Integrated Community Clerkship-ICC

Presentation to Department of Family Medicine, DeGroote School of

Medicine,

March 2008

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 the method 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

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?”

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

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.

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.

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

The First Programs

University of Minnesota, 35+ years experience

Flinders Riverland program (started 1996) and other Australian programs

USA -- Cambridge, UCSF

Canadian Experience

Chilliwack Northern Ontario School of Medicine University of Alberta / University of

Calgary

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

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

Morbidity in the Community

From Fry J, Light D, Orton P: Reviving Primary Care – a US-UK Comparison, 1995

Here’s what the curriculum focuses on

The Evidence

Key Names in the Literature:

Gwen Halaas Paul Worley Lucie Walters Molly Cook

Accreditation Issues

Defined objectives Community of learning & scholarship

(integration of faculty; multiple levels of learners)

Opportunities for experiential learning & interactions between students and faculty

Accreditation Issues

Central administration & responsibilityClear accountabilities within FacultyEquitable experiencesProgram evaluation (outcomes,

achievement of objectives)Student support

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

ICC Communities

• Rural communities of 8,000 to 15,000

• Two students are assigned to each site

• History of teaching

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

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.

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

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).

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

Some Expected Outcomes

• Improved resiliency

• Comfort with uncertainty

• Patient-centred care

QUESTIONS???

jill.konkin@ualberta.ca