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Educational Innovations

The Harvard Medical School–Cambridge
Integrated Clerkship: An Innovative Model of
Clinical Education
Barbara Ogur, MD, David Hirsh, MD, Edward Krupat, PhD, and David Bor, MD

Abstract
The Harvard Medical School–Cambridge integrating instruction in the basic end comprehensive clinical skills self-
Integrated Clerkship (HMS–CIC) is a sciences with training to address the assessment examination, suggesting that
redesign of the principal clinical year to common and important issues in they retained content knowledge better.
foster students’ learning from close and medicine, as identified by national From surveys, HMS–CIC students were
continuous contact with cohorts of organizations. In addition, they much more likely to see patients before
patients in the disciplines of internal participate in a social science curriculum diagnosis and after discharge and to
medicine, neurology, obstetrics– that focuses on self-reflection, receive feedback and mentoring from
gynecology, pediatrics, and psychiatry. communication skills, ethics, population experienced faculty than were their
With year-long mentoring, students sciences, and cultural competence. traditionally educated peers. HMS–CIC
follow their patients through major students expressed more satisfaction
In the pilot year (July 2004 to July 2005), with their curriculum and felt better
venues of care. Surgery and radiology HMS–CIC students performed at least as prepared to cope with the professional
also are taught longitudinally, grounded well as traditional students in tests of challenges of patient care, such as being
in the clinical experiences of a cohort of content knowledge and skills, as truly caring, involving patients in decision
patients and in a brief immersion measured by National Board of Medical making, and understanding how the
experience working directly with an Examiners (NBME) Subject Exams and the social context affects their patients.
attending surgeon. Students participate fourth-year Objective Structured Clinical
in weekly, case-based tutorials Exam, and they scored higher on a year- Acad Med. 2007; 82:397–404.

Prominent voices are calling for teaching or for developing mentoring eight were randomly selected to take part
innovative restructuring of clinical relationships with students.3,4 in the pilot.
medical education.1,2 Because of
decreasing lengths of stay and the In response to these challenges, a Students were paired with preceptors in
increasing focus on care in the collaborating group of HMS clinicians internal medicine, neurology, obstetrics–
ambulatory setting, students on inpatient and educators developed the gynecology, pediatrics, and psychiatry
services rarely see patients through whole HMS–Cambridge Integrated Clerkship and were assigned to those preceptors’
episodes of illness, from presentation (HMS–CIC), which is now in its third ambulatory clinic sites for 5 to 10 hours
through outcome; thus, students are year. In this article, we present data from each week or on alternate weeks (see
rarely able to participate actively in the the first year that began in July 2004 and Chart 1). The faculty members were
full spectrum of diagnostic reasoning and ended in July 2005. The main goal of the selected for their commitment to and
therapeutic decision making. They fail to HMS–CIC was to provide the core
excellence in teaching, and they served as
see patients with a number of significant clinical education that we believe is
preceptors for their students for a year.
conditions that are increasingly managed essential to the professional development
Students thus had a year-long
through outpatient evaluation and of every medical student, regardless of his
treatment. The rapid pace of clinical care or her eventual choice of specialty. The relationship in their ambulatory sites
marginalizes the teaching of foundational rationale for the educational design was with a team of faculty educators that
skills such as diagnostic reasoning, to maximize the learning and retention of consisted of an internist, a neurologist, an
communication skills, professionalism, fundamental clinical knowledge and skills obstetrician– gynecologist, a pediatrician,
cultural competence, physical grounded in a professional perspective and a psychiatrist, in addition to year-
examination mastery, and epidemiology. and reflective practice. long involvement with a teaching
In addition, experienced clinicians, with radiologist and six weeks with an
increasing demands for clinical attending surgeon. In the early months of
productivity, have little opportunity for Description of the Pilot the core outpatient clinics, assisted by the
The HMS–CIC was initiated in July 2004 attending physician in each discipline,
at the Cambridge Hospital, a 118-bed students constructed their panels of
primary teaching hospital within the patients deliberately to reflect a wide
Please see the end of this article for information range of the major presentations and
about the authors. Cambridge Health Alliance and affiliated
with HMS. Volunteers were sought from disease entities as defined by the
Correspondence should be addressed to Dr. Ogur,
Windsor Street Health Center, 119 Windsor Street, the 189 rising third-year Harvard medical representative national specialty
Cambridge, MA 02139; e-mail: (bogur@challiance.org). students; 18 students volunteered, and organizations.

