Continuity in Undergraduate Medical Education: Mission Not Accomplished.

Evidence is mounting that longitudinal medical student clerkships provide better educational experiences than traditional block clerkship "silos." Education studies across institutions demonstrate positive effects of continuity on medical students, including creating patient-centered learning environments, improving fidelity of evaluations and feedback, improving medical student patient-centeredness, enabling more autonomous functioning in the clinical workplace, and increased recruitment and retention of students into primary care careers. Outcome studies show potential for longitudinal students to add value to patient care. This perspective piece summarizes the current evidence basis for longitudinal clerkships broken down by Kirkpatrick level (reactions, perceptions/attitudes, knowledge, behaviors, and patient benefits). Despite this evidence, expansion of longitudinal clerkships has been slow-i.e., fewer than half of current US medical schools offer one. While more recent curricular innovations center around Entrustable Professional Activities (EPAs), there are clear opportunities for medical schools to use longitudinal clerkships as a lens through which EPAs can be effectively evaluated. This perspective highlights the synergy between longitudinal clerkships and EPAs, showing that successful implementation of the former should empower the latter. While large, complex educational interventions are daunting tasks, change is needed. Regulatory organizations should mandate continuity-focused experiences for US medical graduates.

Learning to balance efficiency and innovation for optimal adaptive expertise.

It is critical for health professionals to continue to learn and this must be supported by health professions education (HPE). Adaptive expert clinicians are not only expert in their work but have the additional capacity to learn and improve in their practices. The authors review a selective aspect of learning to become an adaptive expert: the capacity to optimally balance routine approaches that maximize efficiency with innovative ones where energy and resources are used to customize actions for novel or difficult situations. Optimal transfer of learning, and hence the design of instruction, differs depending on whether the goal is efficient or innovative practice. However, the task is necessarily further complicated when the aspiration is an adaptive expert practitioner who can fluidly balance innovation with efficiency as the situation requires. Using HPE examples at both the individual and organizational level, the authors explore the instructional implications of learning to shift from efficient to innovative expert functioning, and back. They argue that the efficiency-innovation tension is likely to endure deep into the future and therefore warrants important consideration in HPE.

Longitudinal integrated clerkships.

There is increased interest in longitudinal integrated clerkships (LICs) due to mounting evidence of positive outcomes for students, patients and supervising clinicians. Emphasizing continuity as the organizing principle of an LIC, this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.

Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships.

BACKGROUND: Hidden curriculum literature suggests that different learning environments and curricular designs reinforce disparate values and behaviors. AIM: This study explores potential differences in learning environments afforded by two clerkship models through perceptions of the ideal student. METHODS: In this qualitative study, research assistants interviewed 48 third-year students and 26 clinical supervisors from three US medical schools. Students and supervisors participated in longitudinal integrated clerkships (LICs) or block clerkships. Students and supervisors described the ideal student in their clerkship. Using phenomenographic techniques, authors identified five ideal student profiles and coded students' and supervisors' descriptions for alignment with one or more profiles. RESULTS: Most students in both models described an ideal student who matched a learner profile (proactive and self-directed). More LIC students described an ideal student who fit a caregiver profile (engaging with and advocating for patients) and more block students described performer (appearing knowledgeable and competent) and team-player (working well with others) profiles. Supervisors' descriptions paralleled students' descriptions but with less emphasis on caregiving. CONCLUSIONS: Ideal student descriptions in LIC and block models may reflect different learning experiences and values emphasized in each model. These findings suggest implications for students' construction of professional identities that warrant further exploration.

Student Continuity with Patients: A System Delivery Innovation to Benefit Patient Care and Learning (Continuity Patient Benefit).

