Education for Health

GENERAL ARTICLE
Year
: 2014  |  Volume : 27  |  Issue : 2  |  Page : 138--142

Challenges in transformation of the "traditional block rotation" medical student clinical education into a longitudinal integrated clerkship model


William Heddle, Gayle Roberton, Sarah Mahoney, Lucie Walters, Sarah Strasser, Paul Worley 
 School of Medicine, Flinders University, Bedford Park, South Australia and Darwin, Northern Territory, Australia

Correspondence Address:
Prof. William Heddle
c/- Department of Cardiology, Flinders Medical Centre, Bedford Park, SA 5042
Australia

Abstract

Background: Longitudinal integrated clerkships (LIC) in the first major clinical year in medical student training have been demonstrated to be at least equivalent to and in some areas superior to the «DQ»traditional block rotation«DQ» (TBR). Flinders University School of Medicine is starting a pilot changing the traditional teaching at the major Academic Medical Centre from TBR to LIC (50% of students in other locations in the medical school already have a partial or full LIC programme). Methods: This paper summarises the expected challenges presented at the «DQ»Rendez-Vous«DQ» Conference in October 2012: (a) creating urgency, (b) training to be a clinician rather than imparting knowledge, (c) resistance to change. Results: We discuss the unexpected challenges that have evolved since then: (a) difficulty finalising the precise schedule, (b) underestimating time requirements, (c) managing the change process inclusively. Discussion: Transformation of a «DQ»block rotation«DQ» to «DQ»LIC«DQ» medical student education in a tertiary academic teaching hospital has many challenges, many of which can be anticipated, but some are unexpected.



How to cite this article:
Heddle W, Roberton G, Mahoney S, Walters L, Strasser S, Worley P. Challenges in transformation of the "traditional block rotation" medical student clinical education into a longitudinal integrated clerkship model.Educ Health 2014;27:138-142


How to cite this URL:
Heddle W, Roberton G, Mahoney S, Walters L, Strasser S, Worley P. Challenges in transformation of the "traditional block rotation" medical student clinical education into a longitudinal integrated clerkship model. Educ Health [serial online] 2014 [cited 2019 Oct 16 ];27:138-142
Available from: http://www.educationforhealth.net/text.asp?2014/27/2/138/143744


Full Text

 Background



There are global calls for new approaches to clinical education that move it from an informative to a transformative process. [1] Clinicians teaching in the medical curriculum at Flinders University were especially concerned with the accumulating international evidence of ethical erosion that occurs in medical students, [2],[3] the impact of traditional clinical education on student well-being [4] and the difficulty in establishing the trust necessary to provide meaningful roles for medical students in the traditional short block rotations. [5]

One approach that has overcome many of these difficulties is the longitudinal integrated clerkship (LIC). [2],[3],[5],[6] Rural LIC was first introduced by the University of Minnesota [7] and then by the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) group of universities in the northwest United States of America. [8] Flinders followed this approach, first in rural areas [9] and more recently in urban community settings. [10] The challenge remained to apply this approach for those students who remained studying in the tertiary hospital environment. [11] This study discusses the challenges faced by the Flinders Medical School in developing a LIC model for an academic teaching hospital.

The School of Medicine at Flinders University began as the first purpose-built academic health science centre in Australia, enrolling 60 students into a six-year undergraduate programme at its Flinders Medical Centre (FMC) campus in 1974. [12] In 1996, it was the first School in Australia to move to a four-year graduate entry programme; [13] and, in 1997, the first rural LIC programme was developed in the Riverland region of South Australia. [9] In 2012, of the now 160 Year 3 students, 85 were involved in partial or full LICs across rural South Australia and the Northern Territory and in urban community settings in Darwin and Southern Adelaide. [14],[15] The remaining 75 students undertook their study in traditional block rotations (TBRs) based at the original academic medical centre, FMC. The rotation consisted of eight weeks each in Surgery, Internal Medicine, Obstetrics and Gynaecology, Paediatrics and Psychiatry with General Practice placements being undertaken for one half-day per week over 16 weeks of the year.

At its annual curriculum conference in October 2011, with input from our Sir Ewen Waterman Visiting Fellow, Dr. David Hirsh from Harvard, a decision was made to proceed with LIC pilots at both FMC and in the hospital at the remote central Australian town of Alice Springs, to commence in January 2013. This initiative became known as the LIFT programme (Longitudinal Integrated Flinders Training).

