The longitudinal integrated clerkship (LIC): The future of third year?

[breakintheroof]

More than a dozen medical schools have replaced the traditional block clerkship model with the longitudinal integrated clerkship (LIC). There hasn’t been a whole lot of discussion that I can find on SDN about it.

In a LIC, the focus is on continuous relationships with patients and preceptors. Instead of spending a year in blocks on one service at a time, students split their time among different services on different days of the week, and typically also follow a panel of patients throughout their clinical course. Here’s an example of a weekly schedule from UCSF’s PISCES program:

LICs have existed for some time in rural, primary care-focused settings, especially in Australia and Canada. There are now about a dozen or so that I can find in the US, about half of them with a primary care, underserved, or regional mission.

One of the catalysts for expansion seems to have been Harvard’s implementation of the Cambridge Integrated Clerkship (CIC), which began in 2004. The program administrators have compared students who completed that program with those who did a traditional third year after signing up for CIC but not being selected in the random drawing for entry, with impressive results:

CIC students performed as well as or better than their traditionally trained peers on measures of content knowledge and clinical skills. CIC students expressed higher satisfaction with the learning environment, more confidence in dealing with numerous domains of patient care, and a stronger sense of patient-centeredness.

More recently the same investigators reported a lasting impact 4-6 years after the program:

The immediate post-clerkship finding that CIC students held more patient-centred attitudes was sustained over time... Graduates of the CIC attained awards and published papers at the same rates as peers, and were more likely to engage in health advocacy work… Among those expressing a preference, no CIC graduates said they would choose a traditional clerkship, but 6 (27%) of the traditionally trained graduates said they would choose a longitudinal integrated clerkship.

LICs I could find:

Harvard: Cambridge Integrated Clerkship (12 students)
UCSF: PISCES (16 students), KLIC (8 students), and several others including hybrids VALOR and LIFE
Columbia: Columbia-Bassett (10 students)
TCMC: All students (said to be changing to a hybrid)
Indiana: Bloomington (8 students)
South Dakota-Sanford: All students?
North Dakota: MILE (~10 students, thanks to @WillburCobb for the correction)
Colorado: Denver Health (8 students)

Primary care, underserved, or regionally focused:
Duke: Primary Care Leadership
Minnesota: Metro-PAP (urban), and RPAP (rural, and one of the earliest LICs)
Tufts: Maine Track
Tulane: TRIP (rural program)
WWAMI: TRUST (rural primary care, hybrid)
UNC: Asheville (20 students, primary care focused)

Last edited 2/19 to add Colorado information.

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[TxC]

http://www.ncbi.nlm.nih.gov/pubmed/19550184

"No differences were noted in nationally normed exam scores between program participants and those in the traditional clerkships. Limited outcomes data suggest that students who participate in these programs are more likely to enter primary care careers."

Maybe LIC could help alleviate the PCP shortage? Who knows.

I do like the whole idea of continuity.

 

[breakintheroof]

I think it sounds terrible. The clinical years are meant to do two things - one is to have you learn clinical medicine content, largely through patient encounters. The other is to have you learn how to perform clinical medicine, largely by integration with a clinical team (i.e. faculty and resident preceptors). This model seems to nearly completely abandon the latter.

From the resident perspective I have no idea how I would be able to develop any significant teaching relationship with a medical student. I'm also not sure what role they would even be able to play on the team - if on any given day they have one patient from their "cohort" on my service and they simply drop in and out of rounds. It would be like a never ending parade of students with no continuity with the team and with a marginalized role in actual patient care.

Thanks for this perspective. I have met several LIC students while interviewing who are going into inpatient-focused specialties, including surgery, and I've wondered what kind of questions their experience would raise. How they respond to the challenge of being part of a team in this model seems like something that would be interesting to ask them.

I did find a blog post by a Harvard CIC student specifically aimed at addressing these concerns among surgeons. Reading between the lines, it seems that while she was very happy with the mentoring relationship she had with an attending, she did in fact have less contact with residents than a typical clerkship student.

While my classmates in the traditional block rotations may have finished third year with a better understanding of the life of a house officer, I certainly had an excellent perspective on life after residency. Because my primary teacher was an attending physician, my surgical rotation reflected the workflow of an attending surgeon from how he spent his time to the kinds of relationships he had with patients.

