Longitudinal, Vertical, Diagonal: How Do We Learn Best?

Today I had my first clinic of the CEEP selective – it was called GIM Longitudinal.  I spent lots of time on CTU’s and consult teams during my electives, but it has been a while since I’ve been in an outpatient clinic.  The term “longitudinal” resonated with me today for a number of reasons.

Hirsh et al. highlighted that continuity in the learning environment extends across three spheres: continuity of care, continuity of curriculum, and continuity of supervision. Let’s distill these points.

• Continuity of care – Much of the satisfaction we derive in internal medicine stems directly from the therapeutic alliance we have with our patients. Patients derive benefit from seeing the same trainees and physicians in clinic, and trainees and physicians derive fulfillment from this too.  A study by Butler et al. from the Department of Medicine in Kettering Medical Center, Ohio articulated that in a model whereby a team of residents was responsible for a cohort of patients, rather than patients seeing a different resident each visit, a couple of things improved.  First, patients were seen consistently by the same subset of residents and second, communication between providers improved.  For example, in clinic today we reviewed a patient who was seen for cutaneous lesions that had been worsening for over a decade.  I had the opportunity to review the previous notes from physicians in the internal medicine team at TWH and simultaneously, the patient herself felt we had a good grasp of her story.
• Continuity of curriculum – In internal medicine we are afforded the unique opportunity to see patients both acutely in the inpatient setting and emergency department but also as outpatients.  We see different manifestations of the same chronic diseases, requiring us to synthesize the information we learn across a number of spheres.  For example, the management of a hypertensive emergency/urgency in an acute setting differs from the way you will manage and follow hypertension in clinic.  Fazio et al. described that ambulatory clinics create a balanced learning experience.  Nontraditional settings such as community health centers or inner-city clinics provide trainees with diversity.  Furthermore, these experiences provide us with the opportunity to explore the needs and demands of different patient populations.
• Continuity of supervision – Today I had the opportunity to work with one of my attending physicians from my core CTU rotation and today it was in the GIM Longitudinal clinic.  From my CTU rotation, I’ll never forget one of the bedside teaching exercises we went through in the emergency room when reviewing a patient with decompensated aortic stenosis.  She asked our team of medical students and residents to take turns listing up to 10 things we noticed in the room purely with visual inspection before examining the patient.  We came up with a lot which highlighted the importance of that bedside technique.  Today in clinic we reviewed how to counsel patients when discharging from clinic and the things to discuss with them so that they are aware of when to return.  Continuity of supervision is important because, as Hirsh et al. pointed out, it forms a strong learning community.  Students are encouraged to take intellectual risks in their learning but are also open to coaching and feedback.

Another example of this movement is that undergraduate medical education structure is changing. For example, the new Foundations Curriculum has weaved various longitudinal themes into the components that are being delivered to students.

Educational continuity has many benefits as described above and I am grateful to have experienced these today!

Until tomorrow,

SH

Resources:

Fazio, S. B. et al. (2017). The Challenges of Teaching Ambulatory Internal Medicine: Faculty Recruitment, Retention, and Development: An AAIM/SGIM Position Paper. The American Journal of Medicine, 130(1): 105 – 110. DOI: https://doi.org/10.1016/j.amjmed.2016.09.004

Hirsh, D. A. et al. (2007).  “Continuity” as an Organizing Principle for Clinical Education Reform.  The New England Journal of Medicine, 356(8): 858 – 866.

Butler, M. et al.  (2017).  Improved continuity of care in a resident clinic.  The Clinical Teacher, 14(1): 45 – 48. doi: 10.1111/tct.12489. Epub 2016 Jan 8.