Instilling Resiliency in Surgical Education: The Benefits of Longitudinal Medical Student Learning.

The longitudinal clerkship has been recognized as an innovative, unique model in medical education that demonstrates significantly higher student and preceptor satisfaction with comparable long-term outcomes like performance on standardized examinations. At the center of this model is the student-preceptor relationship, which promotes effective student-directed learning and personal and professional relationships with established faculty mentors. The University of California, San Francisco (UCSF) has two clerkships models: a traditional or "block" model consisting of 2-month sequential clinical rotations in seven core clerkships, and a longitudinal model that integrates parallel out-patient clinical experiences over the entire year with one-on-one faculty preceptors from each core discipline with focused 2-week intensive inpatient rotations. In the setting of the Covid-19 pandemic beginning in Spring of 2020, this arrangement allowed for a natural experiment to evaluate the resiliency of the respective models in the face of unprecedented disruptions in education and healthcare delivery. As described in this perspective, both clerkships required rapid pivots; however, students enrolled in the longitudinal clerkship were more likely to develop stronger relationships with surgical faculty and felt more prepared for making career choices. Medical school curricula may benefit from incorporating longitudinal components, as this model provided flexibility and fostered greater faculty-student mentorship in the setting of disruption to medical education.

Continuity in Undergraduate Medical Education: Mission Not Accomplished.

Evidence is mounting that longitudinal medical student clerkships provide better educational experiences than traditional block clerkship "silos." Education studies across institutions demonstrate positive effects of continuity on medical students, including creating patient-centered learning environments, improving fidelity of evaluations and feedback, improving medical student patient-centeredness, enabling more autonomous functioning in the clinical workplace, and increased recruitment and retention of students into primary care careers. Outcome studies show potential for longitudinal students to add value to patient care. This perspective piece summarizes the current evidence basis for longitudinal clerkships broken down by Kirkpatrick level (reactions, perceptions/attitudes, knowledge, behaviors, and patient benefits). Despite this evidence, expansion of longitudinal clerkships has been slow-i.e., fewer than half of current US medical schools offer one. While more recent curricular innovations center around Entrustable Professional Activities (EPAs), there are clear opportunities for medical schools to use longitudinal clerkships as a lens through which EPAs can be effectively evaluated. This perspective highlights the synergy between longitudinal clerkships and EPAs, showing that successful implementation of the former should empower the latter. While large, complex educational interventions are daunting tasks, change is needed. Regulatory organizations should mandate continuity-focused experiences for US medical graduates.

Learning to balance efficiency and innovation for optimal adaptive expertise.

It is critical for health professionals to continue to learn and this must be supported by health professions education (HPE). Adaptive expert clinicians are not only expert in their work but have the additional capacity to learn and improve in their practices. The authors review a selective aspect of learning to become an adaptive expert: the capacity to optimally balance routine approaches that maximize efficiency with innovative ones where energy and resources are used to customize actions for novel or difficult situations. Optimal transfer of learning, and hence the design of instruction, differs depending on whether the goal is efficient or innovative practice. However, the task is necessarily further complicated when the aspiration is an adaptive expert practitioner who can fluidly balance innovation with efficiency as the situation requires. Using HPE examples at both the individual and organizational level, the authors explore the instructional implications of learning to shift from efficient to innovative expert functioning, and back. They argue that the efficiency-innovation tension is likely to endure deep into the future and therefore warrants important consideration in HPE.

Longitudinal integrated clerkships.

There is increased interest in longitudinal integrated clerkships (LICs) due to mounting evidence of positive outcomes for students, patients and supervising clinicians. Emphasizing continuity as the organizing principle of an LIC, this article reviews evidence and presents perspectives of LIC participants concerning continuity of care, supervision and curriculum, and continuity with peers and systems of care. It also offers advice on implementing or evaluating existing LIC programs.

Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships.

BACKGROUND: Hidden curriculum literature suggests that different learning environments and curricular designs reinforce disparate values and behaviors. AIM: This study explores potential differences in learning environments afforded by two clerkship models through perceptions of the ideal student. METHODS: In this qualitative study, research assistants interviewed 48 third-year students and 26 clinical supervisors from three US medical schools. Students and supervisors participated in longitudinal integrated clerkships (LICs) or block clerkships. Students and supervisors described the ideal student in their clerkship. Using phenomenographic techniques, authors identified five ideal student profiles and coded students' and supervisors' descriptions for alignment with one or more profiles. RESULTS: Most students in both models described an ideal student who matched a learner profile (proactive and self-directed). More LIC students described an ideal student who fit a caregiver profile (engaging with and advocating for patients) and more block students described performer (appearing knowledgeable and competent) and team-player (working well with others) profiles. Supervisors' descriptions paralleled students' descriptions but with less emphasis on caregiving. CONCLUSIONS: Ideal student descriptions in LIC and block models may reflect different learning experiences and values emphasized in each model. These findings suggest implications for students' construction of professional identities that warrant further exploration.

