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Nandiwada DR, Farkas AH, Nikiforova T, Leung PB, Donovan AK, Killian K, Thomas ML, Singh MK, Gallagher B, Callender DM. Exploring Models of Exposure to Primary Care Careers in Training: a Narrative Review. J Gen Intern Med 2024; 39:277-282. [PMID: 37989819 PMCID: PMC10853099 DOI: 10.1007/s11606-023-08532-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/08/2023] [Indexed: 11/23/2023]
Abstract
Multiple models of clinical exposure to primary care exist within undergraduate medical education (UME) and graduate medical education (GME). In this narrative review, we explore the evidence behind these different models of exposure, their alignment with positive promoters of primary care careers, and the pros and cons of each. Without positive exposure to primary care during training, sustaining the future primary care work force becomes increasingly challenging. Here, we explore multiple models of clinical exposure in UME, including longitudinal integrated clerkships, primary care tracks, and primary care clerkships. Within GME, we will review the impact of primary care tracks, Area Health Education Centers, block scheduling models, and continuity clinic scheduling models. The goal of this narrative review is to allow educators to think broadly and intentionally about the array of models to develop positive primary care experiences and perceptions in training, ultimately sustaining the primary care workforce.
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Affiliation(s)
- D Rani Nandiwada
- Perelman School of Medicine, University of Pennsylvania, 51 North 39Th Street, MAB 102, Philadelphia, PA, 19104, USA
| | - Amy H Farkas
- Milwaukee VA Medical Center, 5000 W National Ave, Milwaukee, WI, 53211, USA
| | - Tanya Nikiforova
- Division of General Internal Medicine, UPMC Montefiore Hospital, 9 West 921, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Peggy B Leung
- Weill Cornell Internal Medicine Associates, 505 East 70Th St, HT-4, New York, NY, 10021, USA
| | - Anna K Donovan
- Division of General Internal Medicine, UPMC Montefiore Hospital, 9 West 930, 200 Lothrop Street, Pittsburgh, PA, 15213, USA
| | - Katherine Killian
- Weill Cornell Internal Medicine, 178 East 85Th Street, Floor 2, New York, NY, 10028, USA
| | - Mary L Thomas
- University of Tennessee, 920 Madison Ave, Suite 531, Memphis, TN, 38163, USA
| | - Mamta K Singh
- Case Western Reserve University, VA Northeast Ohio Healthcare System, 1620 Magnolia Drive, Administrative Building, RM 5M678, Cleveland, OH, 44106, USA
| | | | - David M Callender
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA, 22908, USA.
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Hirsh DA, Crampton PES, Osman NY. Applying self-determination theory to stem medical schools' clinical teacher sustainability crisis. MEDICAL EDUCATION 2024; 58:118-128. [PMID: 37593835 DOI: 10.1111/medu.15181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/19/2023]
Abstract
THE PROBLEM Medical schools require highly skilled and committed clinical faculty to teach, assess, supervise and mentor students' clinical care. Medical education is facing a crisis in recruiting and sustaining these clinical teachers. Faced with multiple demands and responsibilities in fast-paced clinical environments, teachers may not have the time, resources or stamina to sustain these critical roles. Medical school leaders must commit to and provide structures and processes to attract, sustain and retain clinical teachers. CONCEPTUAL FRAMEWORK The authors use the lens of self-determination theory to frame approaches to support teacher sustainability. Self-determination theory describes sources of human motivation. The theory and its evidence base characterise three human psychological needs: autonomy, competence, and relatedness. This theory can bridge individual psychological and institutional leadership perspectives to help medical school leaders anticipate and respond to their clinical teachers' needs. The authors propose three practical steps: practices to advance employee-centredness, processes to align individual and institutional values, and restructuring education to support clinical teachers' needs alongside student and patient needs. The authors describe limitations to this relational approach that focuses on leadership actions and consider individual agency as another key factor for sustainability. DISCUSSION Medical school leaders can develop and apply theory-driven approaches to advance sustainability. Sustainability now and in the future requires careful attention to the needs of clinical teachers and to their relationships with and within medical schools.
