The Significance of Longitudinal Clerkships in Medical School
The following is an in-depth meditation on longitudinal clerkships by a recent VALUE student. - ed.
I: An Old Valve
There was an excitement in the voice of Dr. David Griffin that I hadn’t heard in the few days we’d known each other. Following our afternoon in clinic, he walked me down to meet a longtime patient, we’ll call him Mr. Y, who was being prepped for surgery to take place the next morning. Mr. Y had been feeling short of breath for the past year, and it was getting worse. Recently, he had started driving his golf cart to the mailbox at the end of his driveway. He was an outgoing elderly man, jolly and loud despite his precarious health. It was hard to know whether the volume of his voice was related to his cheer or his hearing-loss, but I prefer to believe it was the former.
We found Mr. Y’s room, knocked and entered. He was thrilled to see Dr. Griffin, even though we caught him while he was in the bathroom, door open, only wearing white briefs and an unbuttoned dress shirt. I was introduced without awkwardness, as the medical student that would be following his care for the next ten months. After a brief chat, we left him to finish getting ready for bed. He had a big morning ahead.
To repair severe aortic stenosis in someone of Mr. Y’s age and health, the best option is what’s known as Transccatheter Aortic Valve Replacement (TAVR). With this method, an interventional cardiologist feeds a catheter through the femoral artery—accessing this vessel at the patient’s groin—and up into the left-side of the patient’s heart. A replacement valve is fed along the line that has been positioned, and is expanded within the damaged leaflets of the native valve, crushing them to the side, leaving a functional prosthetic in its place.
II: The VALUE Clerkship
This was the second week of the VALUE program, an experiment in medical education conducted through the University of Minnesota at the Veterans Affairs Medical Center in Minneapolis. VALUE stands for “VA Longitudinal Undergraduate Medical Education.” The name does a pretty good job of explaining what it is, and, as importantly, forms a memorable acronym, which doctors to seem to enjoy.
Traditional “clerkships,” as they are known, are two-to-eight-week-long clinical experiences in each of the many medical specialties taken during the third and fourth years of medical school. During these programs, students see patients and learn directly from the doctors responsible for their care. It’s a combination of structured didactic learning, self-directed experience, and day-to-day grunt work. After the month-plus spent in, for example, neurology, students get comfortable thinking about common problems people seeing neurologists might have and the options for dealing with those problems… and then they move on to the next clerkship.
These immersive experiences are short and not standardized. Each clinic, hospital ward, or operating room can only accommodate a few medical students without totally derailing efficiency and patient care. Traditional clerkship experiences, therefore, are very dependent on, among other things, which physicians are working during the month of your rotation, what hospital you are assigned to, how many patients are sick during those days and with what maladies.
At the center of each traditional clerkship is the specialty in question. What goes on in a pediatric clinic? How does a general surgeon spend their days? What problems do psychiatrists address? But the VALUE program, and other programs like it, have rearranged the focus. Regardless of what specialties they may need to access, the center of the program is the patients.
In VALUE, as the website reads: “[Students have] scheduled time in each discipline (Internal Medicine, Psychiatry, Neurology, Surgery, etc.) to ensure fundamentals of each discipline are acquired. However, the main goal of VALUE is to have students follow a cohort of patients across multiple clinic settings.
“For example, Mr. S is initially seen in primary care clinic with right upper quadrant pain. Mr. S is referred for an ultrasound, the medical student reads the ultrasound with the radiologist and it shows gallstones. Mr. S is referred to general surgery. His medical student goes to that appointment for his pre-op evaluation and then is present and participating in the operating room for his cholecystectomy. The medical student follows Mr. S in the hospital and then again in surgery clinic for a post-op evaluation. Eventually Mr. S is again seen in primary care for a preventative care visit. Mr. S's medical student was present and participating in the entire illness episode.”
The only way this model works is to make the program longitudinal, i.e. over the course of ten months. This prolonged period allows for enough structured time in each of the disciplines. It also allows patients from a student’s cohort time to access different modalities of medicine, or to return repeatedly with a chronic disease, providing educational opportunities for students like me along the way.
III: The New Valve
After chatting with Mr. Y, Dr. Griffin and I went to find the cardiologist who would be doing the TAVR in the morning. We found Dr. Santiago Garcia looking over recent CT scans of Mr. Y’s vessels, conducting final reviews of the anatomy he would have to navigate the next day.
