The Harvard Medical School-Cambridge Integrated Clerkship: An Innovative Model of Clinical Education
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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 397Educational Innovations
Chart 1
Sample Weekly Schedule for a Student in the Harvard Medical
School–Cambridge Integrated Clerkship, Harvard Medical School, 2004 to 2005*
* Each student had longitudinal ambulatory clinics in internal medicine, neurology, obstetrics– gynecology,
pediatrics, and psychiatry. Inpatient internal medicine, pediatric, and psychiatric patients were admitted from
their longitudinal cohorts and from regular sessions in the emergency department. Weekly structured, case-
based tutorials and weekly social science rounds supplemented the curriculum.
Over the course of the year, students need of diagnostic evaluation were week in the emergency department,
followed these patients to scheduled visits selected, often allowing students to where the goal was to have early, ongoing
and, whenever possible, to consultations benefit from both the generalist’s initial exposure to a patient who was likely to be
or for acute care, admissions, deliveries, approach and consultant’s contributions. admitted. Although the majority of these
surgical procedures, or rehabilitation Students were able to follow highly admissions were internal medicine
visits. This longitudinal follow-up was specialized cohorts of patients in patients, some had acute surgical or
greatly facilitated by an electronic neurology and psychiatry clinics, neurological problems. Over the course
information program that notified providing views of the variations in of the year, each student admitted at least
students when their assigned patients presentations, responses to treatments, 15 acutely ill internal medicine inpatients
registered anywhere in the clinical care and patients’ experiences over time. To whom he or she first saw either in the
system. Students maintained a paper ensure adequate obstetrical experience,
emergency department or the ambulatory
portfolio consisting of all of the notes students followed at least 10 pregnant
care setting. Students followed their
written at each encounter and a record of patients longitudinally and participated
inpatients by rounding twice a day,
the learning topics covered, diagnoses in their prenatal care, deliveries, postnatal
seen, and time spent in each discipline. care, and, when possible, newborn care. communicating with the house officer
team and consultants, and writing daily
Although some of the cohort patients’ Several mechanisms were put in place to notes, a discharge summary, and a
illnesses were typical of those found in an ensure adequate acute, surgical, postdischarge follow-up note. Four
ambulatory primary care practice, in gynecologic, and inpatient care mornings a week, dedicated teaching
general, sicker patients and patients in experiences. Students took call once a rounds were conducted by the student
398 Academic Medicine, Vol. 82, No. 4 / April 2007Educational Innovations
inpatient teaching attending or master Weekly case-based small-group tutorials needs were documented and discussed.
clinician. In these rounds, students were a major component of the didactic In conjunction with the student’s self-
presented and discussed their inpatients experiences. Tutorial topics, selected in assessment, this formative feedback to
at an educationally appropriate level. advance by the multidisciplinary students at midyear provided an
curriculum committee, consisted of opportunity to set explicit learning goals
In addition to following emergency diseases and syndromes reflecting many and to guide remediation.
admissions and longitudinal cohort of the most common and important
patients to surgery, students had six issues in medicine, as identified by
weeks of a more intensified surgical national organizations representing each Program Evaluation
experience, during which they decreased discipline.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, 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, on rounds, and in the purpose of integrating the relevant basic review boards, was comprehensive and
operating room. This enabled them not and clinical science. Tutorials were systematic. It consisted of a variety of
only to see patients during evaluation, further augmented by medical simulation methods and instruments to evaluate
during surgery, during the postoperative exercises to teach skills in diagnosis and both quantitative and qualitative data.