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Affiliation(s)
- David A Hirsh
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - Paul E S Crampton
- Health Professions Education Unit, Hull York Medical School, University of York, York, UK
| | - Nora Y Osman
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Lin-Beckford S, Osman NY, Krupat E, Hirsh DA. An exploratory study of goal orientations of traditional block and longitudinal integrated clerkship students. MEDICAL TEACHER 2023; 45:1275-1282. [PMID: 37262297 DOI: 10.1080/0142159x.2023.2216362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Achievement goal theory links goal setting, motivation, and learning and describes three orientations: 'mastery' (seeking learning), 'performance' (seeking positive judgments), and 'performance-avoidance' (avoiding negative judgments). Mastery orientation is considered most adaptive. The authors investigated goal orientations of traditional block clerkship (TBC) and longitudinal integrated clerkship (LIC) students. METHODS This was an exploratory study conducted at one US medical school. Three hundred and twenty students completed an anonymous survey consisting of three tools with validation evidence: Patterns of Adaptive Learning Survey, Task-choice Goal Measures, and Questionnaire Goal Choice Items. The authors analyzed the data using regression analyses, Chi-square, and Wilcoxon's rank-sum tests. RESULTS While all students rated mastery items most highly on the five-point Likert scale (mean 4.58/5.00), LIC students rated performance-orientation lower (β = -0.36, p = .04), chose personal mastery-orientation items more frequently (92% vs. 64.4%, p = .005), and perceived their learning environment as promoting less performance (β = -0.60, p = .002) and performance-avoidance (β = -0.78, p < .001) compared to TBC students. CONCLUSIONS LIC and TBC students differed in their report of personal and clerkship goal orientations. These differences may inform educational design and future research to promote students' mastery orientation.
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Affiliation(s)
- Stephanie Lin-Beckford
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nora Y Osman
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Edward Krupat
- Harvard Medical School, Boston, MA, USA
- Brigham Education Institute, Brigham and Women's Hospital, Boston, MA, USA
| | - David A Hirsh
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Cambridge Health Alliance, Boston, MA, USA
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Shagrin BS, Gheihman G, Sullivan AM, Li H, Hirsh DA. Faculty perspectives on facilitating medical students' longitudinal learning: A mixed-methods study. MEDICAL EDUCATION 2022; 56:1002-1016. [PMID: 35599241 DOI: 10.1111/medu.14842] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 05/01/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Medical students' longitudinal care of patients supports clinical learning and promotes patient-centredness. The literature presents little empirically derived guidance for faculty to facilitate students' longitudinal learning and care. Informed by the conceptual framework of relational learning, this study investigated faculty perspectives about longitudinal teaching, their strategies for facilitating students' longitudinal learning and perceived barriers and enablers. METHODS Using a convergent mixed-methods approach at a single academic medical centre, the authors conducted a survey and two focus groups in 2018-2019 with faculty members teaching in three longitudinal clinical courses. Quantitative analyses included descriptive statistics and chi-square tests. Qualitative content analysis described deductive categories and identified inductive themes. RESULTS Forty-three eligible faculty (69%) completed the survey. Ninety-one percent (n = 39) reported that teaching in a longitudinal model enhanced their experience as preceptors. Faculty described activities students performed to provide longitudinal care: spending time with patients independently (n = 38, 88%), making follow-up phone calls (n = 35; 81%) and participating in home- and community-based visits (n = 20, 47%), among others. Twelve faculty participated in two focus groups. Deductive analysis characterised strategies for facilitating students' longitudinal learning and barriers and enablers. Strategies included "encouraging students to follow patients," "faculty adaptability," "offering guidance and setting expectations," and "careful patient selection." Barriers included scheduling limitations, and enablers included student initiative. Inductive analysis identified two themes: faculty goals for students and faculty benefits from teaching. Goals included meaningful engagement with patients and their illness over time. Benefits from teaching included personal gratification, mentorship, and holistic student assessment. DISCUSSION Our survey and focus group findings demonstrated positive faculty attitudes and experiences, characterised faculty goals and approaches, and identified elements of the educational context that hindered or facilitated longitudinal teaching and learning. This study's faculty perspectives build upon prior investigations of students' and patients' perspectives, offer teaching strategies, and may guide faculty development.