 

[WillburCobb]

The ROME program at UND is different than the LIC model you're describing and more similar to the traditional clerkship model; it is geared toward those interested in rural primary care though. UND has a program called MILE which is based on the LIC model, but there are only spots for ~10 students. http://www.med.und.edu/minot/mile-program.html

 

[breakintheroof]

The ROME program at UND is different than the LIC model you're describing and more similar to the traditional clerkship model; it is geared toward those interested in rural primary care though. UND has a program called MILE which is based on the LIC model, but there are only spots for ~10 students. http://www.med.und.edu/minot/mile-program.html

Thanks for the correction, my mistake. I got most of these off of this website, and I didn't double-check this one carefully.

I've updated the first post. Is MILE primary care or rural care focused too?

 

[giantswing]

As much as i dislike continuity, i learned the most rounding on the same patients everyday, seeing how they went from er consult, to admit, to surgery, to recovery, and discharge.

Terrible idea.

 

[WillburCobb]

Thanks for the correction, my mistake. I got most of these off of this website, and I didn't double-check this one carefully.

I've updated the first post. Is MILE primary care or rural care focused too?

Not really, pretty much just a different educational opportunity for 3rd year, and a way to try and accommodate more students on the Minot campus, so that they can accommodate the increased class size. UND as a whole is very primary care focused so in that regard I guess it is.

 

[Tman90]

.

 

[jqueb29]

This looks awful to me

 

[Cyberdyne 101]

I would consider it an honor though if @SouthernSurgeon would do me in though

🤣

 

[mvenus929]

I like the idea of some sort of continuity experience. I honestly feel that continuity makes it easier to learn based on a patient, and focuses more on patient-oriented care than on chugging through the system. There are patients who I would love to follow their course throughout their hospitalization and subsequent follow-up, but am unable to because I switch rotations. It's up to me to go back and chart review those patients, which is made difficult by the fact that my hospital is not completely electronic.

That said, there is also something to be said about volume, which is difficult to accomplish with a specified cohort of patients. As others have said, if you only have one patient on medicine/surgery rounds, and peace out after rounds are done to do clinic, how do you learn the day-to-day management of the hospitalized patient?

I think there is a program or two (I'm not sure if they are among those listed above), who do some sort of continuity during first or second year, which I think would be useful. You'd be assigned a cohort of patients from one of the primary clinics associated with your institution, and would be contacted whenever they come to the clinic, ED, are admitted, referred somewhere, etc, so you can follow the progression of disease in a small set of patients. Allows pre-clerkship students to get some clinical experience while simultaneously seeing the interface of the patient and clinicians from more of a patient perspective. Seems an interesting concept, anyway.

 

[Ariodant]

LIC requires a different learning style and allows a greater degree of flexibility in one's schedule. Some of the self-directed study time will be used to follow the cohort of longitudinal patients, some will be used to do preceptorships in specialties of interest. I think it benefits someone who wants to do mostly outpatient work, is very proactive in designing their own schedules, and is comfortable jugging multiple balls all year long. I agree it doesn't suit specialties with a significant inpatient component. I do know a PISCES student from UCSF matching into neurosurgery, though. The stats given by the directors indicate PISCES students have equivalent shelf scores/# of honors and better CPX performance, so I guess they are fine.

I found myself a clinic to attend two days per week as I finish up my PhD. So far the residents have all been nice to me, probably because they don't have to evaluate me or drag me around everyday for weeks. I have worked with the attending longer than many of them and have seen some of the patients multiple times. The residents actually appreciate the occasional help from me in filling them in on the patients, or more frequently, the particular idiosyncrasies of that attending...😉

 

[rugbyram7]

Personally I think it's an interesting concept. Obviously as a pre-med I don't know whether LIC or the traditional block format is better for preparing a student for residencies or a career in medicine, but I interviewed at a school that used this model and they explained the reasoning behind it by saying it allows students to see medicine not only in the inpatient, but also the outpatient settings. The LIC format also allows you to see the entire process of a patient's experience. For example, during a traditional OB/GYN block you might deliver a baby, but with the LIC you could follow the mother throughout her pregnancy to childbirth. Plus, it ensures you're integrating everything you learn in each rotation to the other rotations. There are disadvantages, as people have mentioned above, but I think it's a format that could be beneficial.

 

[breakintheroof]

...there is also something to be said about volume, which is difficult to accomplish with a specified cohort of patients. As others have said, if you only have one patient on medicine/surgery rounds, and peace out after rounds are done to do clinic, how do you learn the day-to-day management of the hospitalized patient?

