Answer to "What barriers do I need to overcome? "

Challenges to overcome when introducing a new model of clinical clerkship such as a longitudinal integrated clerkship (LIC) may include:

a) Resistance to moving away from traditional block rotations

Many clinicians may feel the way they were trained was perfectly fine and do not understand the need for change.   It is important to acknowledge the resistance of those wanting to reinstitute or maintain the ‘old way’ of doing clinical clerkships, and engage with such ‘doubters’, building a relationship with them and seeking proactive ways to overcome obstacles to change that they may pose. In addition to producing evidence demonstrating the success of a LIC, a competent LIC student or graduate, an experienced LIC preceptor or patient can be a powerful partner to address concerns. Indeed patients have provided significant evidence on how they value longitudinal relationships with students in LIC programmes. 

b) Initial student concerns

Student concerns must also be acknowledge and addressed.  Some students will need more support initially to manage any disorientation with the need to self-direct and self-assess their own learning.  A LIC graduate from the same or even another programme can be very helpful to reassure students. 

c) The amount of inpatient care required for LIC student learning, and in which disciplines 

The core disciplines of medicine, surgery, paediatrics, mental health and woman’s and reproductive health remain important for undergraduate medical education. The integrated curriculum of a LIC allows the student to learn these and other disciplines in a range of settings.

Currently there is no evidence to define a certain allocation of inpatient care in a LIC programme. Primary care offers the student ‘first contact’ with the patient, to assess and initially manage potential diagnoses and follow the patient through their care journey. Inpatient care gives students opportunity to manage disease progression with the inpatient care team, experience that is valuable in preparing for the junior doctor years. Surgery is one example where there is debate on how much inpatient care a LIC student needs. A surgical illness episode includes pre-operative, operative and post-operative care.  While some programmes offer a 2-week block of inpatient surgery to cover all these settings, LIC students have also performed well in summative exams with longitudinal operating room and clinic time with a surgical preceptors. 

It can be difficult for a student to manage concurrent demands to join the inpatient team or follow their patients to various healthcare interventions, such as imaging, surgery or obstetric deliveries.  LIC directors, local coordinators and/or preceptors should assist the student where necessary, to manage a balance of inpatient care and opportunity to experience the benefits arising from continuity with patient care.

d) Resource limitations

While health workforce shortage can be seen as a barrier in some settings, the students’ increasingly active participation in local healthcare teams has proven beneficial to the local healthcare service, and the community it serves.  Potential competition for consulting space has been addressed above.

e) Accreditation

While early LIC programmes, or those in new medical schools, may have received close scrutiny by national accreditors, there has been a willingness to accept LICs if the programme meets the following requirements: equivalent core competencies to those in other clinical clerkship models at the same university; the programme is well planned and implemented; and has the appropriate resources for delivery.  The worldwide uptake of LICs, with evidence of learning gains for LIC graduates, is likely to result in greater confidence in the LIC model.

References

Cox M, Talley RC, Irby DM.  2016. Setting the Stage. In: Poncelet AN, Hirsh D, editors. Longitudinal Integrated Clerkships: Principles, Outcomes, Practical Tools and Future Directions. North Syracuse, NY: Gegensatz Press; p.19-28.

Hudson JN, Knight, PJ, Weston, KM. 2012. Patient perceptions of innovative longitudinal integrated clerkships based in regional, rural and remote primary care: A qualitative study. BMC Fam. Pract. 13;72.

Poncelet A, Bokser S, Calton B, Hauer KE, Kirsch H, Jones T, Lai CJ, Mazotti L, Shore W, Teherani A, Tong L, Wamsley M, Robertson P. 2011. Development of a longitudinal integrated clerkship at an academic medical center. Med Educ. Online:16.

Poncelet AN, Wamsley M, Hauer KE, Lai, C, Becker T, O’Brien B. 2013. Patient views of continuity relationships with medical students. Med. Teach. 35:465–471.

Poncelet A, Hudson JN.  2015. Student Continuity with Patients: A System Delivery Innovation to Benefit Patient Care and Learning (Continuity Patient Benefit). Healthcare 3:607-8.

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