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Affiliation(s)
- Bianca S Shagrin
- Cambridge Integrated Clerkship, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - Galina Gheihman
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amy M Sullivan
- Shapiro Institute for Education and Research, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Honghe Li
- Institute for International Health Professions Education and Research, China Medical University, Shenyang, China
| | - David A Hirsh
- Cambridge Integrated Clerkship, Harvard Medical School/Cambridge Health Alliance, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Savaria MC, Min S, Aghagoli G, Tunkel AR, Hirsh DA, Michelow IC. Enhancing the one-minute preceptor method for clinical teaching with a DEFT approach. Int J Infect Dis 2021; 115:149-153. [PMID: 34883233 PMCID: PMC8805221 DOI: 10.1016/j.ijid.2021.12.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/04/2022] Open
Abstract
Few validated methods that are grounded in educational theory exist to effectively teach medical knowledge, clinical skills, and diagnostic reasoning to learners at different stages of medical training. The goal of this Perspective was to address potential gaps in clinical education pedagogy by modeling new concepts for teaching in the field of infectious diseases. Our approach involved synthesizing the relevant literature, identifying proven approaches, and enhancing an existing educational microskills model — the one-minute preceptor. Our strategy was to emphasize the essential core elements of the one-minute preceptor using a descriptive acronym — DEFT (Diagnosis, Evidence, Feedback, Teaching), meaning skillful — as a potentially helpful reminder to improve the quality of interactions between learners and preceptors. The need for learners to discuss risk factors, mechanisms of disease, and potential complications, and for preceptors to model analytical and diagnostic skills, was further illustrated using a practical example of a teacher-learner interaction about a child with a respiratory infection. The one-minute preceptor/DEFT approach is experiential, adaptable, case-driven, and skills-focused, and also applicable to clinical training in other specialties.
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Affiliation(s)
- Michael C Savaria
- Office of Medical Education, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Sugi Min
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Ghazal Aghagoli
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Allan R Tunkel
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - David A Hirsh
- Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, USA
| | - Ian C Michelow
- Department of Pediatrics, Division of Infectious Diseases, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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Osman NY, Hirsh DA. The organizational growth mindset: Animating improvement and innovation in medical education. MEDICAL EDUCATION 2021; 55:416-418. [PMID: 33377544 DOI: 10.1111/medu.14446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Nora Y Osman
- Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David A Hirsh
- Harvard Medical School, Boston, MA, USA
- Cambridge Health Alliance, Cambridge, MA, USA
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7
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Gupta S, Howden S. Medical students' perceptions of 'community' in a longitudinal integrated clerkship. EDUCATION FOR PRIMARY CARE 2020; 32:157-165. [PMID: 33342354 DOI: 10.1080/14739879.2020.1850211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Shalini Gupta
- School of Medicine, University of Dundee, Dundee, UK
| | - Stella Howden
- School of Medicine, University of Dundee, Dundee, UK
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Romanski PA, Bartz D, Pelletier A, Johnson NR. The "Invisible Student": Neglect as a Form of Medical Student Mistreatment, a Call to Action. JOURNAL OF SURGICAL EDUCATION 2020; 77:1327-1330. [PMID: 32507361 DOI: 10.1016/j.jsurg.2020.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/27/2020] [Accepted: 05/10/2020] [Indexed: 06/11/2023]
Abstract
The mistreatment of trainees is known to lead to burnout, loss of empathy, and career changes. Medical students in particular are vulnerable to mistreatment due to their lack of seniority and frequent transitions to new teams. Traditionally, initiatives to eliminate medical student mistreatment have focused on preventing their victimization surrounding verbal, physical, and sexual misconduct. While initiatives to eliminate these types of behaviors are exceedingly important, the most common form of mistreatment that is reported by medical students is not these active forms of abuse. Instead, students on their clinical rotations more frequently report the covert "obstruction of learning" or "exclusion from the medical team" as the most common form of mistreatment experienced. Though the passive neglect of a medical student is not seemingly as serious an offense as active abuse, it can certainly have an impactful, lasting negative effect on student development, morale, and career choice. In this perspective, we recognize the importance of observational learning as a component of medical education, but state that the neglect or exclusion of a medical student should not be considered acceptable and should be labeled what it is-a form of mistreatment. We additionally provide examples for how to prevent medical student neglect by establishing a supportive and inclusive teaching environment.
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Affiliation(s)
- Phillip A Romanski
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Deborah Bartz
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrea Pelletier
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Natasha R Johnson
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Osman NY, Sloane DE, Hirsh DA. When I say … growth mindset. MEDICAL EDUCATION 2020; 54:694-695. [PMID: 32242964 DOI: 10.1111/medu.14168] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Nora Y Osman
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David E Sloane
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - David A Hirsh
- Harvard Medical School, Boston, Massachusetts, USA
- Cambridge Health Alliance, Cambridge, Massachusetts, USA
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Englander R, Holmboe E, Batalden P, Caron RM, Durham CF, Foster T, Ogrinc G, Ercan-Fang N, Batalden M. Coproducing Health Professions Education: A Prerequisite to Coproducing Health Care Services? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:1006-1013. [PMID: 31876565 DOI: 10.1097/acm.0000000000003137] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
In 2016, Batalden et al proposed a coproduction model for health care services. Starting from the argument that health care services should demonstrate service-dominant rather than goods-dominant logic, they argued that health care outcomes are the result of the intricate interaction of the provider and patient in concert with the system, community, and, ultimately, society. The key notion is that the patient is as much an expert in determining outcomes as the provider, but with different expertise. Patients come to the table with expertise in their lived experiences and the context of their lives.The authors posit that education, like health care services, should follow a service-dominant logic. Like the relationship between patients and providers, the relationship between learner and teacher requires the integrated expertise of each nested in the context of their system, community, and society to optimize outcomes. The authors then argue that health professions learners cannot be educated in a traditional, paternalistic model of education and then expected to practice in a manner that prioritizes coproductive partnerships with colleagues, patients, and families. They stress the necessity of adapting the health care services coproduction model to health professions education. Instead of asking whether the coproduction model is possible in the current system, they argue that the current system is not sustainable and not producing the desired kind of clinicians.A current example from a longitudinal integrated clerkship highlights some possibilities with coproduced education. Finally, the authors offer some practical ways to begin changing from the traditional model. They thus provide a conceptual framework and ideas for practical implementation to move the educational model closer to the coproduction health care services model that many strive for and, through that alignment, to set the stage for improved health outcomes for all.