period, and after discharge; it also treatment, in medical procedures, in Domains investigated were student
allowed students to witness the real work- teamwork, and in error reduction. In attitudes and perceptions, using data
life of an attending surgeon. addition, the group had a planned derived from midyear and end-of-
curriculum on professionalism, reflective clerkship questionnaires and focus
Attending preceptors in ambulatory practice, communication, cultural groups; fund of knowledge and accuracy
clinics in each discipline taught students competence, and population health as of self-assessment from NBME Subject
throughout the course of the year. These these topics related to their actual Exams and the NBME Comprehensive
attending physicians served as the main patients. All didactic sessions were taught Clinical Science Self-Assessment
preceptors and educators (an alternative by experienced faculty educators in the (CCSSA); clinical skills and reasoning,
to the more traditional inpatient basic, clinical, and social sciences. from the HMS Objective Structured
structure in which teaching is done by Clinical Evaluation (OSCE); and clinical
rotating interns and residents). Although Students learned radiology and pathology experiences, from patient logs. A
students worked closely with house through a combination of experiences. 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, 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, and
an attending dedicated to student them with the tools for clinical work, and from other third-year volunteers. The
teaching. Additionally, master they had time dedicated as part of many students in the control group rotated
clinicians—preeminent, experienced tutorials to review the principles of through seven core clerkships, moving
physician– educators—met weekly radiologic and pathologic evaluation from hospital to hospital, as is typical for
throughout the year with groups of pertinent to the weekly tutorial topic. In all HMS third-year students. These
students to work on clinical reasoning addition, regular rounds were held with students were treated just as were those in
and the formulation of complex cases. the radiology and pathology teaching the rest of their class, receiving no special
attendings to review films and specimens training or attention, although they did
In the HMS–CIC, the didactic of patients from the student cohorts. agree to participate in several assessment
curriculum (i.e., weekly structured case- activities designed for the evaluation of
based tutorials and social science rounds) Students were assessed by longitudinal the HMS–CIC. For assessment activities
and the clinical teaching in each preceptors in each discipline, 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.g., NBME
framework derived from the Examinations in Surgery, Pediatrics, Subject Exams, HMS OSCE), it was
Accreditation Council for Graduate Psychiatry, and Obstetrics–Gynecology— possible to compare the HMS–CIC and
Medical Education competencies. The by clinical skills evaluations, the Mini- control group students against a larger
HMS–CIC curriculum committee, Clinical Evaluation Exercise (Mini-CEX), group consisting of all the remaining
consisting of representatives from each of review of portfolios, observed psychiatric members of their class. Because it was not
the participating disciplines, first adapted and neurological interviews and case possible to randomly select or to match
these competencies for medical students formulations, and by their assigned the HMS–CIC students to the control
and then developed a plan to assist contributions in tutorial sessions. In group students, 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. In their HMS internal medicine clerkships, the comparable with one another and with
clinics and in tutorials, students learned NBME Internal Medicine Subject the rest of their class on several available
progressively more complex skills and Examination was not required. Each measures. 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. Faculty and students student’s progress informally throughout virtually identical, 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. At this retreat, each second-year OSCE scores, in their plans
teaching and learning. student’s progress to date and learning for future practice, or in their attitudes
Academic Medicine, Vol. 82, No. 4 / April 2007 399Educational Innovations
toward patient-centered care. Neither with 28 core diagnoses.* 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
these measures. Tests of statistical and congestive heart failure. TOMS is a questionnaire that asks
significance were performed using t tests students to rank order the importance of
or 2 as appropriate. Thus, the program was successful in eight physicians’ tasks, four biomedical
attaining three of its fundamental goals (e.g., perform a thorough physical exam;
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, four psychosocial (e.g., make a human
fundamental goals by assessing whether it teaching by experienced faculty, and connection with the patient; identify the
had attained several of its structural exposure to a wide breadth of core patient’s goals). At the beginning of the
objectives. First, did the students have the clinical problems. year, the HMS–CIC students ranked
opportunity to follow patients through Student outcomes were measured in psychosocial concerns slightly, but not
whole illness episodes, meeting the several ways. In tests of content significantly, higher than did the
patient before diagnosis and following knowledge and clinical skills, assessed by traditional students. However, by the end
him or her through hospitalization and students’ performance on four NBME of the year, the HMS–CIC students’
after discharge? Responses to the end-of- subject exams, the NBME CCSSA scores had increased, and those of the
year survey revealed that 100% of the examination, and the fourth-year HMS traditional students had decreased,
HMS–CIC students responded that they OSCE, the HMS–CIC students suggesting that ethical erosion did not
“very often” or “often” saw patients performed at least as well and, in some occur in the students participating in the
before diagnosis and decision for cases significantly better, than did the HMS–CIC.
