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Perm J. 2014 Spring; 18(2): 50–56.
PMCID: PMC4022558

Creating a Longitudinal Integrated Clerkship with Mutual Benefits for an Academic Medical Center and a Community Health System

Ann Noelle Poncelet, MD
Professor of Neurology, the Rowe Endowed Chair for Teaching in Neurology, and the Longitudinal Integrated Clerkship and Structured Clerkship Program Director at the University of California, San Francisco. E-mail: ann.poncelet/at/ucsf.edu.
Lindsay A Mazotti, MD
Assistant Professor of Clinical Medicine at the University of California, San Francisco and an Internist at the Oakland Medical Center in CA. E-mail: lindsay.a.mazotti/at/kp.org.
Bruce Blumberg, MD
Director of Graduate Medical Education for Kaiser Permanente Northern California. E-mail: bruce.blumberg/at/kp.org.
Maria A Wamsley, MD
Professor of Clinical Medicine at the University of California, San Francisco. E-mail: maria.wamsley/at/ucsf.edu.
Tim Grennan, MD
Clinical Professor of Internal Medicine at the University of California, Davis and an Internist at the Sacramento Medical Center in CA. E-mail: tim.grennan/at/nsmtp.kp.org.

Abstract

The longitudinal integrated clerkship is a model of clinical education driven by tenets of social cognitive theory, situated learning, and workplace learning theories, and built on a foundation of continuity between students, patients, clinicians, and a system of care. Principles and goals of this type of clerkship are aligned with primary care principles, including patient-centered care and systems-based practice. Academic medical centers can partner with community health systems around a longitudinal integrated clerkship to provide mutual benefits for both organizations, creating a sustainable model of clinical training that addresses medical education and community health needs.

A successful one-year longitudinal integrated clerkship was created in partnership between an academic medical center and an integrated community health system. Compared with traditional clerkship students, students in this clerkship had better scores on Clinical Performance Examinations, internal medicine examinations, and high perceptions of direct observation of clinical skills.

Advantages for the academic medical center include mitigating the resources required to run a longitudinal integrated clerkship while providing primary care training and addressing core competencies such as systems-based practice, practice-based learning, and interprofessional care. Advantages for the community health system include faculty development, academic appointments, professional satisfaction, and recruitment.

Success factors include continued support and investment from both organizations’ leadership, high-quality faculty development, incentives for community-based physician educators, and emphasis on the mutually beneficial relationship for both organizations. Development of a longitudinal integrated clerkship in a community health system can serve as a model for developing and expanding these clerkship options for academic medical centers.

Introduction

Medical student education is in an exciting period of transformation because medical schools are actively working to incorporate modern learning principles into their structure and align the forces affecting delivery of care with educational priorities. Important recent advances in the learning sciences expand the understanding of learning beyond the acquisition of knowledge, which is individual in focus (behaviorist, cognitivist, humanist, and constructivist learning theories),1,2 to participation, with learning being contextual and embedded in social processes (situated learning, social cognitive theory, workplace learning).1,3 Learning is tied to context with the learner joining a community of practice. The novice initially has legitimate peripheral participation in the authentic work of the practice then moves to more central participation with the growth of the skills of the learner and the trust of the community. The learners’ participation over time transforms the community.

The recent study of medical education by the Carnegie Foundation for the Advancement of Teaching in Stanford, CA, included 14 site visits and review of the research on medical education and the learning sciences.3 The study found medical education to have the following characteristics3:

  1. inflexible, long, and not learner centered
  2. overly focused on the inpatient clinical experience
  3. situated in hospitals with marginal capacity to support a teaching mission
  4. poor connection between formal knowledge and experiential learning
  5. inadequate attention to patient populations and health care systems
  6. inadequate opportunities to work with patients longitudinally.

The harm created by the fragmentation of clinical training and the importance of continuity as a vehicle for learning has gained awareness in the medical education community. This fragmentation is a barrier to situated learning in a community of practice.4,5

Four key recommendations emerged from the Carnegie study3: 1) integration of knowledge and experience, 2) habits of inquiry and improvement with a focus on excellence, 3) standardization and individualization (setting outcomes and allowing flexibility in learning), and 4) focus on development of professional values and dispositions (identity formation). Longitudinal clinical experiences were recommended as a method of integrating formal and experiential knowledge. Such clinical experiences also were recommended as a way of supporting professional identity formation with a commitment to values, dispositions, and aspirations by participation in a community of practice; observation of role models; and coaching, instruction, assessment, and feedback.