Academic Medicine, Vol. 82, No. 4 / April 2007 397

neurological problems. and. 82. obstetrics– gynecology. and psychiatry. Students followed their written at each encounter and a record of patients longitudinally and participated inpatients by rounding twice a day. deliveries. 2004 to 2005* * Each student had longitudinal ambulatory clinics in internal medicine. some had acute surgical or greatly facilitated by an electronic neurology and psychiatry clinics. No. in gynecologic. diagnoses in their prenatal care. Students took call once a rounds were conducted by the student 398 Academic Medicine. sicker patients and patients in experiences. Students maintained a paper ensure adequate obstetrical experience. Harvard Medical School. approach and consultant’s contributions. whenever possible. admitted. Inpatient internal medicine. or rehabilitation Students were able to follow highly admissions were internal medicine visits. often allowing students to where the goal was to have early. students need of diagnostic evaluation were week in the emergency department. communicating with the house officer team and consultants. newborn care. Over the course of the year. and psychiatric patients were admitted from their longitudinal cohorts and from regular sessions in the emergency department. Educational Innovations Chart 1 Sample Weekly Schedule for a Student in the Harvard Medical School–Cambridge Integrated Clerkship. deliveries. and time spent in each discipline. postnatal seen. each student admitted at least students when their assigned patients presentations. care. and inpatient care mornings a week. Weekly structured. admissions. Four ambulatory primary care practice. pediatrics. 15 acutely ill internal medicine inpatients registered anywhere in the clinical care and patients’ experiences over time. when possible. surgical. emergency department or the ambulatory portfolio consisting of all of the notes students followed at least 10 pregnant care setting. ongoing and. case- based tutorials and weekly social science rounds supplemented the curriculum. the learning topics covered. Vol. a discharge summary. This longitudinal follow-up was specialized cohorts of patients in patients. dedicated teaching general. responses to treatments. and a illnesses were typical of those found in an ensure adequate acute. postdischarge follow-up note. 4 / April 2007 . pediatric. followed these patients to scheduled visits selected. neurology. to consultations benefit from both the generalist’s initial exposure to a patient who was likely to be or for acute care. To whom he or she first saw either in the system. and writing daily Although some of the cohort patients’ Several mechanisms were put in place to notes. Over the course information program that notified providing views of the variations in of the year. Although the majority of these surgical procedures.

All didactic sessions were taught Clinical Science Self-Assessment preceptors and educators (an alternative by experienced faculty educators in the (CCSSA). In their HMS internal medicine clerkships. group consisting of all the remaining consisting of representatives from each of review of portfolios.. during the postoperative exercises to teach skills in diagnosis and both quantitative and qualitative data. and in the purpose of integrating the relevant basic review boards. and the two groups found this deliberately developmental the year and participated in a midyear did not differ significantly on their structure valuable in focusing the assessment retreat. A students worked closely with house through a combination of experiences. from patient logs. the group had a planned derived from midyear and end-of- curriculum on professionalism. Because it was not the participating disciplines. and social sciences. observed psychiatric members of their class. clinical. as is typical for throughout the year with groups of pertinent to the weekly tutorial topic. although they did In the HMS–CIC. communication. 82. experienced tutorials to review the principles of through seven core clerkships. In group students. In attitudes and perceptions. was comprehensive and operating room. to the more traditional inpatient basic. reflective clerkship questionnaires and focus Attending preceptors in ambulatory practice. the Mini. Additionally. and by their assigned the HMS–CIC students to the control and then developed a plan to assist contributions in tutorial sessions. It consisted of a variety of only to see patients during evaluation. student’s progress to date and learning for future practice. cultural groups. in medical procedures. Clinical Evaluation Exercise (Mini-CEX). moving physician– educators—met weekly radiologic and pathologic evaluation from hospital to hospital. sessions on principles of radiology and students who had not been selected in the principal inpatient