admission, compared with only 20% of traditional students (see Table 1).
the comparison group (P ⬍ .001). Faculty perceptions of the clerkship were
Results from the OSCE indicate that
Similarly, when asked, “How often have also positive. Surveys of faculty
HMS–CIC students’ communication
you seen patients you have treated after satisfaction showed that 82.6% of all
skills, 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, were considerably found their professional lives more
“often” compared with 10% of the higher at the end of the year. Also, the satisfying because of their involvement,
comparison group (P ⬍ .001). HMS–CIC students, as assessed by the whereas only 17.4% found their lives
end-of-year multidisciplinary CCSSA either the same or slightly less satisfying.
A second goal was to ensure that students examination, had improved retention
were principally taught by faculty rather of content knowledge compared with
than house officers. 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. In class). long, longitudinal, integrated approach to
addition, compared with the control the principal clinical year. Central to the
Clear differences were found between the
group, they received almost three times as educational design of the HMS–CIC was
HMS–CIC and control group students’
much of their feedback (88.1% versus creating a continuity of patient care16: the
responses to surveys about their
31.5%) and more than twice as much of opportunity for students to follow a
perceptions of their third-year
their mentoring (77.5% versus 37%) cohort of patients reflecting a wide range
experience. HMS–CIC students found
from attendings. the year more rewarding and less of important clinical diagnoses from each
marginalizing. Importantly, HMS–CIC of the core clinical disciplines. 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, to deal connections with patients longitudinally
diagnoses selected as core clinical with ethical dilemmas, to see how the through the evolution of chronic diseases
problems. HMS–CIC students’ social context affects patients, to respond or through acute episodes, beginning
longitudinal patient cohort sizes ranged to patients of diverse backgrounds, and with initial presentation, through
from 46 to 115, with significant variation to involve patients in decision making differential thinking, workup, treatment,
among students in their criteria to enter (see Table 2). It has been reported that and outcome. Students thus witnessed
patients into their longitudinal cohort. 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,17 imbuing
proved to be quite difficult because of year.12–14 To assess this, all students were their learning with the motivation that
varying levels of student participation, arises from having a relevant impact on
results obtained from monitoring student patients’ care, and grounding their
*Abdominal pain, adolescent physical exam, adult
logs indicate that HMS–CIC students had professionalism and ethics in the
physical exam, anemia, anxiety disorder, appendicitis,
at least as many contacts with major asthma, chest pain, confusion, congestive heart immediacy of real issues.18,19 Continuity
clinical diagnoses as did traditional failure, COPD, depression, diabetes mellitus, of care also permitted students to witness
students. Both the HMS–CIC students dyspnea, edema, fever, headache, HIV/AIDS, patients’ experiences of illness20 and their
hypertension, jaundice, joint pain, newborn exam,
and the control group students were schizophrenia, shock, somatic symptoms, TIA/CVA, interactions with many facets of the
asked to log meaningful patient contacts abnormal vaginal bleeding, and well child exam. health care system.
400 Academic Medicine, Vol. 82, No. 4 / April 2007Educational Innovations
Table 1
Mean Scores on End-of-Year Tests of (1) Eight Students in the Harvard Medical
School–Cambridge Integrated Clerkship (HMS–CIC), (2) 11 Students in a Control
Group, and (3) the Other 170 Students in the Harvard Medical School Third-Year
Class, Harvard Medical School (HMS), 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 70.40 77.13 .204 .628 70.60 .242 .693
...................................................................................................................................................................................................................................................................................................................
