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      Broadening the clinical spectrum for medical students towards primary care: a pre-post analysis of the effect of the implementation of a longitudinal clerkship in general practice

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          Abstract

          Background

          Exposure to a broad spectrum of patient cases is a mainstay of undergraduate medical education. This study aimed to assess how many primary care-specific clinical pictures final-year medical students in traditional block rotations had encountered, and how this changed after a curricular change that included the implementation of a four-year longitudinal clerkship in primary care.

          Methods

          Final-year students before, and after, implementation of the clerkship were asked which of the clinical pictures most relevant to primary care they had seen. We compared the overall proportions of clinical pictures seen by the two cohorts.

          Results

          In the first cohort, 96 (66%) students responded, and 94 (65%) in the second. Before the curricular change, students had encountered a mean of 26.3 of the 34 primary care-specific clinical pictures (77.2%). After implementation of the longitudinal clerkship, this increased by 1.1 (4.2%, P = 0.038).

          Among the eight clinical pictures seen the least by students in the first cohort, we found a significant increase in the proportion of students seeing polymalgia rheumatica, frozen shoulder, epicondylitis and Dupuytren’s contracture after the clerkship’s implementation.

          Conclusion

          The undergraduate longitudinal clerkship in primary care broadened the spectrum of clinical pictures seen by medical students, to include more clinical pictures commonly seen in primary care.

          Electronic supplementary material

          The online version of this article (10.1186/s12909-018-1152-z) contains supplementary material, which is available to authorized users.

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          Most cited references18

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          A review of longitudinal community and hospital placements in medical education: BEME Guide No. 26.

          David King, S Mahoney, Elise Chong … (2013)
          Traditionally, clinical learning for medical students consists of short-term and opportunistic encounters with primarily acute-care patients, supervised by an array of clinician preceptors. In response to educational concerns, some medical schools have developed longitudinal placements rather than short-term rotations. Many of these longitudinal placements are also integrated across the core clinical disciplines, are commonly termed longitudinal integrated clerkships (LICs) and often situated in rural locations. This review aimed to explore, analyse and synthesise evidence relating to the effectiveness of longitudinal placements, for medical students in particular to determine which aspects are most critical to successful outcomes. Extensive search of the literature resulted in 1679 papers and abstracts being considered, with 53 papers ultimately being included for review. The review group coded these 53 papers according to standard BEME review guidelines. Specific information extracted included: data relating to effectiveness, the location of the study, number of students involved, format, length and description of placement, the learning outcomes, research design, the impact level for evaluation and the main evaluation methods and findings. We applied a realist approach to consider what works well for whom and under what circumstances. The early LICs were all community-based immersion programs, situated in general practice and predominantly in rural settings. More recent LIC innovations were situated in tertiary-level specialist ambulatory care in urban settings. Not all placements were integrated across medical disciplines but were longitudinal in relation to location, patient base and/or supervision. Twenty-four papers focussed on one of four programs from different viewpoints. Most evaluations were student opinion (survey, interview, focus group) and/or student assessment results. Placements varied from one half day per week for six months through to full time immersion for more than 12 months. The predominant mechanism relating to factors influencing effectiveness was continuity of one or more of: patient care, supervision and mentorship, peer group and location. The success of LICs and participation satisfaction depended on the preparation of both students and clinical supervisors, and the level of support each received from their academic institutions. Longitudinal placements, including longitudinal integrated placements, are gaining in popularity as an alternative to traditional block rotations. Although relatively few established LICs currently exist, medical schools may look for ways to incorporate some of the principles of LICs more generally in their clinical education programmes. Further research is required to ascertain the optimum length of time for placements depending on the defined learning outcomes and timing within the programme, which students are most likely to benefit and the effects of context such as location and type of integration.
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            The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education.

            Barbara Ogur, Edward Krupat, David Hirsh … (2007)
            The Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC) is a redesign of the principal clinical year to foster students' learning from close and continuous contact with cohorts of patients in the disciplines of internal medicine, neurology, obstetrics-gynecology, pediatrics, and psychiatry. With year-long mentoring, students follow their patients through major venues of care. Surgery and radiology also are taught longitudinally, grounded in the clinical experiences of a cohort of patients and in a brief immersion experience working directly with an attending surgeon. Students participate in weekly, case-based tutorials integrating instruction in the basic sciences with training to address the common and important issues in medicine, as identified by national organizations. In addition, they participate in a social science curriculum that focuses on self-reflection, communication skills, ethics, population sciences, and cultural competence. In the pilot year (July 2004 to July 2005), HMS-CIC students performed at least as well as traditional students in tests of content knowledge and skills, as measured by National Board of Medical Examiners (NBME) Subject Exams and the fourth-year Objective Structured Clinical Exam, and they scored higher on a year-end comprehensive clinical skills self-assessment examination, suggesting that they retained content knowledge better. From surveys, HMS-CIC students were much more likely to see patients before diagnosis and after discharge and to receive feedback and mentoring from experienced faculty than were their traditionally educated peers. HMS-CIC students expressed more satisfaction with their curriculum and felt better prepared to cope with the professional challenges of patient care, such as being truly caring, involving patients in decision making, and understanding how the social context affects their patients.
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              Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career: A Systematic Review.

              Eva Pfarrwaller, Johanna Sommer, Neo Christopher Chung … (2015)
              Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context.
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                Author and article information

                Contributors
                Roman Hari:
                ORCID: http://orcid.org/0000-0002-3972-9056
                + 41 631 58 70 , roman.hari@biham.unibe.ch
                Michael Harris: + 41 631 58 70 , michaelharris681@btinternet.com
                Peter Frey: + 41 31 632 89 92 , peter.frey@meddek.unibe.ch
                Sven Streit: + 41 631 58 70 , sven.streit@biham.unibe.ch
                Journal
                Journal ID (nlm-ta): BMC Med Educ
                Journal ID (iso-abbrev): BMC Med Educ
                Title: BMC Medical Education
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1472-6920
                Publication date (Electronic): 14 March 2018
                Publication date PMC-release: 14 March 2018
                Publication date Collection: 2018
                Volume: 18
                Electronic Location Identifier: 34
                Affiliations
                ISNI 0000 0001 0726 5157, GRID grid.5734.5, Institute of Primary Health Care Bern (BIHAM), University of Bern, ; Gesellschaftsstrasse 49, 3012 Bern, Switzerland
                Author information
                http://orcid.org/0000-0002-3972-9056
                Article
                Publisher ID: 1152
                DOI: 10.1186/s12909-018-1152-z
                PMC ID: 5853096
                PubMed ID: 29540163
                SO-VID: d6d34c56-fb25-46b9-99c1-90f5487b5a51
                Copyright © © The Author(s). 2018
                License:

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 28 June 2017
                Date accepted : 11 March 2018
                Categories
                Subject: Research Article
                Custom metadata
                issue-copyright-statement © The Author(s) 2018

                ScienceOpen disciplines: Education
                Keywords: clinical teaching & learning. primary care. curriculum evaluation. undergraduate education
                Data availability:
                ScienceOpen disciplines: Education
                Keywords: clinical teaching & learning. primary care. curriculum evaluation. undergraduate education

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