Continuity in Education

In clinic this week:

Preceptor: Where does U of T incorporate longitudinal outpatient experiences?

Me: Do you mean in which rotations did I see patients more than once?

Preceptor: No.  Did you ever follow patients longitudinally in an outpatient setting?

Me: Never.

I believe this to be a true deficit of my medical education here.  Of course I occasionally saw patients repeatedly as outpatients (never more than twice) but it was always by fluke and not by design.  I recently matched into a rural Family Medicine residency program in BC.  My future career as a rural family physician will be heavily centered on longitudinal patient care, mainly in an outpatient setting.  Yet, despite what I said in my residency interviews, I don’t know what this feels like.  Maybe I don’t even like it.  My current academic understanding and processing of longitudinal patient care may turn out to be quite contrary to my experience.

This reflection has inspired me to read around longitudinal clerkship experiences.  The first references to these types of clerkship training experiences for medical students date back to the University of Minnesota in 1971, who initialed rural longitudinal clerkship to increase training of rural physicians.  Famously Harvard started their own longitudinal clerkship in 1997 and has provided much research to support that both students and patients benefit from longitudinal interactions.  The goal of these longitudinal clerkship experiences is to make medical students responsible for the longitudinal primary care of a panel of patients thereby integrating the diagnosis, care, and treatment of disease while building and maintaining an appropriate therapeutic relationship with a patient. 

I worked alongside three clinical clerks during my 4 week rural family medicine elective in Dryden who were doing a longitudinal clerkship through their medical school, the Northern Ontario School of Medicine.  Currently NOSM is the only medical school in Canada which requires all of its students to participate in a longitudinal clerkship, which they all do in their third year.  (By comparison, I spent my third year doing discrete rotations in various specialty and primary care areas of medicine).  The NOSM clerks’ time and my time in Dryden was not that different: we all did family medicine clinics, primary care obstetrics, hospitalist medicine, and ER shifts (normal family physician duties in Dryden).  The difference was that their experience was 7 months longer than mine.  Longitudinal clerkship experiences were easy to come by in Dryden, as the family doctors all operate comprehensive family practices including hospitalist care.  The NOSM clerks were also exposed to specialty clinics and surgical specialties on the days when they were present in Dryden.      

The University of Toronto is initiating a 10 student pilot of longitudinal integrated clerkship at St. Michael’s Hospital starting September 2015.  I will be interested to see the feasibility and organization of this, especially in the heart of Toronto, where most family physicians do not practice comprehensive care.  I feel that the logistics of having medical students provide longitudinal care are much more complex in the tangled web of hospitals and specialists in Toronto, yet I am excited to see this initiative.  I think that this will truly give students the oppourtunity to experience primary care while learning how to build relationships and care for patients’ overtime.  Communication, empathy, and professional boundaries are all skills that can be optimally developed in longitudinal experiences where students see themselves as the point person responsible for orchestrating the healthcare needs of their patients.

Will this longitudinal exposure to patients in a primary care model increase medical student interest in pursuing a career in primary care OR will it decrease exposure to specialty disciplines leading to more students pursuing primary care by default?  The answer will likely depend on the organization and the details of Toronto’s first longitudinal integrated clerkship.  My only hope is that longitudinal clerkship will set students up to be competent and caring physicians in any and all medical specialties.