Pediatrics Subject Exam 74.22 76.25 .689 .198 71.04 .108 .590
...................................................................................................................................................................................................................................................................................................................
Psychiatry Subject Exam 70.60 81.25 .128 .937 72.13 .011 .924
...................................................................................................................................................................................................................................................................................................................
Surgery Subject Exam 73.2 77.38 .437 .417 70.87 .220 .694
...................................................................................................................................................................................................................................................................................................................
HMS OSCE 63.9 70 .143 .821 60.8 .001 1.31
...................................................................................................................................................................................................................................................................................................................
Comprehensive Clinical Science
Self-Assessment 398.9 513.8 .043 1.07 na na na
...................................................................................................................................................................................................................................................................................................................
Tasks of Medicine Scale ranking of
psychosocial tasks (at start of clinical year) 3.35 3.93 .172 .60 na na na
...................................................................................................................................................................................................................................................................................................................
Tasks of Medicine Scale ranking of
psychosocial tasks (at end of clinical year) 3.12 4.22 .007 1.54 na na na
* The end-of-year tests covered content knowledge, skills, and professionalism. 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. na, not applicable.
A second central goal was to provide care. Students and faculty participated patient connections foster in students a
students continuous, 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. The HMS–CIC supported
educators.16 Students were supervised by the curriculum. The year-long didactic these relationships with curricular
experienced faculty, 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. Ongoing mentoring by
relationship to facilitate learning over developmentally, beginning with an faculty also provided intergenerational
time.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, then progressing to and professional issues arose. Learners
learning experience and to guide the therapeutics at the end. All tutorials were and teachers collectively reviewed and
student’s professional development. In organized around key tasks of clinical processed important issues, creating a
each setting, and as a consequence of care, similar to the model of task-based community focused on professionalism
their longitudinal contacts with students, learning developed at the University of and service, intellectual rigor, and a
faculty educators served as role models Dundee School of Medicine.22 Actual commitment to improve the health care
and mentors. These supportive student cases representative of the topic system.
relationships allowed for serial, iterative served as the focus for the discussion.
assessment from a variety of perspectives Our program confirms the experiences of
on the full range of student abilities, with The application of this planned a number of longitudinal clinical
attention to remediation. It also provided curriculum over one year allowed for the programs, 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, University of South Dakota,23 the
discipline and across disciplines to assess physical examination, clinical reasoning, longitudinal track at the University of
each student’s abilities. and the formulation and investigation of Hawaii at Mãnoa John A. Burns School
clinical questions relevant to the patient’s of Medicine,24,25 The University of
A third goal was to structure didactic care.3,4 The planned didactic curriculum Minnesota Medical School’s Rural
and clinical learning around a also ensured coverage of cross- Physician Associate Program,26 the
developmentally progressive, planned disciplinary topics as well as topics Cambridge Community-Based Clinical
curriculum and assessment, 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,27 and the
from all of the major disciplines.16 In of the basic and social sciences with Parallel Rural Community Curriculum of
each discipline, clinical teaching, clinical medicine. the School of Medicine of Flinders
didactics, and assessment were structured University of Flinders, Australia,28 all of
to promote progressively more complex The program explicitly sought to preserve which have emphasized the use of
skills. As students achieved benchmarks and nurture students’ idealism. We longitudinal ambulatory sites for training
within and across disciplines, faculty believe that students’ idealism arises from third-year students, often with the
assisted them to assume progressively meaningful, longitudinal relationships mandate to train rural primary care
more responsibility in their direct patient with patients.16 These central student– physicians. The goal of our program is to
Academic Medicine, Vol. 82, No. 4 / April 2007 401Educational 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, Harvard Medical School, 2005*
HMS–CIC
Question: How much has your clinical year students’ Traditional clerkship
prepared you . . . ranking students’ ranking P value Effect size
to be truly caring in dealing with patients? 5.75 4.90 .03 1.21
...................................................................................................................................................................................................................................................................................................................
to deal with ethical dilemmas? 5.13 3.70 .01 1.36
...................................................................................................................................................................................................................................................................................................................