Great point. Some (maybe all?) of these programs are really more of a hybrid, with a portion of the clinical year devoted to abbreviated inpatient blocks. I wonder if these are effective enough in exposing students to day-to-day inpatient management. Here's Columbia-Bassett's curriculum diagram showing the "Rapid Inpatient Block" at the start:

I think it benefits someone who wants to do mostly outpatient work, is very proactive in designing their own schedules, and is comfortable jugging multiple balls all year long.

Thanks for your insight. I think you're right that this model appeals to a subset of students with particular interests and goals. It seems very intuitively appealing to me (and these programs are very popular at places like Harvard, Columbia, and perhaps UCSF) but there are plenty of people who seem to find nothing positive about them.

 

[mimelim]

I am all for innovating and changing up how we teach medical students. You can't teach people, 'too well'. But, this system does not allow students to have a good experience on virtually any specialty. It is bad enough when students have to disappear from their services for excessive or inefficient didactics, this blows up learning how to function in a working environment entirely.

By far the biggest issue for incoming interns is that they have a student mentality rather than a taking care of patients mentality. This just reinforces that and doesn't allow for learning how to actually practice medicine.

 

[breakintheroof]

I am all for innovating and changing up how we teach medical students. You can't teach people, 'too well'. But, this system does not allow students to have a good experience on virtually any specialty. It is bad enough when students have to disappear from their services for excessive or inefficient didactics, this blows up learning how to function in a working environment entirely.

By far the biggest issue for incoming interns is that they have a student mentality rather than a taking care of patients mentality. This just reinforces that and doesn't allow for learning how to actually practice medicine.

If I understand correctly, this means that students who split their attention among different specialties do not participate fully in any of them. When they finish the year, they have missed their opportunity to fulfill a role in a clinical team, which they will take on full-time as an intern. Is that right?

I'd love to hear more about how you would change medical education to better prepare students for internship. What elements would you reform in a traditional clerkship? Does any aspect of the LIC appeal to you?

 

[Ariodant]

By far the biggest issue for incoming interns is that they have a student mentality rather than a taking care of patients mentality. This just reinforces that and doesn't allow for learning how to actually practice medicine.

I'm curious as to why you believe following patients longitudinally for a year doesn't encourage a taking care of patients mentality? For physicians in largely outpatient settings such as PCP, LIC actually resemble their way of practicing medicine more closely than the traditional clerkship model. It's not for everyone, but I don't agree that it's inherently inferior to the current model.

 

[mimelim]

If I understand correctly, this means that students who split their attention among different specialties do not participate fully in any of them. When they finish the year, they have missed their opportunity to fulfill a role in a clinical team, which they will take on full-time as an intern. Is that right?

I'd love to hear more about how you would change medical education to better prepare students for internship. What elements would you reform in a traditional clerkship? Does any aspect of the LIC appeal to you?

The biggest problem that medical students have when becoming residents is that they are stuck as students. The traditional model tries to combat this by integrating students as part of treatment teams as if they were a junior member of them. This is not always successful and there are a lot of schools where students routinely show up having essentially spent their MS3 year shadowing residents and attendings. But, I would argue that it does help a lot of students learn how to 'work' or learn how to take care of patients, people and problems. We all, residents, fellows and attendings still have to read and study, but it is in the context of taking care of patients. This is very difficult for a lot of people to do. I think that the LIC curriculum enforces this mentality of being a student by taking students out of the team and putting them on a rapid fire week without day to day continuity of care. Medical care is also largely unpredictable. What happens if there are no cases Thursday between 9-12 when you are supposed to be in the OR. What if one of your patients is being operated on while you are supposed to be at your family medicine rotation? What about all that medical care that doesn't happen on rounds in the morning on your patients? If you are a part of a traditional medical team, you will have the opportunity to follow the patient a lot more closely than if you have to run off to do other stuff.

These "Rapid inpatient blocks" are meaningless. Spending 2 weeks is worthless, by the time you actually understand how the team works, you are moving on to the next rotation. It is a waste of 10 weeks.

I'm curious as to why you believe following patients longitudinally for a year doesn't encourage a taking care of patients mentality? For physicians in largely outpatient settings such as PCP, LIC actually resemble their way of practicing medicine more closely than the traditional clerkship model. It's not for everyone, but I don't agree that it's inherently inferior to the current model.

From a practical standpoint, you are not replicating how an outpatient based physician functions. You may be seeing patients in the same way that they see that one particular patient, but you are not replicating how their day actually functions. Is it a waste of time for the outpatient based specialties? No. But, this is at the sacrifice of all of your inpatient based rotations which is detrimental to the students. You are also forcing students to function as 'students' who are going to disappear because they have other things to do, rather than apprenticing them to learn how to be a part of a profession. Practicing medicine is not just about the clinical knowledge, it is about learning to care for patients, which you can not do by dedicating 3 hours a week to a bunch of different things.

