Study underscores value of continuity in med student clerkships

Medical students allowed to work with the same patients and mentors throughout their clinical clerkships report higher satisfaction and demonstrate better clinical competency than peers trained with less continuity, says a study in the January 2013 issue of Academic Medicine.

Researchers at the University of California, San Francisco School of Medicine evaluated 563 students in three clerkship models with varying levels of continuity between 2006 and 2010. They found that students in all three programs preferred consistency during their clinical education. Those who participated in clerkships that offered more continuity scored higher than students in the block rotations on the clinical knowledge section of the U.S. Medical Licensing Exam Step 2, said the study, which was published online Nov. 16.

There has been debate in medical education for years about the third year of medical school and whether traditional clinical block rotations provide the best exposure and training for physicians, said lead study author Arianne Teherani, PhD.

“As the landscape of health care has changed, there has been a lot of discourse on the best level of continuity in clinical training in the clerkship year,” said Teherani, associate professor in the Dept. of Medicine at the UCSF School of Medicine.

Medical schools have experimented with structuring clerkships. The models studied at UCSF were: a year-long, longitudinal, integrated clerkship; a six-month hybrid clerkship; and traditional block rotations.

In both the longitudinal and hybrid programs, students worked with the same faculty advisers in core specialties and maintained a panel of patients representing a wide spectrum of medical conditions throughout the clerkship. In the block rotations, students changed specialties, mentors and patients every few months.

Students in the longitudinal integrated clerkship rated several aspects of their training higher than the other students, including faculty teaching, faculty observation of clinical skills, feedback and the clerkship overall. They also reported observing more positive role modeling of behaviors and had more patient-centered experiences.

“The issue of increasing continuity is one that has had a lot of discussion. This study is helpful in having some data to compare different models,” said Carol A. Aschenbrener, MD, chief medical education officer with the Assn. of American Medical Colleges.

Longitudinal clerkships allow students to develop relationships with patients, mentors and faculty. Increased continuity also will help as schools move toward assessing students’ competency, she said. Faculty members can mentor students over extended periods, provide feedback and observe their improvement.

“That assessment is a complex process, but it is facilitated by having continuity,” Dr. Aschenbrener said. “One of the things we really want to cultivate in the learning environment is a culture of safety — so that students feel comfortable saying ‘I don’t know how to do that.’ ”

Teherani said she hopes the study will help inform more schools about the importance of continuity. But there are challenges for schools in implementing longitudinal clerkship opportunities. Such programs require training sites with multiple specialties and physicians who can spend more time with students, she said.

UCSF School of Medicine recently launched two new longitudinal integrated clerkship programs in Fresno and Oakland, Calif., that will accommodate more students.

Dr. Aschenbrener said increasing continuity in clerkship training is part of a larger re-evaluation of how medical education is structured.

“We are more and more realizing that we need to think about the process of preparation of physicians, not in several buckets — medical school, residency, fellowship. We need to think about the quality of the experiences,” she said. “It’s not about how many courses you take. It’s about the quality of the experiences that you have.”