Answer to "What resources are needed to do a LIC?"

A variety of resources are needed to build for longitudinal integrated clerkship (LIC) success, and the institution must commit these, from internal or external sources, such as government funding, before the initiative is developed and implemented.

a) Human resources

Leadership must come from a LIC director with: ability to lead the team, defining and enthusiastically communicating the vision for the LIC; ability to engage and consult with a wide range of stakeholders; good communication skills, including willingness to listen; and experience and expertise in clinical education.   The course coordinator plays a crucial administrative role, organising many aspects such as student placements, student schedules and day-to-day liaison with all stakeholders.

Distributed LIC programmes require academic and administrative leadership in each LIC site, and these core staff should be included in the LIC management committee.  Resources are also required for professional development of LIC preceptors and other health professionals about the LIC model, student learning and assessment in a LIC.

b) Structural resources

For many LIC programmes, infrastructure resources, such as hospital in-patient wards, and operative theatres, already exist. However, there can be competition between practitioners and LIC students for access to outpatient clinic or practice consulting rooms. LIC students need to “parallel consult” with their preceptor, in their own consulting room.  The preceptor continues to see patients, while the student consults in an adjoining or nearby room, first assessing the patient before preceptor review. While patient care must be prioritised, students need first access to undifferentiated patients to develop their reasoning and diagnostic skills, and acquire their own panel of patients to follow longitudinally.  While there is usually limited or no funding for teaching activities, students can assist with patient flow, once they have achieved a level of competence. 

In many community-based LICs, students rely primarily on private practitioners in general (family) practice for supervision.  Apart from the potential benefits of parallel consulting to the practice longitudinally, external funding grants can assist in developing the necessary consulting room infrastructure in private practices.  In Australia, considerable rural government funding has enabled human and infrastructure resource for many LIC programmes, and facilitated buy-in from preceptors.  Practices usually accept government or institutional funding for practice modifications in return for a multi-year commitment to hosting LIC students.  

In distributed LIC models, particularly in rural communities, resource is also required to provide appropriate student accommodation. Funding to support this has come from the institution, local and national government, and from the local communities hosting the student(s).  Students also need funding support to travel to and from their community.

c) IT resources

LIC programmes, often in distributed sites or settings distant from the major institutional centre, require relevant curriculum structures and vehicles for distributed learning.  The curriculum, assessment materials and information, together with all associated administrative information, should be housed on a Web-based learning platform.  Ideally this learning platform is used by all students, regardless of their clerkship model, to ensure equity of access to learning resources.  In addition to initial allocation of funding to develop the required IT resources, educational technology should be improved and enhanced continuously. The school should also strive to foster a culture of developing creative online resources.

Sufficient band-width is needed to facilitate quality teleconference student learning sessions, delivered by teachers at any of the sites, and to link academics and course coordinators for inclusive LIC management meetings. While students use social media to connect with friends and peers in their class, videoconferencing can also facilitate student connection with each other, for social and academic support.  To facilitate connection with peers and academic resources, student accommodation provided in rural areas should be enabled for e-learning. 

d) Financial resources

There is limited evidence on the financial costs of LIC programmes.  A hypothetical model of the financial impact of a student on a rural general practice over time was developed from data involving seven general practitioners supervising long-term students.  This challenged the view that medical students are always a financial burden on rural general practices, and can be helpful to recruit preceptors for long- rather than short-term students.

 

Support for the hypothetical model has come from early evaluation data from another school with a whole class LIC, showing that students can be cost-neutral or have a small positive financial impact on the practice within a few months. This finding was supported by perceptions of the preceptors involved, with most (66%) perceiving the longitudinal placement as financially neutral or favourable. While 19% of preceptors reported a negative financial impact, other supervisors were unconcerned about costs, adding that minor financial loss was outweighed by personal satisfaction. Data such as this are useful for ongoing preceptor recruitment and commitment.

Sample budgets for a rural LIC (University of Washington School of Medicine, WWAMI Rural Integrated Training Experience) and an urban LIC (Harvard Medical School Cambridge Integrated Clerkship) have been provided in Chapter 15 of the book referenced below (Brooks et al, 2016). 

e) Other enablers for a LIC programme

  • Continued high level support of the LIC model by University leadership.

  • Commitment of full-time staff resources to manage the workload.

  • Practical and continuing development of all academic teams.

  • Planning for succession at all levels.

  • Embracing new ideas or better ways of doing things as learning about the initiative progressed.

References

Brooks KD, Erikson JS, Bor DH. Resource and Logistical Issues. In: Poncelet AN, Hirsh D, editors. Longitudinal Integrated Clerkships: Principles, Outcomes, Practical Tools and Future Directions. North Syracuse, NY: Gegensatz Press; p.135-146.

Hudson JN, Weston K, Farmer L. 2012. Medical students on long-term regional and rural placements: what is the financial cost to supervisors? RRH 12:1951.

Hudson JN, Farmer EA, Weston KM, Bushnell JA. 2015. Using a framework to implement large-scale innovation in medical education with the intent of achieving sustainability. BMC Med Educ.15:2.

Walters L, Worley P, Prideaux D, Lange K.  2008. Do consultations in rural general practice take more time when practitioners are precepting medical students? Med Educ. 42(1):69-73.

Worley P, Kitto P. 2001. Hypothetical model of the financial impact of student attachments on rural general practices. RRH 1:83.

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