The following morning I stood six feet away, watching as Dr. Garcia concentrated on the delicate balance between applying enough pressure to move instruments through calcified, elderly arteries, but not so much pressure as to puncture any of the blood highways. We all had lead aprons and neck shields to guard our insides from the radiation necessary to visualize catheters as they snaked up ancient routes through the body prone on the operating table. Occasionally, he would ask a question of one of the other half dozen people in the room, either requesting an action from one of them, or a widget of information, all of which were vitally important to the actions he was taking to extend the man’s life by, hopefully, up to five years.
“What was the angle on his aortic arch?”
“Hand me a Kelly clamp please.”
“I think I’m getting caught on his inguinal ligament here, do you agree?”
In just under two hours, Mr. Y’s new valve was in place, his femoral incisions were sewn up, and the team walked out, smiling. There was one more TAVR scheduled for that day, and they took a deserved break while the room was prepped.
As a medical student, I had no role to play in this intricate ballet, and I was grateful for that. In medicine, and other disciplines, it is often said, “Watch one, do one, teach one.” I would probably want to watch a few more before I was ready to try replacing a patient’s heart valve.
When I saw Mr. Y the next day in the hospital, he was preparing to go home and happy to see me. He wondered what had gone on in the operating room the day before. I did my best to explain what I had seen before we quickly moved on to a discussion of when he could go fishing again.
IV: A Very Brief History of Medical Education
Medical education has remained largely unchanged since 1889, when a young William Osler was recruited to be the chair of medicine at the newly formed Johns Hopkins Medical School in Baltimore. Borrowing principles he learned at universities in Europe, he established the Hopkins’ residency model, originally named because doctors-in-training lived in the hospitals where they apprenticed. He also recognized the importance of bringing students to the patient’s bedside during their early training, understanding that basic scientific principles are better retained when applied to real-world illness. He went so far as to have his epitaph read, “I taught medical students in the wards.”1
In 1910, Abraham Flexner—a researcher at the Carnegie Foundation for the Advancement of teaching—published a relatively scathing critique after visiting all 155 of the medical schools in the United States and Canada. He was critical of the lack of scientific grounding of medical schools’ curricula, and their focus on profits over quality education. His report helped promote the push toward analytic reasoning and evidence-based clinical practice, as well as establishing quality standards for what it means to be a medical school in North America.2
Osler and Flexner inspired a monumental shift in how physicians are educated in North America, by establishing the importance of medicine based in scientific inquiry, and by devising an experiential model for medical education. Since then, U.S. medical education has been structured in a four-year curriculum, the first two years devoted to the basic sciences and the next two focused on clinical training. Though this happened more than a century ago, it was arguably the most recent structural change of any significant magnitude.
Modern trends in the practice of medicine have put strains on these core principles of medical education. The base of scientific knowledge has ballooned, with the incorporation of new fields, such as genetics and molecular biology. It is now much more cumbersome to directly apply all of the necessary basic science at the patient’s bedside. Public expectations for healthcare have increased as medical breakthroughs have defeated disease after disease. This has made it more difficult, ethically and legally, to allow students to take an active role in their patient’s care.