to see how the social context affects patients and their problems? 5.75 4.70 .01 1.41
...................................................................................................................................................................................................................................................................................................................
to involve patients in decision making? 5.50 4.40 .03 1.18
...................................................................................................................................................................................................................................................................................................................
to relate well to a diverse patient population? 5.88 5.10 .02 1.34
...................................................................................................................................................................................................................................................................................................................
to be a self-reflective practitioner? 5.50 4.10 .01 1.48
* Ratings were on a scale where 1 ⫽ very poorly and 6 ⫽ very well.
facilitate the learning of the core traditional departmental teaching. Many evolution of the teaching faculty’s
knowledge and skills required for the faculty members did not initially believe commitment and ability. The political
undifferentiated student, regardless of they could teach sufficient content from and operational challenges required a
specialty interest. We ensure that HMS– their discipline solely in the office setting. dedicated process of multidisciplinary
CIC students learn directly from both They also were concerned about the lack collaboration and governance. Resolution
generalists and specialists, 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. Faculty system that permitted students to
foundation of broad general knowledge needed to learn to use longitudinal monitor their patients’ visits. And, most
and skills and of discipline-specific patient care as a vehicle for students to important, students’ dedication to their
knowledge and skills. learn progressively. In addition, 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, cultural/ with clinical sciences required ongoing, and their patients’ care providers.
political, pedagogical, and operational. deliberate attention.
Fiscal obstacles included the start-up Our intervention was a pilot program of
costs of planning and implementing the Operationally, because faculty initially small size, with randomly chosen but
program and the ongoing administrative had concerns about the potential for volunteer participants. The control group
costs. The model reimburses faculty insufficient exposure to severe or acute also consisted of a small volunteer group.
teaching time instead of relying on free illness, faculty and students tended to The groups were found to be comparable
resident time, and it requires adequate overschedule their clinical and didactic on all those measures that we
space for students to see ambulatory experiences. Students, motivated by their investigated, but it is still possible that the
patients, study, meet, and sleep. Our sense of responsibility to their patients, intervention and control groups may
institutional administration willingly spontaneously chose to work longer have differed initially in ways that we
invested in the program, recognizing its hours than did their traditional peers. were not able to assess. 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. to institute a developmental progression subsequent groups of integrated clerkship
Traditional departmental structure of responsibility and expectations. students and controls are studied. In
creates both a cultural ethos and a Students felt conflicted when important addition, although the value of the
functional unit for traditional training. patient-centered learning experiences intervention has a great deal of face
Our program required new cross- were occurring simultaneously—for validity, one cannot rule out that our
disciplinary collaboration and the example, 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, curriculum development, the consultation, delivery, surgery, or performance (although the same
didactic tutorial curriculum, assessment, inpatient procedure. The program influence could apply to the control
oversight, and mentoring. The committee developed guidelines to assist group students). 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. most critical in generating whatever
provided vehicles for collaborative positive effects we observed. All of these
planning and the resolution of The organizational challenges required factors limit the conclusions that can be
differences. institutional commitments of money, drawn.
space, and faculty time. 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, Vol. 82, No. 4 / April 2007Educational Innovations
time immersed in each one. 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, 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, • Longitudinal patient contact across care
incomplete patient encounters venues acquisition of important core skills of
doctoring.
• 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). In its pilot year,
mentors
the model was highly successful in
• Basic, clinical, and social science • Integration natural when grounded in achieving its structural goals and its
integration difficult patients
outcome goals. 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, actively participating in the core
evaluating content knowledge content knowledge, skills, and skills of doctoring: information
professionalism gathering; diagnostic reasoning; the
• Discipline-specific skill attainment • “Transcendent” core, cross-discipline planning, implementation, and
skill attainment assessment of therapy; and the provision
of comfort and support to the patient.