Longitudinal integrated clerkships are a curricular structure that incorporates many of the recommendations of the Carnegie report and that are strongly influenced by situated learning, social and cognitive learning theory, and work-place learning. Although longitudinal integrated clerkships are diverse in their structure and contextual characteristics, they all share three foundational elements: 1) medical students participate in the comprehensive care of patients over time, 2) they participate in continuing learning relationships with these patients’ clinicians, and 3) they meet most of the year’s core clinical competencies, across multiple disciplines simultaneously through these experiences (consensus definition, Consortium of Longitudinal Integrated Clerkships, 2007).6 An additional element for some programs is the opportunity to develop a connection between the student and the clerkship host community. Longitudinal integrated clerkship programs have been successfully created in settings that range from remote rural primary care practices to urban academic medical centers.6

The principles of longitudinal integrated clerkships closely mirror those of primary care7,8 and are based on patient-centered care and longitudinal relationships with faculty preceptors and patients in acute and chronic care settings.911 In 2005, the University of California, San Francisco (UCSF) began incorporating aspects of continuity with patients, peers, preceptors, and a medical system into students’ core clerkship training, and the university successfully launched a one-year longitudinal integrated clerkship at its academic medical center in 2007.11 Currently, 20% of the medical school class participates in a longitudinal integrated clerkship program, with another 30% of medical students participating in hybrid clerkship programs that include continuity with peers, faculty, and health systems.

The literature reports numerous documented benefits of longitudinal integrated clerkships. Continuity with faculty preceptors in these clerkships provides increased opportunities for observation and feedback on clinical skills,5,11 and continuity with a health care system provides opportunities to better understand systems-based practice.11,12 Continuity with patients allows students to form deeper relationships and to contribute in meaningful ways to patient care.12 Students participating in longitudinal integrated clerkships do not experience the erosion of patient-centered values that is well-documented during medical school, and they are less subject to the negative effects of the “hidden curriculum.”9,13 The hidden curriculum is defined as the “set of influences that function at the level of the organizational structure and culture” and has been posited as a key factor in the degradation of student values during medical training.14 Students in longitudinal integrated clerkships report that their participation in the clerkship inspires commitment, advocacy, and idealism.12 Finally, students in longitudinal integrated clerkships have more continuity with patients and spend more time independently performing patient care in a physicianlike role compared with students in traditional block rotations.15,16 However, longitudinal integrated clerk-ships can be faculty and resource intensive.11,17 One strategy for an academic medical center to expand placements in longitudinal integrated clerkships is to partner with a community health system because there are advantages for both organizations (symbiosis).

Symbiosis is defined as a mutually beneficial partnership between persons, organizations, or concepts of different kinds.18 In this spirit, UCSF approached Kaiser Permanente (KP) to develop a joint longitudinal integrated clerkship. Founded in 1945, KP is the nation’s largest not-for-profit Health Plan, serving more than 8.8 million members. The mission of KP is to provide high-quality, affordable health care services and to improve the health of its members and the communities it serves. The KP model is based on the delivery of complete, integrated care orchestrated by the primary care physician and specifically focused on disease prevention, early intervention, and chronic disease management. These KP principles mirror the principles of longitudinal integrated clerkships, which emphasize the importance of continuity between the clinician and the patient as well as the care of the whole patient across care settings (inpatient, ambulatory) and across different disciplines.

Methods

In 2009, Longitudinal Integrated Clerk-ship Directors from UCSF met with multiple KP sites, with the introduction and support of the KP Regional Graduate Medical Education Director, who had an interest in collaborating on such a model. Simultaneously, UCSF Longitudinal Integrated Clerkship Directors met with educational deans, curricular oversight committees, and all participating Clerkship Directors to present and vet this new clerkship proposal. In 2010, KP Oakland Medical Center in Oakland, CA (KP Oakland), was selected as the location for the clerk-ship because of its commitment from leadership and its prior successful track record with graduate medical education (teaching first- through fourth-year medical students both from UCSF and other institutions).

KP hired a Clerkship Director at 40% full-time employment (FTE), appointed an Assistant Clerkship Director at 10% FTE, and hired a full-time clerkship administrator. In addition, KP began to recruit liaisons and preceptors from each department. The organizational relationship between UCSF and KP Oakland is seen in Figure 1.

