1. Join the conversation! Our Twitter hashtag is MSE12 Launch of a New Longitudinal Integrated Curriculum for Third Year Medical Students Peggy R. Cyr, M.D. Maine Medical Center

2. How familiar are you with the LIC model of teaching third year medical students? 1.Not at all 2.Somewhat well 3.Very well 4.I run a LIC program poll

3. Objectives of this session Gain an understanding of what the LIC is Learn the methods we used to start an LIC Exposure to a competency based education Lessons learned from our Inaugural Year How to Learn more about LIC Understanding Family Medicine’s Key Role

4. Why change from the Traditional Model? Decreased inpatient length-of-stay Most patients already diagnosed Random whatever-comes-in-the-day More outpatient-based, chronic illnesses Ethical erosion/Hidden Curriculum Clinical demands, duty hours limit time with learners New themes emerging [e.g., multidisciplinary]

5. Clerkship Models Internal Med Peds Psych/ Neuro Family Med SurgeryOB-Gyn Internal Medicine Pediatrics Psychiatry/Neurology Family Medicine Surgery Obstetrics/Gynecology BLOCKBLOCK LICLIC

6. LIC Basics Initial student panel of 8-10 patients, deliberate selection of patient problems Follow patients throughout health care experience Accrue patients into panel via ER and in preceptors offices Same discipline-specific learning and evaluation as Traditional Track More authentic evaluation of students Longitudinal relationship with teams of faculty educators IT-facilitated Focus is on continuity, both patient care and educational

7. Maine Medical Center.Tufts University School of Medicine (MMC.TUSM) Medical School Program 36 “Maine Track” Students First class matriculated 8/2009 Students spend years 1 and 2 in Boston Return to Maine for years 3 and 4

8. Mission Mission: The MMC-TUSM Longitudinal Integrated Curriculum Program commits to develop and implement a community-based innovative medical curriculum that will train medical students to become exceptional, compassionate physicians.

9. Values Commitment to innovative Patient and Student centered learning. Recognition of healthcare delivery systems as collaborative team models. Creativity, Integrity, Inspiration and Collegiality. Encouragement of students to pursue careers in all geographic areas of Maine

10. MondayTuesdayWednesdayThursdayFridaySaturdaySunday Pre-round on inpatientsED shift (any) or Day off ED shift (day or evening only) or Day off Inpatient attending rounds/ didactics (see note below) - Family Medicine clinic Surgery clinic Internal Medicine Clinic Ob/GYN clinicPeds Clinic __________ Self Directed Learning TIS Tuesday Integrative Sessions Psych ClinicSelf- directed learning

11. LIC EXAM SCHEDULE MMC-LIC Exam DateLocation Psychiatry Shelf Exam7/26/2011Med Ed - Portland Ob/Gyn Shelf Exam9/2/2011Med Ed - Portland Pediatrics CLIPP Exam10/4/2011 Urban - Med Ed; Rural - at rural site Family Medicine online exam11/9/2011Med Ed - Portland Medicine Shelf Exam12/15/2011 Urban - Med Ed; Rural - at rural site Surgery Shelf Exam1/23/2012Med Ed - Portland

12. MMC.TUSM LIC PROGRAM

14. Maine Medical Center LIC Webiste http://www.mmc.org/mmc_milestone.cfm?id=7 218

15. Meeting One: 6 Core Disciplines TUSM competencies Tagged each competency (discipline and #) Identified 6 ACGME competencies to each Common EXCEL format for all

16. Meeting Two: As a group, we identified Competencies common to all disciplines in Patient Care Pediatric Clerkship Director volunteered to “distill” those competencies into combined competencies

17. Meeting Three: Met as a group and reviewed/approved the Patient Care combined competencies Assigned the 5 other ACGME categories to individuals to find common themes and distill them into a combined list

18. Meeting Four: A looong meeting Met as a group and reviewed all the work done Made some corrections, re-wording, etc. Exchanged work with clerkship directors to review

19. LIC Combined Competencies Recognition of overlap/redundancies across core discipline competencies Belief that some competencies could be achieved in multiple disciplines Commitment to innovation, collaboration link to spreadsheet

20. https://web.mmc.org/meded/MOCA

21. How Do We Know LICs Work? Lots of Research and Evidence

22. The Harvard Medical School Cambridge Integrated Clerkship The Harvard Medical School Cambridge Integrated Clerkship Results: Meaningful Connections with Patients How often have you been involved in establishing relationships with patients that you would term as meaningful? P<0.05

