This presentation summarizes a study conducted by researchers at the University of Notre Dame Australia that used the Harvard Medical School-Cambridge Integrated Clerkship tool to measure attributes of professionalism in final year medical students. The study found that female students scored higher than male students in patient-practitioner orientation, though there was no significant difference between students in metropolitan versus rural clinical schools. The researchers concluded the pilot study provided a baseline to measure the effects of longitudinal integrated clerkships on professionalism attributes in the medical curriculum going forward.

1. How do we compare?
Longitudinal Integrated Clerkships:
A snapshot of an Australian Rural Clinical School
curriculum for final year medical students
Dr Andrew Dean MBBS FACEM
Dr Zelda Doyle PhD
Presented at MUSTER - October 2014
Andrew.dean@nd.edu.au
Zelda.doyle@nd.edu.au

2. Presenter disclosure
• Dr Andrew Dean MB BS FACEM
• Head of Ballarat Rural Clinical School
• School of Medicine Sydney
• University of Notre Dame Australia (UNDA)
• Dr Zelda Doyle PhD
• Epidemiologist
• Rural Clinical School
• School of Medicine Sydney
• University of Notre Dame Australia
• Relationships with commercial interests:
– Grants/Research Support: UNDA sponsored our attendance at MUSTER 2014
– Speakers Honoraria/Consulting Fees: nil
– Other: Dr Andrew Dean is employed by St John of God Hospital, Ballarat, Victoria,
Australia.

3. Outline of Presentation
• 1. The UNDA Medical Course Curriculum
• 2. ‘Ethical erosion’ and the Longitudinal
Integrated Curriculum
• 3. Our Study Results
– How do our students perform on measures of
ethical erosion, using the HMS-CIC tool?
– Is there a rural / metropolitan difference?

4. Presenter disclosure
• Dr Andrew Dean MB BS FACEM
• Head of Ballarat Rural Clinical School
• School of Medicine Sydney
• University of Notre Dame Australia (UNDA)
• Dr Zelda Doyle PhD
• Epidemiologist
• Rural Clinical School
• School of Medicine Sydney
• University of Notre Dame Australia
• Relationships with commercial interests:
– Grants/Research Support: UNDA sponsored our attendance at MUSTER 2014
– Speakers Honoraria/Consulting Fees: nil
– Other: Dr Andrew Dean is employed by St John of God Hospital, Ballarat, Victoria,
Australia.

5. Disclosure of Commercial Support
• This paper has not received commercial support
• Authors’ conflicts of interest: nil declared
• No commercial product or company will be endorsed
during this presentation

6. Mitigating Potential Bias
• Neither researcher participated in data collection
• Neither researcher spoke with students about the
study
• Student participation was voluntary

7. Course Structure
UNDA School of Medicine Sydney
• 4 year Post-graduate MB BS course ~ 112 student intake per
year
• ‘Foundation Years’
– All students based in Sydney for first and second year
• ‘Clinical Years’
• Third year rotations within Sydney, Melbourne,
Hawkesbury and Auburn clinical schools
– Fourth year rotations within metropolitan and rural clinical
schools

8. Course Structure
UNDA School of Medicine Sydney
• MED1000: Foundations of a Medical Vocation
– Basic Sciences, four PBL sessions per week in groups of 8
students; all tutors are practicing clinicians
– LOGOS programme in Theology, Ethics and Philosophy
• MED2000: Systematic Preparation for Clinical Practice
– Ongoing Basic Sciences, PBL sessions in groups of 8
• MED3000: Apprenticeship in Clinical Practice
– 8 x 5 week Clinical Rotations, weekly Back to Base days
• MED4000: Preparation for Internship
– 8 x 4 week Clinical Rotations, weekly Back to Base days

9. MED4000 (Final Year)
• 25% MED4000 spend final year in a Rural Clinical
School (RCS) in WaggaWagga, Lithgow or
Ballarat
• 75% MED4000 remain in Metropolitan Clinical
Schools in Sydney or Melbourne, with a 4 week
RCS rotation.

10. ‘Professionalism’ teaching at UNDA
• Ethics and Philosophy units in MED1000
and MED2000 (the LOGOS programme)
• Active clinician tutors mentor groups of 8
students throughout the PBL programme
• The Back to Base programme in MED3000
and MED4000 incorporates ethics,
interpersonal communication and
professionalism

11. Preparation for Internship (PRINT)
• A weekly tutorial programme throughout MED4000
with expert clinician facilitator
• Case scenarios involve ethical dilemmas, also
personal and professional development issues for the
group to discuss.

12. UNDA PRINT tutorial programme
Example of a PRINT tutorial learning objectives (Week 5 GI Bleeding) :
Week 5 - GI Bleeding
By the completion of this PRINT tutorial the student should be able to
• Assess and manage a patient with a GI bleed.
• Maintain professionalism in dealing with situations in the workplace that are
provocative and open to interpretation.
• Know how to access sources of information on standard hospital protocols.
• Know how to use evidence-based medicine tools appropriately.
• Seek help from senior colleagues when needed.
• Know how to use self-awareness to overcome individual hidden biases.
• Develop a way of incorporating self-care into professional life.