Figure 1.
Organizational structure of curriculum oversight for the Kaiser Longitudinal Integrated Clerkship (KLIC).

Clerkship Design and Student Experience

The Kaiser Longitudinal Integrated Clerkship (KLIC) was launched at KP Oakland in April 2011 and uses the same model as the longitudinal integrated clerk-ship at UCSF.11 Eight students simultaneously complete eight primarily ambulatory core clerkship rotations (anesthesia, family medicine, internal medicine, neurology, obstetrics and gynecology, pediatrics, psychiatry, and surgery) along with experiences in emergency medicine and the surgical subspecialties. They also complete short inpatient experiences in surgery, medicine, and obstetrics and gynecology, and “mini-immersions” of four to five days in pediatrics and neurology. A one-week sample schedule is shown in Table 1.

Table 1.
Example of weekly student schedule for longitudinal integrated clerkship

Students are paired with 1 preceptor in each discipline, attending each clinic approximately once every other week. They establish a panel of 50 to 75 patients and have independent learning time (usually 2 afternoons per week) to follow their panel patients to clinic visits, surgeries, and deliveries or to engage in independent learning based on core competencies they are expected to meet for each discipline. In a given morning in an outpatient clinic, a student will see 2 or 3 patients. The most common pattern is after obtaining consent from the patient, the student will do the interview and brief examination alone, then return to the preceptor to present the patient’s case and discuss his or her findings, initial assessment, and care plan. The student and preceptor then return together to reexamine the patient and confirm the plan. Students have full access to the electronic health record and document a medical student note in the patient’s chart. Students also participate in a weekly didactic seminar with lectures from each discipline and interdisciplinary lectures, modeled off the curriculum of the UCSF Longitudinal Integrated Clerkship but taught locally by KP physicians.19 In addition, there are simulation sessions and a Health Systems and Leadership Curriculum that includes a quality-improvement project.

Clerkship Administration and Faculty Oversight

The KLIC Clerkship Director and Assistant Director report to the clerkship steering committee at UCSF. They are responsible for meeting UCSF School of Medicine requirements and act as a link between UCSF and KP. The discipline-specific Clerkship Directors oversee all grading and evaluation of the overall KLIC experience, individual specialty experience, student evaluation, preceptor evaluation, and curriculum evaluation. They also design, with the KLIC administrator, the student schedules and didactic curriculum.

The Clerkship Directors oversee a liaison in each department, who also serves as the Clerkship Site Director for UCSF and the lead for each specialty’s preceptors. At KP Oakland, these liaisons are given a small amount of FTE for their position. The Clerkship Directors and liaisons meet monthly as a team to review student progress, to discuss faculty development efforts, and to continuously improve the clerkship experience.

Clerkship students are assigned to an advisor, a KP physician who is not their direct preceptor. The advisor helps monitor the students’ quarterly progress, provides feedback on individual learning plans that the students are asked to complete, helps intervene and problem solve, and advocates on the students’ behalf to program leadership.

Clerkship Preceptors

Preceptors undergo an orientation at the start of each year as well as ongoing faculty development on topics such as clinical teaching, time-efficient teaching, and writing evaluations. The number of clinic half days vary for each specialty depending on the number of weeks the clerkships traditionally span at UCSF, and range from 16 half days with psychiatry preceptors to 27 half days with internal medicine preceptors. Surgical specialties see their students both in clinic and in the operating room. Preceptors are recruited on the basis of their interest in clinical teaching as well as their ability to meet their clinical demands. Preceptors are generally given some release time from their clinic (average, 30 to 45 minutes), which is supported by their department.

Evaluation

Students are evaluated quarterly in the same manner as for the UCSF Longitudinal Integrated Clerkship, in which a student’s preceptors complete an online competency-based evaluation and are asked to participate in a quarterly evaluation meeting in which their shared student’s progress is discussed.11 Students evaluate their preceptors quarterly and submit midyear and end-of-year evaluations on each specialty and the overall KLIC experience. These evaluations are completed through UCSF’s online evaluation system. Student performance on Clinical Performance Examinations, an examination for each discipline (from UCSF), and national board scores are also tracked by UCSF. Final grades are compiled by the KP liaison and submitted to the UCSF Clerkship Director, who submits the final clerkship grade.

