This document describes a study analyzing clinical log entries from medical students participating in a longitudinal integrated clerkship (LIC) in regional, rural, and remote areas of Australia. The analysis found that 14.8% of patient presentations involved repeat experiences with the same patients. Student narratives revealed that LIC fostered a sense of belonging within the healthcare community, supported their development of professional skills and abilities, and helped them recognize their own humanity in their role as doctors. The conclusion states that LIC has great potential to shape future physicians if preceptors, practices, hospitals, and patients welcome students into the community of practice.

1. “I followed him all the way”
The continuity-of-care experiences of
longitudinal clerkship medical students
Kathryn Weston, David Garne, Nicky Hudson,
John Bushnell, Sheree Lloyd
Graduate School of Medicine
University of Wollongong, NSW
Australia

2. We have no conflict of interest
to disclose
Weston KM, Garne DL, Hudson
JN, Lloyd S, Bushnell JA

3. Aim
To describe the continuity-of-care
experiences of a cohort of
longitudinal integrated
clerkship medical students
placed in regional, remote or
rural settings in Australia.
3

4. About the course…
• 4-year course
• Active engagement: “Tell me and I forget, teach me
and I remember, involve me and I learn.” Benjamin
Franklin 1706-1790
• Graduate entry
• Small cohorts 68 to 85 students per year
• Case-based learning approach

5. 5
12 month longitudinal
placement
Phase 3
Year 1 Year 2 Year 3 Year 4
Phase 1 Phase 2 Phase 4
Phase 3: Extended integrated
community placement in rural /
regional primary and hospital
care with electronic case based
learning core

6. 6
Phase 3
student clinical log entries
Year 1 Year 2 Year 3 Year 4

7. Analysis of clinical log entries
• 2010 cohort, entered Phase 3 in 2012 for 12
months
• 80 students provided 21,664 entries (av. 270
entries per student)
• 20 students ‘coded’ patients so we could analyse
continuity of care experiences
• 14.8% of presentations involved repeat
presentation experiences
7

8. Age group for repeat (>1) presentations
8
35
30
25
20
15
10
5
0
Prem to
>1
1 to 4 5 to 14 15 to 24 25 to 44 45 to 64 65 to 74 75+
Percentage of continuity experiences
Age range (years)

9. Location of continuity of care encounter
9
Location %
GP only 86.9
Hospital only 5.3
GP + hospital 4.6
Other 3.1

10. Increased re-presentations with
increasing patient age
10
100
80
60
40
20
0
Number of repeat
presentations
Prem-<1 1 to 4 5 to 14 15-24 25-44 45-64 65-74 75+
Percentage of each type of
repeat presentation
Age range (years)
2
3
4
5
6
7
8
9

11. Beyond the numbers…
What do the clinical log narratives
reveal about the student
continuity of care experiences?
11

12. Students ‘belonging’ in the
community of practice
12

13. Belonging
13
I was present during the labour and due to my
rapport with the patient and family I was able be
more involved with the labour, supporting the
midwives. My preceptor assisted me with hands
over hands to perform the delivery of a healthy
boy weighing 3452g with APGARs of 8 and 9.

14. Belonging
This man had been lost to the system and was on a
slippery downward slope. I saw him on a regular
basis. On the first consultation he was very
reserved and quite defensive when questioned
about his alcohol consumption. Over the
consultations I developed good rapport and over
the course of the year we managed to
significantly reduce his alcohol consumption, gain
better control of his diabetes and managed to get
him to have a colonoscopy, which was a massive
task for him.
14

15. Belonging
Primary ovarian cancer. I saw this lady multiple
times before the summer holidays with a
number of complications. …… It was difficult to
leave knowing she probably wouldn't survive
until I returned 6 weeks later.
15

16. Developing professionalism;
students becoming
16

17. Professionalism; becoming
renal failure ..Seeing this patient at the beginning
of phase 3 would have been extremely difficult.
Having seen him numerous times now and being
familiar with his case means that I am now better
able to manage such a complex patient. It makes
me realise the importance of continuity of care in
such patients. I was really proud after seeing
him, as I realised how far I have come and how
my abilities have increased dramatically.
17

18. Professionalism; becoming
I followed him all the way through presentation
with the ambulance, his stay in the district
hospital, thrombolysis and eventually to his
transfer to hospital for query pericarditis. …Even
the cardiologist was not sure what the patient
had. It showed to me that you need to manage
the patient first and that the diagnosis can come
later. I am not a magician.
18

19. Students recognition of their own
humanity in their role as a doctor
19

20. Humanity
I had previously seen the patient for ante-natal
visits. She felt ashamed about post-natal depression.
… I was able to relate to her situation as I had
experienced some of these feelings after the birth of
my daughter. ….The patient seemed to be relieved
that other people had felt like her and that she was
not abnormal. She was then able to open up more
about her feelings and feel less embarrassed.
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21. Humanity
21
I have seen this patient weekly for about a month
with her husband. They are a lovely elderly couple
and I always enjoyed the appointments… I
discussed the case with my preceptor - one of the
few cases I have had in which the point was not to
cure the patient of an illness but to walk with
them as they approached death. My preceptor
discussed the unique position a doctor is in at the
end of their patient’s life and the part we play.

22. My preceptor discussed the unique position
a doctor is in at the end of their patient’s
life and the part we play.
• Belonging
• Becoming
• Humanity

23. Conclusion
LIC has great potential to provide for early
experiences that shape the futures of our doctors.
Impossible without the preceptors, practice staff,
hospitals, other teachers in the community and
the patients, who accept and embrace the
students into the community of practice.
Many thanks to the students for their narratives
and insight.