Quantitative ultrasound of denervated hand muscles.

INTRODUCTION: Presentations to the neuromuscular clinic commonly involve hand muscle denervation, but few studies have evaluated hand muscle ultrasound. METHODS: Ultrasound studies of abductor pollicis brevis, first dorsal interosseous, and abductor digit minimi were prospectively performed in a cohort of 34 patients (77 muscles) with electromyography (EMG)-confirmed denervation, compared with 58 healthy control subjects. RESULTS: In control subjects, muscle thickness was highly reproducible [intraclass correlation coefficient (ICC) = 0.88-0.98], and echogenicity was moderately reproducible (ICC = 0.542-0.686). Age, gender, and body mass index influenced muscle thickness and echogenicity. Ultrasound changes in denervated muscles correlated with the severity of EMG abnormalities. A z-score cutoff of 0 identified denervated muscles with a sensitivity of 100% and 89% for echogenicity and muscle thickness, respectively. CONCLUSIONS: Hand muscle ultrasound provides a noninvasive method to quantify muscle denervation and may be useful as a screening tool before EMG studies.

Patient views of continuity relationships with medical students.

INTRODUCTION: Continuity relationships between students and patients, that occur in a longitudinal integrated clerkship (LIC), enrich medical students' opportunities to learn from patients and provide patient-centered care. Patient preferences for continuity with a primary provider are well-documented, but little is known about patients' experiences of continuity with students. This study examines patients' perception of continuity with and care received by students. METHODS: This qualitative study uses data from semi-structured interviews with 32 patients of LIC students at an academic medical center. Data were analyzed for themes about continuity and experiences of care provided by students. RESULTS: Patients valued relationships with students over time and across settings. Students' contributions to their care included enhanced access to and coordination of care, communication, patient education and wellbeing. Patients with substantial continuity and/or who were moderately or severely ill described their student in a physician-like role more frequently than other patients. Patients appreciated patient-centered attitudes and behaviors in their students. CONCLUSION: Patients value continuity relationships with students, akin to that described between patients and their physicians. Patients described a variety of ways in which students enhanced their care and assumed a physician-like role. These patient perceptions support the concept of mutually beneficial relationships between students and patients.

Identifying Value Factors in Institutional Leaders' Perspectives on Investing in Health Professions Educators.

Importance: Investing in educators, educational innovation, and scholarship is essential for excellence in health professions education and health care. Funds for education innovations and educator development remain at significant risk because they virtually never generate offsetting revenue. A broader shared framework is needed to determine the value of such investments. Objective: To explore the value factors using the value measurement methodology domains (individual, financial, operational, social or societal, strategic or political) that health professions leaders placed on educator investment programs, including intramural grants and endowed chairs. Design, Setting, and Participants: This qualitative study used semi-structured interviews with participants from an urban academic health professions institution and its affiliated systems that were conducted between June and September 2019 and were audio recorded and transcribed. Thematic analysis was used to identify themes with a constructivist orientation. Participants included 31 leaders at multiple levels of the organization (eg, deans, department chairs, and health system leaders) and with a range of experience. Individuals who did not respond initially were followed up with until a sufficient representation of leader roles was achieved. Main Outcomes and Measures: Outcomes include value factors defined by the leaders for educator investment programs across the 5 value measurement methodology domains: individual, financial, operational, social or societal, and strategic or political. Results: This study included 29 leaders (5 [17%] campus or university leaders; 3 [10%] health systems leaders; 6 [21%] health professions school leaders; 15 [52%] department leaders). They identified value factors across the 5 value measurement methods domains. Individual factors emphasized the impact on faculty career, stature, and personal and professional development. Financial factors included tangible support, the ability to attract additional resources, and the importance of these investments as a monetary input rather than output. Operational factors identified educational programs and faculty recruitment or retention. Social and societal factors showcased scholarship and dissemination benefits to the external community beyond the organization and to the internal community of faculty, learners, and patients. Strategic and political factors highlighted impact on culture and symbolism, innovation, and organizational success. Conclusions and Relevance: These findings suggest that health sciences and health system leaders find value in funding educator investment programs in multiple domains beyond direct financial return on investment. These value factors can inform program design and evaluation, effective feedback to leaders, and advocacy for future investments. This approach can be used by other institutions to identify context-specific value factors.

