Anyone who has worked – or been a patient — in a large teaching hospital knows what a traditional third-year medical student clerkship can look like: Specialist sweeps in, accompanied by a gaggle of students; specialist has a few words with the patient; students nod and occasionally take notes; specialist leaves, accompanied by retinue. Students move on to next rotation and never see patient again.
A relatively new model, the longitudinal integrated clerkship (LIC), wants to change all that. It answers decades of increasing calls from the medical education community to revise the prevailing century-old current “block” model of clinical learning, which can present fragmented views of disease and allow only snips of caregiving in the current outpatient care-based healthcare system.
Within an LIC, students work with mentors in core specialties on their principal clinical year and follow cases from beginning to end — be that an hour, a day or a year — in a process that is patient- rather than program-oriented. It is designed to give students a broader and more empathetic view of healing, and lasting lessons in doctor-patient relationships and communication. Some 15 schools in the U.S., Australia, Canada and South Africa have large and established programs, but more than a 100 schools have joined an international consortium to discuss and explore the option.
“Students are there as things unfold for the patient. They are part of the team. They see the evolution of the disease. They follow patients long enough to see them recover, to see the denouement and the outcome of their decisions,” says David Hirsh, MD, director and co-founder of the Harvard Medical School-Cambridge Integrated Clerkship at Cambridge Health Alliance, assistant professor of Medicine at Harvard Medical School, and lead author of the most comprehensive study of program results to date.
In that study, published last March in Academic Medicine, LIC students performed at least as well as their peers on measures of content knowledge, and reported feeling much more prepared in patient-centered aspects of care, including handling ethical dilemmas, involving patients in decision-making, and relating well to a diverse population.
Patient Care With Context
Students also reported a higher level of satisfaction with their med school education. Not surprisingly, patients seem to like the arrangement, too.
“ ‘I have my own personal medical student,’ ” they’ll say. And to me, they’ll say, ‘Where’s your student today? Because you’re a much better doctor when your student is around.’ ” Hirsh says.
Students in an LIC are also ideally better able to understand a patient’s values and social context and to spot communications roadblocks. As one student wrote in a reflective narrative on the LIC experience:
“Without me I can confidently say this illiterate, non-English-speaking patient, even with his very supportive and involved family, would have fallen through the cracks. The number of appointments and communications and miscommunications would have been so numerous, and it would have taken so long, that he probably would have just stopped showing up.”
“It’s not the student just accomplishing some task. Nor are they seeing the patient as a case study. It’s not ‘the liver in room six’ – it’s ‘Mrs. So-and-So whom I have known many months, whom I know well,’ ” Hirsh says.
Though patient outcomes haven’t yet been studied, Hirsh believes an LIC, in which students navigate our complex healthcare system in tandem with their patients, can also give them a better vantage point from which to treat chronic disease.
“For example, say a diabetic patient has low blood sugar. You’re there for that, and you’re there for the treatment. Commitments are fostered. You might try harder to help with education and secondary prevention. There comes a stronger desire to learn, ‘Who is that person? Who is that patient?’ “ he says. As another student wrote,
“Each time we see Ms. O, attempting to understand her evolving health adds another piece to our medical repertoire. Each time we grow to understand a bit more about the toll that hospitalizations and chronically deteriorating health can have on a patient and her family.”
Perhaps most significantly, graduating from an LIC can give a future doctor a better grounding in the humanism necessary to her or his profession, Hirsh says.
Research suggests that as students progress through medical school, med students become more cynical, with a resulting decline in patient centeredness.
“Their moral development is shattered, their empathy is declining – how can that be? That’s the opposite of medicine’s goals. We want to sustain and nourish our students to be their best selves. Who they will be when they’re doing their life’s work?” Hirsh says.
In contrast, Hirsh’s research shows that students show an increase in patient-centeredness as they go through their training as compared to those doing a traditional clerkship.
From a student:
“I’ve heard traditional third- year students describe their horror at the sight and smell of the necrotic feet seen in vascular clinic. It had never occurred to me to be disgusted by F. When we noticed the first signs of an ulcer on her toe and when erythema gave way to necrosis, then osteomyelitis, I remember feeling concern, but not disgust. And when we finally had to serially amputate her forefoot, I remember thinking only that I wanted to do right by her—to find vital tissue. “
Hirsh says, “Ethics has to do with the students having meaningful roles. The student needs to matter to the patient, and the patient needs to matter to the student.
“Our students want to know the science because they want to help their patient.”
— Stacy Lu