How to build longitudinal Integrated Clerkships to fit context: Practical tools for modern pedagogy (Prof. David Hirsh, Harvard Medical School)
Last week I attended a seminar by Prof. David Hirsh from Harvard Medical School, where he discussed the implementation of the Longitudinal Integrated Clerkship (LIC) in their programme. Here are my notes from the seminar.
We hold close the ideas we have of what education should be but don’t question where we get those ideas from. Sometimes, it’s worth questioning.
How does longitudinal clerkship impact on educational design? The case for change was premised on three main ideas: Flexner, ethical erosion, science of learning.
Flexner: Flexner suggested that continuity of teachers and the “closeness” of students as they follow their patients, that students should be “close” to reality. However, the context of care has changed since 1910. Now, patients and students rotate through placements too quickly to be close to anything.
Ethical erosion: There is a decline in students’ professionalism / humanism as a consequence of current approaches to medical education. Students decline in patient-centredness seems to occur as a consequence of their clinical year and exposure to teachers. Their empathy declined significantly in medical school. Medical students seem to show blunted moral development as a direct consequence of medical education during their clinical years. Unprofessional behaviour among medical students predict subsequent unprofessional behaviour.
Learning science: There is no learning theory to suggest that random, dissociated clinical placements, where students are directed by junior clinicians with no pedagogical training (the current model), is a good learning environment for students. There is therefore very little evidence that supports the current model of medical education.
If there’s a gap between where you are and where you believe you should be, that’s reason for change.
Continuity of care: students and patients and students need to matter to each other i.e. it is relationship-based (“my student” not “the student” / “my patient”, not “a patient”)
We need to see:
- Continuity of curriculum: assessment matches learning
- Continuity of supervision
- Continuity of idealism
Need to move away from clinical blocks to streams with “perforations” between the streams to allow movement of concepts and interactions between them. Students follow cohorts of patients throughout the whole year, which allows them to see patients in multiple venues of care. The patient is the organising principle, not the venue or their condition.
We have a tendency to want to match time to the old model of traditional blocks e.g. 4 weeks in an orthopaedic rotation. However, we should rather match time according to the educational and patient needs e.g. spend more time in areas where the patient or student needs it.
In studies of efficacy, we commonly see no significant difference between and within groups who did either the LIC or “block” curriculum. However, tests did show that the LIC group trended towards being slightly better on all tests.
Longitudinal: Students should be present throughout the patient’s time under treatment, including diagnosis and initial presentation (“whole illness episode”). Students were entering the interaction too late, without being exposed to the human being. They were seeing “conditions with human beings attached”.
How often do students establish meaningful relationships with patients?
Even though LIC students found their course to be more stressful and hectic, they also found it to be more rewarding, satisfying, transformational, humanising, etc. LIC students’ scientific rigor and spirit of inquiry is driven by a desire to help their patients. These feelings held true 4-6 years after graduation.
Students are more patient-centred but are still “grouchy” about their overall educational experience. In other words, the LIC students are not made to feel special or given special consideration.
Medical education is not an end in itself and should be directed towards some purpose. Processes should be aimed towards having students “flow” towards that purpose.
The curriculum has “many moving parts”, which feels modern…and scary. From educational change comes systems change. Disruption is powerful. We need to be more intentional about how we design this medical education machine if we really believe that education can be used for transformational change.
“Run toward the gaps” in the curriculum.
The presentation below is not the one I attended, but the content is similar.