Opinion: Reflections on Longitudinality in Medical Education
For half of my sabbatical, I have chosen to look at alternate models of clerkship. The aim is to bolster my opinion, which is shared by others, that our current hospital-based block hierarchical structure is not the best way to nurture and educate our budding physicians of the future.
I argue that medical education is a continuum and should move along rather like an apprenticeship model; not just in residency but right from the beginning. I decided to explore the longitudinal integrated clerkships (LIC) started by Flinders University in South Australia, initially in their rural clinical schools. At these schools, clerkship students spend an entire year living in a small town, based in a general practitioner’s office, while attending tutorials once weekly and going to the hospital with various consultants. Recently, several articles have been published about the benefits of this program not just for enticing students to stay in small towns but rather for the development of resiliency. It appears that by being with a small group of students and one single tutor for the entire year fosters a strong sense of community.
Other schools around the world, notably the United States and Canada, have formed similar clerkships. In these cases, the clerkships are usually in response to some type of need. In Australia, the government has insisted 25% of their medical students need to work in rural areas upon completion of their training. Therefore, if you select students from small towns, immerse them in small towns and then hopefully offer training in small towns, then they are more likely to stay rurally. A Canadian examples of something similar is the Northern Ontario School of Medicine. In California where I visited various offshoots of the University of California, they have applied the same principle of a year long clerkship based program, not necessarily based in family medicine, for select groups of students hoping to either fulfill a work force need or serve the growing number of marginalized populations.
As the medical education literature around longitudinal clerkships evolved, it has become apparent that these type of clerkships offer additional benefits such as fostering resiliency and potentially nurturing the maintenance of altruism and social responsibility that most students possessed on entry to medical school. This is especially important in an era of increasing rates of burnout, depression and suicidality amongst all levels of medical trainees. Several studies have tried to understand which components of LICs may account for this and conclude at least in part it is related to feeling safe within a community of similar learners, consistent supervisor and faculty support.
The literature also supports that students experiencing clerkships this way do no worse than their more traditionally trained compatriots on high stakes licensing or shelf exams. Besides the humanistic benefits to longitudinal learning in an era of competency-based assessment and entrustable professional activities, it is easy to understand how much more satisfactory it is for supervisors to make that judgment after seeing their mentee develop over a period of time rather than in six week blocks where they are lucky to work with the same student twice during that time period. With the current hospital-based block structure, students only just figure out how to adapt to their surroundings and demonstrate what they are capable of before they are on to the next discipline which reinforces the disease oriented focus rather than the preferable patient-centered approach.
I argue that given the increasing fragmentation, complexity and globalization of medicine which has lead to unprecedented numbers of populations moving for a variety of reasons with their own culturally based health care beliefs, physicians and health professionals of the future need to approach health, or the absence of it, differently. We need a new breed of resilient health professionals able to withstand government upheaval (whatever the country), migratory populations with unique cultural beliefs and expectations, increased complexity and chronicity. And all this is done in the context of increasing marginalization and inequity. To do this we must nurture humanism, give equal weight to the competencies of advocate, communicator and leader as we do already to medical expert and scholar and think of health professional education as a continuum.
What degree of longitudinality is enough? Is there an optimal time? There are no studies yet addressing this despite a growing array of models with many variations. Flinders is moving to a type of modified LIC for all of their students, including the large number based in urban Adelaide. They are hoping twenty weeks with the same longitudinal preceptor in a variety of disciplines will be enough. Time will tell but as Thomas Edison said, “innovation without execution is hallucination.” I applaud Flinders for making the leap to offer all its students rather than a select group, the benefits of longitudinality despite the uncertainty and logistical issues.
I prefer to think of longitudinality as part of the educational continuum and think the benefits apply not just to pre –clinical and clinical medical education but also into residency programs and indeed out into independent practice. Medicine in most cases in the developed world is moving out of hospitals into ambulatory clinics that do increasingly sophisticated procedures.
It is time we considered how we may alter both our undergraduate and postgraduate approach to not only keep abreast of the changing times and needs of the populations we serve, but also to innovate and remove the barriers constructed over time between the hierarchical structure of hospitals and the communities of caring and learning we serve.
Dr. Keyna Bracken is an associate professor in the Department of Family Medicine at McMaster University. In addition to Maternal Child Care and International Health work, Keyna is passionate about the process of medical education, especially as it relates to the development of resilient, reflective, professionals. Keyna is currently involved in medical education research looking at the uses of social power in clinical learning environments.
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