Medical Students Can Learn Surgery Effectively in a Rural Longitudinal Integrated Clerkship

A value analysis of longitudinal integrated clerkships: consideration of costs and benefits

Longitudinal Integrated Clerkships (LICs) prioritise longitudinal relationships with faculty, patients, and place. Research shows that LICs benefit students and faculty, but most medical schools have limited LIC programmes. This is likely due to perceptions that LICs are more costly and complex than traditional block rotations (TBRs). The perceived cost versus evidence-based value related to clerkship education has not been examined in detail. Until recently, no 'All-LIC' medical school exemplars existed in the US, limiting the value of this model as well as the ability to examine relative cost and complexity. In this paper, we draw on our experience launching three 'All-LIC' medical schools in the United States - schools in which the entire clerkship class participates in a comprehensive clerkship-year LIC. We propose that the known benefits of LICs coupled with cost-mitigation strategies related to running an 'All LIC' model for core clinical clerkships, rather than block and LIC models simultaneously, results in a higher value for medical schools.

Longitudinal Integrated Clerkships and Undergraduate Surgical Education: A Scoping Review and Gap Analysis

OBJECTIVE

Longitudinal integrated clerkships (LICs) are an increasingly popular approach to medical student clinical education, and the literature describing them is expanding. Despite this, there is a lack of understanding for how surgery didactics and skills are currently taught as a part of the LIC curriculum.

DESIGN

We conducted a scoping literature review in July 2022 using terms related to LIC and surgical education. Abstract and full-length text screening followed. Data extraction was completed in August 2022. Articles published in English, focused on LIC students, and discussed any element of LIC curriculum surgical education was included.

SETTING

Scoping literature review.

PARTICIPANTS

A total of 282 studies describing LICs were identified from the scoping literature review. After applying inclusion and exclusion criteria, 37 (13%) studies describing some element of surgical education were included.

RESULTS

Of these 37 studies, the majority did not delve into pertinent details related to students' surgery experience, expectations, and surgical skills accomplishments. Four studies (11%) reported on the outpatient surgical experience, such as minimum required time that students were expected to be in the clinic, and 8 studies (22%) described the inpatient and operating room exposure. Only 1 study (3%) described the surgical floor management of surgical patients, including tasks like documentation and wound care, and 3 studies (8%) reported formal assessment of surgical skills, such as suturing technique.

CONCLUSIONS

Our study highlights the paucity LIC literature examining the relationship between this curricular innovation and the unique needs of medical students on a surgical clerkship. Surgeon educators should embrace the opportunity to contribute LIC curriculum development and subsequent investigation into how this modality interfaces with the learning objectives of undergraduate surgical education. A formal description of essential curriculum components for all surgical LIC programs is needed to ensure appropriate surgical education across the varied LIC models.

Patient outcomes in a Longitudinal Integrated Clerkship: A systematic literature review

CONTEXT

Patient-student relationships are at the heart of Longitudinal Integrated Clerkships (LICs). Outcomes for students and preceptors are beneficial, but patient outcomes remain unclear. This systematic literature review explored the current evidence base of patient outcomes in an LIC. Patient outcomes were defined as issues related to patient safety, clinical effectiveness or patient experience.

METHODS

Seven bibliographic databases were searched. A wider search strategy included a hand search of three medical education journals' previous issues and backward/forward citation searching of included studies and of a relevant systematic review. Included studies were quality appraised and assessed for their strength and level of evidence. A qualitative data synthesis was performed.

RESULTS

Databases searches identified 7237 titles. Following the removal of duplicates, titles and abstracts were reviewed against the inclusion criteria. Forty-eight studies had a full-text review. Nineteen met the inclusion criteria. Seven studies were included from the wider search strategy. From the 26 included studies, two major themes were identified. (1) 'A trusting patient-student relationship' contains the sub-themes: 'care and compassion', 'patient education and empowerment' and 'the loss of the student as 'my' doctor'. (2) 'The student acts as an agent of change for the patient' contains the sub-themes: 'patient advocacy', 'supporting the patient to navigate the healthcare system', 'communication between patient and healthcare professional' and 'enhancement of preceptors' care, healthcare services and communities'.

