This document discusses the strengths and challenges of longitudinal integrated clerkships (LICs) in urban academic medical centers (AMCs). It provides an overview of two LIC programs, PISCES at UCSF and LIFT pilots at Flinders, describing their structures and elements. Unique strengths of LICs in AMCs include access to specialized resources and mentors. Challenges include issues with faculty engagement, continuity of care, and alignment with standard care models. Strategies to mitigate challenges include leveraging technology, rewarding teachers, and focusing on LIC principles of continuity. Student outcomes data shows equivalent or better performance on exams and evaluations for LIC students compared to traditional students.

1. University of California, San Francisco
Longitudinal Integrated Clerkship (LIC) in an
Academic Medical Centre (AMC)
Strengths and Challenges
Ann Poncelet (UCSF)
Bill Heddle (Flinders)
School of Medicine

2. university of california, san francisco
school of medicine
Workshop
LIC in AMC
• Overview and scope
• Introductions—participants’ stages of
development
• Examples of programs (PISCES, LIFT)
• Unique strengths of LIC in AMC
• Unique challenges of LIC in AMC
• Mitigating strategies/Success factors
• Visioning for the future

3. university of california, san francisco
school of medicine
Expected Outcomes
• Understanding
– Unique strengths in establishing LIC in urban AMC
– Unique challenges in establishing LIC in urban
AMC
– Mitigating challenges and leveraging strengths
– Imaging the future of LICs in AMCs
– Developing community of centres using LIC in
AMC

4. university of california, san francisco
school of medicine Overview
• LIC programs started in Rural and Community Settings
• Benefits of such programs have resulted in LIC in
AMCs
• Anticipated benefits of LIC are demonstrated to occur in
urban AMC setting
• There are unique strengths and challenges for LICs in
the urban AMC setting
• Anticipating these unique characteristics are essential
for having a successful urban AMC LIC

5. university of california, san francisco
school of medicine
PISCES
• One-year integrated longitudinal clerkship
(third year) at Urban Academic Medical
Center
• Launched in 2007 with 8 students and
expanded to 16 in 2006 (10% of class)
• >100 students are alumni of the PISCES
program

6. university of california, san francisco
school of medicine PISCES
• Core Elements
– Patient cohort
– Longitudinal Preceptor clinics
– Peer cohort
– Advising/mentoring program
– Longitudinal curriculum
– Emergency room, operating room, and
call sessions
– Inpatient immersion

7. PISCES Structure (streaming)
Medicine clinic
Surgery OR and clinic
Family medicine clinic
Neurology clinic
Psychiatry clinic
Pediatics clinic
OB/GYN clinic
Anesthesia OR and clinic
Surgical subspecialty OR and clinic

8. Sample Student Schedule Week 1
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Surgery
Rounds
7-8am
If students have a patient in their cohort or who they are following after a surgical procedure, they will
round with the team/chief resident in the morning.
Medicine
Rounds
8-9am
If students have a patient in their cohort or who they are following who is in the hospital, they will
round with the team/chief resident in the morning.
AM
Clinic
9 - 12
Internal
Medicine
OB/GYN Surgery
Clinic
Neurology Pediatrics
PM
Clinic
1-5
Self
Directed
&
Cohort
Learning
PISCES
School
or KLIC
Klass
Self
Directed
& Cohort
Learning
Emergency
Department
Self
Directed
& Cohort
Learning
Evening/
Night
6p - 7a
One evening per week, students will take call in the evenings with
Emergency Department, Pediatric ER/Urgent Care or discipline specific call
4 hours.
One weekend day per
month, students will
take call with
Emergency
Department, Pediatric
ER/Urgent Care or
discipline specific call
8 hours.

9. LIFT Pilots
• Challenge - Creating longitudinal
integrated training in setting of siloed and
fragmented health care system (patient
journey fragmented – between inpatient
and ambulatory care and between hospital
units)

10. Examples - Flinders LIFT pilots
• AMC with 70-80 (of 160) year 3 students
• Groups of 8 in 3 LIFT pilots (2013, 2014, 2015)
• LIFT Pilot 1
– As per PISCES except no anaesthesia
– 7 preceptors per student + weekly tutorials
– Not transferable to whole 70-80
– “grass is greener” TBR vs LIFT pilot

11. Change from Pilot 1 to Pilot 2
• As a result of feedback
– Need more ward service
– Need to use resident teaching as well as
consultant teaching
– Limited teaching capacity in Paediatrics

12. LIFT Pilots
• Pilot 2 (2014)
– Unit based attachments with later paediatrics
– Lack of continuity of Faculty
• Pilot 3 (2015)
– Three preceptors for year plus longitudinal in
other disciplines