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

CONTEXT: Traditional block clerkship (BC) structures may not optimally support medical student participation in the workplace, whereas longitudinal integrated clerkship (LIC) structures seem more conducive to students' active engagement in patient care over time. Understanding the ways in which these two clerkship models influence students' roles and responsibilities can inform clinical learning programme design. METHODS: This was a multicentre qualitative study. We conducted semi-structured interviews with LIC and BC medical students at three institutions early and late in the core clinical year to explore their experiences with patients and the roles they served. Using the framework of 'workplace affordances', qualitative coding focused on students' roles and qualities of the learning environment that invited or inhibited student participation. We compared transcripts of early- and late-year interviews to assess students' changing roles and conducted discrepant case analysis to ensure that coding fit the data. RESULTS: Fifty-four students participated in interviews. They described serving three major roles in clinical care that respectively involved: providing support to patients; sharing information about patients across health care settings, and functioning in a doctor-like role. Both LIC and BC students served in the providing support and transmitting information roles both early and late in the year. By contrast, LIC students commonly served in the doctor-like role in managing their patients' care, particularly late in the year, whereas BC students rarely served in this role. Continuity in settings and in supervisors, and preceptors' endorsement of students' legitimate role afforded opportunities for students to participate actively in patient care. CONCLUSIONS: Although both LIC and BC students reported serving in important roles in supporting their patients and sharing information about their care, only LIC students consistently described opportunities to grow into a doctor role with patients. The high level of integration of LIC students into care systems and their deeper relationships with preceptors and patients enhanced their motivation and feelings of competence to provide patient-centred care.

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

CONTEXT: Longitudinal integrated clerkships (LICs) are established, rapidly growing models of education designed to improve the core clinical year of medical school using guiding principles about workplace learning and continuity. This study is the first to report data from direct observations of workplace learning experiences of students on LICs and traditional block clerkships (BCs), respectively. METHODS: This multi-institution study used an observational, work-sampling methodology to compare LIC and BC students early and late in the core clinical year. Trained research assistants documented students' activities, participation (observing, with assistance, alone), and interactions every 10 minutes over 4-hour periods. Each student was observed one to three times early and/or late in the year. Data were aggregated at the student level and by in-patient or out-patient setting for BC students. One-way analysis of variance (anova) was used to compare two groups early in the year (LIC and BC students) and three groups late in the year (LIC, out-patient BC and in-patient BC students). RESULTS: Early-year observations included 26 students (16 LIC and 10 BC students); late-year observations included 44 students (28 LIC, eight out-patient BC and eight in-patient BC students). Out-patient activities and interactions of LIC and BC students were similar early in the year, but in the later period LIC students spent significantly more time performing direct patient care activities alone (25%) compared with out-patient (12%) and in-patient (7%) BC students. Students on LICs were significantly more likely to experience continuity with patients as 34% of their patients returned to them, whereas only 5% of patients did so for out-patient BC students late in the year. CONCLUSIONS: By late year, LIC students engage in patient care more independently and have more opportunities to see clinic patients on multiple occasions than BC students. Consistent with the principles of workplace learning, these findings suggest that yearlong longitudinal integrated education models, that rely mostly on ambulatory settings, afford students greater opportunities to participate more fully in the provision of patient care.

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.

The do's, don'ts and don't knows of establishing a sustainable longitudinal integrated clerkship.

INTRODUCTION: The longitudinal integrated clerkship is a model of clinical medical education that is increasingly employed by medical schools around the world. These guidelines are a result of a narrative review of the literature which considered the question of how to maximize the sustainability of a new longitudinal integrated clerkship program. METHOD: All four authors have practical experience of establishing longitudinal integrated clerkship programs. Each author individually constructed their Do's, Don'ts and Don't Knows and the literature that underpinned them. The lists were compiled and revised in discussion and a final set of guidelines was agreed. A statement of the strength of the evidence is included for each guideline. RESULTS: The final set of 18 Do's, Don'ts and Don't Knows is presented with an appraisal of the evidence for each one. CONCLUSION: Implementing a longitudinal integrated clerkship is a complex process requiring the involvement of a wide group of stakeholders in both hospitals and communities. The complexity of the change management processes requires careful and sustained attention, with a particular focus on the outcomes of the programs for students and the communities in which they learn. Effective and consistent leadership and adequate resourcing are important. There is a need to select teaching sites carefully, involve students and faculty in allocation of students to sites and support students and faculty though the implementation phase and beyond. Work is needed to address the Don't Knows, in particular the question of how cost-effectiveness is best measured.

