Summary
This essay was selected as the winner of the 2015 Canadian Undergraduate Surgical Education Committee student essay competition. It was written in response to the prompt: “How is your school preparing you for residency — be it surgical or medical?”.
There is an increasing understanding at the University of British Columbia (UBC), Canada, and internationally of the importance of an integrated curriculum in undergraduate medical education. One of the ways UBC medicine is putting this theory into practice is through its integrated community clerkship programs.1 These programs are a model of third-year medical education better known as longitudinal integrated clerkships (LICs). Instead of the traditional rotation-based clerkship (RBC) approach in which students spend a set amount of time in single disciplines during their third year of medical school, the LIC program enables students with the desire and drive for a more self-directed experience to integrate their learning and define their own education. LIC students complete their core program objectives and clinical experiences in all disciplines simultaneously throughout their clerkship year. The result of this approach is that a student’s progression through an LIC program does not depend on the amount of time a student spends within a particular discipline, but rather the student’s competency within that discipline. As such, LICs represent an invaluable opportunity for the incorporation of competency-based medical education at the undergraduate level.
Benefits of this approach include greater appreciation for continuity of care,1 increased independence and responsibility in patient care,2 and enhanced participation in interprofessional teams.3 This is partly because throughout the LIC program students are encouraged to follow patients through different clinical contexts from the initial presentation of their disease and illness through its various treatment modalities and ultimate resolution. I will never forget the time I was working on a general surgery service and was consulted on a patient presenting with ascites. Two weeks later working in a gynecology clinic I saw that same patient in consultation for the ovarian cancer we had diagnosed. Through this exposure students are better able to appreciate continuity of care across health care disciplines and gain a better sense of independence in the care of patients. This level of integration and responsibility facilitates the progression of the clerk through the early stages of their clinical education to the point where they become the primary care provider all under the careful supervision of preceptors that have been working closely with them throughout their third year of medical school.
LIC experiences also provide longitudinal mentorship and assessment, which facilitates better acquisition of higher-level knowledge and clinical skills as compared with RBCs. Hauer and colleagues2 studied how the role of a clerk differs between LICs and RBCs and found that LIC students consistently take on more advanced clinical roles in the care of their patients earlier in their training and to a greater extent than their RBC peers. One study found that with respect to surgical training specifically, LIC students received more than 1.6 times as much operating room exposure, see 3 times as many surgical cases, and are the first assistant 4 times as often as their RBC peers.4 This increased expectation and opportunity is largely because students in LIC programs benefit from longitudinal relationships with both their clinical preceptors and their patients. At UBC, LIC students are paired with a family doctor with whom they will work on a weekly basis for their entire third year to facilitate this mentorship and training. Without the limitation of rotations that may involve working with multiple preceptors in just a few weeks, LIC clerks have the benefit of time to develop their competency and build a professional relationship with their preceptors. Once a preceptor knows a student well and has had the chance to personally assess their competence, they are better able to decide which clinical decisions and activities they can trust the student to perform independently. This longitudinal approach is not only ideal for giving trainees a gradual and holistic approach to increasing their clinical acumen and skill level, but also provides preceptors with a far greater ability to assess the strengths, weaknesses and, most importantly, the progress of their students.
It is well documented that LIC students achieve equivalent or better performance on standardized exams than their RBC counterparts;1,4,5 however, I would argue that the true strength of LICs is that they provide optimal preparation for competency-based training within residency. LICs already base the expectations and responsibilities of students on their competency, not on the amount of time they have spent within a particular discipline. As discussed, the longitudinal format of these clerkships provide the time necessary for preceptors to assess their students’ competency and trust that competency in the care of their patients. Hirsh and colleagues3 argued that providing “time to trust is necessary to realize competency-based education.” My question is why does this have to wait until residency? The answer is that it doesn’t. LICs already exemplify competency-based education at the medical undergraduate level. Both in their format and approach, LICs are far more congruent with competency-based postgraduate residency training than traditional rotation-based clerkships. What better preparation for residency can a clerk obtain than a training program that promotes the roles, responsibilities and assessment expected of a junior resident?
I feel incredibly fortunate to be part of an LIC program for my third year at UBC. I believe that the LIC model is preparing me for residency with a competency-based approach. I have the unique opportunity to guide my learning, gradually develop my clinical skills and understand the complexity and interdependence of services in the care of my patients — all with a level of preceptor continuity that is unparalleled. Completing a third year that pushes me beyond the role and responsibilities of a traditional clerk can be intimidating at times, but it is also tremendously exciting and gratifying. Already I serve a meaningful role as part of the health care team, I feel the sense of duty and responsibility that comes with following my own patients as they navigate their care, and I know that this approach is the best possible preparation for the challenges of residency and my future career.
Key Points
Longitudinal integrated clerkships (LICs) are gaining recognition as an alternative approach to rotation-based clerkships (RBCs).
Graduates of LICs demonstrate equivalent or better academic performance and participate in more advanced clinical roles throughout their clerkship year than graduates of RBCs.
LICs provide a valuable opportunity to incorporate competency-based education at the medical undergraduate level.
Footnotes
This work was presented at the Canadian Undergraduate Surgical Education Committee Symposium, Ottawa, Ont., Nov. 12–15, 2015.
Competing interests: None declared.
- Received December 1, 2016.
- Accepted July 12, 2016.