Even more recently, decreased length of hospital stays and increased focus on outpatient care (while good for reducing medical expenditures and allocating resources) make it more difficult for students to see patients through the whole episode of an illness. In theory, this could lead to deficits for students in learning the full arc of diagnostic and therapeutic reasoning. Furthermore, this acceleration in the pace of clinical care puts demands on experienced clinicians that reduces the time they are able to spend on teaching and mentoring.3
V: The Case for Longitudinal Clerkships
In 1971, The University of Minnesota Medical School began the Rural Physician Associate Program (RPAP). This was developed in response to the Minnesota Legislature threatening to withdraw funding from the medical school unless a program was designed to train primary care physicians to practice in rural areas of the state, places where there was a dangerous shortage.4 While not the primary focus, RPAP was also one of the first longitudinal clerkship models. Through the program—now in its 44th year—approximately 30 third-year University of Minnesota medical students are placed at rural hospitals for 9 months, learning directly under physicians there. The program has been highly successful, with 75% of their trainees entering primary care specialties.5
Still, longitudinal curricula are relatively rare and recent developments. In 2004, Harvard Medical School initiated a yearlong program at its associated Cambridge Hospital, which eight students participated in, called the Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC). These eight were randomly selected from the pool of 18 who applied, and were then compared to the ten other applicants who took traditional clerkships. Compared to their peers, the eight who went through the longitudinal curricula did at least as well in National Board of Medical Examiners (NBME) subject exams, and scored higher on comprehensive skills assessments. The participants were also more likely to see patients before diagnosis and after discharge, and were more likely to receive thorough feedback and mentoring.3
Most importantly—from my perspective—based on surveys taken before and after their third years, longitudinal students expressed more satisfaction with the curricula, and felt they were better prepared to cope with professional challenges of patient care. They also expressed decreased erosion of idealism and empathy, unfortunately a common problem these days among medical students at many universities.3
Similar outcomes have been shown at other institutions, including the University of California, San Francisco, which began the yearlong Parnassus Integrated Student Clinical Experiences program (PISCES) in 2005. Data from this program showed longitudinal students did at least as well as their peers on the US Medical Licensing Examination Step 2 Exam, which is the second of three national exams required to become a licensed physician.6
Of note, students surveyed from the HMS-CIC program expressed that their experience was more “hectic,” and “stressful,” and felt it was equivalently “frustrating,” as their peers’ in traditional curricula. These feelings could be due to the inevitable growing pains of a new program, or could be inherent to trying to achieve comfort in multiple specialties all at once.3
Now that I’m most of the way through the VALUE program, I suspect that the data is true, both the major positives and minor negatives. And, for me, when it is hectic, and even stressful, I leave the VA Medical Center most days caring about the patients I have gotten to know, and feeling as though the faculty is deeply invested in the education I am receiving. I’m also able to stay grounded with moral support from the cohort of nine other bright young medical students who provide both humor and additional learning from what they see during their time on the wards each day.
Dr. Nacide Ercan-Feng is an endocrinologist at the Minneapolis VA, and is one of the directors of the VALUE program. She told me what surprised her most about the program thus far is that “The ownership that the students have for their patients, and, likewise, the ownership that the preceptors have for the students, is remarkable.”
Trust is required in order for mentors, in any field, to allow their apprentices to fully participate in their work. This is especially true in a field with so much at stake, and one that requires such a large body of knowledge. Even the most advanced medical students will require a few weeks to prove they are competent to their supervising doctors. Until then, doctors won’t completely rely on the histories students obtain from patients, on the stitches students place in incisions, or on the conversations students have with other providers managing their patients’ care. Longitudinal programs allow trust to be built between doctor and student, maximizing the depth of their learning experiences.
There is now a Consortium of Longitudinal Integrated Clerkships composed of faculty from universities around the world that is devoted to developing, implementing, and studying integrated longitudinal clerkships for medical students. Twenty-nine institutions in the U.S., Canada, Australia, and South Africa have these programs in place—many of which have more than one longitudinal option for their students.7
The University of Minnesota itself has the RPAP and MetroPAP programs, with VALUE being an expansion and derivation of those previous experiments. (The U of M is also participating in the multi-center Education in Pediatrics Across the Continuum [EPAC] project, which is structured similarly to the previous three, but has slightly different goals.)
The other director of VALUE, a primary care internist at the VA named Dr. Amy Candy Heinlein, told me why she was motivated to get involved in implementing longitudinal curricula. “We know these are not worse than other clerkships. But are they better? At this point, we think so.” Ideally, physicians are evidence-driven. Those involved in implementing these programs are no different. These aren’t renegade ideologues trying to overthrow an established system, but, rather, experienced educators and clinicians seeking to fix real problems they see in medical education, while patiently accumulating data that, thus far, seems to support their intuition.
Those glowing things said, there has been some criticism of the clerkship’s structure from various peripheral staff, for understandable reasons. It is difficult to know where VALUE students will be at any given time, sometimes making coordination difficult, and potentially making it easier to skirt responsibility for students so inclined. There is also concern that, as we prance amongst various learning experiences, VALUE students miss out on intangibles that are gained from being part of a specific medical team for a continuous chunk of time. While those worries are valid, I don’t believe they will actually hobble our medical education. It is the first year of the VALUE clerkship, and the organization of our responsibilities has become more clearly communicated even within the first few months. I suspect this will only continue in future years. I also regularly remind myself that, this is a ten-month longitudinal experience, not my entire medical education. There will be ample time, in fourth year, as well as in residency, to pick up small things we may miss by participating in VALUE.