Medical education is continuing to evolve to meet the healthcare needs of the future. The longitudinal integrated clerkship (LIC) model is an important innovation in medical education. It has in its vision and structure "patient- and learner-centered education", using longitudinal relationships between patients and students as a foundational element in its design. LIC students have shown more patient-centered attitudes and behaviors that persist after medical school. They remain connected with the patient experience of care, which supports empathy and student moral development. The time that LIC students spend acting independently with patients also supports the development of higher order clinical and cognitive skills and professional identity formation. Student participation in a more meaningful way in the care of their patients promotes patient wellbeing, and helps patients with transitions of care, communication and preventative care. Patients report feeling empowered to be more active agents in their own care and feel an accountability and pleasure in the training of new physicians. Focusing on the patient/student relationship as a foundational element of clinical education has meaningful benefits to the patient and student with the potential to improve patient care directly and in the future, as these students become physicians.

Quantitative ultrasound of denervated hand muscles.

INTRODUCTION: Presentations to the neuromuscular clinic commonly involve hand muscle denervation, but few studies have evaluated hand muscle ultrasound. METHODS: Ultrasound studies of abductor pollicis brevis, first dorsal interosseous, and abductor digit minimi were prospectively performed in a cohort of 34 patients (77 muscles) with electromyography (EMG)-confirmed denervation, compared with 58 healthy control subjects. RESULTS: In control subjects, muscle thickness was highly reproducible [intraclass correlation coefficient (ICC) = 0.88-0.98], and echogenicity was moderately reproducible (ICC = 0.542-0.686). Age, gender, and body mass index influenced muscle thickness and echogenicity. Ultrasound changes in denervated muscles correlated with the severity of EMG abnormalities. A z-score cutoff of 0 identified denervated muscles with a sensitivity of 100% and 89% for echogenicity and muscle thickness, respectively. CONCLUSIONS: Hand muscle ultrasound provides a noninvasive method to quantify muscle denervation and may be useful as a screening tool before EMG studies.

A comparison of ultrasonographic and electrophysiologic 'inching' in ulnar neuropathy at the elbow.

OBJECTIVE: The present study aimed to clarify the relationship between structural ulnar nerve changes and electrophysiological nerve dysfunction in patients with ulnar neuropathy at the elbow (UNE). METHODS: High-resolution ultrasonography of the ulnar nerve was performed on 17 limbs with clinically and electrophysiologically confirmed UNE, and 52 control subjects at four standardised sites proximal and distal to the medial epicondyle (P2, P1, D1, D2), corresponding to segments of ulnar short-segment nerve conduction studies ("inching studies"). RESULTS: Ulnar nerve cross-sectional area (CSA) and hypoechoic fraction were significantly increased in patients with UNE immediately distal (D1) and proximal (P1) to the medial epicondyle (p<0.01). In patients with UNE, hypoechoic fraction was similar in asymptomatic and symptomatic limbs. Motor nerve conduction velocity across the elbow correlated with CSAmax and the maximum hypoechoic fraction (R=0.6, p<0.05). CSA and hypoechoic fraction of individual segments did not correlate with corresponding latencies on inching studies, but latencies across the D1 segment correlated with CSA at P1 (R=0.80, p<0.0001) and D2 (R=0.65, p<0.01). CONCLUSIONS: Sonographic abnormalities in UNE may not be maximal at the site of electrophysiological nerve dysfunction. SIGNIFICANCE: Sonographic abnormalities may reflect secondary pathophysiological changes in segments adjacent to regions of nerve compression.

Patient views of continuity relationships with medical students.

INTRODUCTION: Continuity relationships between students and patients, that occur in a longitudinal integrated clerkship (LIC), enrich medical students' opportunities to learn from patients and provide patient-centered care. Patient preferences for continuity with a primary provider are well-documented, but little is known about patients' experiences of continuity with students. This study examines patients' perception of continuity with and care received by students. METHODS: This qualitative study uses data from semi-structured interviews with 32 patients of LIC students at an academic medical center. Data were analyzed for themes about continuity and experiences of care provided by students. RESULTS: Patients valued relationships with students over time and across settings. Students' contributions to their care included enhanced access to and coordination of care, communication, patient education and wellbeing. Patients with substantial continuity and/or who were moderately or severely ill described their student in a physician-like role more frequently than other patients. Patients appreciated patient-centered attitudes and behaviors in their students. CONCLUSION: Patients value continuity relationships with students, akin to that described between patients and their physicians. Patients described a variety of ways in which students enhanced their care and assumed a physician-like role. These patient perceptions support the concept of mutually beneficial relationships between students and patients.