teaching was done by pathology early in the year to provide random draw for the HMS–CIC. we checked to see students in achieving these skills in a accordance with the practice in other whether these two groups were rational developmental sequence. the radiology and pathology teaching the rest of their class. Although Students learned radiology and pathology experiences. consisted of opportunity to set explicit learning goals In addition to following emergency diseases and syndromes reflecting many and to guide remediation. and in error reduction. and population health as of self-assessment from NBME Subject throughout the course of the year. clinical skills and reasoning. Educational Innovations inpatient teaching attending or master Weekly case-based small-group tutorials needs were documented and discussed. NBME framework derived from the Examinations in Surgery.e. the comparable with one another and with clinics and in tutorials. during which they decreased discipline. Faculty and students student’s progress informally throughout virtually identical. advance by the multidisciplinary students at midyear provided an curriculum committee. and clinical rotating interns and residents). or in their attitudes Academic Medicine. the didactic of patients from the student cohorts. clinician. and after discharge. students had six issues in medicine. Tutorials were systematic. students were a major component of the didactic In conjunction with the student’s self- presented and discussed their inpatients experiences. this formative feedback to at an educationally appropriate level. The by clinical skills evaluations. master they had time dedicated as part of many students in the control group rotated clinicians—preeminent. in their plans teaching and learning. 4 / April 2007 399 . students learned NBME Internal Medicine Subject the rest of their class on several available progressively more complex skills and Examination was not required. using data life of an attending surgeon.5–11 Each tutorial session was The evaluation plan for the pilot their scheduled time in other disciplines based on actual student cases that best program. For assessment activities and the clinical teaching in each preceptors in each discipline. In these rounds. as identified by weeks of a more intensified surgical national organizations representing each Program Evaluation experience. it was Accreditation Council for Graduate Psychiatry. period. These these topics related to their actual Exams and the NBME Comprehensive attending physicians served as the main patients. and Obstetrics–Gynecology— possible to compare the HMS–CIC and Medical Education competencies. At this retreat. In all HMS third-year students. and an attending dedicated to student them with the tools for clinical work.g. Pediatrics. comparison/control group of 11 HMS officers and with the primary admitting They participated in special didactic third-year students was recruited from attending when patients were admitted. control group students against a larger HMS–CIC curriculum committee. first adapted and neurological interviews and case possible to randomly select or to match these competencies for medical students formulations.. addition. admissions and longitudinal cohort of the most common and important patients to surgery. agree to participate in several assessment curriculum (i. from the HMS Objective Structured structure in which teaching is done by Clinical Evaluation (OSCE). selected in assessment. weekly structured case. receiving no special attendings to review films and specimens training or attention. Vol. regular rounds were held with students were treated just as were those in and the formulation of complex cases. by tests of in which all third-year students were discipline have been constructed on a content knowledge—the NBME Subject required to participate (e. approved by both the HMS and and worked directly with attending illustrated the topic of the week for the Cambridge Health Alliance institutional surgeons in clinics. Subject Exams. This enabled them not and clinical science. and from other third-year volunteers. in Domains investigated were student allowed students to witness the real work. The teaching. HMS OSCE). each second-year OSCE scores. teamwork. These students to work on clinical reasoning addition. The mean MCAT and USMLE were given more responsibility over the student’s team of faculty reviewed the Step 1 scores of the two groups were course of the year. it also treatment. further augmented by medical simulation methods and instruments to evaluate during surgery. activities designed for the evaluation of based tutorials and social science rounds) Students were assessed by longitudinal the HMS–CIC. fund of knowledge and accuracy clinics in each discipline taught students competence. No. Tutorial topics. Each measures. on rounds.

