships, and the authoring of scholarly publications, as often as their traditionally trained peers do. Like their COM counterparts, CIC graduates choose a wide variety of careers, with some preferring fields considered to be more relational, and at the same time CIC students report a significantly greater sense of preparedness to integrate clinical practice with its basic science underpinnings. Although there are no significant differences in the fields chosen at graduation, data combined post hoc suggest more CIC students matched initially in primary care specialties (family medicine, and primary care tracks in internal medicine and paediatrics). However, these initial match data do not include students who switched fields, and we do not yet know about ultimate practice or subsequent specialisation. It would be premature to draw conclusions as to whether CIC graduates enter the primary care workforce in greater or lesser proportion than their non-longitudinally trained peers. Optimistically, we believe that these results may indicate that CIC training might very well represent the best of both worlds, providing solid preparation for a variety of specialties and allowing the patient-centred ethos of the graduates to permeate their work. Limitations Limitations temper the generalisability of our findings. This was a study of small cohorts at a single institution with a follow-up period of only 4–6 years. We could not enlarge the cohorts by extending the study through additional years of observation because HMS adopted aspects of longitudinality throughout its curriculum after the third year of this innovation and thus no equivalent control groups could be recruited. We hope to follow subsequent CIC cohorts
580
over time and track their perceptions and career paths to enlarge the sample size. In all 3 years in which CIC and COM data were collected, there were no discernible baseline differences between the groups across a range of relevant measures. We cannot exclude the possibility that other unmeasured and undetected differences might exist between the two groups and account for differences found in our outcome measures. Although we found no differences between respondents and non-respondents in either group, there remains the possibility of self-selection bias among those who consented to respond to the survey. Additionally, we cannot isolate the role of the curriculum per se from the influences of the culture of the public hospital in which the CIC functions. Nonetheless, if venue is so powerful and effective, educators should remain open to the potential advantages to be derived by situating training outside traditional settings. Finally, we cannot know whether these findings are predictive of these doctors’ values, behaviours or practice choices even further into the future.
CONCLUSIONS
Longitudinal integrated clerkships are rapidly growing in size, number and diversity nationally and internationally. Evidence exists that LICs advance our profession’s social accountability mission and can address workforce distribution.37 Our findings contribute to the evidence that LICs stimulate learners to become the humanistic doctors and agents of change our society demands and deserves.5 This study stands alongside those reporting the benefits of LICs in the realms of learning and professional development.7,10–12,27,30–32,38 It is the first to demonstrate that those benefits are sustained over time.
Contributors: EG, DH and DB contributed to the study conception and design, the design of the survey tool and the interpretation of data. EK contributed to the study conception and design, particularly of the methods, and to the analysis and interpretation of data. BO contributed to the study conception and design, and the interpretation of data. SP contributed to the analysis, interpretation and presentation of data. DBR contributed to the acquisition and analysis of data. EG, DH and DB led the drafting and revision of the article, in which all authors participated. All authors approved the final manuscript for submission. Acknowledgements: the authors thank the Arnold P Gold Foundation. In particular, EG is grateful for an Arnold P Gold Foundation professorship. The authors also wish to
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Longitudinal integrated clerkships and patient-centredness acknowledge the Cambridge Health Alliance, Harvard Medical School, and the Consortium of Longitudinal Integrated Clerkships for their support. Funding: none. Conflicts of interest: none. Ethical approval: this study was considered exempt from requirements for ethics approval by the institutional review boards of the Cambridge Health Alliance and Harvard Medical School.
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