Correction to: The do's, don'ts and don't knows of establishing a sustainable longitudinal integrated clerkship.

Unfortunately information regarding the disclaimer of Paul Worley's affiliation is missing from the original article. Please find the information here:Paul Worley is affiliated to the Prideaux Centre for Research in Health Professions Education, Flinders University, Adelaide, Australia. He is the ….

Current state of educational compensation in academic neurology: Results of a US national survey.

In the current medical climate, medical education is at risk of being de-emphasized, leading to less financial support and compensation for faculty. A rise in compensation plans that reward clinical or research productivity fails to incentivize and threatens to erode the educational missions of our academic institutions. Aligning compensation with the all-encompassing mission of academic centers can lead to increased faculty well-being, clinical productivity, and scholarship. An anonymous survey developed by members of the A.B. Baker Section on Neurologic Education was sent to the 133 chairs of neurology to assess the type of compensation faculty receive for teaching efforts. Seventy responses were received, with 59 being from chairs. Key results include the following: 36% of departments offered direct compensation; 36% did not; residency program directors received the most salary support at 36.5% full-time equivalent; and administrative roles had greatest weight in determining academic compensation. We believe a more effective, transparent system of recording and rewarding faculty for their educational efforts would encourage faculty to teach, streamline promotions for clinical educators, and strengthen undergraduate and graduate education in neurology.

Student Continuity with Patients: A System Delivery Innovation to Benefit Patient Care and Learning (Continuity Patient Benefit).

Medical education is continuing to evolve to meet the healthcare needs of the future. The longitudinal integrated clerkship (LIC) model is an important innovation in medical education. It has in its vision and structure "patient- and learner-centered education", using longitudinal relationships between patients and students as a foundational element in its design. LIC students have shown more patient-centered attitudes and behaviors that persist after medical school. They remain connected with the patient experience of care, which supports empathy and student moral development. The time that LIC students spend acting independently with patients also supports the development of higher order clinical and cognitive skills and professional identity formation. Student participation in a more meaningful way in the care of their patients promotes patient wellbeing, and helps patients with transitions of care, communication and preventative care. Patients report feeling empowered to be more active agents in their own care and feel an accountability and pleasure in the training of new physicians. Focusing on the patient/student relationship as a foundational element of clinical education has meaningful benefits to the patient and student with the potential to improve patient care directly and in the future, as these students become physicians.

A comparison of ultrasonographic and electrophysiologic 'inching' in ulnar neuropathy at the elbow.

OBJECTIVE: The present study aimed to clarify the relationship between structural ulnar nerve changes and electrophysiological nerve dysfunction in patients with ulnar neuropathy at the elbow (UNE). METHODS: High-resolution ultrasonography of the ulnar nerve was performed on 17 limbs with clinically and electrophysiologically confirmed UNE, and 52 control subjects at four standardised sites proximal and distal to the medial epicondyle (P2, P1, D1, D2), corresponding to segments of ulnar short-segment nerve conduction studies ("inching studies"). RESULTS: Ulnar nerve cross-sectional area (CSA) and hypoechoic fraction were significantly increased in patients with UNE immediately distal (D1) and proximal (P1) to the medial epicondyle (p<0.01). In patients with UNE, hypoechoic fraction was similar in asymptomatic and symptomatic limbs. Motor nerve conduction velocity across the elbow correlated with CSAmax and the maximum hypoechoic fraction (R=0.6, p<0.05). CSA and hypoechoic fraction of individual segments did not correlate with corresponding latencies on inching studies, but latencies across the D1 segment correlated with CSA at P1 (R=0.80, p<0.0001) and D2 (R=0.65, p<0.01). CONCLUSIONS: Sonographic abnormalities in UNE may not be maximal at the site of electrophysiological nerve dysfunction. SIGNIFICANCE: Sonographic abnormalities may reflect secondary pathophysiological changes in segments adjacent to regions of nerve compression.