13. ‘Ethical atrophy’ in medical courses
• Traditional block rotations structure during the
clinical training years may lead to an ‘erosion of
positive attitudes between entry and graduation’
(6)(8), including a
– Decline in ‘patient centredness’
– Decline in empathy, and a
– Decline in professionalism

14. Modelling and mentoring
• Students in clinical rotations commonly identify a
‘disconnect between the values espoused by
(hospital clinical) faculty, versus those that are
modelled’ (6)
• “Unprofessional behaviours by medical students
predict future behaviours” (1)(7)

15. Longitudinal Integrated Clerkships
• How can we avoid the ‘erosion of ethics and
professionalism’ in medical students?
(2)(3)(5)(8)
• The Longitudinal Integrated Clerkship (LIC) model for
the clinical years emphasises
– Continuity of patient care
– Continuity of curriculum
– Continuity of supervision
– Continuity of idealism

16. Measuring ‘positive attributes of
professionalism’ in medical students
The Harvard Medical School-Cambridge
Integrated Clerkship (HMS-CIC) tool was
developed to compare positive attributes of
professionalism in students undertaking the
LIC programme with a control group
undertaking a traditional block rotation
model
(2)(3)(4)(5)

17. Teaching professionalism
• The literature suggests that a longitudinal
integrated curriculum (LIC) model strengthens
positive attributes and attitudes, compared to
the traditional ‘block rotations’ in the principal
clinical years (2)(3)(5)(8)
• Mentoring and role-modelling is an integral
component of LIC (2)(4).
• We wanted to benchmark our curriculum, which
incorporates ongoing mentoring, against an
established LIC programme, by using the HMS-CIC
tool

18. Participants and Settings
• The study was approved by UNDA Human
Research and Ethics Committee
• Student participation was voluntary
• Researchers were blinded to student participation
• HMS-CIC questionnaires were made available to
all 109 metro (81) and rural (28) MED4000
students
• “Metro”: Sydney and Melbourne Clinical Schools
• “Rural” : Lithgow, WaggaWagga and Ballarat
Rural Clinical Schools

19. Methods
• We measured baseline numerical values for a sample
of our MED4000 students using the HMS-CIC tool for
the following indicators of professionalism
– Patient – Practitioner Orientation Scale (PPOS)
• Sharing PPOS, Caring PPOS (range 1 – 6)
– Tasks of Medicine Scale (ToM)
• Bio-Medical ToM, Psycho-social ToM (range 1 – 6.5)

20. Results: gender and location
• In 2014, 61% of the 109 students in the MED4000
cohort are female, which correlates with the gender
ratio in the survey sample

21. Metro vs Rural PPOS and ToM

22. Results: Is rural better?
• No significant difference between UNDA rural and
metro clinical schools, for PPOS and ToM scores

23. Gender differences in PPOS (for whole sample)

24. Results: Does gender matter?
• PPOS for females significantly higher than for males
(p=0.003)
• Metro cohort: no significant difference between
males and females
• Rural cohort: significant differences between males
and females

25. Gender differences: Rural cohort

26. PPOS score: Metro v Rural
Metro
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Caring Sharing Mean
Male Female
Rural
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Caring Sharing Mean
Male Female

27. Discussion
• Of the MED4000 students, females score higher
in PPOS than males, but more significantly in the
rural cohort
• Overall, we did not demonstrate significant
difference in PPOS or ToM between metro and
rural sample cohorts, suggesting either
– Equivalence in student attitudes or experiences, or
– Sampling bias

28. Limitations of the study
– Self-selection by participants
– Overall, a 50% response rate for the year
cohort
– No previous measurements of this cohort, in
the early years of their medical course
– No comparisons with medical courses in
other Universities

29. Future research
• This is a pilot study to provide a baseline
measurement of the ‘positive qualities of
professionalism’ within our 2014 MED4000
student group.
• We can use the HMS-CIC tool to survey / compare
the effects of LIC programmes introduced to the
future UNDA medical curriculum

30. Acknowledgements
• University of Notre Dame Australia, School of Medicine
Sydney, Rural Clinical School for funding and support for the
project
• Dr David Hirsh, for allowing use of the HMS-CIC survey tool

31. References
• 1. Murden RA, Way DF, Hudson A, Westman JA. Professionalism
deficiencies in a first-quarter doctor-patient relationship course predict
poor clinical performance in medical school. Academic Medicine
2004;79(10): s46-s48 .
• 2. Strasser R, Hirsh D. Longitudinal integrated clerkships: transforming
medical education worldwide? Medical Education 2011;45:436-437.
• 3. Ogur B, Hirsh D, Krupat E, Bor D. The Harvard Medical School-Cambridge
Integrated Clerkship: an innovative model of clinical education. Academic
Medicine Apr2007;82(4):397-404
• 4. O’Brien BC, Poncelet AN, Hansen L, Hirsh DA, Ogur B, Alexander EK,
Krupat E, Hauer KE. Students’ workplace learning in two clerkship models:
a multi-site observational study. Medical Education 2012;46:613-624.

32. References
• 5. Ogur B, Hirsh D. Learning through longitudinal patient care – narratives
from the Harvard Medical School-Cambridge Integrated Clerkship.
Academic Medicine July2009;84(7):844-850
• 6. Krupat E, Pelletier S, Alexander EK, Hirsh D, Ogur B, Schwartzstein R. .
Can Changes in the Principal Clinical Year Prevent the Erosion of Students’
Patient-Centered Beliefs? Academic Medicine May2009; 84(5): 582-586.
• 7. Teherani A, O’Sullivan PS, Lovett M, Hauer KE. Categorization of
unprofessional behaviours identified during administration of and
remediation after a comprehensive clinical performance examination
using a validated professionalism framework. Medical Teacher
2009;31(11):1007-1012.
• 8. Hirsh DA, Ogur B, Thibaullt GE, Cox M. “Continuity” as an organising
principle for clinical education reform. NEnglJMed Feb2007;356(8):858-
866.

33. Thankyou
Dr Zelda Doyle
Dr Andrew Dean
MUSTER
October 2014