CONCLUSIONS

LICs provide educational continuity allowing the creation of a trusting patient-student relationship. This relationship leads to students becoming agents of change for patients by enhancing patient outcomes. This review provides further evidence on the benefits of having an LIC as part of the medical education curricula and implications for its successful delivery. Further research is needed to explore educationally induced benefits for patients and look at objective assessments of patient health outcomes.

The Perception of Surgery Program Directors of Residency Applicants From Longitudinal Integrated Curriculum Medical Schools: A Survey of the Association of Program Directors in Surgery Members

Research statement This study explores whether longitudinal integrated clerkship (LIC) students are competitive general surgery applicants and if they are perceived as adequately prepared for general surgery residency compared to traditional block rotation (BR) students. Background/relevance of the study There is increasing interest in LIC models of clinical education versus BR models. LIC students have been shown to perform similarly on examinations to BR students. However, while LICs seem well suited for students pursuing primary care specialties, little is known about how this approach impacts clinical education for surgery. Design and methods An electronic survey was prepared and approved by the Association of Program Directors in Surgery (APDS) and our university's institutional review board (IRB). Ten multiple-choice questions were administered along with an option for narrative comments. Surveys were sent over a one-month period to members of APDS Listserv. Returned emails were de-identified, and the results were tabulated. Results From 43 responses, the majority identified as program directors (PDs) (65%) and reported being somewhat familiar or very familiar with LICs (90%). When asked about the statement "LIC students are prepared for surgical residency," 22% "disagreed" or "strongly disagreed." When asked "How would you rank a LIC prospective applicant in comparison to a BR student?" 35% responded that they would rank the LIC student lower or not at all. Of the respondents, 47% reported that they have current residents who were LIC students. Most of these residents (65%) are graded as "average" for current performance. Conclusions The results suggest that medical students who are trained using LICs may be disadvantaged when applying to general surgery residencies. Interpretation is limited by the small number of respondents, and it only reflects the opinions of active APDS Listserv members. Further study is needed to confirm these findings and elucidate the basis of perceived deficiencies in LICs. Students from these schools should be advised to obtain additional surgery experience.

Royal Australasian College of Surgeons Rural Health Equity Strategic Action Plan: excellence through equity

Wherever there are people there will be a need for surgical care. Rural people have all kinds of problems and need all kinds of surgeons. The Royal Australasian College of Surgeons (RACS) Rural Health Equity Strategic Action Plan (RHESAP) was endorsed by Council in December 2020. The goal is to increase the rural surgical workforce and increase access to care, through providing motivated surgeons with the training they need to work where they are needed most. The Royal Australasian College of Surgeons Surgical Education and Training Programs (SET) aim to train generalist surgeons across all nine surgical disciplines. To increase the rural surgical workforce and increase access to care, we need to select for rural origin, rural medical school and rural work experience, provide all trainees with the opportunity for positive rural work exposure with an aligned rural curriculum, and we need to support surgeons already living and working in rural areas. In future, with persistent health inequity for underserved populations and the impacts of climate change, we anticipate an increasing need for a culturally and emotionally intelligent, broad-scope surgical workforce, across all surgical disciplines, with the skills, confidence and motivation to work collaboratively and effectively in surgical teams, in areas of need and limited resource environments, including globally.