Data Analysis

With assistance from UCSF’s Office of Medical Education, we examined demographics of the KLIC students from 2011 through 2013 (N = 12) and the students who completed traditional clerkships from 2011 through 2013 (N = 181) to determine, with a χ2 and Fisher exact test, whether there were statistically significant differences regarding their sex. Using analysis of variance (ANOVA) tests, we also examined the students’ US Medical Licensing Examination (USMLE) Step 1 scores (completed before entry into the third year), and their USMLE Step 2 scores and Clinical Performance Examination scores in the domains of data gathering and communication skills. Both the USMLE Step 2 and Clinical Performance Examinations were performed after the completion of the clerkship year.

Using ANOVA tests, we then compared the mean scores of the end-of-year summary evaluations by the KLIC students from 2011 through 2013 with the mean scores of the end-of-clerkship evaluations from the traditional students. We examined perceptions of overall quality of faculty clinical teaching, quality of formal teaching, adequacy of direct observation and feedback, perceived achievement of course objectives, and rating of the clerkship as a whole. We also report in further detail the results of specific components of the KLIC experience. This survey has no comparison survey with the traditional students, because it pertains to the unique aspects of KLIC. Using ANOVA tests, we compared the end-of-clerkship examination scores and the percentage of students given honors in each clerkship between KLIC students and traditional students. Last, we report residency matriculation for the KLIC graduates of 2011 and 2012.

Results

Twelve of 16 students completed the KLIC experience. For personal or academic reasons, 4 KLIC students did not complete the clerkship year. There were no significant differences in sex between the 2 groups using Fisher exact test (traditional clerkship male-to-female ratio = 86:95, KLIC ratio = 2:10, p = 0.069).

Step 1 scores before entering the third year did not differ between KLIC and traditional clerkship students, nor did the Step 2 Clinical Knowledge scores, taken after the completion of the clerk-ship year. The Clinical Performance Exam scores demonstrated significantly higher performance by the KLIC students in the domain of data gathering (Table 2).

Table 2.
Comparison of US Medical Licensing Examination Steps 1 and 2 and Clinical Performance — Examinaton scores between Kaiser Longitudinal Integrated Clerkship (KLIC) (N = 12) and traditional students (N = 181)

In end-of-year UCSF clerkship evaluations, the perceptions of KLIC students did not differ significantly from the traditional students, except that KLIC students perceived better direct observation of clinical skills than did traditional students (Table 3).

Table 3.
Comparison of end-of-year University of California, San Francisco clerkship evaluations between Kaiser Longitudinal Integrated Clerkship (KLIC) students and traditional students, 2011–2013a

Year-end evaluations of the KLIC are demonstrated in Table 4. Table 5 reports the percentage of honors received by KLIC and traditional students in each clerkship, which were not significantly different in χ2 tests. Examination scores were also compared using χ2 tests, and KLIC students received significantly higher internal medicine examination scores than did traditional students (KLIC student mean = 85.33, SD = 8.88 vs traditional student mean = 78.24, SD = 8.80). Family and community medicine was the most common choice for residency (4 students), followed by emergency medicine (2 students), psychiatry (2 students), internal medicine (1 student), and pathology (1 student). Two students are currently taking a year off before applying to residency.

Table 4.
Year-end evaluations of Kaiser Longitudinal Integrated Clerkship (KLIC), 2011–2013 (N = 12)a
Table 5.
Percentage of clerkship honors for Kaiser Longitudinal Integrated Clerkship (KLIC) (N = 12) and traditional students who completed each clerkship in 2011–2013

Discussion

We have created a successful longitudinal integrated clerkship partnership between a community medical center (KP) and an academic medical center (UCSF). On the basis of our experience and the literature, this symbiotic partnership has benefits for students, patients, clinicians, and both organizations (Table 6). Advantages for UCSF include mitigating the resources required to integrate continuity into clinical training, providing primary care training, and addressing core competencies such as systems-based practice, practice-based learning, and interprofessional care. This partnership also provides an opportunity to begin clinical placements at KP in the preclerkship years as UCSF moves toward incorporating clinical and systems continuity for medical students across the four-year curriculum, to engage students in systems-based practice and to integrate undergraduate and graduate medical education along a competency-based advancement continuum. Advantages for KP include faculty development and academic appointments, professional satisfaction, exposing students to an integrated primary care delivery system, and recruitment of future physicians. An overarching vision for both organizations is to create a sustainable approach for medical education to address the future health care needs of the US.