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Affiliation(s)
- Robert Englander
- R. Englander is associate dean, undergraduate medical education, and professor, pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota. E. Holmboe is chief, research, milestones development and evaluation, Accreditation Council for Graduate Medical Education, Chicago, Illinois. P. Batalden is emeritus professor, Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. R.M. Caron is professor, Department of Health Management and Policy, College of Health and Human Services, University of New Hampshire, Durham, New Hampshire. C.F. Durham is professor and director, interprofessional education and practice, and director, education-innovation-simulation learning environment, School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. T. Foster is professor of obstetrics and gynecology and of community and family medicine, Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. G. Ogrinc is senior associate dean for medical education and professor of medicine, Dartmouth Institute of Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. N. Ercan-Fang is associate director for medical education for primary and specialty care services, co-director, the VA longitudinal integrated clerkship, and associate professor of medicine, Minneapolis VA Health Care System and the University of Minnesota Medical School, Minneapolis, Minnesota. M. Batalden is interim chief quality officer, Cambridge Health Alliance, and assistant professor of medicine, Harvard Medical School, Boston, Massachusetts
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Bartlett M, Couper I, Poncelet A, Worley P. The do's, don'ts and don't knows of establishing a sustainable longitudinal integrated clerkship. PERSPECTIVES ON MEDICAL EDUCATION 2020; 9:5-19. [PMID: 31953655 PMCID: PMC7012799 DOI: 10.1007/s40037-019-00558-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
INTRODUCTION The longitudinal integrated clerkship is a model of clinical medical education that is increasingly employed by medical schools around the world. These guidelines are a result of a narrative review of the literature which considered the question of how to maximize the sustainability of a new longitudinal integrated clerkship program. METHOD All four authors have practical experience of establishing longitudinal integrated clerkship programs. Each author individually constructed their Do's, Don'ts and Don't Knows and the literature that underpinned them. The lists were compiled and revised in discussion and a final set of guidelines was agreed. A statement of the strength of the evidence is included for each guideline. RESULTS The final set of 18 Do's, Don'ts and Don't Knows is presented with an appraisal of the evidence for each one. CONCLUSION Implementing a longitudinal integrated clerkship is a complex process requiring the involvement of a wide group of stakeholders in both hospitals and communities. The complexity of the change management processes requires careful and sustained attention, with a particular focus on the outcomes of the programs for students and the communities in which they learn. Effective and consistent leadership and adequate resourcing are important. There is a need to select teaching sites carefully, involve students and faculty in allocation of students to sites and support students and faculty though the implementation phase and beyond. Work is needed to address the Don't Knows, in particular the question of how cost-effectiveness is best measured.
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Affiliation(s)
- Maggie Bartlett
- Education in General Practice, Dundee University School of Medicine, Dundee, UK.
