As part of clinical curricular reform at UCSF, the LIC model was implemented as an innovative approach to the increasing challenges of clinical training of medical students. A key element of the LIC model is continuity, proposed as an organizing principle for medical education reform (2
) to address the fragmented process of clinical training (19
). AMCs potentially have significant barriers to educational continuity, including referral patients with infrequent appointments, underinvestment in ambulatory care, complex information technology infrastructure, departmental boundaries and culture, limited resources to support administrative and faculty teaching efforts, and lack of interdisciplinary teaching models and competency-based evaluation instruments (2
). Our student perception and outcome data support the efficacy of the LIC model for core clerkship training in AMCs. Continuity with preceptors, patients, and peers was highly valued by the students. They performed equivalently on discipline-specific examinations and USMLE step 2 CK, and slightly better on standardized clinical examinations compared to traditional clerkship students, consistent with the experience of other LIC programs (5
). PISCES is the first LIC successfully implemented in an academic tertiary care medical center, and can serve as a model for educational continuity in this setting.
Success factors for developing and implementing an LIC at our medical center included clear articulation of the limitations of the traditional model, commitment to key principles for clinical training, participation by faculty and clerkship directors from all core clinical clerkships, support from clerkship directors, department chairs, and educational leadership at UCSF, and modest funding to support development, implementation, and management of the pilot program.
Successful implementation of an LIC model should capitalize on strengths of the site and adhere to key features of an LIC. In an academic setting, access to both generalists and subspecialists allows flexibility to redirect clinical experiences over the year to ensure contact with core diagnoses. The complex medical conditions of subspecialized patients are both a resource and a challenge for students in our setting. The relative value of continuity with a preceptor and clinical service versus clinical variety deserves further research in both LIC and traditional models.
The continuity inherent in the LIC model can enhance opportunities for meaningful feedback to students. Traditional clerkship students at UCSF and nationally report that direct observation of clinical skills by supervisors occurs infrequently and feedback on performance is often inadequate (20
). Gil et al. documented that students had a lower perception than faculty of the amount of feedback they received during clinical clerkships (21
). Notably, the PISCES students rated observation and feedback significantly higher than their traditional clerkship peers. We believe that, in PISCES, continuity with faculty and use of a structured tool for direct observation and feedback contribute to the enhanced experience with feedback.
There were a number of challenges encountered in our LIC. Preceptor recruitment, support, and development are difficult in any AMC (2
), including ours. Concerns about clinical productivity, lack of funding for preceptor teaching, overlap with traditional students, and clinic space constraints are ongoing potential barriers to preceptor recruitment. On the other hand, faculty preceptors were rewarded with meaningful year-long teaching relationships, and participation in a community of teachers committed to longitudinal learning. Unique to our tertiary care setting, half of our faculty were subspecialists, which can limit the breadth of patient types a student sees with their preceptor. This can be mitigated by acute care experiences, discipline-specific call, patient simulation, and ‘swaps’ between preceptors within a discipline.
There were also challenges for the LIC students. Students in an LIC initially struggle with having to learn multiple disciplines simultaneously. However, compared to their peers, our students achieved equivalent or superior knowledge and clinical skills by the end of the year. Another question is whether this model is optimal for any type of learner, or whether certain students are more likely to thrive in this program. In addition, despite receiving rich and frequent feedback on their performance model, students described progressive anxiety in waiting for grades until the end of the year.
The student advisor program received lower student ratings than other elements of PISCES. Students were uncomfortable having an evaluating preceptor as an advisor, even though the preceptor had the benefit of direct observation of the student's performance. Students also struggled with integrating into the inpatient setting when following their panel patients. We worked with the different specialties to develop guidelines on how PISCES students could interface with the inpatient teams – such as rounding times, faculty and chief resident contacts, and role expectations. In reality, however, teams often varied their daily structure, with new residents rotating from different sites, resulting in unfamiliarity with the PISCES program and how best to integrate the students in this unusual role. Now that the program is more established, faculty and residents are more familiar with it and understand the students' roles and expectations better. Another barrier was the challenge of trying to join rounds and present a patient to the inpatient team the next day. We attempted to schedule non-clinic mornings after call nights to facilitate the students joining rounds, but this was not consistently possible. However, based on student feedback, we have incorporated more free mornings on post-call days so that students can join the inpatient teams and present their patients.
Doubling the size of the program after its first year was challenging, as it doubled the number of preceptors required, increased the number of PISCES school faculty needed, and increased the necessary administrative support. Traditional third-year clerkship programs continued concurrently with PISCES at all PISCES sites. Transforming these sites completely to the LIC model would require PISCES positions for 60 students. Faculty, clerkship leadership, and department chairs were unwilling to expand the program further in 2008 without evidence of improved learning outcomes. Resources for 60 LIC students including preceptors, teachers, space for five or six PISCES school small groups, and increased administrative support would need to be addressed, although resources currently used for traditional clerkships would shift to an expanded program. PISCES provides the equivalent of 144 core clerkships and decompresses our traditional sites, but the shift in costs is difficult to quantify. The cost of this model compared to traditional clerkships is as yet unknown and merits further investigation.
In parallel to the PISCES program, aspects of the LIC model have been incorporated into a six-month traditional clerkship program for UCSF students at San Francisco General Hospital (25 students) and the San Francisco Veteran's Administration Medical Center (18 students). Further growth of UCSF LIC opportunities have come by partnering with community medical centers. UCSF Fresno launched a six-month LIC for nine students in 2010, and Kaiser Permanente Medical Center in Oakland will launch a one-year LIC program for eight UCSF medical students in 2011. As our curriculum continues to evolve, we hope ultimately to offer clerkship options to all our medical students that incorporate some or all of the key principles underlying the LIC model and leverage the strengths of our individual sites. PISCES is one of the programs participating in a three-school study (Harvard Medical school/Cambridge Integrated Clerkship and Yankton Model Program of the Sanford School of Medicine of the University of South Dakota) funded by the Josiah Macy Foundation to assess the impact of the LIC model on student learning processes and outcomes compared to traditional clerkships.