More is better: students describe successful and unsuccessful experiences with teachers differently in brief and longitudinal relationships.

PURPOSE: Clerkship experiences that structure student-teacher continuity may promote learning differently than brief student-teacher relationships. The authors compared students' successful and unsuccessful teaching experiences in brief and longitudinal relationships. METHOD: A multicenter, qualitative interview study was conducted in 2009-2010 of students in two clerkship models that provide different durations of student-teacher relationships. Each student described a successful and unsuccessful teaching relationship early and late in the core clerkship year. Questions explored teachers' strategies and behaviors and students' efforts to improve unsuccessful relationships. Interview transcripts were coded to identify major themes. RESULTS: Fifty-four students completed interviews. Students in brief relationships struggled to be known; students in longitudinal relationships felt respected as learners and partners. Teaching strategies differed in the two relationship durations. Questioning about factual knowledge was common in brief relationships; collaborative knowledge sharing and application to patients occurred in longitudinal relationships. Hierarchy characterized brief relationships. Longitudinal students experienced evolving expectations in response to their growing skills and contributions. Only students in longitudinal relationships described successfully intervening to improve unsuccessful relationships; students in brief relationships felt powerless. CONCLUSIONS: Clerkship students in brief relationships learn to adapt to teachers' preferences and questioning to facilitate their participation and knowledge acquisition; longitudinal students experience collaborative interactions focused on their development as care providers. In longitudinal relationships, students gain confidence to influence their own learning and modify circumstances to meet their learning needs. These findings suggest that medical students' clinical experiences may be enhanced by deliberately structuring longitudinal attachments to supervisors.

Better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships.

Interest in longitudinal integrated clerkships (LICs) as an alternative to traditional block rotations is growing worldwide. Leaders in medical education and those who seek physician workforce development believe that "educational continuity" affords benefits to medical students and benefits for under-resourced settings. The model has been recognized as effective for advancing student learning of science and clinical practice, enhancing the development of students' professional role, and supporting workforce goals such as retaining students for primary care and rural and remote practice. Education leaders have created multiple models of LICs to address these and other educational and health system imperatives. This article compares three successful longitudinal integrated clinical education programs with attention to the case for change, the principles that underpin the educational design, the structure of the models, and outcome data from these educational redesign efforts. By translating principles of the learning sciences into educational redesign efforts, LICs address the call to improve medical student learning and potential and advance the systems in which they will work as doctors.

The role of role: learning in longitudinal integrated and traditional block clerkships.

CONTEXT: Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design. METHODS: This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data. RESULTS: Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care. CONCLUSIONS: Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.

Students' workplace learning in two clerkship models: a multi-site observational study.

CONTEXT: Longitudinal integrated clerkships (LICs) are established, rapidly growing models of education designed to improve the core clinical year of medical school using guiding principles about workplace learning and continuity. This study is the first to report data from direct observations of workplace learning experiences of students on LICs and traditional block clerkships (BCs), respectively. METHODS: This multi-institution study used an observational, work-sampling methodology to compare LIC and BC students early and late in the core clinical year. Trained research assistants documented students' activities, participation (observing, with assistance, alone), and interactions every 10 minutes over 4-hour periods. Each student was observed one to three times early and/or late in the year. Data were aggregated at the student level and by in-patient or out-patient setting for BC students. One-way analysis of variance (anova) was used to compare two groups early in the year (LIC and BC students) and three groups late in the year (LIC, out-patient BC and in-patient BC students). RESULTS: Early-year observations included 26 students (16 LIC and 10 BC students); late-year observations included 44 students (28 LIC, eight out-patient BC and eight in-patient BC students). Out-patient activities and interactions of LIC and BC students were similar early in the year, but in the later period LIC students spent significantly more time performing direct patient care activities alone (25%) compared with out-patient (12%) and in-patient (7%) BC students. Students on LICs were significantly more likely to experience continuity with patients as 34% of their patients returned to them, whereas only 5% of patients did so for out-patient BC students late in the year. CONCLUSIONS: By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.