 

[Ariodant]

From a practical standpoint, you are not replicating how an outpatient based physician functions. You may be seeing patients in the same way that they see that one particular patient, but you are not replicating how their day actually functions. Is it a waste of time for the outpatient based specialties? No. But, this is at the sacrifice of all of your inpatient based rotations which is detrimental to the students. You are also forcing students to function as 'students' who are going to disappear because they have other things to do, rather than apprenticing them to learn how to be a part of a profession. Practicing medicine is not just about the clinical knowledge, it is about learning to care for patients, which you can not do by dedicating 3 hours a week to a bunch of different things.

I see what you mean. But I doubt the traditional rotations exactly replicate how an inpatient-based physician functions, either. Entirely different capabilities and expectations. Most LIC programs are still young and the sample size is small, but I'm sure schools are tracking LIC students closely. In a few years we will hopefully know if there is any significant difference in their performance as interns and residents.

 

[ridethecliche]

I mean I'd love to spend a year hanging with the chair of MGH and having his personal cell phone too. Probably makes you a pretty sure thing to match, lol. But I'm not sure how well that prepares you for residency...

I think that's a Cambridge hospital program at Cambridge Health Alliance (CHA) not an MGH one.

 

[mimelim]

I see what you mean. But I doubt the traditional rotations exactly replicate how an inpatient-based physician functions, either. Entirely different capabilities and expectations. Most LIC programs are still young and the sample size is small, but I'm sure schools are tracking LIC students closely. In a few years we will hopefully know if there is any significant difference in their performance as interns and residents.

If you got rid of didactics, most in patient rotations function with the medical students as being simply the most junior members of the physician treatment team. The near universal expectation is that you lay the groundwork for becoming a resident and a physician. Basic presentation skills, H&Ps, consults, problem solving, paperwork, etc. It takes time to develop those things and patience, which exists a lot more for MS3s than for interns. Where in an LIC curriculum do you learn to write an H&P and learn the basics of honing in on what clinicians care about?

I don't think that you will ever get a good data set out of this. There isn't a good way of measuring these things. Maybe all of those people will stay out of inpatient medicine, but certainly talking with the residents in our break room (where I am now), they would universally be against recruiting/trying to match someone who went through that kind of curriculum into our specialty (primarily inpatient based)

 

[breakintheroof]

Most LIC programs are still young and the sample size is small, but I'm sure schools are tracking LIC students closely. In a few years we will hopefully know if there is any significant difference in their performance as interns and residents.

I agree, and there is lots of active research. The only relevant study I can find so far was limited to family medicine residents who graduated from one Canadian medical school; they found little difference in residency directors' evaluations of LIC vs. block graduates. (LIC alumni also have been found to have similar surgical skills and to have spent more time in direct patient care and independent patient care.)

I just found a great PowerPoint from Sanford summarizing the evidence on LICs. Here's a key slide that makes sense with @mimelim's earlier point (BC = block clerkships):

Maybe all of those people will stay out of inpatient medicine, but certainly talking with the residents in our break room (where I am now), they would universally be against recruiting/trying to match someone who went through that kind of curriculum into our specialty (primarily inpatient based)

There are LIC alumni who are in or will be in inpatient-focused specialties. @Ariodant mentioned a neurosurgery applicant coming out of UCSF's PISCES, and I have met surgeons from other programs.

I'll mention again a blog post written by a Harvard CIC alumna aimed at people like the residents in your break room: Five Reasons I loved my Longitudinal Integrated Surgery Clerkship. This is the person @ridethecliche just mentioned; she did her clerkship at Cambridge Health Alliance, and she is now in fact an intern in general surgery at MGH. Would any of you be swayed by what she wrote?

 

[ridethecliche]

MGH is a harvard residency. If they didn't support the medical school, it would look bad.

I'd be more interested in seeing how residency programs evaluated students that came from the two different backgrounds. Kind of hard to study this as it relies a lot on recall bias.

 

[breakintheroof]

I'd be more interested in seeing how residency programs evaluated students that came from the two different backgrounds. Kind of hard to study this as it relies a lot on recall bias.

There are certainly ways to explore this. Similar to how researchers look at racial bias in hiring practices, they could ask PDs how they would evaluate otherwise similar applications from LIC vs. traditional applicants.