| | - Ian Couper
- Faculty of Medicine and Health Sciences, Ukwanda Centre for Rural Health, Stellenbosch University, Stellenbosch, South Africa
| | - Ann Poncelet
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Paul Worley
- Department of Health, GPO Box 9848, 2601, Canberra, Australian Capital Territory, Australia
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Boroumand S, Stein MJ, Jay M, Shen JW, Hirsh M, Dharamsi S. Addressing the health advocate role in medical education. BMC MEDICAL EDUCATION 2020; 20:28. [PMID: 32000759 PMCID: PMC6993364 DOI: 10.1186/s12909-020-1938-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 01/16/2020] [Indexed: 05/24/2023]
Abstract
The health advocate role is an essential and underappreciated component of the CanMEDs competency framework. It is tied to the concept of social accountability and its application to medical schools for preparing future physicians who will work to ensure an equitable healthcare system. Student involvement in health advocacy throughout medical school can inspire a long-term commitment to address health disparities. The Social Medicine Network (SMN) provides an online platform for medical trainees to seek opportunities to address health disparities, with the goal of bridging the gap between the social determinants of health and clinical medicine. This online platform provides a list of health advocacy related opportunities for addressing issues that impede health equity, whether through research, community engagement, or clinical care.First implemented at the University of British Columbia, the SMN has since expanded to other medical schools across Canada. At the University of Ottawa, the SMN is being used to augment didactic teachings of health advocacy and social accountability. This article reports on the development and application of the SMN as a resource for medical trainees seeking meaningful and actionable opportunities to enact their role as health advocates.
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Affiliation(s)
| | - Michael J Stein
- Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Mohammad Jay
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julia W Shen
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hirsh
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shafik Dharamsi
- College of Health Sciences, The University of Texas at El Paso, El Paso, TX, USA
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Flick RJ, Felder-Heim C, Gong J, Corral J, Kalata K, Marin A, Adams JE. Alliance, Trust, and Loss: Experiences of Patients Cared for by Students in a Longitudinal Integrated Clerkship. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2019; 94:1806-1813. [PMID: 31169536 DOI: 10.1097/acm.0000000000002812] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
PURPOSE The longitudinal integrated clerkship (LIC) model, which allows medical students to participate in comprehensive care of a panel of patients over time, is rapidly expanding because of recognized benefits to students and faculty. This study aimed to determine how LIC student contact affected patients' experiences and self-described health outcomes. METHOD This qualitative case study used semistructured patient interviews to understand the impact of LIC learners at the University of Colorado School of Medicine on patients at Denver Health. Patients with at least 3 encounters with an LIC student and over age 18 were selected. Thirty patients were invited to participate in 2016-2017; 14 (47%) completed interviews before the thematic analysis reached saturation. Four researchers independently analyzed interview transcripts and reached consensus on emergent categories and themes. RESULTS Six broad themes were identified: beginnings of a relationship, caring demonstrated by student, growing to trust student, reaching a therapeutic alliance, improvement of patient outcomes due to student involvement, and a sense of loss after students completed the LIC program. CONCLUSIONS Patients deeply valued the therapeutic alliances built with LIC students involved in their care over time. These alliances led to improved patient experience, mitigation of perceived health system failures, and subjective improvement in health outcomes. Patients described a sense of loss at the end of the LIC when students were no longer involved in their care. Curricula that support students building longitudinal therapeutic relationships with their patients are an opportunity to improve patient experience while promoting students' professional development.
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Affiliation(s)
- Robert J Flick
- R.J. Flick is a resident physician, Osler Medical Residency Training Program, Johns Hopkins Hospital, Baltimore, Maryland; ORCID: https://orcid.org/0000-0002-8155-6398. C. Felder-Heim is a resident physician, Family and Community Medicine Residency Program, University of California, San Francisco, San Francisco, California. J. Gong is assistant professor, Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado; ORCID: https://orcid.org/0000-0001-7530-8358. J. Corral is associate professor, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; ORCID: https://orcid.org/0000-0001-8576-6192. K. Kalata is a fourth-year medical student, University of Colorado School of Medicine, Aurora, Colorado. A. Marin is a fourth-year medical student, University of Colorado School of Medicine, Aurora, Colorado. J.E. Adams is director, Denver Health Longitudinal Integrated Clerkship, assistant dean of clinical curriculum, and associate professor, Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, and Denver Health and Hospital Authority, Denver, Colorado; ORCID: https://orcid.org/0000-0002-5433-8600
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McKeown A, Mollaney J, Ahuja N, Parekh R, Kumar S. UK longitudinal integrated clerkships: where are we now? EDUCATION FOR PRIMARY CARE 2019; 30:270-274. [DOI: 10.1080/14739879.2019.1653228] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Andrew McKeown
- Department of Primary Care and Public Health, Undergraduate Primary Care Education Team, Imperial College London, London, UK
| | - Jenna Mollaney
- Department of Primary Care and Public Health, Undergraduate Primary Care Education Team, Imperial College London, London, UK
| | - Neha Ahuja
- Department of Primary Care and Public Health, Undergraduate Primary Care Education Team, Imperial College London, London, UK
| | - Ravi Parekh
- Department of Primary Care and Public Health, Undergraduate Primary Care Education Team, Imperial College London, London, UK