This paper summarises what we have learned in this development process, describes the resultant curriculum approach, and outlines our plans for evaluation, with a view to the future for LIFT to include all the remaining students at FMC.

 Methods



Expected Challenges

At the Rendez-Vous 2012 Conference, a participant described developing longitudinal integrated training in medical schools with a tradition of block-based specialty teaching as being "like taking a chip off the hardest diamond". We didn't expect this to be easy….

Some challenges could be predicted a priori, as reported by Elleway and colleagues; [16] expected challenges came from the leadership team's knowledge of educational change management, [17] while other challenges were identified through the group's reflection and knowledge of previous curriculum change. [18]

Creating urgency

This involves engaging the student body and the clinical teachers - balancing the desire to gain broad ownership and input with the tendency towards inertia in working within any large organisation.

Selling the solution

"Coveritis" [19] is a debilitating condition that induces clinicians to believe they must personally teach all the critical issues in their specialty before a student is adequately trained. This view overemphasises the role of the medical educator in imparting knowledge(filling the empty bucket approach to teaching) and undervalues the role of teaching "how to be a doctor" and giving a contextual framework for students to learn, apply and elaborate their clinical knowledge. It, therefore, became critical to be able to convince students and colleagues that the curriculum can be fully covered without dedicated exposure to the clinical specialties and sub-specialties. We found it harder to convince faculty of this than the students, although the latter were initially concerned.

Making change possible

Resistance to change, especially in an already overstretched clinical environment, was clearly expected. In tight economic times, it was anticipated that there would be competition for resources from within the school and difficulty in finding additional external funding. Clinicians would require engagement strategies and education in order to adopt a new model of teaching. It became a priority to organise the time for faculty development to ensure engagement of very busy clinicians under considerable time pressure to service the clinical load of a tertiary hospital often running at over 100% capacity.

"Buy In"

It was considered vital to have support from key academics and clinicians before embarking upon such a project; this proposal started because of the vision of Professor Paul Worley and the established success of the Parallel Rural Community Curriculum with proof of the value of LICs. This resulted in the Curriculum Conference in October 2011 where all participants (the conference was open to all students and faculty) were able to freely give their opinions. Outcomes, including the recommendation of developing a LIFT Pilot, were achieved by consensus.

Curriculum Development Approach

The school appointed lead and deputy academics to oversee the development, reporting to a Curriculum Renewal Taskforce chaired by the Dean. Funding was provided to enable a team of hospital-based clinical academics to visit two sites in North America, Harvard, and University of California San Francisco (UCSF), that had undertaken similar initiatives. Strong supportive links were formed with the leaders and faculty of these programmes.

The school organised a whole of faculty seminar to report on the findings of the visits and outline the emerging plans for the LIFT. Similar presentations were made to groups of hospital clinicians and to the Year 2 students who would be the Year 3 class in 2013. As a result of this consultative process, it was decided to call for volunteer students to participate in an eight student pilot in 2013. Student allocation for the third-year of the four-year degree is done by students indicating their first and subsequent preferences into a computer-based form; then a programme is run, which matches preferences against available places (this results in a random selection of the students selecting a particular option; that is if a group of more than eight students select "LIFT FMC" as their first option, the computer randomly allocates eight of this group to "LIFT FMC"). As a general rule, approximately 80-85% of students achieve their first preference and the only bias in the allocation process comes from the students' requests.

These eight students were then significantly engaged in the final curriculum design process. The resultant curriculum was founded on the principle of continuity, [2] and recognised the importance of symbiosis in a number of important relationships including: Doctor-patient, student-teacher, student-clinical service and student-community. [20]

In terms of the final model, initially, the students will have a month of "immersion" in the different specialties to familiarise themselves with the clinical environments, and then commence their specific preceptor attachments in ambulatory care. Each student is allocated six (unique) clinical preceptors, one in each discipline of Paediatrics, Medicine, Obstetrics and Gynaecology, Psychiatry, Surgery, and General Practice, as well as having weekly sessions in the emergency department with specific emergency physician educators. Once a week, the group of LIFT students will have a tutorial following a defined programme to cover the core conditions required by the curriculum; the tutorials are to be student-led with specialty faculty input with oversight from a clinical educator. Each student is expected to develop a panel of patients with their preceptors, and to follow these patients in ambulatory and inpatient care. Each student will have a minimum of three "sessions" (half-days) of white space time per week to both follow their patients and for self-directed learning. "Mentors" have been allocated to the students to ensure both coverage of the curriculum and "pastoral care".