Another way is to look at who matches in their first choice specialty and residency. This is obviously prone to various biases. But it's been done by a Canadian med school (n=27 LIC, 108 rotation-based clerkship). I'm sure more studies like this will come.

Of those who chose a specialty, LIC and RBC students did not differ in their ability to match to their first choice discipline (92.6% vs. 90.7%, ns). Of those who matched to their first choice of discipline, LIC students were more likely to be matched to their first choice of program location than RBC students (80.0% vs. 57.7%, p = .04).

 

[breakintheroof]

I read her blog, she sounds like she loved it.

But she's also big into med ed and innovation so you have to consider how much attitude plays a role in it. If someone is told how awesome and amazing and innovative and patient-centered this new model is and they buy into it, I think they are going to be tremendously predisposed to love it.

But that doesn't convince me it's for the best, nor specifically does it convince me that it is good preparation for surgical residency. That's not always something a student is in a good position to evaluate. She says she thinks it was better because of the mentorship she got and that she got to focus on what her career looks like as an attending and not the myopic view of residency.

Well, residency may be myopic but it is also, in the case of MGH general surgery, 7 years of hard-work, long-hours, and "beats" (try reading her blog entry on that one if you want to gag). General surgery has 20% attrition...someone going through a model like this one might be predisposed to that, which has a non-trivial impact on your career path.

Like @mimelim said - I am all for effective innovation in medical education. There are lots of things we could do better or even radically different.

And I have no personal experience with this model. From the outside looking in I see a lot of potential flaws. An anecdote from a student who (since she got into Harvard and matched to MGH) would probably have been very successful regardless of her curriculum doesn't exactly sway me. I'd need more exposure to the details of this model and how exactly it works to really know for sure; what I read about it has enough to give me some concerns is all.

All of this is fair. I'm trying to evaluate how to weight the potential to participate in a LIC in my med school decision, and I have had lots of opportunities to talk to people from inside the LIC environment, but not so many with people on the outside looking in. I've been impressed with the level of critical reflection among LIC students, and I feel pretty bought into it. You and @mimelim have provided great skeptical perspective.

I'm thinking especially about the idea of learning how to be a team member vs. a caregiver. I can see how someone coming from a LIC could be seen as a risk or an unknown while applying in an inpatient specialty. And yet I feel the reorientation toward being with patients, toward the perspective of an attending rather than a resident, has great appeal for me personally.

 

[mimelim]

I agree, and there is lots of active research. The only relevant study I can find so far was limited to family medicine residents who graduated from one Canadian medical school; they found little difference in residency directors' evaluations of LIC vs. block graduates. (LIC alumni also have been found to have similar surgical skills and to have spent more time in direct patient care and independent patient care.)

I just found a great PowerPoint from Sanford summarizing the evidence on LICs. Here's a key slide that makes sense with @mimelim's earlier point (BC = block clerkships):

There are LIC alumni who are in or will be in inpatient-focused specialties. @Ariodant mentioned a neurosurgery applicant coming out of UCSF's PISCES, and I have met surgeons from other programs.

I'll mention again a blog post written by a Harvard CIC alumna aimed at people like the residents in your break room: Five Reasons I loved my Longitudinal Integrated Surgery Clerkship. This is the person @ridethecliche just mentioned; she did her clerkship at Cambridge Health Alliance, and she is now in fact an intern in general surgery at MGH. Would any of you be swayed by what she wrote?

Any system will work with highly motivated students. This Harvard CIC student, "spent all my free time for the entirety of my third year going to the OR and scrubbing cases. The OR staff became like a second family, the attending surgeons all got to know me very well, and I had the chance to practice technical skills regularly for 12 months straight." or referring to after hours... "I would go to the hospital to assist on urgent and emergent cases." She also talks about how her primary teacher was an attending physician. If you can guarantee that in any system, I would hazard a guess that people would be a) happier and b) better prepared.

She focuses a lot in this article about how she learned about being an attending physician and her colleagues learned how to be better house staff. MGH has a 7 year general surgery residency, in which over 20% (as of this year) don't finish. Point of fact, I ranked them outside of my top 10 when I made my match list. Granted, I was applying both general surgery and vascular, but given that #1 they are a vascular power house, #2 Cambria is there and #3 I had 3 general surgery programs in my top 6, I think that it means something. Having an understanding of what life is like after being a resident is very important. Focusing on it, rather than how to progress and do well at the next step is another.