| | - Sonia Kumar
- Department of Primary Care and Public Health, Undergraduate Primary Care Education Team, Imperial College London, London, UK
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Mazotti L, Adams J, Peyser B, Chretien K, Duffy B, Hirsh DA. Diffusion of innovation and longitudinal integrated clerkships: Results of the clerkship directors in internal medicine annual survey. MEDICAL TEACHER 2019; 41:347-353. [PMID: 29793380 DOI: 10.1080/0142159x.2018.1472369] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE Longitudinal integrated clerkships (LICs) are innovative educational models that emphasize medical student continuity with patients, preceptors, peers, and health systems. We characterize LIC growth in the US and interpret the growth using Rogers' Diffusion of Innovation Theory. METHODS In 2015, we surveyed 123 US allopathic medical schools affiliated with Clerkship Directors in Internal Medicine (CDIM). The organization's annual survey was supplemented with questions aimed to quantify the number of current and planned LICs and to determine the intended purpose of starting LICs. RESULTS Of the 94 (out of 123 possible) schools which were responding, 35 (37%) have at least one LIC of six months or greater; of these 20 are year-long. Nineteen schools are engaged in planning a new LIC or increasing the number of students in an LIC. At least 45 (48%) responding schools will have LICs in future years. Respondents report implementing LICs to foster continuity of care, support patient-centeredness, advance inter-professional education, and address workforce shortages. CONCLUSIONS The number of LICs is increasing across the US. We considered the data through the lens of Diffusion of Innovation Theory, speculated that LIC growth has reached "critical mass," and considered why the LIC innovation may be self-sustaining.
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Affiliation(s)
- Lindsay Mazotti
- a Kaiser Permanente , Oakland , CA , USA
- b School of Medicine , University of California , San Francisco , CA , USA
| | - Jennifer Adams
- c School of Medicine , University of Colorado , Aurora , CO , USA
| | - Bruce Peyser
- d School of Medicine , Duke University , Durham , CA , USA
| | - Katherine Chretien
- e School of Medicine and Health Sciences , George Washington University , Washington , DC , USA
| | - Briar Duffy
- f Medical School , University of Minnesota , Minneapolis , MN , USA
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Brown MEL, Anderson K, Finn GM. A Narrative Literature Review Considering the Development and Implementation of Longitudinal Integrated Clerkships, Including a Practical Guide for Application. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2019; 6:2382120519849409. [PMID: 31206031 PMCID: PMC6537286 DOI: 10.1177/2382120519849409] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/15/2019] [Indexed: 05/31/2023]
Abstract
Hailed by supporters as the answer to many challenges facing medical schools and the wider health care system, longitudinal integrated clerkships (LICs) offer a practical and sustainable alternative to more traditional block rotational models. Given this, their popularity as a curricular measure is increasing, although such clerkships remain relatively novel within the United Kingdom. This narrative literature review of international work provides a comprehensive introduction to developing and implementing LICs within medical education. This review generates a practical guide for medical educators with a focus on the development and implementation of LICs within the United Kingdom, on which there is little work. Using illustrated examples and with reference to contemporary literature, it outlines the rationale for considering an LIC within a curriculum, the different types of LIC, barriers and enabling factors to LIC implementation and considers the contemporary application of LIC models within the United Kingdom. The practical guide details key questions educators must consider when developing and implementing an LIC, particularly within the landscape of UK medical education.
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Affiliation(s)
- Megan EL Brown
- Health Professions Education Unit, Hull York Medical
School, University of York, York, UK
| | - Kevin Anderson
- Health Professions Education Unit, Hull York Medical
School, University of York, York, UK
| | - Gabrielle M Finn
- Health Professions Education Unit, Hull York Medical
School, University of York, York, UK
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Gheihman G, Jun T, Young GJ, Liebman D, Sharma K, Brandes E, Ogur B, Hirsh DA. A review of longitudinal clinical programs in US medical schools. MEDICAL EDUCATION ONLINE 2018; 23:1444900. [PMID: 29542394 PMCID: PMC5907349 DOI: 10.1080/10872981.2018.1444900] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Longitudinal clinical experiences are a common component of undergraduate medical curricula, yet these programs have not been systematically characterized in US medical schools. OBJECTIVE Our study sought to identify and characterize longitudinal clinical programs (LCPs) in US medical schools and measure associations between programs' structures and goals. DESIGN Using a mixed-methods approach, we conducted a secondary analysis of data from publicly available websites. We conducted a systematic keyword search of the websites of 137 LCME-accredited US medical schools to identify LCPs. We included programs with student-patient interactions of at least six months. We categorized programs using qualitative thematic analysis and compared associations between program structures and goals. RESULTS We identified 98 LCPs in 69 schools. Half (52.0%) of LCPs occurred during the core clinical year. Program structures included 'clinic attachments' (50.0%), 'longitudinal integrated clerkships' (26.5%), and 'patient attachments' (20.4%). We identified goals in 89 programs, including 'exposing students to specific topics, patient demographics, or practice settings' (78.7%); 'clinical or professional skill development' (65.2%); and 'understanding the patient experience' (19.1%). Patient attachments were associated with 'exposure to specific patient demographics' (P = .04) and 'understanding the patient experience' (P = .03). Pre-clinical programs were associated with clinical skills development (P = .01). CONCLUSIONS Our study identifies the scope and nature of LCPs in US medical schools. Understanding connections between educational structures and goals may guide program design and research investigations of educational processes and outcomes.