VI: The VA of VALUE
The VALUE program is different from other long-term clerkships because it takes place at the VA Medical Center, a setting that lends itself well to this type of curricula. As with longitudinal programs elsewhere, our hospital has many of the core specialties all under one roof, making student access seamless to each. We have to do our Pediatrics and Obstetrics/Gynecology rotations before or after the VALUE program, as there are not—yet—any children veterans, and there are not enough female veterans (particularly pregnant ones) to provide us with a rich experience in those fields.
Those exceptions aside, there are myriad reasons why a Veteran population might need healthcare at higher rates than the general population, Combat exposure to chemical exposure to substance abuse (and the associated complications), among others. In addition, Veterans with “service connected,” health problems are given priority when registering to receive care at the VA, and it is only these Veterans who get their healthcare subsidized by the government. Revealingly, only 31% of Veterans in the state of Minnesota receive their healthcare from the VA.8 As a result, students participating in the VALUE program are not seeing any perfectly healthy individuals.
Another benefit is that the Veteran’s Health Administration is federally funded. Practically, this means the VA administration is generous and financially flexible enough to give physician-mentors more time to devote to teaching. This additional time spent with VALUE students means slightly decreased patient capacity in their clinics. More time is also spent on each clinical encounter, which means students such as myself can see the patient on our own before the physician joins, with time after to discuss the findings. The VALUE clerkship, therefore, has relatively low start-up costs for the University of Minnesota itself, with the University paying only for the time of some of the program administrators.
It warrants mention that the VA has been in the news in recent years for all the wrong reasons. Long patient wait-times and unscrupulous administrative behavior at certain VA locations have shone a negative light on the whole system. That said, the majority of what I have seen during my time at the Minneapolis VA has been high-quality, caring, on-time healthcare for Veterans who need it. Perhaps there isn’t the breakneck efficiency of some private health providers. But this allows time for reflection and relationship building. Content teachers and willing patients allow for great medical education to occur. The VA appears to me to be a truly symbiotic space, where those in need of healthcare, because of what they have done for our country, are paired with those who need experience providing said care, and who, in different ways, want to serve the nation too.
Veterans of war have been through things most of us will thankfully never experience, leaving their minds and bodies with scars that will never heal. From a medical student’s perspective, this is a perfect environment to see what the human body can endure physiologically, and how we as providers can facilitate healing. From a human perspective, particularly a privileged human living in a peaceful community, this is an ideal environment to see what the human mind can endure and still go on to lead a meaningful, positive life.
VII: Follow-Ups and Downs
I saw Mr. Y again in Dr. Griffin’s primary care clinic a couple of weeks after his TAVR procedure. He was there with his wife, and was doing well. He hadn’t regained all of his exercise tolerance, but a few weeks out he was walking on his own to the mailbox. His wife said he was much less fatigued, and they both seemed excited about the rest of their lives together. She asked if what I had seen made me want to be a cardiologist. I wasn’t sure how to answer.
The whole procedure was fascinating, awe-inspiring and, well… insert other grandiose adjectives here. The truth is, it made me happy to be a VALUE student.
I said goodbye to the elderly couple, knowing I would see them back in the clinic at least a few more times in the coming months. And if Mr. Y needed care for a new problem, an unexpected one, as often is the case with elderly health management, I would be ready and well versed on his recent clinical course.
Of course, not all patient outcomes leave us feeling warm and satisfied. Deep, long-term investment in patients’ lives can be hard to stomach when their health takes a turn for the worse, as was the case with a man we’ll call Mr. Z. He was in the hospital before the VALUE program had even begun. The Agent Orange-related cancer in his throat had recurred, or perhaps it was a new malignancy altogether, inspired by the radiation he received to treat the first. Either way, it had invaded the tissue near his spine, and, so, was too precarious to remove surgically.
I walked into the room to introduce myself and to ask him if there were questions he had for me, a random 26-year-old wearing a white coat. Speaking with an electronic amplifier due to the hole in his larynx, he said he didn’t think so. But I couldn’t understand him. So I asked him what he said. He shrugged and looked away.
A couple of weeks later, after we were certain an infection he had was adequately treated, and after a tube was placed through his abdominal wall into the stomach so that he could receive nutrition despite a tumor closing-off the standard route food travels, Mr. Z was discharged home.