In short:
#1 If you put strong, motivated students in any curriculum they will thrive. If you give them less constraints and more free time, they will do extremely well.
#2 Your average medical student is no different than your average pre-med and are not going to pursue opportunities like she did. It is hard enough to get some of them to work 40 hours a week, much less show up on a Saturday for a non-mandatory patient encounter.
#3 It is impractical to do what she did with more than a handful of students. You don't have enough faculty that would be willing to take on students like this.
#4 The benefits that she got from having this system can be attributed more to a large number of other variables than to the difference in curriculum.

 

[breakintheroof]

#1 If you put strong, motivated students in any curriculum they will thrive. If you give them less constraints and more free time, they will do extremely well.
#2 Your average medical student is no different than your average pre-med and are not going to pursue opportunities like she did. It is hard enough to get some of them to work 40 hours a week, much less show up on a Saturday for a non-mandatory patient encounter.
#3 It is impractical to do what she did with more than a handful of students. You don't have enough faculty that would be willing to take on students like this.
#4 The benefits that she got from having this system can be attributed more to a large number of other variables than to the difference in curriculum.

To sum up, it seems you and @SouthernSurgeon agree: She's a superstar who would have found a way to excel in any program. You would counsel applicants like me to think twice before assuming that what she did could be replicated.

Having an understanding of what life is like after being a resident is very important. Focusing on it, rather than how to progress and do well at the next step is another.

This is that really interesting point that you've raised in this discussion. I now feel like I have better questions I can ask my friends and acquaintances about their LIC experience. Thank you for that.

 

[Spinach Dip]

To me it looks like too many subjects going on at once.

I mean THREE HOURS of psych/OR/anesthesia PER WEEK? How much can you honestly learn in that amount of time?

 

[Ariodant]

I don't think that you will ever get a good data set out of this. There isn't a good way of measuring these things. Maybe all of those people will stay out of inpatient medicine, but certainly talking with the residents in our break room (where I am now), they would universally be against recruiting/trying to match someone who went through that kind of curriculum into our specialty (primarily inpatient based)

I wonder if matching results can be used to gauge that. Should there be a noticeable difference in their competency as an inpatient clinician and team player, it will be harder for LIC students to match into inpatient specialties, or at least get their top choices in inpatient specialties.

#1 If you put strong, motivated students in any curriculum they will thrive. If you give them less constraints and more free time, they will do extremely well.
#2 Your average medical student is no different than your average pre-med and are not going to pursue opportunities like she did. It is hard enough to get some of them to work 40 hours a week, much less show up on a Saturday for a non-mandatory patient encounter.

I agree. LIC doesn't offer forced immersion, if the students are minimally motivated, they will get minimal benefit out of LIC. But the motivated and efficient students can take advantage of the flexibility of their schedules to suit their specialty preference and educational goals. I don't think it should be the standard curriculum for MS3 for the reasons you highlighted above (although UCSF is thinking of doing that, will see how that works out), but having such an option available will be fantastic for the highly motivated medical students.

 

[mimelim]

To sum up, it seems you and @SouthernSurgeon agree: She's a superstar who would have found a way to excel in any program. You would counsel applicants like me to think twice before assuming that what she did could be replicated.This is that really interesting point that you've raised in this discussion. I now feel like I have better questions I can ask my friends and acquaintances about their LIC experience. Thank you for that.

For me personally, I think that I would thrive in a system like this. It gives you flexibility to focus on things that are important to you and kinda do minimal on the others. I'm not sure if that would have helped me personally, but I think that it would have been very very tempting. Certainly if schools are going to commit as much time and resources to their students as this girl had, I would tell you to take the opportunity, but recognize the potential pitfalls. I mean if you get direct mentorship from faculty multiple days a week and flexibility to explore on your own and you think you will actually do that, you should definitely do it.

I just have a lot of misgivings about this being a good idea for the vast vast vast majority of students. If you are highly motivated, this is an attractive option. If you are the kind of person that will do what you need to in order to get an 'A' and ignore opportunities that infringe on your leisure time, then it really isn't the right choice. I also think that this is safer for people that are non-trads or people that have worked inpatient stuff before etc. who are going to be the minority, but also are the people that aren't going to learn as much as your traditional medical students.

 

[Ariodant]

I don't think you can extrapolate much from matching.

For one, it takes every problem we generally bring up about match lists and magnifies it by shrinking your data set down to a couple dozen students. There's so many biases. Students entering these programs may be predisposed to outpatient or primary care fields. Students may be strongly swung towards a specialty by a particularly magnetic preceptor (e.g. the Harvard student and her surgery preceptor). The match list doesn't tell you about the students' choices either.