Transition to clerkship courses: preparing students to enter the workplace.

PURPOSE: Despite curricular shifts toward a clinically oriented first two years of medical school, students continue to struggle with the transition to clerkships. Transition courses are a curricular intervention to mitigate the challenges of entering clinical workplaces. The authors examine the objectives, content, educational strategies, and resources associated with transition courses. METHOD: The authors invited curricular deans and transition course directors at U.S. and Canadian medical schools to complete a Web-based survey in 2008. A prior qualitative study of transition courses informed the list of survey questions. The authors organize the key course features according to a preparation-for-workplace-learning framework and report the frequencies of course features based on descriptive statistics. RESULTS: Of the 83 schools (58% response rate) responding to the survey, 73 (88%) reported having transition courses. Most courses covered content relevant to key elements of workplace learning: roles and expectations of clerks, advice from senior students, professionalism, stress management, and procedural skills. Whereas 65 courses (98%) used didactic sessions and 49 (74%) incorporated hands-on practice, only 14 (21%) included practice in clinical settings. CONCLUSIONS: The intent of transition courses is to prepare students for workplace learning, but the most common approaches provide limited exposure to real clinical settings. Transition courses could better prepare students for workplace learning by increasing exposure to the routines, norms, and professionals that students encounter in clinical settings.

Burden, responsibility, and reward: preceptor experiences with the continuity of teaching in a longitudinal integrated clerkship.

BACKGROUND: To address challenges to clinical education, clerkships should be designed to promote continuity of educational experiences including continuity in teaching. Yet, little is known about how continuity in teaching impacts clinical teachers. Experiences of clinical teachers who precept students during a longitudinal integrated clerkship (LIC) must be examined. METHOD: The authors interviewed 27 preceptors who could compare their LIC with traditional clerkship teaching experiences. RESULTS: Teaching during an LIC had a significant impact on preceptors' time, effort, and clinic responsibilities. Preceptors felt they bore sole responsibility for teaching a discipline and ensuring students' learning, and they experienced a deep sense of reward observing students' growth. CONCLUSIONS: To support and sustain the reward of LIC teaching for faculty, LIC developers should focus on targeted faculty development and resource allocation to clinical teaching.

Peripheral neuropathy in scleroderma.

Because patients with scleroderma report neuropathic symptoms including numbness, paresthesias, and dysesthesias, we assessed peripheral nerve function in such patients. Fourteen scleroderma patients underwent complete neurologic examination, nerve conduction studies (NCS) and quantitative sensory testing (QST). Neurologic examination revealed reduced vibration (7) or pinprick (4) sensation in the upper or lower extremities, focal atrophy or proximal weakness (2), and decreased deep tendon reflexes (2). NCS showed reduced sensory nerve action potentials (1) and carpal tunnel syndrome (1). QST of the upper and lower extremity revealed increased cold or vibration detection thresholds in 8 of 14 patients. Our findings suggest that peripheral neuropathy occurs in patients with scleroderma at a higher frequency than previously appreciated. These findings cannot be ascribed to compression neuropathies, but rather involve large and small fibers in a non-length-dependent fashion. Larger, prospective studies using the more sensitive QST as well as pathologic studies of nerve, including cutaneous innervation, are needed to further assess the characteristics and etiology of the neuropathy.