1. An Integrated, Longitudinal Clerkship: Next Step Report Susan Runyan, MD, MPH Bill Shore, MD University of California, San Francisco, Dept. of Family and Community Medicine STFM Predoctoral Education Conference-January 23, 2009

2. Challenges in the Traditional Third Year Loss of ownership of patient care Increasing transitions in medical care (shorter and more acute hospital stays, 80 hour work week, shorter attending rotations) Erosion of relationship with the patient, the course of illness, the inpatient team, and faculty Limited observation of skills, communication, professionalism Lack of continuity between rotations regarding skills development across third year

3. Background: New Models for the Third-Year New clerkship models at UCSF:  “Model Fresno”,  “Model SFGH”,  “VALOR” Integrated, longitudinal clerkships already developed in primary care settings:  Yankton, South Dakota  Cambridge Hospital, Harvard  Canada  Australia  CLIC-Consortium of Longitudinal Integrated Clerkships

4. Integrated-Longitudinal Clerkship Definition: 1. Students follow patients over the course of year 2. Students work with same faculty over the year 3. Students simultaneously meet the core clinical competencies across multiple disciplines

5. Parnassus Integrated Student Clinical Experiences

6. PISCES Family Medicine Overview Pilot year (2007-2008): 8 students This year (2008-2009): 16 students at UCSF, Community clinics and SFGH-FHC

7. Core Elements of PISCES Longitudinal preceptorship clinics in each discipline that run in parallel Continuity relationships with a faculty member from each discipline Limited inpatient immersion experiences: (one week of OB; two weeks of surgery; two weeks of medicine)

8. 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

9. PISCES’ GOALS Promote longitudinal relationships with patients during the entire 3 rd year Provide longitudinal relationships with faculty preceptors Structure “real-world” outpatient clinical settings Expose students to undiagnosed illness Follow the course of chronic illness Develop skills in patient-centered care Decrease student end of year “burn-out”

10. Student Cohort of Patients Acquired through outpatient preceptorships, the emergency room, and acute care clinics Patients followed through different settings:  Primary preceptorships-FM/Medicine  Specialty appointments  ER visits  Inpatient admissions Cohort patients selection  Target specific core competencies for each discipline  Target patients who would benefit from coordination of care

11. Sample Student Schedule Monday Tuesday Wednesday Thursday Friday Saturday Sunday Surgery Rounds 7-8am If students have a patient in their cohort or who they are following after a surgical procedure, they will round with the team/chief resident in the morning. Medicine Rounds 8-9am If students have a patient in their cohort or who they are following who is in the hospital, they will round with the team/chief resident in the morning. AM Clinic 9- 12 Family Medicine OB/GYN Surgery Clinic Neurology Pediatrics PM Clinic 1-5 Self Directed & Cohort Learning PISCES School Self Directed & Cohort Learning Emergency Department Self Directed & Cohort Learning Evening/ Night 6p- 7a One evening per week, students will take call in the evenings with Emergency Department, Pediatric ER/Urgent Care, and Acute Care (SAC). 4 hours. Two weekend days per month, students will take call with Emergency Department, Pediatric ER/Urgent Care, and Screening and Acute Care (SAC).8 hours.

12. Longitudinal Curriculum (PISCES School) Didactic sessions which mirror curriculum offered to students on the traditional clerkships Morning report style sessions Reflection sessions Peer to peer small group learning/ support QI/ Community Project

13. Structured Student Assessment Eight Clinical Observations from each preceptor. Student is observed with the patient and given directed feedback BSCO Comprehensive Evaluation Sessions each preceptor from all disciplines attends quarterly meetings to discuss student progress-RIME Discipline specific grades and exams

14. university of california, san francisco school of medicine PISCES Advisor Faculty (may be preceptor) who serves as 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 Periodically reviews learning portfolios

15. End of the Year Student Assessment Global PISCES Evaluation Discipline Specific Evaluation - For family medicine will include preceptor evaluation, participation in behavioral science seminars, home visit report, COPC or QI project, final exam

16. Pisces End of Year Evaluation QuestionApplicable Answers MeanScaleStd Dev Formal Teaching Quality (i.e. seminars, didactics) 84.751 to 50.46 Achievement of Course Objectives 84.501 to 50.53 Feedback (adequacy of feedback on your performance) 84.501 to 50.53 Faculty Clinical teaching- Preceptorships overall 85.001 to 50.00 Patient Cohort Experience84.881 to 50.35 Internal Med. Inpt. Experience84.501 to 50.76 Pisces Advisor Program84.001 to 50.76 Pisces Program Overall84.751 to 50.71

17. Student Feedback Program allows me to be “proactive and responsible” for my learning “Longitudinal relationships with preceptors facilitates my learning and dissipates fears of grading and asking silly questions” My family medicine preceptor really understood “my strengths and weaknesses” and tailored appropriate learning experiences

18. Student Feedback Developed “a huge appreciation for how hard the job [of a family physician] is” Understanding of “how relationship facilitates the patients’ care” Appreciation of how the “context of patients’ lives and family situations” can impact health Learned to “sit and listen” and “be there for the long haul” even when no treatments were particularly effective

19. Challenges HUGE logistical challenge to coordinate schedules Time consuming for preceptors to have longitudinal learner VERY resource intensive: Moves most of teaching in third-year from inpatient to outpatient setting Need to expand pool of preceptors involved with outpatient teaching Need to recruit self-motivated and self-directed learners

20. Our Burning Questions Is this a better model for teaching family medicine? How do we compare this model to the traditional block clerkship model? How do we incorporate the teaching of community medicine principles? Should we move from a discipline-specific curriculum to a competency-based curriculum? Should this model be expanded?

21. Questions How can we effectively include community (not full time faculty) preceptors? Should community preceptors be paid? Is this the right model for all learners? What studies need to be done to compare this to traditional curriculum? With an increased understanding of and appreciation for “continuity of care”, why aren’t students choosing Family Medicine (or Primary Care)?