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Affiliation(s)
| | - Tomi Jun
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | | | - Barbara Ogur
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
| | - David A. Hirsh
- Harvard Medical School, Boston, MA, USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, MA, USA
- CONTACT David A. Hirsh Department of Medicine, Cambridge Health Alliance (CHA), Macht Building 4th floor, 1493 Cambridge St, Cambridge, MA02139, United States
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Teodorczuk A, Yardley S, Patel R, Rogers GD, Billett S, Worley P, Hirsh D, Illing J. Medical education research should extend further into clinical practice. MEDICAL EDUCATION 2017; 51:1098-1100. [PMID: 29024150 DOI: 10.1111/medu.13459] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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Latessa RA, Swendiman RA, Parlier AB, Galvin SL, Hirsh DA. Graduates' Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2017; 92:1313-1319. [PMID: 28248695 DOI: 10.1097/acm.0000000000001621] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE The authors explored affordances that contribute to participants' successful learning in longitudinal integrated clerkships (LICs). METHOD This dual-institutional, mixed-methods study included electronic surveys and semistructured interviews of LIC graduates who completed their core clinical (third) year of medical school. These LIC graduates took part in LICs at Harvard Medical School from 2004 to 2013 and the University of North Carolina School of Medicine-Asheville campus from 2009 to 2013. The survey questions asked LIC graduates to rate components of LICs that they perceived as contributing to successful learning. A research assistant interviewed a subset of study participants about their learning experiences. The authors analyzed aggregate data quantitatively and performed a qualitative content analysis on interview data. RESULTS The graduates reported multiple affordances that they perceive contributed to successful learning in their LIC. The most reported components included continuity and relationships with preceptors, patients, place, and peers, along with integration of and flexibility within the curriculum. CONCLUSIONS As LIC models grow in size and number, and their structures and processes evolve, learners' perceptions of affordances may guide curriculum planning. Further research is needed to investigate to what degree and by what means these affordances support learning in LICs and other models of clinical education.
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Affiliation(s)
- Robyn A Latessa
- R.A. Latessa is director and assistant dean, University of North Carolina (UNC) School of Medicine-Asheville Longitudinal Integrated Clerkships Program, Asheville, North Carolina, and professor of family medicine, UNC School of Medicine, Chapel Hill, North Carolina. R.A. Swendiman is a general surgery resident, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. A.B. Parlier is a research project coordinator, Center for Research at Mountain Area Health Education Center, Asheville, North Carolina. S.L. Galvin is director of research, Center for Research at Mountain Area Health Education Center, Asheville, North Carolina, and adjunct assistant professor, Department of Obstetrics/Gynecology, UNC School of Medicine, Chapel Hill, North Carolina. D.A. Hirsh is director, Harvard Medical School Cambridge Integrated Clerkship, Cambridge Health Alliance, Cambridge, Massachusetts, director, Harvard Medical School Academy Medical Education Fellowship, and associate professor of medicine, Harvard Medical School, Boston, Massachusetts
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Structuring Medical Education for Workforce Transformation: Continuity, Symbiosis and Longitudinal Integrated Clerkships. EDUCATION SCIENCES 2017. [DOI: 10.3390/educsci7020058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Green-Thompson LP, McInerney P, Woollard B. The social accountability of doctors: a relationship based framework for understanding emergent community concepts of caring. BMC Health Serv Res 2017; 17:269. [PMID: 28403860 PMCID: PMC5389126 DOI: 10.1186/s12913-017-2239-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 04/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Social accountability is defined as the responsibility of institutions to respond to the health priorities of a community. There is an international movement towards the education of health professionals who are accountable to communities. There is little evidence of how communities experience or articulate this accountability. METHODS In this grounded theory study eight community based focus group discussions were conducted in rural and urban South Africa to explore community members' perceptions of the social accountability of doctors. The discussions were conducted across one urban and two rural provinces. Group discussions were recorded and transcribed verbatim. RESULTS Initial coding was done and three main themes emerged following data analysis: the consultation as a place of love and respect (participants have an expectation of care yet are often engaged with disregard); relationships of people and systems (participants reflect on their health priorities and the links with the social determinants of health) and Ubuntu as engagement of the community (reflected in their expectation of Ubuntu based relationships as well as part of the education system). These themes were related through a framework which integrates three levels of relationship: a central community of reciprocal relationships with the doctor-patient relationship as core; a level in which the systems of health and education interact and together with social determinants of health mediate the insertion of communities into a broader discourse. An ubuntu framing in which the tensions between vulnerability and power interact and reflect rights and responsibility. The space between these concepts is important for social accountability. CONCLUSION Social accountability has been a concept better articulated by academics and centralized agencies. Communities bring a richer dimension to social accountability through their understanding of being human and caring. This study also creates the connection between ubuntu and social accountability and their mutual transformative capacity as agents for social justice.