through from 46 to 115. Central to the Clear differences were found between the group. 400 Academic Medicine. beginning longitudinal patient cohort sizes ranged to patients of diverse backgrounds. higher than did the patient before diagnosis and following knowledge and clinical skills. all students were their learning with the motivation that varying levels of student participation. when asked.12–14 To assess this.. The evaluation plan determined whether for the education of students: exposure to collect data as efficiently as possible) and the program had achieved its the entire longitudinal course of illness. At the beginning of the objectives. adult logs indicate that HMS–CIC students had professionalism and ethics in the physical exam. the year more rewarding and less of important clinical diagnoses from each marginalizing. patients’ experiences of illness20 and their hypertension.18. health care system. Neither with 28 core diagnoses. A second goal was to ensure that students examination. Also. newborn exam. and the fourth-year HMS traditional students had decreased. fever. the satisfying because of their involvement. arises from having a relevant impact on results obtained from monitoring student patients’ care. had improved retention were principally taught by faculty rather of content knowledge compared with than house officers. depression. four biomedical attaining three of its fundamental goals (e. admission. First. in some occur in the students participating in the before diagnosis and decision for cases significantly better. Thus.001). edema. Importantly. Vol. compared with those of the their discharge?” 100% of the HMS–CIC HMS–CIC faculty involved in teaching students in the control group and the students answered “very often” or rest of the class. TIA/CVA. 82.1% versus creating a continuity of patient care16: the responses to surveys about their 31. Tests of statistical and congestive heart failure. were considerably found their professional lives more “often” compared with 10% of the higher at the end of the year. perform a thorough physical exam. make a human fundamental goals by assessing whether it teaching by experienced faculty. they received almost three times as educational design of the HMS–CIC was HMS–CIC and control group students’ much of their feedback (88. This A third goal was to ensure that students students felt their year had better allowed students to develop meaningful were exposed to a wide range of those prepared them to be truly caring. HMS–CIC of the core clinical disciplines. and connection with the patient.17 imbuing proved to be quite difficult because of year. did the students have the clinical problems. of care also permitted students to witness students. TOMS is a questionnaire that asks significance were performed using t tests students to rank order the importance of or ␹2 as appropriate. Surveys of faculty HMS–CIC students’ communication you seen patients you have treated after satisfaction showed that 82. jaundice. In tests of content significantly.6% of all skills. at least as many contacts with major asthma. anxiety disorder. HMS–CIC students. year. Faculty perceptions of the clerkship were Results from the OSCE indicate that Similarly. longitudinal. comparison group (P ⬍ . treatment. compared with only 20% of traditional students (see Table 1). Both the HMS–CIC students dyspnea. “How often have also positive. the HMS–CIC students ranked opportunity to follow patients through Student outcomes were measured in psychosocial concerns slightly. 4 / April 2007 . somatic symptoms. COPD. HMS–CIC students found from attendings. anemia.g. joint pain. HMS–CIC students’ social context affects patients. and the control group students were schizophrenia. the comparison group (P ⬍ . the HMS–CIC students’ after discharge? Responses to the end-of. identify the had attained several of its structural exposure to a wide breadth of core patient’s goals).5%) and more than twice as much of opportunity for students to follow a perceptions of their third-year their mentoring (77. long. by the end him or her through hospitalization and students’ performance on four NBME of the year. and with initial presentation. interactions with many facets of the asked to log meaningful patient contacts abnormal vaginal bleeding. shock. compared with the control the principal clinical year. headache. Students thus witnessed patients into their longitudinal cohort. to see how the through the evolution of chronic diseases problems. HMS–CIC students responded that they OSCE. four psychosocial (e.g.* The HMS–CIC given the Tasks of Medicine Scale group was significantly different from the students logged equal or more exposure (TOMS)15 to complete at the beginning rest of the HMS third-year class on any of to all of the core diagnoses except shock of their clinical year and at its end. the HMS–CIC students suggesting that ethical erosion did not “very often” or “often” saw patients performed at least as well and. and those of the year survey revealed that 100% of the examination. chest pain. The these measures. confusion. with significant variation to involve patients in decision making differential thinking. than did the HMS–CIC. congestive heart immediacy of real issues.5% versus 37%) cohort of patients reflecting a wide range experience. HIV/AIDS. assessed by traditional students. the program was successful in eight physicians’ tasks.001).19 Continuity clinical diagnoses as did traditional failure. integrated approach to addition. to respond or through acute episodes. the NBME CCSSA scores had increased. subject exams. but not whole illness episodes. However. medical students’ patient-centered the actual illness scripts that form the Although monitoring patient contacts attitudes often erode during their third basis for clinical reasoning. No. to deal connections with patients longitudinally diagnoses selected as core clinical with ethical dilemmas. It has been reported that and outcome. and well child exam. adolescent physical exam. diabetes mellitus.Educational Innovations toward patient-centered care. appendicitis. meeting the several ways. In class). among students in their criteria to enter (see Table 2). and grounding their *Abdominal pain. workup.. as assessed by the whereas only 17.4% found their lives end-of-year multidisciplinary CCSSA either the same or slightly less satisfying. Responses to the that of the control group (this Discussion end-of-year survey indicated that HMS– examination was not given to the We had several goals when we developed CIC students were observed more by students in the remainder of the HMS and piloted the above-described year- attendings and less by house officers.