It doesn't tell you anything about the independent effect of the LIC program - since as mimelim notes a highly motivated student would likely excel in either curriculum.

I also don't think you can extrapolate match results from Harvard and UCSF - 2 of the very top schools in the country - to any other schools considering implementing a similar model.

The predisposed students will likely not apply to inpatient specialties. The question is not how many LIC students choose inpatient specialties, but for those that do, how well they match. If LIC students applying to inpatient specialties consistently match less well than students doing traditional clerkships, then we have evidence that LIC handicaps students going into those specialties. The small n will be a problem, though. I believe schools survey their students about choices post-match?

Even within Harvard and UCSF, one can compare match results of LIC vs. traditional students, or their performance in MS4 sub-Is, etc. If a real discrepancy exists, there likely will be a way to detect it. If LIC students consistently screw up on inpatient wards, sooner or later someone will complain.

 

[breakintheroof]

I disagree for several reasons.

1. How do you define "better" matches. You can't get consensus agreement on SDN for that for any individual field. Much less on a wide basis.
2. Confounding. How do you determine independent effect of the curriculum. You'd have to control for Step 1 and 2 scores, LORs, pre-clinical grades, research, pubs, etc. What parts of that do you attribute to the students vs the curriculum.
3. Innate ability (another form of confounding). If the 12 spots in Harvard's program are even more competitive than Harvard itself, you're potentially pre-selecting for the best of the best. So attributing their success to the LIC is a misattribution.

I agree with 1 and 2. For #3, however, in the case of Harvard's LIC, students are selected by lottery from those who put it as their first choice. (It apparently gets several times as many applicants as it can take.) This is how the Harvard study about post-LIC outcomes was designed.

 

[Ariodant]

Confounding factors exist in all studies, if there's no way to clearly demonstrate that LIC students are inferior medical students/interns/residents/attendings, why all the negativity? LIC is not for everyone, but if people are dismissing it altogether with nothing more than "it must be terrible because I imagine it would be", then I will have to respectfully disagree. So far no one has reported even anecdotal evidence of LIC students performing poorly in an inpatient setting.

Like William Edwards Deming purportedly said: In God we trust, all others must bring data.

 

[Ariodant]

I'm not dismissing it. I like talking about medical education and can do so pretty much all day. But I have some reservations and skepticism which I and others have outlined above - with more thought than just "I don't like it".

And saying confounding factors exist in all studies doesn't mean confounding is always equal, nor that it is unimportant. In an unmatched, non-random, extremely small study with a difficult to quantify outcome - confounding matters a ton. Which is part of the challenge inherent education research in general but in studying this topic (how to evaluate novel curricula) specifically. There's a reason the major paper they published out of the Harvard program was a feels study, not a hard outcome based study.

I'm not talking about you, I'm referring to the posts declaring "they can't learning anything", "must be awful", and "won't work with one even though I've never seen one". UCSF alone has pumped out more than 100 LIC students, if they are consistently sub-par they have to notice. UCSF will also start to roll out they new LIC-like curriculum in 2016, will be interesting to see how their students fare.

 

[TraumaLlamaMD]

Speaking of patient continuity, I'm not sure how it's possible with the schedules I've seen posted here - unless I'm misunderstanding, and students are given more leeway to rearrange their schedules to follow their patients as necessary. When I'm on service for a month, I see my patient present as a trauma case on day 1, and follow him to the OR. I round on him in the ICU, I'm there for his weaning trials and his pneumonia and I'm there when he gets taken for a trach on day 14. I'm there to pull out his chest tube on day 21. I am there every day to dress his wound and see it start to heal before my eyes. I'm there on day 25 when he is finally able to go home.

So yes, I won't have that sense of followup for a patient I see for the first time on day 29 of my clerkship - but for inpatient services, there's a lot to be gained in terms of patient continuity by being in the same place every day. I was able to accompany my patients to the cath lab, to biopsies, to the OR. I was able to stop by the pathology lab or micro lab and see their slides and cultures. I was able to call in consults and genuinely participate in coordinating their care, which I wouldn't have been able to do if I was only around for 5 hours once or twice a week.

Does the LIC have a way to address patient continuity during an inpatient hospital stay, when multiple things may be occurring for your patient all throughout a single day?

 

[breakintheroof]

Speaking of patient continuity, I'm not sure how it's possible with the schedules I've seen posted here - unless I'm misunderstanding, and students are given more leeway to rearrange their schedules to follow their patients as necessary.