Table 6.
Mutual benefits for University of California, San Francisco (UCSF) School of Medicine and Kaiser Permanente (KP) Oakland Medical Center

Our results are similar to outcomes published on the UCSF-based longitudinal integrated clerkships.11 The KLIC students and traditional students perceive their clerkships to be equivalent, with the exception that KLIC students perceive more direct observation, likely secondary to the ongoing relationships they have with their preceptors.20 The percentage of honors given to KLIC students and traditional clerkship students did not differ significantly, and examination performance was equivalent with the exception of the internal medicine examination, on which KLIC students performed significantly better than their peers did. Reasons for this difference are uncertain.

Participation in KLIC may allow for improved data gathering in clinical encounters, based on the KLIC students’ Clinical Performance Exam scores, possibly because students spend more time in the workplace seeing patients compared with traditional students16 and are able to hone their interview skills given this increased amount of patient interaction. Clinical Performance Exam cases are also all ambulatory-based cases, and traditional students spend much less time in ambulatory settings.

Challenges to creating a community-based longitudinal integrated clerkship include cost and coordinating a clerkship program off-site from the academic medical center. First, the cost of a longitudinal integrated clerkship is high if absorbed by the community health system, both in terms of supporting the clerkship leadership and in terms of productivity. Faculty time is required not only at the Program Director and program administrator levels but also for leadership roles in each department and for faculty release time for teaching and assessment. Developing faculty can also be costly, especially in a system unfamiliar with teaching, requiring intensive foundational elements of clinical teaching and assessment. Fortunately, our community health system had a tradition of undergraduate and graduate clinical education, allowing us to focus more on longitudinal teaching and assessment. Second, communication and coordination with the Clerkship Directors, administrators, and medical school educational leadership need to be active and ongoing. Ensuring that changes in the traditional clerkship curriculum are translated to community sites is an ongoing need for both traditional and longitudinal integrated clerkships. Working with a struggling student can be a challenge to any longitudinal integrated clerkship program, and close coordination with the leadership at the academic medical center is critical in these situations, especially in a distributed setting.

Establishment of KLIC was made possible through the support and funding from both local and regional KP leadership, as well as support of UCSF educational leaders and Clerkship Directors. Contributions from experienced administrators and an on-site Clerkship Director, as well as experienced medical student preceptors, also ensured success. Close collaboration and communication with UCSF Clerk-ship Directors and governing bodies was necessary. End-of-year clerk-ship evaluations by students demonstrated high student satisfaction with preceptor-ships and didactics and a strong sense of community among those involved in KLIC. A new undergraduate medical education committee was created to focus on medical student education at KP Oakland.

Expanding the relationship between a community health system and an academic medical center requires faculty development and dissemination of a culture committed to high-quality teaching and assessment. The UCSF faculty development seminars are open to KP physicians. KP appointed a physician lead to collaborate with UCSF, organize quarterly faculty development workshops on-site at KP, and serve on the UCSF Faculty Development Committee. A KP physician participates in a yearlong UCSF faculty development program in medical education. Additionally, UCSF is working to streamline the process of obtaining volunteer clinical faculty status for KLIC faculty, providing an incentive to community physician educators.

As academic medical centers strive to apply the principles of longitudinal integrated clerkships across the continuum of medical education, we anticipate continued engagement with community hospitals and health systems, particularly KP, as a nationwide health care organization. Such partnerships could focus on longitudinal clinical experiences in the first few years of medical school, third-year longitudinal integrated clerkships, and systems-based practice/population health experiences and curricula in a functional primary care system. Factors critical to the success of these partnerships include continued support and investment from community and academic medical center leadership, improvement and organization of faculty development, provision of incentives for community-based physician educators, and emphasis on the mutually beneficial relationship for both medical centers. Our early experience with the UCSF-KLIC program is one of a sustainable, mutually beneficial partnership that translates current educational principles into practice and has the potential to inform and transform the delivery of health care in the US.

Acknowledgments

The authors wish to thank John Loftus, MD; Tom Barber, MD; Juan Guerra, MD; and Stanton Siu, MD, at the Oakland Medical Center and Helen Loeser, MD; and Susan Masters, PhD, at the University of California, San Francisco for their initial and continued support of the Kaiser Longitudinal Integrated Clerkship.

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

Footnotes

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

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Articles from The Permanente Journal are provided here courtesy of Kaiser Permanente