We also had placed a port in his chest, with a line sitting in his heart, to allow easy, high-throughput access to his blood stream in preparation for the chemotherapy he would receive soon.
He returned a few days before he was scheduled to meet with the oncologists, which was not a good sign. The tube we put in his stomach had fallen out at home, and the line we put in his heart had likely become infected. We rearranged a few things, delivered more bactericidal fluid into his system, and sent him home again, crossing our fingers that the next time we saw him we could address the cancer that was necessitating all of the other care.
At the next visit, following another couple weeks of recuperation, an oncologist presented Mr. Z with his treatment options, none of them promising. Palliative chemotherapy with a high risk of reinfection, radiation therapy with a high risk of life threatening damage to an already severely scarred neck area, or forgoing treatment altogether. He and his wife went home to discuss which option they thought would allow him an acceptable quality of life for the longest period of time.
I got a call on a Saturday, a week or so later. Mr. Z had returned to the hospital, but over the phone it didn’t seem overly urgent, just “failure to thrive,” and some increased pain in his neck. I saw him Sunday, by which point arm weakness had been added to his problem list. The Monday MRI showed an epidural abscess and osteomyelitis eating away at the vertebrae in his cervical spine, compressing his spinal cord, causing progressive paralysis and intense pain. There was nothing to be done from a surgical standpoint, as Mr. Z was too frail, too complicated, and too far down a steep mountain side. He was transferred to hospice care on a different ward, downstairs, which was to be his final stop.
I wasn’t ready for such a precipitous decline in Mr. Z’s health. I knew he was likely to die before the end of the VALUE program, but I thought I’d have time to see him fight some more, time to prepare for his end, time to talk to his wife about how great of a season the Vikings had. My sentimental daydreams were dissolved, leaving only the understanding that I didn’t have many visits left with this friendly young grandfather, whose body I’d palpated, whose stool I’d asked about, whose lips I’d learned to read, whose family I’d grown to know.
Of course, this scenario more closely resembles how practicing physicians might experience the care they provide for their patients. Accepting the death of those you’ve become familiar with is part of the job, and just because it is hard doesn’t mean it should be omitted until later in training. I’m grateful for the losses a longitudinal curriculum has provided, as well as for the victories.
VIII: Closing Remarks
Medical education needs a refresh and institutions across the country would be wise to start evaluating potential improvements to their clinical curriculum.
My experience with the VALUE program has led me to believe strongly in the power of LICs and their ability to improve the quality of medical training. Overall, my LIC peers are very invested in the patients they are caring for—and less jaded by the rapid turnover of people and places—while still performing as well as their counterparts on standardized tests.
The VALUE program is connecting students with patients in a meaningful way that I believe has improved our ability to deliver care with compassion. I think—I hope—Mr. Y, Mr. Z, and many others, would agree with me.
- Dornan, T. Osler, Flexner, apprenticeship and 'the new medical education'. Journal of the Royal Society of Medicine. 2005;98(3):91–95.
- Cox, M, Irby, DM, Cooke, M, Irby, DM, Sullivan, W, Ludmerer, KM. American Medical Education 100 Years after the Flexner Report. New England Journal of Medicine N Engl J Med. 2006;355(13):1339–1344.
- Ogur, B, Hirsh, D, Krupat, E, Bor, D. The Harvard Medical School-Cambridge Integrated Clerkship: An Innovative Model of Clinical Education. Academic Medicine. 2007;82(4):397–404.
- Verby, JE. Changing the medical school curriculum to improve patient access to primary care. JAMA: The Journal of the American Medical Association. 1991;266(1):110–113.
- Brooks, K, et al. RPAP Outcomes. Rural Physician Associate Program. Available at: https://www.med.umn.edu/md-students/rural-physician-associate-program-rp.... Accessed November 11, 2015.
- Poncelet, A, Bokser, S, Calton, B, et al. Development of a longitudinal integrated clerkship at an academic medical center. Medical Education Online. 2011;16.
- Allison, R. CLIC- The Consortium of Longitudinal Integrated Clerkships. Available at: http://www.clicmeded.com/. Accessed November 14, 2016.
- Veterans Statistics 2015. United States Census Bureau. Available at: http://www.census.gov/library/infographics/veterans-statistics.html. Accessed November 30, 2016.