Rural longitudinal integrated clerkships and medical workforce outcomes: a scoping review protocol

INTRODUCTION

The shortage of doctors in rural locations is an international problem, contributing to limited access to healthcare and a health disparity between rural and metropolitan populations. To encourage additional doctors to work in rural locations, more doctors than ever are being trained in rural settings. One rural clerkship model that is gaining recognition for fostering rural careers is the Longitudinal Integrated Clerkship. Longitudinal Integrated Clerkship programmes vary in terms of settings and durations, but at their core have the fundamental commonality of continuity, with students learning the curriculum in an integrated manner. The scoping review will synthesise the literature pertaining to medical workforce outcomes of rural Longitudinal Integrated Clerkship programmes, to uncover areas that require further research and establish elements of medical education programme design that positively influence rural workforce outcomes.

METHODS AND ANALYSIS

The review will follow Arksey and O'Malley's six step scoping review framework. MEDLINE, CINAHL complete (EBSCOhost), Scopus, Embase (Elsevier) and ISI Web of Science databases will be searched along with Google, Google Scholar, ProQuest and WHO library database. Single design studies examining the geographic work locations and/or medical specialty of rural Longitudinal Integrated Clerkship graduates will be included. Data from quantitative and mixed-methods studies will be included. Only studies written in English will be included. There will be no date range restriction imposed on the reviewed studies. Two reviewers will independently screen and critically appraise the articles to determine if they meet the inclusion criteria. Data from eligible studies will be extracted for synthesis.

ETHICS AND DISSEMINATION

Scoping reviews do not require ethics approval. Results will be submitted to a peer-reviewed journal and may be presented at relevant conferences. The findings will also be shared within the Longitudinal Integrated Clerkship community of medical educators.

The impact of longitudinal integrated clerkships on patient care: a qualitative systematic review

BACKGROUND

Longitudinal Integrated Clerkships (LIC) are a relatively novel type of clinical placement model within medical education, particularly within the UK. The research on LICs primarily focuses on the impact of the model on students, tutors, communities, and organisations. The impact of LICs on patients has not yet been adequately synthesised. This systematic review aims to fill this gap by examining empirical evidence regarding the impact of LICs on patient care using quality-of-care measures, namely, health process measures and outcome measures.

METHODS

A systematic search was conducted in MEDLINE, PsycINFO, Academic Search Premier, Education Research Complete, CINAHL Complete, ERIC, Web of Science, and Scopus. Two reviewers independently conducted the screening process for study selection. Results across studies were analysed and summarised by thematic analysis.

RESULTS

The reviewers screened 1632 records. Seven studies met the inclusion criteria following a full-text review, from which four themes were created. Three themes describe health process measures, including: 1) Advocacy within healthcare system, 2) Provision of supplementary and personalised care, and 3) Providing companionship with care. One theme described a health outcome measure: Therapeutic Alliance.

CONCLUSION

Current evidence demonstrates an overall beneficial impact of LICs on patient health processes and outcome measures. However, the available evidence is weak and limited. Further research is required to illuminate the true impact of LICs on patient health.

The impact of clerkship model and clinical setting on medical student's participation in the clinical workplace: A comparison of rural LIC and rural block rotation experience

PURPOSE

To compare the participation of rural Longitudinal Integrated Clerkship (LIC) and rural Block Rotation (BR) students in surgical clinical activities.

METHODS

Third-year medical students from Deakin University's Rural Clinical Schools were invited to record their participation during clinical encounters with ten common surgical conditions, using a descriptive five-point progressive entrustment scale. Participation levels of LIC and BR students were compared for differences, according to clinical task and context.

RESULTS

LIC students recorded greater active participation across all clinical tasks.Highest levels of active participation occurred in General Practice, a setting only LIC students were exposed to at this course stage. BR students recorded the majority of their surgical encounters in the hospital inpatient setting, where their involvement was predominantly observational. Both groups recorded high levels of participation in the Emergency Department.

CONCLUSIONS

Active participation in clinical encounters with surgical patients was enhanced by participation in a LIC program and cannot be attributed to the rural context alone. Student participation is influenced by clinical context, presenting the opportunity to reconsider the design of clerkships to include models that facilitate active student participation. Further research is required to investigate the learner, supervisor and contextual factors influencing entrustment decisions within clerkships.