Students are given this leeway in the programs I am familiar with. Students construct panels of patients, either choosing their own (Columbia-Bassett) or having them chosen by preceptors (Harvard). When a panel patient has an appointment or procedure, LIC students typically have the flexibility to attend it in place of the clinic they had been assigned.

LIC students I have talked to have done different things with this. Some have focused on following many patients closely and others have stuck more with their assigned services.

Also note that, for example, in the weekly schedule in the original post, the "Self-Directed & Cohort Learning" time is meant in part to allow for following these patients, as @Ariodant pointed out earlier.

Does the LIC have a way to address patient continuity during an inpatient hospital stay, when multiple things may be occurring for your patient all throughout a single day?

I'm not sure to what degree, it might be program-dependent. Certainly it would be harder to do this day after day as you describe students doing in a traditional clerkship.

 

[pkwraith]

I am actually glad that I was one of the last students on the traditional block curriculum. Having seen what the students have to do with the "LIC" seems quite disorienting. For me, it takes a few days to get into the groove of things on a rotation, and I'd be quite disoriented moving from specialty to specialty. It would've been tougher for letters too because you it's less likely you work with the same Attending. Plus the multiple-shelf exams. But some people seem to like it (most just tolerate it).

 

[TraumaLlamaMD]

I also hate to say it...but when I think of a model, I don't worry about the highly motivated learners. They'll be fine pretty much regardless of what you do to them. I worry about the lowest common denominator.

What's to keep a student from getting out of their assigned clinic for the morning by saying "oh one of my cohort patients is having an ERCP done today that I told them I'd go with them to".

Or to use the 3 afternoons per week of self-directed cohort learning to just take off early.

The team-based structure provides some accountability (although students do still try to lie and get out of obligations in that structure too).

Yeah, I feel like you'd need to be above-average in terms of motivation to keep track of what's going on with your patients even when you aren't seeing them every day. I also don't think I'd have gotten nearly as much procedural exposure - I can't imagine someone deciding a patient needs a central line, for instance, and then paging the assigned med student and waiting for them to drive over from clinic to put it in. When you're sitting around on the floors and ICU, you get the option to participate in the little things that pop up suddenly.

 

[DrBowtie]

Medical students are already pulled off services too much as it is for didactics, random meetings etc.

I can't help but think that this LIC would further marginalize their role as it would be unclear exactly when and for how long they'll be there each day. You just can't plan to incorporate them with so many variables.

Plus what was said before, it provides them easy excuses to avoid either hard work or subjects they don't enjoy by giving them too much freedom to come and go.

 

[TraumaLlamaMD]

At least where I am, if I'm not around and part of the team, residents don't remember to tell me when things are happening with my patients, and they don't make an effort to teach. You'd miss out on a lot here with this format, I fear.

 

[Psai]

That schedule looks like crap. It takes me about three weeks to really get into things. I spend the first week not knowing who anyone is or what's going on. The second week, I know where things are and who to ask for help. The third week, I know what's going on, what I should be doing and I'm starting to do it well. Fourth week I do things more or less up to people's expectations. Anything less than 2 weeks is not even close to enough experience. A morning doing this and an afternoon doing that? And since when are rounds one hour? When will you have time to go from place to place? Ridiculous.

How third year should be set up: student on a solid team that has enough residents to cover all the patients and an attending with a wealth of knowledge that is willing to teach. Residents aren't bogged down by a bunch of worthless lectures every day and having to write 10 progress notes along with taking care of new admissions, doing discharges, etc. for attendings that frown on copy/pasting even when nothing is going on and patient is just waiting for placement. Rounds set up so that you aren't spending more time going from floor to floor than seeing patients. Student is given a chance to interview the patient first so that they are able to get a full H&P, talk to the resident to see what they missed and weren't thinking about so they can develop the proper way of seeing patients with a differential in mind and eventually a plan to treat. Student goes with resident to see how the resident handles the H&P and discusses differential, most likely diagnosis, treatment plans. Round with the attending in which you have an opportunity to see which parts of the exam are important to focus on for this patient and elicit subtle findings. Discuss issues with patient care such as impaired renal function changing medication regimen, proper testing to rule diagnoses in and out without doing "routine labs" or "shotgunning", discussing drug side effects in patients on multiple drugs that should have been spotted before prescription to avoid things like prolonged qt.

Also I hate all the stupid surveys they make you fill out about your team. They always ask too many questions and it's a "grade them from 1-5 with no thought process whatsoever for questions that have little to do with medical education"