13. LIFT Pilot 2
• Constrained by need for separate
Paediatric block
• 28 weeks attached to surgical and medical
team
• Continued family medicine weekly
• Weekly “academic tutorials”
• Longitudinal antenatal and psychiatry

14. LIFT Pilot 3 - 2015
• Attachment to surgical and medical unit
and unique consultants per student
• Continued academic program, antenatal,
psychiatry (based on medical patients),
family medicine

16. university of california, san francisco
school of medicine
LIC in Urban AMC
Strengths
• Group Brainstorm

17. university of california, san francisco
school of medicine
LIC in Urban AMC
Strengths (1)
• Teaching experience of faculty
• Faculty development infrastructure already
built in
• Emergency/acute care sessions where
students see undiagnosed patients
• Access to technological resources
including simulation

18. university of california, san francisco
school of medicine
LIC in Urban AMC
Strengths (2)
• Sub-specialization attractive to students
considering academic medicine
• Ability to explore diverse career interests
• Availability of basic scientists as
preceptors who provide academic
mentoring role for students interested in
research

19. university of california, san francisco
school of medicine
LIC in Urban AMC
Strengths (3)
• Authentic and valuable role in assisting
patients with transition of care.
• Students form a valuable peer learning
community that facilitates their learning
and well being
• Builds community of faculty across
disciplines for teaching and patient care

20. university of california, san francisco
school of medicine
LIC in Urban AMC
Challenges
• Group Brainstorm

21. university of california, san francisco
school of medicine
LIC in Urban AMC
Challenges-external
• “Coveritis” (Guilbert)
• Resistance to change
• Inflexibility
• Funding, especially for change management
• Ignorance of educational principles and
outcome data for LIC

22. “coveritis”
• coveritis is `a more or less strong belief or
propensity, conscious or unconscious,
held by a teacher (or a student), leading to
the overwhelming desire to cover a
teaching subject exhaustively or
comprehensively during an academic
course'. (Guilbert Medical Education1998;
32: 65-69).

23. university of california, san francisco
school of medicine
LIC in Urban AMC
Challenges-internal (1)
• Faculty engagement
• Lack of generalists and perception of
subspecialists that they cannot act as
generalists
• Space shortage
• What is the “community” of AMC

24. university of california, san francisco
school of medicine
LIC in Urban AMC
Challenges-internal (2)
• Inpatient versus ambulatory care
• Difficulty of continuity of care (ambulatory)
• Alignment of LIC and standard inpatient
patterns of care
• Adaptation of surgical units to LIC

25. university of california, san francisco
school of medicine
LIC in Urban AMC
Challenges-internal (3)
• Competing priorities
• Changes to medical system, delivery of
patient care
• Productivity pressures
• Curriculum creep
– Internal to LIC
– Overall curriculum

26. university of california, san francisco
school of medicine
LIC in Urban AMC
Mitigating Challenges (1)
• Swaps between subspecialists
• Paired preceptors
• Ensuring continuity with several key
preceptors
• Broad array of clinical experiences to address
gaps (e.g. newborn nursery)
• Rewarding teachers

27. university of california, san francisco
school of medicine
LIC in Urban AMC
Mitigating Challenges (2)
• Leveraging technology
– Automatic pager to connect students and patients
– Scheduling templates that connect students and
preceptors
– Simulation, virtual patients to address gaps

28. university of california, san francisco
school of medicine
LIC in Urban AMC
Success factors (1)
• Leadership support (Deans, Chairs, clerkship
directors, medical center directors)
• Local champions (preceptors, patients, students)
• Involve students in projects that benefit the
system and share outcomes with hospital,
medical center leadership
• Involve students in improving the program

29. university of california, san francisco
school of medicine
LIC in Urban AMC
Success factors (2)
• Evidence to allay concerns
– Performance on written and clinical exams
– Performance on senior rotations
– Career outcomes
• Evidence to demonstrate benefits
– Learner outcomes
– Patient outcomes
– Preceptor outcomes
– System outcomes

30. university of california, san francisco
school of medicine
LIC in Urban AMC
Success factors (3)
• Leverage community of LIC educators (CLIC)
• Resilience! Learn, regroup, redesign, keep trying
• Get involved in partnering with Medical School to
address big challenges (e.g. mission based
management)
• Keep the focus on essential LIC principles
– Continuity with patients
– Continuity with preceptors

31. “The main strength of PISCES is its implicit
assumption, in its structure and execution, that 3rd
year students are capable of doing meaningful,
substantive work. This theme ran through my
interactions with preceptors and cohort patients, and is
more important than any single part of the program.
With the constant context switching, I grew to feel
confident in my clinical skills as something I carry with
me separate from the subculture or preferences of a
specialty or team. My experiences have built a
personal inner standard of the kind of medical care I
would like to deliver, taking into account what patients
most desire in their physician.”

