Exploring Longitudinal Integrated Clerkships: It is time to go global

1. Exploring Longitudinal Integrated Clerkships: It is time to go global Paul Worley September 2011

7. Recent reviews of how to make a doctor � Bridget O�Brien here todayRecent reviews of how to make a doctor � Bridget O�Brien here today

8. Major shifts in approach � each builds on the nextMajor shifts in approach � each builds on the next

9. Longitudinal Integrated Clerkships Consortium of Longitudinal Integrated Clerkships (CLIC) Integrated � all clinical disciplines concurrently Longitudinal � at least six months

10. Yankton take-aways We are attracting a generation of smart students who really care about their world. Our curriculum needs to equip them to be change agents in the health system � Henry Weil The beauty and the richness of the experience in context rather than the burden of proof and generalizability � Carol Suddards

11. CLIC Outcomes Academic results Career choices Empathy/altruism/social orientation Professionalism Mental health/enjoyment Sustainable Supervision

12. Academic performance over PRCC year

13. Impact on clinicians The mean time for the three kinds of consultations were: no student present: 13 mins 42 sec����� Precepting consultation: 13 mins 18 sec����� Parallel consultations: 12 mins 45 sec

14. Student a benefit not a burden

15. Career Choices

18. Clinical Decision MakingClinical Decision Making

19. Quality of teaching better from student perspectiveQuality of teaching better from student perspective

20. Better retention of knowledgeBetter retention of knowledge

21. Schauer et al, 2006 ROME Learning Outcomes No significant differences between LIC and traditional students in: MCAT scores Step 1 scores Subject exam scores (internal medicine, surgery, obstetrics/gynecology, pediatrics, family medicine) Step 2 scores Better exam performance in national testsBetter exam performance in national tests

22. In tests of humanism and professionalism, we are intrigued by results on the PPOS. While traditional students did show some erosion of scores, CIC students� did notIn tests of humanism and professionalism, we are intrigued by results on the PPOS. While traditional students did show some erosion of scores, CIC students� did not

23. Mechanism hypotheses Continuity � patients/supervisor/curriculum Integration � health system/curriculum Mentorship/coaching Symbiotic Relationships Supportive context Greater idealism/motivation Greater connection to patients/meaning Theoretical frameworks are emergingTheoretical frameworks are emerging

24. BUT�.. Are these results generalizable?

25. AND�.. How long is longitudinal? How much integration is needed? Is there a selection bias for students and teachers in any one institution? What about specialty vs generalist? What about rural vs urban? What about developed vs developing? Integration Eg Queens integrates Family Med and Psych, Melbourne Med and SurgIntegration Eg Queens integrates Family Med and Psych, Melbourne Med and Surg

26. Longitudinal Integrated Clerkships Is it the new PBL? Did have a strong theoretical framework developed around it Controversy over what is TRUE PBL Still controversy over outcomes, very few multi-centre studies Did have a strong theoretical framework developed around it Controversy over what is TRUE PBL Still controversy over outcomes, very few multi-centre studies

27. CLIC A �movement� Viral rather than formal Disruptive Technology

28. Change in Medical Education

29. Not everyone is with us!!

30. CLIC No problem while our work doesn�t impact on resources of established teaching centres Expect strong resistance when resource allocations have to be re-prioritised PBL wasn�t prepared with the evidencePBL wasn�t prepared with the evidence

31. CLIC Be prepared ! � Malcolm Cox, 2010 PBL wasn�t prepared with the evidencePBL wasn�t prepared with the evidence

32. Yankton challenges to CLIC Hard data is critical and needs to be disseminated � Robert Talley We need �comparisons of features� research to disentangle what it is that makes the difference � David Irby Are there opportunities for a LIC model to shorten medical school for some students? � Deborah Powell

33. Research questions Are there generalizable outcomes from LICs? What are the crucial elements that lead to the positive outcomes observed? What is the relative influence of each identified element? What interactions are present between the elements?

34. Collaborative research opportunity Use the current global natural experiment to compare different approaches compare same approach in more than one context compare different combinations of approaches

35. Collaborative research opportunity Develop a collaborative international database that can inform an evidence based framework for LICs without applying for a formal grant A viral approach to educational research

36. Inspired by the home of archery in the USAInspired by the home of archery in the USA

37. The Clinical MISSILE studies Clinical Learning: a Multi-centre International Simultaneous Studies of Integrated Longitudinal Education

38. Method Multi-institutional prospective cohort study/s over one academic year Keep it simple Keep it low cost

39. Use existing data sources Agree on what standard demographic and exam result data to pull out of student records

40. Share common effective tools Pool the known valid tools that different schools have used to form one single pre-mid-post survey instrument Add known validated tools where important areas not covered

41. Collaborative ethics Develop common ethics protocol that includes the opportunity to pool de-identified data pilot ethics application and assessment at one school prior to other schools seeking ethics approval

42. Recruit locally Apply this single e-survey instrument at beginning and end of the year to entire year of LIC cohort within each school Where schools have voluntary LICs this will result in case-control data

43. Analysis Analyse our own results as internal quality assurance for each institution � minimal cost Share analysis of the collective results for evidence for global action � minimal cost

44. Mixed methods Multiple methods eg change in empathy t-tests for difference between LIC and standard curriculum logistic regression with odds ratios to account for possible impact of gender, age, length of LIC etc Grounded theory for student experiential accounts

45. Publish Individual schools and regional groups of schools can publish their individual data as opportunities arise International pooled data analysis published by the collaboration aim for high impact journals

46. Store for the future Each School stores their data for further longitudinal studies Use Australian Medical Schools Outcomes Database for protocol template Agreed protocols for data access for participating Schools Agreed protocols for use of data for publication

47. Four School Example Flinders, Australia Northern Ontario School of Medicine, Canada Harvard Medical School, USA University of Witwatersrand, South Africa

49. But what if other schools joined the study�

56. Further research Database can act as reference point for individual schools to pilot new quantitative and interpretivist research methods Once shown to be useful, these new methods can be added to the shared set of tools for others to replicate Replicate, replicate, replicate�

57. Often feel isolated and impotent on our own. Don�t have to do this alone ! Often feel isolated and impotent on our own. Don�t have to do this alone !

58. Strength together.Strength together.