1. An Integrated, Longitudinal Clerkship: Is This a Better Model for Family Medicine Clerkships? Susan Runyan, MD, MPH; William Shore, MD Brook Calton, MS3 UCSF-Department of Family and Community Medicine STFM 2008 Predoctoral Education Conference-(L20A)

2. Objectives: Describe the integrated, longitudinal (pilot) clerkship at UCSF Discuss the complexities of this innovative clerkship model Discuss advantages of this model for FM Discuss challenges of this model for FM Discuss the student’s experience Recommend potential evaluation methodologies

3. Challenges in Current 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, professionalism, communication Lack of continuity between rotations regarding skills development across third year

4. Background: New Models for the Third-Year Need for new models in clinical training to prepare students for current medical practice settings UCSF has already developed new clerkship models (“Model SFGH”, “VALOR”) Integrated, longitudinal clerkships have been previously developed in primary care settings (Yankton, S.D. and Cambridge Hospital, Harvard)

5. Integrated-Longitudinal Clerkship Definition (1) : 1. Students participate in the comprehensive care of patients over time 2. Students participate in continuing learning relationships with faculty 3. Students meet, through these experiences, the majority of the year’s core clinical competencies and do so across multiple disciplines, simultaneously (1) The Consortium for Longitudinal Integrated Clerkships (CLIC)

6. UCSF-Pilot of a One-Year Integrated Clerkship Goals: Promote longitudinal relationships with patients during the entire 3 rd year Provide longitudinal relationships with faculty preceptors Integrate experience across disciplines 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”

7. Parnassus Integrated Student Clinical Experiences

8. PISCES Overview One-year integrated longitudinal clerkship addressing core competencies for all third- year clerkships 8 students are spending their third year at UCSF Parnassus-affiliated clinics (the main tertiary care center) Pilot year April 2007-2008

9. PISCES curriculum is addressing 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

10. Core Elements of PISCES Longitudinal preceptorship clinics in each discipline that run in parallel across the year in primary care and specialty settings Continuity relationships with a faculty member from each discipline, who guides the student’s learning throughout the year

11. Core Elements of Pisces: Inpatient Immersion A focused inpatient component of 1 week obstetrics and 2 weeks internal medicine A 2 week inpatient selective in the second half of the year in the specialty of the students’ choice

12. Core Elements of PISCES Acute Care sessions in ER, Adult Urgent Care, and Pediatric Acute Care Clinics OR sessions where students participate in anesthesia and surgical care of patients

13. Student Cohort of Patients Acquired through outpatient preceptorships, the emergency room, and adult and pediatric acute care settings Students follow their patients into various settings including specialty appointments and inpatient admissions Cohort patients selection  Target specific core competencies for each discipline  Enable students to follow the course of identified acute and chronic care diseases.

14. Longitudinal Curriculum (PISCES School) Didactic sessions which mirror curriculum offered to students on the traditional clerkships Morning report style sessions with student selected inpatient and some outpatient presentations. Reflection sessions Peer to peer small group learning/ support QI Project

15. Sample Student Schedule Week 1 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.

16. Sample Student Schedule Week 2 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 Surgical Subs Urgent Care Psychiatry Operating Room Anesthesia PM Clinic 1-5 Self Directed & Cohort Learning PISCES School Self Directed & Cohort Learning Internal Medicine 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.

17. Advising/ Mentoring Program Faculty advisor who meets with the student regularly during the year  To ensure that the recommended number and type of patients are being seen by the student  To provide problem solving and support as the student progresses through the year

18. Structured Student Assessment BSCO – Eight “Brief Structured Clinical Observations” from each preceptor (in all departments) in which the student is observed with the patient and given directed feedback RIME – Comprehensive evaluation sessions in which each preceptor from all disciplines attends quarterly meetings to discuss student progress in the “Reporter, Interpreter, Manager, Educator” format

19. Comprehensive Student Assessment Global PISCES evaluation  RIME/ BSCO – Preceptor Feedback  CPX (clinical practice exam)  Integrated shelf exams  Quality Improvement project  Peer evaluation Discipline Specific—For family medicine will include preceptor evaluation, participation in behavioral science seminars, home visit report, final exam

20. School of Medicine Partners Office of Medical Education Office of Educational Technology Medical Center IT PISCES Oversight Committee

21. PISCES Funding The Drown Foundation Participating departments The Academy of Medical Educators UCSF School of Medicine

22. Brook Calton’s Perspective: Third-Year Pisces Student

23. Advantages Continuity of relationships with faculty preceptors Continuity of relationships with patients Deep understanding of importance of continuity of care and patient-centered approaches Continuity with peer cohort Realistic appreciation of the rewards and challenges of primary care and family medicine

24. 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 outstanding outpatient preceptors Use of longitudinal sub-specialty preceptors – do they provide enough breadth of clinical experience? Need to recruit self-motivated and self-directed learners

25. Our Burning Questions Does this model promote better clinical education for students? How do we compare this model to traditional block clerkship models? How do we incorporate the teaching of community medicine principles? Will this model promote interest in working in medically- underserved communities (one of our department’s missions)? Should we move from a discipline-specific curriculum to a competency-based curriculum? Should this model be expanded for all of the Parnassus-based third-year medical students (about 60 students or 1/3 of the class)?