Integrated Community Clerkship-ICC

1. Integrated Community Clerkship-ICC Presentation to Department of Family Medicine, DeGroote School of Medicine, March 2008

3. Back to Our Roots • “If students have their clinical training mainly in hospitals, especially tertiary care hospitals, they will get the message: ‘this is what disease is and this method for investigating it, is themethod of medicine.’ If they never care for a patient at home, the message will be ‘the home is no place for a physician.’ If they are taught mainly by specialists, they will get the message: ‘this is where authority, prestige, and power lie.’” Ian McWhinney

4. Rotation Based Clerkships • “Traditional Clerkships can leave students with a feeling of being repetitively made to feel grossly incompetent” -Molly Cooke • Each rotation can bring the same questions: “Who are these people?” “Who do I talk to?” “Who am I allowed to talk to?” “Which nurse is truly kind?”

5. What is an integrated longitudinal clerkship? Principles: • continuity of care • educational / preceptor continuity • integrating learning in core disciplines • comfort with uncertainty • based in family medicine/general practice

6. Goals of the ICC • To establish a patient-centred, community-based, pedagogically sound clerkship based in selected rural and regional Alberta communities. • To encourage interested students to pursue generalist careers, particularly family medicine, in rural communities.

7. Goals of the ICC • To strengthen and enhance the relationships between rural communities and urban tertiary teaching institutions. • To further develop distance education strategies, technology and capacity in undergraduate medical education.

8. Goals of the ICC • To use Family Medicine as the core of the clerkship providing students with experience in continuity of care, handling undifferentiated problems, chronic illness management and other key areas of generalist specialties and family medicine while ensuring they develop the knowledge base and skills expected of students in the rotation based clerkship

9. The First Programs • University of Minnesota, 35+ years experience • Flinders Riverland program (started 1996) and other Australian programs • USA -- Cambridge, UCSF

10. Canadian Experience • Chilliwack • Northern Ontario School of Medicine • University of Alberta / University of Calgary

11. The Evidence • students perform as well or better than colleagues in traditional clerkship programs • graduates overwhelmingly choose primary care specialties • in rurally based programs, at least 50% of grads choose rural practice locations

12. The Evidence • 4 months minimum necessary for student to feel they’ve become a valuable member of the health care team • Teaching medical students becomes revenue neutral between 2 & 4 months • Teaching medical students doesn’t always slow physicians down

13. Morbidity in the Community Here’s what the curriculum focuses on From Fry J, Light D, Orton P: Reviving Primary Care – a US-UK Comparison, 1995

14. The Evidence Key Names in the Literature: • Gwen Halaas • Paul Worley • Lucie Walters • Molly Cook

15. Accreditation Issues • Defined objectives • Community of learning & scholarship (integration of faculty; multiple levels of learners) • Opportunities for experiential learning & interactions between students and faculty

16. Accreditation Issues • Central administration & responsibility • Clear accountabilities within Faculty • Equitable experiences • Program evaluation (outcomes, achievement of objectives) • Student support

17. What will the ICC look like? • One week orientation • 34 weeks in the community replacing Medicine, Surgery, O&G, Pediatrics and Psychiatry and Rural FM rotations • 1 week of debriefing • 6 weeks of Selectives • 5 weeks of Electives • No mandatory Urban FM rotation in year 4

18. ICC Communities • Rural communities of 8,000 to 15,000 • Two students are assigned to each site • History of teaching

19. How were these sites chosen? • Minimum of 500 consultations in the practice per week involving patients of all age groups. • 24h and 7day per week coverage by family physicians based in the community. • Ability to provide a minimum of one OR list per student per week • Minimum of 10 obstetrical deliveries per student

20. ICC Communities • Inpatient care of common family medicine, internal medicine, obstetrical, pediatric and psychiatric illnesses. • Comfortable accommodations. • Study rooms and office space for students. • Access to teleconferencing and high speed internet.

21. What will one week look like? • 4-5 half-days in the family medicine clinic (including time spent in the ED, working with visiting specialists, in the labor and delivery room, home visits) • 1 surgical list per week • 1 academic day • 1/2 day with allied health professionals in the community

22. ICC Learning • Work-based learning • Practice, practice, practice…. • Optimising learning by: • More reflective practice • More structure in the haphazard learning process • More feedback, monitoring, guiding, reflection, role modelling • Fostering of learning culture or climate • Fostering of domain-independent skills (professional behaviour, team skills, etc).

23. Some Expected Outcomes • Individuals that demonstrate the knowledge/ability to work within the system for the betterment of the patient (advocacy) • Individuals with situational awareness in a complicated, demanding environment to know what to say and make the correct next choice

24. Some Expected Outcomes • Improved resiliency • Comfort with uncertainty • Patient-centred care

25. QUESTIONS??? jill.konkin@ualberta.ca