university of california, san francisco school of medicine Longitudinal Clerkships at UCSF Bill Shore, MD STFM Conference on Medical Student Education January, 2011

university of california, san francisco school of medicine One-year integrated longitudinal clerkship (third year) at Parnassus- tertiary care, and UCSF Family Med. Faculty Practice Pilot with 8 students April 2007-April 2008 Expanded to 16 students in 2008 – continued. PISCES Overview

university of california, san francisco school of medicine Core Elements –Patient cohort –Longitudinal Preceptor clinics –Advising/mentoring program –Longitudinal curriculum –Emergency room, operating room, and call sessions –Inpatient immersion –Comprehensive student assessment –Program assessment

PISCES addresses competencies and state licensure requirements for: Anesthesiology Family and Community Medicine Internal Medicine Neurology Obstetrics and Gynecology Ophthalmology Orthopedic Surgery Otolaryngology Pediatrics Psychiatry Surgery Urology

Sample Student Schedule Week 1

university of california, san francisco school of medicine Patient Cohort Students acquire their own cohort of patients (50- 75) via acute care sessions, call and preceptorships Students follow their patients wherever they go A pager system notifies students when their patients come to emergency room, labor and delivery, hospital admissions, operating room and clinics Patients selected to target core competencies for each discipline and for continuity COPC or QI project required

university of california, san francisco school of medicine Mini-inpatient immersion –Obstetrics 1 week –Internal Medicine 2 weeks –Surgery 2 weeks Longitudinal curriculum (PISCES school) –½ - 1 day per week interdisciplinary sessions including clinical skills sessions, student directed case report, Student Led Seminars –Reflection sessions –Stress rounds –Palliative care –Hospital systems sessions

university of california, san francisco school of medicine PISCES Advisor Oversight advisor for student during the PISCES program Meets one student regularly during the year Monitors longitudinal progress and reviews performance data Provides and helps interpret feedback Helps student develop learning plans Ensures that the recommended number and type of patients are in the student cohort Provides problem solving and support as the student progresses through the year Advocates for student as necessary and appropriate

university of california, san francisco school of medicine Comprehensive Student Assessment Discipline specific (grades) –Preceptor observation and feedback –Structured observed clinical exams in hospital and clinic settings (e.g. observed neurologic examination, BSCO) –Clerkship or shelf exams similar to current clerkships PISCES global evaluation –CPX (clinical practice exam) with whole class –Integrated shelf exams –Chart Review Exercise/Peer evaluation –Quality improvement project PISCES paragraph in Dean’s letter describing PISCES and unique strengths of each student identified through this program.

Worley et al university of california, san francisco school of medicine Impact

Comparison of longitudinal learning between traditional block clerkship students and Yankton LIC students. 21 YAP students and 52 traditional clerkship students agreed to participate in the study and completed the medicine, surgery and OB/GYN shelf exams in October, March, and June (all three tests 3 times). Traditional clerkship students would have completed one of these clerkships shortly before each testing time.

university of california, san francisco school of medicine Patient Narratives UCSF Methods –Qualitative, cross-sectional study –Semi-structured interviews with 32 patients of LIC students and 12 patients of inpatient medicine clerkship students –General inductive approach –Analyzed for themes about continuity and experiences of care provided by medical students

university of california, san francisco school of medicine Patient Narratives UCSF Impact on patient experience –Continuity of care –Coordination of care –Patient education –Interpersonal connection

university of california, san francisco school of medicine Patient Narratives UCSF “Just again, I just want to reiterate and stress how wonderful [Student] was. Even when I was delivering and going through my labor, even my mom who was with me in the labor room, she mentioned that as soon as he walked in, he really brought a sense of calm to the room. Especially giving birth for the first time can be a stressful situation, but he was cool, calm, and collected, and amazing. I really, really liked the whole experience.” LIC Pt 637 “When I had questions, I didn’t present them to the doctor, she was very open and made me feel at ease, and allowed me to present questions to her and she could answer them so I could understand them, in layman’s terms and not using big, extravagant terms where I couldn’t understand them.” –LIC-H pt 596

university of california, san francisco school of medicine Student Narratives UCSF “Working with Family Medicine preceptors and patients for the entire year has given me a better understanding of what Family Medicine is and an increased appreciation and respects for Family Physicians”. A number of students have chosen the Family Medicine Faculty practice for their personal and family care, including prenatal, delivery and well child care!

Model SFGH: Impact of A Longitudinal Clerkship Model in Teaching Chronic Care of the Underserved Margo Vener, MD University of California, San Francisco

BACKGROUND Can an integrated clerkship model with longitudinal care, six months, improve students’ abilities to care for chronically ill, medically underserved patients? In Model SFGH, 25 third-year students completed three integrated clerkships (IM, FM and Peds or OB/GYN). By providing longitudinal care over 6 months, students had increased continuity with patients, preceptors, and peers.

Goals of Model SFGH Promote continuity with patients, preceptors, peers and health system Enhance learning in chronic care and prevention Support student experience in caring for underserved urban patient population

Methods 25 third-year students 6 months at SGFH and underserved clinics 3 partly integrated rotations (FM, IM, and either Peds or OB) plus outpatient block Longitudinal Family Medicine patient panel – 1 full day per week for 6 months Pediatric or OB continuity patients – follow own well babies or pregnant women periodically over 6 month rotation Seminars in chronic care model and underserved care Overall shift from inpatient to outpatient care compared to traditional students

Module (4 wks) Sample Schedule Sample Schedule 1 Inpatient Medicine 2 Peds or OB 3 Outpatient Block 4 Inpatient Med 5 Peds or OB 6 Vacation/Surg Subs FM Continuity Clinic One full day per week Peds or OB Contin Pts

Mini -CPX – Chronic Care of The Underserved Case Model SFGH vs Traditional blocks NHxPE Pt -Student Inter-action Information Sharing Model SFGH N=22NS**NS M = 64.5% correct* All other students N=131NS M = 55.7% correct* *p < 0.01 **NS = No significant difference Information Sharing = Patient education, involving patient in management, optimizing medication adherence, and arranging follow up.

Take Home Messages: Even a relatively small longitudinal patient panel promotes students’ sense of responsibility and improves skills and insight into chronic care. It is possible to effectively combine block and longitudinal rotations to develop patient panels and improve skills in chronic care.

university of california, san francisco school of medicine Challenges Is the longitudinal, 6 or 12 month, the right model for all students? How can the administrative costs be justified? Preceptor recruitment and quality control How can we develop a truly integrated didactic curriculum? How can we translate this model into larger numbers of students selecting Family Medicine? Are there other models, less complex, that could accomplish similar goals?