Proposed evaluation of the results of the LIFT Pilot will focus on multiple domains:

Academic results in the Topics of "Clinical Performance" (assessed by Multiple Choice, Short Answer Question and OSCE examinations) and "Health Professions and Society" (with student results compared with other students in Year 3 and whether they improved their academic position relative to the other students) aiming initially for non-inferiority (small numbers limit the statistical power)A new test to be developed of complex clinical reasoning to be given to volunteer LIFT and non-LIFT students at the start and end of Year 3 examining both cohort changes and changes between matched pairsA medical school-wide study of "student well-being" is underway, and the LIFT students will be a sub-group of this studyA study of "patient-centredness" is being developed by Dr. Sarah Mahoney and Professor Tim Neild and will be assessed in LIFT and non-LIFT studentsQualitative feedback will be sought on LIFT from both LIFT students and LIFT preceptors.

 Results



Unforseen challenges

During this development process, other significant issues emerged for the development team.

Finalising the fine details of the model

Questions arose and decisions were required to be made on a regular just-in-time basis. Examples include: Creating and supporting a new organisational approach to scheduling the student's weekly activities; deciding how many preceptors each student should have; how to provide computer support for the students at a time of FMC changing the information technology system (to be "rolled out" later in 2013); and how to protect the "white space" time in which the students will have capacity to undertake self-directed learning.

Underestimating time requirements

In the development and initial planning phase, ambitious plans were made regarding the timelines for preparation, roll out, and evaluation of LIFT. Particular issues encountered included:

The lag time to employ new staff resulted in the academics needing to commence planning the schedule before additional administrative support was recruited; and The clinical academic leads on the LIFT project also underestimated the time required to undertake all the discussion and engagement necessary for development of the programme.

Managing the change process inclusively

Flinders University School of Medicine has a highly consultative ethos resulting in course governance that involves a complex committee structure. The tertiary hospital in which LIFT is situated also consists of relatively autonomous clinical units that structure teaching commitments differently. The newly appointed academic leaders of LIFT underestimated the energy required to attend numerous medical school committees to update them on the LIFT pilot and the impact this had on our limited time to actually develop the programme. This involved remembering all the students, administrators (university and hospital) who had to be kept informed of the LIC programme and its development. Distance and knowledge of the tertiary hospital context complicated the process of engaging clinical academics with expertise in LICS in rural health services. They also expressed concern about the potential lack of community engagement of this LIC in the urban academic teaching hospital. Finally, academic leads experienced the challenge of changing the mindset of clinicians who found it confronting to consider that the principal locus of learning sits with the patient, not the teacher.

 Discussion



While many challenges were predicted and planned for, a significant number of issues arose that needed adaptation and flexibility from the leadership team. Some issues remain unresolved, and are the potential subject for ongoing evaluation and analysis during the pilot year.

The resources for evaluation are finite, and so initial evaluation must focus on priority questions, such as:

Developing the knowledge base to facilitate decisions regarding the status of LIFT following the initial pilot and whether to proceed to full LIFT.Whether to remain as a small group in the longer term, or to abandon the pilot.

The medical school's priority is, therefore, to focus on measuring the impact of the LIFT programme on the factors that triggered the need for change: Ethical erosion, student well-being, clinician dissatisfaction with current depth of student contact, and whether students undertake meaningful roles in patient care.

Measurement of these factors will allow the school to begin to understand more specific uncertainties about the LIFT programme including: What faculty development can prepare clinical educators to teach in two curricular approaches (LIFT and TBR) simultaneously; the extent to which students require an "immersion" period in each of the specialties; and the acceptable number of preceptors per student. The answers to these questions will be important to understand if the programme is to be expanded to involve all 75 Year 3 students in the tertiary hospital setting.

In the short term, however, it is anticipated that initial evaluation results will facilitate the management of the potential for "pushback" against LIC students by sceptical clinicians, educators and other students already attached to specific clinical units for TBR. Previous evidence may be useful to manage the ongoing doubt in some clinicians' and students' minds that the traditional curriculum will be adequately covered by this new approach. [5],[21] Our experience with LICs in community environments would indicate that this anxiety is inevitable throughout the first year of the programme.