23. The Harvard Medical School Cambridge Integrated Clerkship The Harvard Medical School Cambridge Integrated Clerkship Results: Meaningful Connections with Patients How often have you felt you made a real difference in the health or well-being of your patients? P<0.05

24. What’s really so different about Longitudinal Integrated Clerkships and Block Clerkships? Findings from a multi-center observational, work sampling study Bridget O ’ Brien, Ann Poncelet, Lori Hansen, David Hirsh, Barbara Ogur, Ed Krupat, Erik Alexander, Iris Ma, Karen Hauer CLIC September 23, 2011

25. Work Sampling Data Form

26. Direct Patient Care Time: Breakdown by Level of Participation

27. Discussion Our findings suggest that: By the last 3 months of the core clinical year, LIC students have more opportunities to participate in direct patient care activities without supervisor present than students in block clerkships

28. Increasing Our Understanding of Successful LICs David M. Irby, PhD University of California, San Francisco

29. Hypotheses and Evidence HypothesesEvidence Supportive Relationships Greater satisfaction More substantive relationships with faculty and patients Greater responsibility for patient care Interviews Surveys Ratings of satisfaction PPOS – Patient-Practitioner Orientation Scale C-3 – communication, curriculum, culture Work sampling observations IntroductionLearning TheoryHypothesesEvidenceFuture Directions

30. Summary Students in LICs are – More satisfied with their experience – More patient-centered – More independent in physician-like roles – Have better clinical skills – Equivalent exam performance

31. Lessons Learned Inaugural Year Initial ER/hospitalist engagement TIS Videoconferencing Feedback mechanisms Early Communication with Students and Preceptors

32. Lessons Learned Initial IT-computer access and paging LIC students perceptions regarding Block

33. Family Medicine’s Key Role in the LIC CONTINUITY Exposure to the early undifferentiated illness patient Family Med Faculty are ideal for teaching integrated sessions – how to read an xray, basic EKG reading etc.. Equal Share of Curricular Time

34. What is Needed to Start an LIC? Develop some institutional experts: Enroll in the Consortium of Longitudinal Integrated Clerkships – annual meeting Site visits of other Successful programs Clerkship Directors On Board Lots of Discussions/Meetings/Communication with Faculty both Urban and Rural

35. What’s Needed Engaged, involved Rural Hospitals and teachers Often the sites of former ambulatory rotations of medical students HRSA GRANT

36. HRSA Rural Workforce Training Grant Awarded 8/13/2010 $600,000 over three years will augment the vital resources needed by member hospitals to effectively establish their collaborative relationship and implement the LIC's curriculum at their site

37. LINKS TO ESTABLISHED US LIC PROGRAMS – RPAP – Minnesota, http://www.med.umn.edu/RPAP/http://www.med.umn.edu/RPAP/ – PISCES, http://medschool.ucsf.edu/curriculum/clinical/PISCES/inde x.aspx http://medschool.ucsf.edu/curriculum/clinical/PISCES/inde x.aspx – WWAMI, WRITE Program, http://depts.washington.edu/write/ http://depts.washington.edu/write/ – HARVARD, all clerkship directors visited, http://www.challiance.org/academics/integrated_clerkshi p.shtml http://www.challiance.org/academics/integrated_clerkshi p.shtml – Yankton, South Dakota, http://www.usd.edu/medical- school/clic.cfmhttp://www.usd.edu/medical- school/clic.cfm – MMC.TUSM http://www.mmc.org/mmc_milestone.cfm?id=7218 http://www.mmc.org/mmc_milestone.cfm?id=7218

38. 2011 CLIC CONFERENCE http://www.usd.edu/medical-school/clic.cfm. http://www.usd.edu/medical-school/clic.cfm

39. CLIC WEBSITE http://clicmeded.com/

40. Where is Thunder Bay? 1. North Carolina Outer Banks 2. Portugal 3. Ontario, Canada 4. Southern Coast of Mexico poll

41. CLIC Conference 2012 http://www.rendez-vous2012.ca/call-for- abstracts http://www.rendez-vous2012.ca/call-for- abstracts

42. Where are you with LIC at your site? 1. We have an LIC 2. We are thinking about an LIC 3. We won’t be doing an LIC poll