Patient-centered care has for some time served as the aspirational rallying cry of truly good medicine. Whether a physician in training, student nurse or fledgling technician, every encounter reinforces for us that patients are people, rather than a disease, diagnosis or test result, and should be the absolute focus of all care decisions.
The notion of patient-centered care has manifested itself in multiple ways in modern medical education, but perhaps the most obvious is the longitudinal integrated clerkship (LIC) – a non-traditional third-year medical school clinical clerkship experience.
In traditional clerkships, student cohorts spend blocks of time immersed in an individual specialty – eight weeks in surgery, the next eight in OB, then family medicine, and so on. LIC students spend their entire clerkship within a single care environment, allowing them to follow the same patients throughout their care journey and working under the same provider preceptors for the duration. In essence, rather than meeting their educational requirements in individual specialty blocks, one after another, LIC students build their experiences in a much more integrated fashion, meeting the majority of their core clinical competencies across multiple specialties simultaneously.
The LIC model is not a new one. Some programs, such as the University of Minnesota Medical School’s Rural Physician Associate Program, began as far back as the 1970s as a way to meet the physician shortage in rural areas.¹ Since that time, LIC programs have been established in medical schools around the world. According to the Consortium of Longitudinal Integrated Clerkships (CLIC), a global network of LIC-focused medical educators, there are now more than 90 programs globally.
A sense of continuity, trust and relationships
There are multiple iterations of the LIC model, but at their core, they offer students the opportunity to fully practice medicine in a single health environment – generally a rural facility – for the duration of their clerkship. Students become totally immersed in the community-based setting, follow patients throughout their journey and establish relationships with the same preceptors over a period of time.
In his piece, The Significance of Longitudinal Clerkships in Medical School, author Nathan Juergens maintains that with traditional programs, the experiences are immersive, but short and not standardized.¹ Traditional clerkship experiences are often dependent on which physicians are working during the month of a student’s rotation, what hospital a student is assigned to, the number of sick patients during a student’s assigned days and their illnesses.
In contrast, LICs provide a level of continuity in patients, education, and supervision not found in traditional clerkships, offering students an early opportunity to become an integral part of the healthcare team, building trust and relationships with both patients and their preceptors. The experience can result in feedback-rich evaluations for students and strong letters of recommendations from physicians who can attest to actually working closely with them. Conversely, the community experience is often enough to draw the student back to the area to practice. In essence, an LIC clerkship for many students means practicing medicine as they imagine it could or should be.
One example is the Tufts University School of Medicine and Maine Medical Center Maine Track LIC program, now in its ninth year. In their third year of medical school, students in the Maine Track can opt to participate in the Maine Track LIC model, in which they live and practice in a Maine urban or rural community for nine months. Assigned to core discipline preceptors at their hospital, they develop their own slate of patients throughout the clerkship. The students then follow these patients holistically for the entire continuum of care, gaining experience in multiple points of care including routine office visits, home visits, subspecialty evaluations, hospital care and other professional staff evaluations.
“LIC students are exposed to patients in different ways,” explains Ashlee Plowman, program manager for the undergraduate medical education program at Maine Medical Center. “They can be more easily called into a delivery for a patient they may have been seeing, or follow a patient through a whole treatment course. They are able to maintain a relationship over several months, whereas with traditional rotations, you may initially see a patient, then never know the outcome.”
The University of Nevada, Las Vegas (UNLV) LIC program, now in its fourth year, differs slightly, with students completing the six core clerkships across a year, broken into 22 sequential units. Although the program formerly consisted of two weeks in a given specialty, in answer to feedback, that specialty time has been expanded to four weeks, while still maintaining the “spirit” of an LIC.
“With LIC, students are able to see how the different specialties relate to each other and overlap in a way they wouldn’t see in traditional clerkships,” says Jessica De Jesus, Administrative Assistant for UNLV’s LIC. “It’s important for students to see that, it gives them a better understanding of medicine.”
Overcoming the logistical challenges
For those administering LIC programs, the non-traditional model can provide some interesting executional challenges. There are multiple sites, students, schedules and preceptors to be juggled, and the ever-present requirement to ensure equivalency in the LIC experience compared to traditional clerkships. Sending and collecting evaluations becomes more challenging as does working with non-academic physicians and professionals across different environments.
For some programs, this complex juggle is achieved through online spreadsheets and extremely manual processes. Both Maine Medical Center and UNLV have turned to MedHub’s scheduling, evaluation, and data management system to streamline data and processes. This decision has reduced time and labor spent on LIC administration for Plowman, De Jesus, and their teams. For Plowman and their LIC students, she noted MedHub manages student demographic profiles and onboarding, which provides a central database to access critical student information quickly and more accurately – by streamlining collection of information, her team has saved hours of manual data entry and upkeep management. De Jesus noted saving hours if not days formerly spent in manual coordination to collect student and preceptor feedback, which has improved their reporting compliance.
“We understand from clients that there are not many providers supporting LICs, given their dynamic and complex nature,” said Mary Beth Titsworth, Director of Client Services for MedHub, “We believe in the mission of LICs and that they provide an important option in medical education – for both students and their practice facilities. As a result, we have worked to understand the needs of those programs and tailor effective solutions to reduce the complexity and help program managers meet their objectives.”
¹The Significance of Longitudinal Clerkships In Medical School by Nathan Juergens, published on the University of Minnesota Medical School site June 9, 2016.