Initiatives developed to address the global shortage and geographical maldistribution of medical workforce [1,2] have included increasing student numbers at existing medical schools and/or establishing new ones, many of the latter being situated in regional (non-capital city urban centres) or rural settings. Community and workplace desire for ‘practice-ready’ and ‘patient-centred’ graduates has prompted the development of new models of clinical education [3-6] that develop the skills and attributes which prepare graduates to work effectively in areas where they are most needed.
The longitudinal integrated clerkship (LIC) is one model that is gathering considerable support internationally [6,7]. It represents a move away from the more traditional curricular structure of clinical clerkship with its emphasis upon ‘block rotations’ and frequent changes in disciplines, to a focus upon the concept of long-term integrated medical student placements. A recent review of outcomes arising from LICs has revealed that they are being increasingly implemented in rural and urban settings [8,9]. In addition to positively influencing LIC students towards primary care and rural career choices [10], other reported outcomes include equivalent or sometimes better academic results, and higher-order clinical and cognitive skills than ‘block rotation’ peers, well-developed patient-centred communication skills and willingness to embrace increased responsibility with patients. Importantly, patients have described a LIC learning environment as learner- and patient-centred with a positive impact on their health care [11].
Outcomes such as these have prompted adoption of the LIC model in a growing number of medical schools with many using the model for a small percentage of their medical students before expanding LIC student numbers [12]. However, it is a daunting challenge to provide a longitudinal curriculum for an entire medical school class from the outset when increasing medical school numbers and medical class sizes are causing significant competition between Schools for scarce clinical supervisors.
This paper provides guidance on the key issues to be addressed when mounting such a large-scale educational program. It is based on the experience of implementing a whole class at the Graduate School of Medicine (GSM), University of Wollongong, Australia. This LIC example was implemented at a time of emerging global reform in clinical education, and was novel due to its scale and whole-class approach. The latter had been introduced by the Northern Ontario School of Medicine a year prior to the GSM on a smaller scale. Reports in the literature include descriptions of various LIC models and their outcomes, but there is little reported discussion of the challenges of establishing a whole school community-based approach. This manuscript describes the barriers, constraints and opportunities when a regional context provided the focus to promote innovation [13].
The GSM four-year graduate-entry medical program was established in 2007 aiming to produce competent, patient-centered graduates with a vocation to serve in regional, rural and remote communities. Its innovative curriculum includes a longitudinal integrated clinical clerkship for a full academic year in the third phase of the course [11,14]. All students live in their allocated community, learning and working in all its health services including primary care, hospitals and extended services. In a typical week, a student spends two days in their host general practice and one day in the hospital emergency medicine department, where they assess undifferentiated patients under the supervision of their preceptor(s). The remaining days comprise an academic day with case-based learning, simulation and/or interprofessional learning activities, and another hospital day. In the latter, the student takes part in a range of learning experiences including ward-based care, surgical assisting and obstetric care.
This LIC model places community-based health education, workplace-based learning and continuity of care [6] at the core of curriculum processes. In doing so, it challenges the traditional practice of two years of predominantly short-term discipline-based clinical education in tertiary hospitals. By creating new and extended community settings for undergraduate clinical education, the LIC model parallels changes within health services that reduce patient time in acute care settings, and uses the educational potential of the increasing availability of patients being treated in ambulatory care, primary care and community settings.
A significant challenge for the School therefore was to work effectively in these new environments to not only create an innovative curriculum model but also to secure its future by using a framework to foster sustainability. This was a major undertaking. Although the School was new, the experience of undergraduate medical education for most of staff and partners in hospitals and primary care was predominantly the traditional curriculum model of short-term clinical placements in tertiary teaching hospitals that they themselves had experienced as students. For several academics and/or clinicians used to teaching and learning in more traditional models, the innovation represented a change in approach and thus generated concern and resistance to departing from established models of clinical education.
To provide the LIC component of the course for all students, the School created new community-based ‘Teaching Microsystems’ [15,16] based in ten regional, rural and remote educational hubs in New South Wales (NSW). The curriculum and hubs have now been in operation for five student cohorts (N = 379) since 2009.
This article articulates our learning from the development and early delivery phase of this substantial change in philosophy and delivery of undergraduate clinical education. Roberto and Levesque’s model [17] (Figure 1), originally described for business, was used a guiding framework for achieving sustainability when implementing the new educational model. The framework’s four core processes and key steps in each informed the approach to rolling out the ‘whole of class’ longitudinal community-based medical education program.