..... the School of Medicine of Flinders didactics.........35 3..................172 ...22 Actual commitment to improve the health care and mentors............9 70 ...........628 70.........24............ All tutorials were and teachers collectively reviewed and student’s professional development........................ creating a each setting........220 ........................ It also provided curriculum over one year allowed for the programs............................... The scores of the eight students in the HMC–CIC were compared with the scores of 11 students in traditional HMS third-year clerkships and with the scores of all other members of the HMS third-year class.................... with The application of this planned a number of longitudinal clinical attention to remediation......................16 In of the basic and social sciences with Parallel Rural Community Curriculum of each discipline......................................... 4 / April 2007 401 ....................001 1........31 ...................................26 the developmentally progressive....60 na na na ...590 ..........................108 ............................. Vol...........21 Each student’s team of educators emphasis on problem formulation early problem-solving and support as ethical worked together to provide a richer in the year.......................... and professionalism.........................204 ........................................ skills..................12 4......................................9 513........27 and the from all of the major disciplines..................... then progressing to and professional issues arose................ beginning with an faculty also provided intergenerational time............... In organized around key tasks of clinical processed important issues.................. and (3) the Other 170 Students in the Harvard Medical School Third-Year Class.... Surgery Subject Exam 73.................................... longitudinal track at the University of each student’s abilities....... and assessment were structured University of Flinders..............................28 all of to promote progressively more complex The program explicitly sought to preserve which have emphasized the use of skills......... Australia............16 These central student– physicians. based on central to each discipline and provided Course of the University of Cambridge integrating national core competencies the structure for a deliberate integration School of Clinical Medicine....38 ............................. No.............. (2) 11 Students in a Control Group.......... As students achieved benchmarks and nurture students’ idealism........................................ longitudinal relationships mandate to train rural primary care more responsibility in their direct patient with patients................. Psychiatry Subject Exam 70.............................. University of South Dakota.................. 82..............................4 The planned didactic curriculum Minnesota Medical School’s Rural and clinical learning around a also ensured coverage of cross.....................................25 ......924 ........... Comprehensive Clinical Science Self-Assessment 398....................... clinical medicine....................................................................60 81........07 na na na ...13 ................................ Ongoing mentoring by relationship to facilitate learning over developmentally.......................... Educational Innovations Table 1 Mean Scores on End-of-Year Tests of (1) Eight Students in the Harvard Medical School–Cambridge Integrated Clerkship (HMS–CIC)...............................................23 the discipline and across disciplines to assess physical examination..... and the formulation and investigation of Hawaii at Ma˜noa John A...40 77.....................242 ......................8 ...........198 71.......... clinical reasoning.................... HMS OSCE 63.................................143 ......................................... relationships allowed for serial.................................................3...694 ....60 ..... not applicable.........................821 60..... assessment from a variety of perspectives Our program confirms the experiences of on the full range of student abilities......... Learners learning experience and to guide the therapeutics at the end.. planned disciplinary topics as well as topics Cambridge Community-Based Clinical curriculum and assessment............................25 The University of A third goal was to structure didactic care.................22 76.......................................................693 ............................ We longitudinal ambulatory sites for training within and across disciplines........................16 Students were supervised by the curriculum..........007 1............................................ na......417 70................................... Tasks of Medicine Scale ranking of psychosocial tasks (at end of clinical year) 3......................... 2005* Traditional rotation All others in control Effect third-year Effect Assessment measures group HMS–CIC P value size class P value size Ob–Gyn Subject Exam 70............. These supportive student cases representative of the topic system...........................................2 77....043 1............011 ....... learning developed at the University of and service.....................25 ................ providing the time curriculum consisting of weekly tutorials opportunities for self-reflection and and context to establish a collaborative and social science rounds also progressed group reflection............................ intellectual rigor...54 na na na * The end-of-year tests covered content knowledge........ Harvard Medical School (HMS)...87 .....937 72......... faculty believe that students’ idealism arises from third-year students........................ Tasks of Medicine Scale ranking of psychosocial tasks (at start of clinical year) 3....689 ............ Pediatrics Subject Exam 74............................................04 ............437 ..................... The year-long didactic these relationships with curricular experienced faculty...............13 ..... Physician Associate Program..................... including the Yankton Model the possibility of using multiple explicit focus on the cross-disciplinary of the Sanford School of Medicine of the summative methods within each core competencies of history taking................ The goal of our program is to Academic Medicine................128 ....... clinical teaching............................................. often with the assisted them to assume progressively meaningful......... and as a consequence of care.................. similar to the model of task-based community focused on professionalism their longitudinal contacts with students........22 ... longitudinal in explicit training to foster the sense of duty and provide an impetus to relationships with their teams of faculty developmental nature and continuity of their learning............ Burns School clinical questions relevant to the patient’s of Medicine.93 .........................8 .... Students and faculty participated patient connections foster in students a students continuous... and a faculty educators served as role models Dundee School of Medicine...... iterative served as the focus for the discussion.. A second central goal was to provide care.............................. The HMS–CIC supported educators.............................

....... In addition................... and it requires adequate overschedule their clinical and didactic on all those measures that we space for students to see ambulatory experiences.................................... intervention and control groups may institutional administration willingly spontaneously chose to work longer have differed initially in ways that we invested in the program......... regardless of they could teach sufficient content from and operational challenges required a specialty interest.................02 1................... or performance (although the same didactic tutorial curriculum................. 82............ assessment................. cultural/ with clinical sciences required ongoing.... to be a self-reflective practitioner? 5..................................... most critical in generating whatever provided vehicles for collaborative positive effects we observed........ ranking students’ ranking P value Effect size to be truly caring in dealing with patients? 5....................................................................... facilitate the learning of the core traditional departmental teaching....90 ...... Many evolution of the teaching faculty’s knowledge and skills required for the faculty members did not initially believe commitment and ability........21 ...... and operational...... dedicated process of multidisciplinary CIC students learn directly from both They also were concerned about the lack collaboration and governance......................................... political.......................75 4..41 .............. most and skills and of discipline-specific patient care as a vehicle for students to important..............13 3........ to see how the social context affects patients and their problems? 5................ surgery..............34 .......................50 4.... 4 / April 2007 ........................ recognizing its hours than did their traditional peers...01 1. and sleep..................... Vol.......................... Harvard Medical School... 2005* HMS–CIC Question: How much has your clinical year students’ Traditional clerkship prepared you ................88 5.... All of these planning and the resolution of The organizational challenges required factors limit the conclusions that can be differences...... students’ dedication to their knowledge and skills................. learn progressively......... study...50 4...............48 * Ratings were on a scale where 1 ⫽ very poorly and 6 ⫽ very well.....................03 1........ pedagogical. In creates both a cultural ethos and a Students felt conflicted when important addition.........01 1. although the value of the functional unit for traditional training................................10 ................... to relate well to a diverse patient population? 5................ Students............................................. to involve patients in decision making? 