Ann Poncelet

The role of role: learning in longitudinal integrated and traditional block clerkships

Medical Education 2012: 46:698–710

More is better: students describe successful and unsuccessful experiences with teachers differently in brief and longitudinal relationships.

Purpose Clerkship experiences that structure student–teacher continuity may promote learning differently than brief student–teacher relationships. The authors compared students’ successful and unsuccessful teaching experiences in brief and longitudinal relationships. Method A multicenter, qualitative interview study was conducted in 2009–2010 of students in two clerkship models that provide different durations of student–teacher relationships. Each student described a successful and unsuccessful teaching relationship early and late in the core clerkship year. Questions explored teachers’ strategies and behaviors and students’ efforts to improve unsuccessful relationships. Interview transcripts were coded to identify major themes. Results Fifty-four students completed interviews. Students in brief relationships struggled to be known; students in longitudinal relationships felt respected as learners and partners. Teaching strategies differed in the two relationship durations. Questioning about factual knowledge was common in brief relationships; collaborative knowledge sharing and application to patients occurred in longitudinal relationships. Hierarchy characterized brief relationships. Longitudinal students experienced evolving expectations in response to their growing skills and contributions. Only students in longitudinal relationships described successfully intervening to improve unsuccessful relationships; students in brief relationships felt powerless. Conclusions Clerkship students in brief relationships learn to adapt to teachers’ preferences and questioning to facilitate their participation and knowledge acquisition; longitudinal students experience collaborative interactions focused on their development as care providers. In longitudinal relationships, students gain confidence to influence their own learning and modify circumstances to meet their learning needs. These findings suggest that medical students’ clinical experiences may be enhanced by deliberately structuring longitudinal attachments to supervisors.

Development of a longitudinal integrated clerkship at an academic medical center

Abstract In 2005, medical educators at the University of California, San Francisco (UCSF), began developing the Parnassus Integrated Student Clinical Experiences (PISCES) program, a year-long longitudinal integrated clerkship at its academic medical center. The principles guiding this new clerkship were continuity with faculty preceptors, patients, and peers; a developmentally progressive curriculum with an emphasis on interdisciplinary teaching; and exposure to undiagnosed illness in acute and chronic care settings. Innovative elements included quarterly student evaluation sessions with all preceptors together, peer-to-peer evaluation, and oversight advising with an assigned faculty member. PISCES launched with eight medical students for the 2007/2008 academic year and expanded to 15 students for 2008/2009. Compared to UCSFs traditional core clerkships, evaluations from PISCES indicated significantly higher student satisfaction with faculty teaching, formal didactics, direct observation of clinical skills, and feedback. Student performance on discipline-specific examinations and United States Medical Licensing Examination step 2 CK was equivalent to and on standardized patient examinations was slightly superior to that of traditional peers. Participants’ career interests ranged from primary care to surgical subspecialties. These results demonstrate that a longitudinal integrated clerkship can be implemented successfully at a tertiary care academic medical center.

Preparing medical students for clerkships: a descriptive analysis of transition courses.

Students have reported several challenging aspects of the transition to clerkships, such as applying clinical knowledge, learning experientially, using clinical skills, adjusting to clinical settings, and understanding roles. In an effort to address some of these challenges, a number of medical schools have added transition courses to their curricula, but little information about these courses has been published. The authors draw on findings from a study of the design and content of 30 transition courses offered in U.S. medical schools, to examine various approaches and provide a framework to guide the design of transition courses. Most courses (83%) were between one day and one week long. The authors identified three primary course themes: presentation of new information and skills, review and application of content covered in the preclerkship curriculum, and student well-being. All courses presented new information and skills, and more than half of the courses (53%) addressed all three themes. The most common curricular topics were technical/procedural skills, safety precautions, orientation to clinical settings, review of clinical skills, and stress management. Hands-on experience was the most frequently used instructional approach. Few courses had explicit goals and objectives, and evaluation of students was rare. Transition courses can address some of the needs and challenges associated with early clerkship experiences. These courses should explicitly target areas of need that are described in the literature as well as those identified within one’s own institution. They should include clear objectives, learning activities tailored to the areas of need and objectives, and student and course evaluations.