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Affiliation(s)
- Lionel P Green-Thompson
- Faculty of Health Sciences, University of the Witwatersrand, PV Tobias Health Sciences Building, 5 York Road, Parktown, 2193, Johannesburg, South Africa.
| | - Patricia McInerney
- Faculty of Health Sciences, University of the Witwatersrand, PV Tobias Health Sciences Building, 5 York Road, Parktown, 2193, Johannesburg, South Africa
| | - Bob Woollard
- Department of Family Practice, University of British Columbia, Vancouver, Canada
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Worley P, Couper I, Strasser R, Graves L, Cummings BA, Woodman R, Stagg P, Hirsh D. A typology of longitudinal integrated clerkships. MEDICAL EDUCATION 2016; 50:922-32. [PMID: 27562892 DOI: 10.1111/medu.13084] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 10/14/2015] [Accepted: 03/14/2016] [Indexed: 05/13/2023]
Abstract
CONTEXT Longitudinal integrated clerkships (LICs) represent a model of the structural redesign of clinical education that is growing in the USA, Canada, Australia and South Africa. By contrast with time-limited traditional block rotations, medical students in LICs provide comprehensive care of patients and populations in continuing learning relationships over time and across disciplines and venues. The evidence base for LICs reveals transformational professional and workforce outcomes derived from a number of small institution-specific studies. OBJECTIVES This study is the first from an international collaborative formed to study the processes and outcomes of LICs across multiple institutions in different countries. It aims to establish a baseline reference typology to inform further research in this field. METHODS Data on all LIC and LIC-like programmes known to the members of the international Consortium of Longitudinal Integrated Clerkships were collected using a survey tool developed through a Delphi process and subsequently analysed. Data were collected from 54 programmes, 44 medical schools, seven countries and over 15 000 student-years of LIC-like curricula. RESULTS Wide variation in programme length, student numbers, health care settings and principal supervision was found. Three distinct typological programme clusters were identified and named according to programme length and discipline coverage: Comprehensive LICs; Blended LICs, and LIC-like Amalgamative Clerkships. Two major approaches emerged in terms of the sizes of communities and types of clinical supervision. These referred to programmes based in smaller communities with mainly family physicians or general practitioners as clinical supervisors, and those in more urban settings in which subspecialists were more prevalent. CONCLUSIONS Three distinct LIC clusters are classified. These provide a foundational reference point for future studies on the processes and outcomes of LICs. The study also exemplifies a collaborative approach to medical education research that focuses on typology rather than on individual programme or context.
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Affiliation(s)
- Paul Worley
- Prideaux Centre for Research in Health Professions Education, School of Medicine, Flinders University, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Ian Couper
- Ukwanda Centre for Rural Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | - Lisa Graves
- Department of Family and Community Medicine, School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | - Beth-Ann Cummings
- Centre for Medical Education, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Richard Woodman
- Flinders Centre for Epidemiology and Biostatics, Flinders University, Adelaide, South Australia, Australia
| | - Pamela Stagg
- Centre for Remote Health, School of Medicine, Flinders University, Darwin, Australia
| | - David Hirsh
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts, USA
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Hamilton JD. Rural, urban: the real world for medical education. Med J Aust 2013; 199:722-3. [DOI: 10.5694/mja13.11323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 11/11/2013] [Indexed: 11/17/2022]
Affiliation(s)
- John D Hamilton
- School of Medicine and Population Health, University of Newcastle, Newcastle, NSW
- Australian Government Department of Human Services and Health, Canberra, ACT
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