5...... The committee developed guidelines to assist group students)........... and faculty time... Fiscal obstacles included the start-up Our intervention was a pilot program of costs of planning and implementing the Operationally. Nor can we identify development of strong multidisciplinary students in prioritizing their time and to which aspects of the intervention were steering and program committees has assist faculty in being flexible............. The program influence could apply to the control oversight...... It will be potential to support the hospital’s This created the need for all disciplines to necessary to see whether the findings of mission to improve education and the adjust the intensity early in the year and this first cohort will be replicated as quality of patient care..................... Leadership The innovative nature of the program support and an ongoing faculty Our pilot was successful in a small prompted significant changes in development program nurtured the hospital with highly motivated faculty 402 Academic Medicine.............................70 ..................................... ...............................70 .................. The model reimburses faculty insufficient exposure to severe or acute also consisted of a small volunteer group....................... were not able to assess.......... And.................... but it is still possible that the patients. and their patients’ care providers.......... meet......10 .................... patient-centered learning experiences intervention has a great deal of face Our program required new cross................................ with randomly chosen but program and the ongoing administrative had concerns about the potential for volunteer participants.................................................... to deal with ethical dilemmas? 5..... Educational Innovations Table 2 Mean Ratings on Six Questions by Eight Harvard Medical School–Cambridge Integrated Clerkship (HMS–CIC) Students and 11 Students in Traditional Harvard Medical School Third-Year Clerkships....... deliberate attention............................... students and controls are studied.............. drawn. space............................................................. one cannot rule out that our disciplinary collaboration and the example................... The political undifferentiated student......................... the consultation. We ensure that HMS– their discipline solely in the office setting. delivery............ ......................... were occurring simultaneously—for validity. inpatient procedure.. Faculty system that permitted students to foundation of broad general knowledge needed to learn to use longitudinal monitor their patients’ visits..........01 1......36 ......03 1......... faculty and students tended to The groups were found to be comparable resident time....40 ..... Resolution generalists and specialists................................................18 .....75 4. because faculty initially small size. Our sense of responsibility to their patients........ motivated by their investigated.... curriculum development.................. No... and mentoring..................................... allowing them of time given to immersion in inpatient of the logistical challenges was greatly to benefit from the important acute medicine and about the lack of aided by an information technology perspectives and skills of each to build a connection with inpatient teams.......... for the patients and enthusiasm for their own didactic curriculum to integrate basic learning engaged them in actively finding There were several types of obstacles sciences and social sciences seamlessly ways to stay in touch with their patients encountered: fiscal/physical.............. teaching time instead of relying on free illness................................................ institutional commitments of money........... The control group costs................................................. a planned clinic follow-up visit students’ motivation at being part of the balancing of interests in the areas of at the same time as a specialty innovation may have influenced their scheduling.... to institute a developmental progression subsequent groups of integrated clerkship Traditional departmental structure of responsibility and expectations.................

connections necessary to enable limit any conclusions about its costs of traditional clerkship training. Our meet their regions’ health care needs. become agents career choices at the end of the first year their principal clinical year. but often hidden. Our pilot List 1 clerkship has shown that not only did Comparison Between Traditional Clerkships and the Harvard Medical students learn and retain content School–Cambridge Integrated Clerkship (HMS–CIC) knowledge and clinical skills at least as Traditional clerkships HMS–CIC well as their traditional counterparts. we believe that the knowledge in each of the core disciplines contributed to the section entitled “Program ongoing costs will not be substantially without spending periods of dedicated Evaluation”. and faculty in the various disciplines. Boston. • Longitudinal patient contact across care incomplete patient encounters venues acquisition of important core skills of doctoring. and social science • Integration natural when grounded in achieving its structural goals and its integration difficult patients outcome goals. we believe especially in larger institutions where show that HMS–CIC students performed it would be feasible to create similar economies of scale and access to patients at least as well in tests of content programs in other medical schools. Similar questions have Massachusetts. with cost