Better learning, better doctors, better delivery system: Possibilities from a case study of longitudinal integrated clerkships

Interest in longitudinal integrated clerkships (LICs) as an alternative to traditional block rotations is growing worldwide. Leaders in medical education and those who seek physician workforce development believe that “educational continuity” affords benefits to medical students and benefits for under-resourced settings. The model has been recognized as effective for advancing student learning of science and clinical practice, enhancing the development of students’ professional role, and supporting workforce goals such as retaining students for primary care and rural and remote practice. Education leaders have created multiple models of LICs to address these and other educational and health system imperatives. This article compares three successful longitudinal integrated clinical education programs with attention to the case for change, the principles that underpin the educational design, the structure of the models, and outcome data from these educational redesign efforts. By translating principles of the learning sciences into educational redesign efforts, LICs address the call to improve medical student learning and potential and advance the systems in which they will work as doctors.

Students' workplace learning in two clerkship models: a multi-site observational study

Medical Education 2012: 46:613–624

Peripheral neuropathy in scleroderma.

Because patients with scleroderma report neuropathic symptoms including numbness, paresthesias, and dysesthesias, we assessed peripheral nerve function in such patients. Fourteen scleroderma patients underwent complete neurologic examination, nerve conduction studies (NCS) and quantitative sensory testing (QST). Neurologic examination revealed reduced vibration (7) or pinprick (4) sensation in the upper or lower extremities, focal atrophy or proximal weakness (2), and decreased deep tendon reflexes (2). NCS showed reduced sensory nerve action potentials (1) and carpal tunnel syndrome (1). QST of the upper and lower extremity revealed increased cold or vibration detection thresholds in 8 of 14 patients. Our findings suggest that peripheral neuropathy occurs in patients with scleroderma at a higher frequency than previously appreciated. These findings cannot be ascribed to compression neuropathies, but rather involve large and small fibers in a non–length‐dependent fashion. Larger, prospective studies using the more sensitive QST as well as pathologic studies of nerve, including cutaneous innervation, are needed to further assess the characteristics and etiology of the neuropathy. Muscle Nerve 28: 330–335, 2003

Comparison of transthecal and subcutaneous single-injection digital block techniques

A randomized double-blinded study was performed on 20 normal volunteers to evaluate 2 different techniques of single-injection digital anesthesia. Single-injection transthecal digital block technique was used to anesthetize 1 index finger and single-injection subcutaneous technique to block the other index finger. Pain and light touch were evaluated and sensory nerve-conduction studies were performed on both index fingers. These data were obtained prior to the nerve blocks and then at 10-minute intervals until recovery from the anesthesia. The method of anesthesia was found to have no effect on the distribution, onset, and duration of anesthesia. Median and radial nerve sensory nerve action potential amplitude reductions following digital anesthesia were also not influenced by the technique of anesthesia. Single-injection subcutaneous block was found to be easier to administer and to produce less pain during and 24 hours after injection than did the single-injection transthecal technique.

Transition to clerkship courses: preparing students to enter the workplace.

Purpose Despite curricular shifts toward a clinically oriented first two years of medical school, students continue to struggle with the transition to clerkships. Transition courses are a curricular intervention to mitigate the challenges of entering clinical workplaces. The authors examine the objectives, content, educational strategies, and resources associated with transition courses. Method The authors invited curricular deans and transition course directors at U.S. and Canadian medical schools to complete a Web-based survey in 2008. A prior qualitative study of transition courses informed the list of survey questions. The authors organize the key course features according to a preparation-for-workplace-learning framework and report the frequencies of course features based on descriptive statistics. Results Of the 83 schools (58% response rate) responding to the survey, 73 (88%) reported having transition courses. Most courses covered content relevant to key elements of workplace learning: roles and expectations of clerks, advice from senior students, professionalism, stress management, and procedural skills. Whereas 65 courses (98%) used didactic sessions and 49 (74%) incorporated hands-on practice, only 14 (21%) included practice in clinical settings. Conclusions The intent of transition courses is to prepare students for workplace learning, but the most common approaches provide limited exposure to real clinical settings. Transition courses could better prepare students for workplace learning by increasing exposure to the routines, norms, and professionals that students encounter in clinical settings.

Longitudinal, Integrated Clerkship Education: Better for Learners and Patients

Editor’s Note: This is a commentary on Norris TE, Schaad DC, DeWitt D, Ogur B, Hunt DD, and Members of the Consortium of Longitudinal Integrated Clerkships. Longitudinal integrated clerkships for medical students: An innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med. 2009;84:902–907; and Ogur B, Hirsh D. Learning through longitudinal patient care—Narratives from the Harvard Medical School–Cambridge integrated clerkship. Acad Med. 2009;84:844 – 850.