33. Year-End Evaluations: PISCES vs. TRADITIONAL CLERKSHIP
On a scale of 1 to 5 rate your satisfaction with…
1=poor, 5=excellent
Mean (SD)
for PISCES
Students
N=47*
Mean (SD) for
Traditional
Students
N=284*
Overall quality of faculty clinical teaching 4.5 (0.4) 4.3 (0.4)
Overall quality of resident clinical teaching 4.1 (0.8) 3.9 (0.6)
Quality of formal teaching 4.2 (0.6) 4.0 (0.5)
Adequacy of direct observation of your clinical skills 4.3 (0.4) 3.8 (0.5)
Adequacy of feedback on your performance 4.2 (0.5) 3.8 (0.5)
Your achievement of course objectives 4.3 (0.5) 4.2 (0.4)
The clerkship as a whole 4.4 (0.4) 4.2 (0.4)
* PISCES and traditional clerkship students from 2008/2009, 2009/2010 and 2010/2011

34. PISCES End of Year Evaluation: Three year data
Item Mean
2010-
2011
Mean
2011-
2012
Mean
2012-
2013
Faculty teaching quality 4.57 4.57 4.33
Resident teaching quality 4.62 4.57 4.50
Formal Teaching quality 3.86 3.86 3.73
PISCES program clinical skills
4.36 4.29 4.20
instruction
Feedback 4.07 4.00 3.93
Objective Achievement 4.29 4.43 4.13
Preceptorships overall 4.57 4.57 4.40
Patient cohort experiences 4.36 4.29 3.67
PISCES inpatient (admitting and
3.07 2.86 2.87
rounding)
Advisor Program 4.00 3.86 3.60
PISCES overall 4.14 4.14 4.13

35. N Mean (SD)
Internal Medicine Written Exam
Traditional
276 83.1 (8.3)
PISCES
47 84.1 (7.8)
Obstetrics and Gynecology Written Shelf
Exam
Traditional
267 74.2 (8.0)
PISCES
47 74.8 (9.9)
Pediatrics Written Exam
Traditional
266 88.1 (7.7)
PISCES
47 87.7 (9.2)
Psychiatry Written Exam*
Traditional
182 73.6 (7.9)
PISCES
32 76.7 (7.2)
Surgery Written Shelf Exam
Traditional
276 74.9 (9.1)
PISCES
47
76.1 (9.3)
* The PISCES students did not take the same exam as traditional students in 2008/2009.
Hence only two years of comparable data are available.

36. university of california, san francisco
school of medicine
PISCES 1-3
Student Outcomes
• Equivalent to better performance between PISCES
and traditional students on CPX.
• No difference between PISCES and traditional
students in number of clerkship honors received or
mean overall score of student summary items from
faculty evaluations of students.
• Student career interests are in a range of specialties
including primary care and surgical disciplines.

37. Student perceptions of brief and
longitudinal relationships with teachers
Brief Relationships Longitudinal
Relationships
Respect Importance of
preceptors knowing
students’ names,
recognizing them
Preceptor confident in
student, gives
responsibility
Strategies for
teaching
Pimping Patient-centered
Developmental
Power Hierarchical
• Student
accommodates
supervisor
preferences
• Student feels at risk
of being judged
Collaborative
 Non-judgemental
Hauer et al, 2012

38. Student Roles/Processes of Learning
17%
Figure 1. % of session performing direct patient care activities at
each level of participation + % session all other activities
9%
16%
23%
6%
4%
10%
2%
19%
5%
20%
25%
17%
12%
7%
59%
56%
65%
45%
81%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
LIC-Early
(n=16)
LIC-Late
(n=28)
Block-Oupt Early
(n=10)
Block-Outpt Late
(n=8)
Block-Inpt Late (n=8)
Observing
Performing with
assistance / under
observation
Performing alone
All other activities

39. university of california, san francisco
school of medicine
PISCES Patient Narratives
• “Just again, I just want to reiterate and stress how
wonderful [Student] was. Even when I was delivering and
going through my labor, even my mom who was with me
in the labor room, she mentioned that as soon as he
walked in, he really brought a sense of calm to the room.
Especially giving birth for the first time can be a stressful
situation, but he was cool, calm, and collected, and
amazing. I really, really liked the whole experience.” LIC
Pt 637
• “When I had questions, I didn’t present them to the
doctor, she was very open and made me feel at ease, and
allowed me to present questions to her and she could
answer them so I could understand them, in layman’s
terms and not using big, extravagant terms where I
couldn’t understand them.” –LIC pt 596