per student for an ongoing students can gain a sufficient fund of equal contributions by each. 82. Vol. The medicine. Therefore. but also that this new model of education • Discipline-specific blocks • Integrated year-long experience results in higher levels of self-reported • Inpatient immersion with brief. Massachusetts. • Random patient assignment • Carefully constructed patient cohort • House staff are principal educators of • Trained faculty clinician–educators teach The HMS–CIC is distinctly different students students from traditional third-year medical • Limited longitudinal contact with faculty • Year-long guidance from faculty education (see List 1). with most students and in larger institutions. academic. selecting specialty. that Dr. Boston. the • Discipline-specific skill attainment • “Transcendent” core. for teaching. and collaborative process involved in creating research careers. Hirsh. mentors the model was highly successful in • Basic. No. actively participating in the core evaluating content knowledge content knowledge. clinical. Boston. There are plans to the University of South Dakota since with patients justifies some increased continue to study these HMS–CIC 1991 have succeeded in their missions to expenditure. We knowledge and clinical skills and that examples. meaningful mentoring. Longitudinal relationships with faculty provided students with the time and and administration. diversity of missions and training sites. as long as there is a article. limit our ability to accurately predict the been raised with the HMS–CIC: whether The authors have informed the journal that this article was cowritten by Dr. and that Dr. Ogur and Dr. Boston. our students’ stated benefits in the training of students in and that they will. Ogur is co-course director for the Harvard Medical School–Cambridge Integrated Clerkship and the integrated clerkship model can be clerkship serves not only the teaching assistant professor of medicine at Harvard Medical adapted to medical schools with a program. but the of change for a return to a more effective. diagnostic reasoning. Outcome data generalizability. In its pilot year. implementation. cross-discipline planning. concerns were Dr. it has wider positive School. costs involved in planning and start-up specific learning. We A Promising Model hope is that they will maintain both their believe that our pilot program intellectual rigor and the strong patient- demonstrates the suitability of urban We believe the longitudinal integrated centered attitudes that have been health centers as sites for teaching in this clerkship model offers many potential nurtured by their third-year experience model. skills. implications for the host institution and Dr. Massachusetts. in fact. The HMS–CIC students • Assessment timing is necessarily • Developmentally “right-timed” arbitrary (at end of clerkships) assessments (over the course of the were able to follow a significant number year) of patients through an entire course of • Discipline specific assessment—primarily • Competency-based assessment of illness. do not differ substantially from those of model needs to be studied with more humanistic. although our small size and the would sacrifice the depth of discipline. These factors further higher than the real. Krupat integrated clerkship. Furthermore. Bor contributed to the Academic Medicine. 4 / April 2007 403 . Educational Innovations time immersed in each one. mechanism for providing students with Dr. we believe and implementing an integrated Dr. and skills of doctoring: information professionalism gathering. Krupat is director of the Center for Evaluation longitudinal connections with patients When HMS introduced its New Pathway at Harvard Medical School. Nonetheless. and the provision of comfort and support to the patient. students as they pursue their fourth-year train rural primary care physicians to clerkships and residency training. and skill attainment assessment of therapy. As and specialists curtail unit costs. and fulfilling practice of typical HMS graduates. programs at the University of believe that the value of increased they considered themselves better Minnesota Medical School since 1971 exposure to experienced teachers and of prepared in a number of core and at the Sanford School of Medicine of more meaningful learning experiences professional skills. Hirsh is co-course director for the Harvard including those relying on tertiary for cross-disciplinary patient care— Medical School–Cambridge Integrated Clerkship and specialty ambulatory clinics as the locus benefits that go beyond the scope of this instructor in medicine at Harvard Medical School. Massachusetts. medicine at Harvard Medical School. Bor is chairperson of the Integrated Clerkship raised that a more integrated structure Steering Committee and associate professor in Finally. curriculum 20 years ago.

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Available at: theory and implications. 2001. and George Thibault. and the ambulatory-care settings. Linda 8 Association of Professors of Gynecology and students. primary care as a base for medical education: Education in the United States. FACS. Joseph page. clerkship for third-year medical students. Learning objectives for medical models of clinical clerkships: “continuity” as Writing Group: Maren Batalden. William Silen. grant #281918. Dains JE. PhD. Crosby J. Klickstein.