Overall, potential problems or challenges with full "roll-out" include:

Acceptance by students and staff of the benefits of LIFT or "hybrid LIC" for all Year 3 studentsAcceptance that the LIFT programme is at least as good as the "block rotation" for struggling studentLimitations in teaching capacity of the smaller specialty units within the hospital, particularly Paediatrics, which has only a single 28-bed inpatient ward and limited clinical academic staffJuggling of individual timetables for 75 students while maintaining an intact and comprehensive academic tutorial programmeFinding enough clinical educators (at least one for two sessions per week for each sub-group of 8-10 students) with the role of running the tutorial programme for that subgroupFinding enough mentors (at least one required for each sub-group of 8-10 students) to oversee the LIFT programme for each student in the sub-groupTime for clinical preceptors, clinical educators and mentors to meet in the midst of clinical service commitments in a very busy academic teaching hospitalAdditional resources for administration, particularly managing the complex scheduling (with different weekly schedule for every student)How to "engage" with the "community" that the hospital serves with about one-half million people from throughout South Australia, the Northern Territory, and western New South Wales and Victoria.

The LIFT pilot students at FMC in South Australia and at Alice Springs Hospital in (Central) Northern Territory have commenced. Twenty-five students volunteered for the eight places at FMC. The outcome of this exciting development is awaited with interest.

References

1Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 2010;376:1923-58.
2Hirsh DA, Ogur B, Thibault G, Cox M. "Continuity" as an organizing principle for clinical education reform. N Engl J Med 2007;356:858-66.
3Hirsh D, Gaufberg E, Ogur B, Cohen P, Krupat E, Cox M, et al. Educational outcomes of the Harvard Medical School-Cambridge Integrated Clerkship: A way forward for medical education. Acad Med 2012;87:643-50.
4Hull SK, DiLalla LF, Dorsey JK. Prevalence of health-related behaviors among physicians and medical trainees. Acad Psychiatry 2008;32:31-8.
5Walters L, Greenhill J, Richards J, Ward H, Campbell N, Ash J, et al. Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ 2012;46:1028-41.
6Walters L, Prideaux D, Worley P, Greenhill J. Demonstrating the value of longitudinal integrated placements for general practice preceptors. Med Educ 2011;45:455-63.
7Zink T, Halaas GW, Finstad D, Brooks KD. The rural physician associate program: The value of immersion learning for third-year medical students. J Rural Health 2008;24:353-9.
8Schwarz MR. The WAMI Program: 25 years later. Med Teach 2004;26:211-4.
9Worley P, Silagy C, Prideaux D, Newble D, Jones A. The Parallel Rural Community Curriculum: An integrated clinical curriculum based in rural general practice. Med Educ 2000;34:558-65.
10Mahoney S, Walters L, Ash J. Urban Community Based Medical Education-General Practice at the core of a new approach to teaching medical students. Aust Fam Physician 2012;41:631-6.
11Poncelet AN, Bokser S, Calton B, Hauer KE, Kirsch H, Jones T, et al. Development of a longitudinal integrated clerkship at an academic medical centre. Med Educ Online 2011;16. doi: 10.3402/meo. v16i05939.
12Fraenkel GJ. A new School of Medicine at Flinders University of South Australia. Med J Aust 1972;2:385-8.
13Finucane P, Nicholas T, Prideaux D. The new medical curriculum at Flinders University, South Australia: From concept to reality. Med Teach 2001;23:76-9.
14Walters LK, Worley PS, Mugford BV. The parallel rural community curriculum: Is it a transferable model? Rural Remote Health 2003;3:236.
15Morgan S, Smedts A, Campbell N, Sager R, Lowe M, Strasser S. From the bush to the big smoke-development of a hybrid urban community based medical education program in Northern Territory, Australia. Rural Remote Health 2009;9:1175.
16Elleway R, Graves L, Berry S, Myhre D, Cummings B, Konkin J. Twelve tips for designing and running longitudinal integrated clerkships. Med Teach 2013;35:989-95.
17Fullan M. The new meaning of educational change. 3 rd ed.. New York: Teachers College Press; 2001.
18Hirsh D, Walters L, Poncelet AN. Better learning, better doctors, better delivery system: Possibilities from a case study of longitudinal integrated clerkships. Med Teach 2012;34:548-54.
19Guilbert JJ. Comparison of the opinion of students and teachers concerning medical education programmes in Switzerland. Med Educ 1998;32:65-69
20Prideaux D, Worley P, Bligh J. Symbiosis: A new model for clinical education. Clin Teach 2007;4:209-12.
21Worley P, Esterman A, Prideaux D. Cohort study of examination performance of undergraduate medical students learning in community settings. BMJ 2004;328:207-9.