Longitudinal relationships with faculty
provided students with the time and
and administration. These factors further higher than the real, but often hidden,
connections necessary to enable
limit any conclusions about its costs of traditional clerkship training,
meaningful mentoring. Outcome data
generalizability. Nonetheless, 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. As and specialists curtail unit costs. We
knowledge and clinical skills and that
examples, 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. 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.
students as they pursue their fourth-year
train rural primary care physicians to
clerkships and residency training. Our
meet their regions’ health care needs. 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. Furthermore, our students’ stated benefits in the training of students in
and that they will, in fact, become agents
career choices at the end of the first year their principal clinical year, but the
of change for a return to a more effective,
do not differ substantially from those of model needs to be studied with more
humanistic, and fulfilling practice of
typical HMS graduates, with most students and in larger institutions. The
medicine.
selecting specialty, academic, and collaborative process involved in creating
research careers. Therefore, we believe and implementing an integrated Dr. 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; it has wider positive School, Boston, Massachusetts.
diversity of missions and training sites, implications for the host institution and Dr. 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,
for teaching, as long as there is a article. Boston, Massachusetts.
mechanism for providing students with Dr. Krupat is director of the Center for Evaluation
longitudinal connections with patients When HMS introduced its New Pathway at Harvard Medical School, Boston, Massachusetts.
and faculty in the various disciplines. curriculum 20 years ago, concerns were Dr. Bor is chairperson of the Integrated Clerkship
raised that a more integrated structure Steering Committee and associate professor in
Finally, although our small size and the would sacrifice the depth of discipline- medicine at Harvard Medical School, Boston,
costs involved in planning and start-up specific learning. Similar questions have Massachusetts.
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. Ogur and Dr. Hirsh, with
cost per student for an ongoing students can gain a sufficient fund of
equal contributions by each; that Dr. Krupat
integrated clerkship, 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 that Dr. Bor contributed to the
Academic Medicine, Vol. 82, No. 4 / April 2007 403Educational Innovations
conception and design of the program and made influence on teaching and learning. Med American Medical Colleges Central Group on
substantial contributions to revising the article Educ. 2004;38:448–454. Educational Affairs; 2005.
critically for intellectual content.
5 The Medical School Objectives Writing 16 Hirsh DA, Ogur B, Thibault GE, Cox M. New
This article was written on behalf of the HMS–CIC Group. Learning objectives for medical models of clinical clerkships: “continuity” as
Writing Group: Maren Batalden, MD, MPH, Carolyn an organizing principle for clinical education
student education— guidelines for medical
Bernstein, MD, Jeanette Callahan, MD, Pieter Cohen,
schools: report I of the Medical Schools reform. N Engl J Med. 2007;356:858 – 866.
MD, David Elvin, MD, Martha Garcia, MD, Elizabeth
Gaufberg, MD, Slava Gaufberg, MD, Arundhati Objectives Project. Acad Med. 1999;74:13–18. 17 Schmidt HG, Norman GP, Boshuizen HPA. A
Ghosh, MD, Wendy Gutterson, MS, Kitt Shaffer, 6 SGIM/CDIM Core Medicine Clerkship cognitive perspective on medical expertise:
MD, PhD, and Derri Shtasel, MD, all of whom Curriculum Guide. Available at: theory and implications. Acad Med. 1990;65:
contributed significantly to the creation, (http://www.im.org/AAIM/Pubs/Docs/CDIM 611–621.
implementation, and oversight of the project. CurriculumGuide/TableofContents.htm). 18 Bordage G. Elaborated knowledge: a key to
Accessed December 26, 2006. successful diagnostic thinking. Acad Med.
Acknowledgments 7 Gelb DJ, Gunderson CH, Henry KA, Kirshner 1994;69:883–885.
HS, Józefowicz RF. The neurology clerkship 19 Spencer J, Blackmore D, Heard S, et al.
The authors acknowledge the following, who
core curriculum. Neurology. 2002;58:849– Patient-oriented learning: a review of the role
made substantial contributions to the project:
852. of the patient in the education of medical
Ronald Arky, MD, Nicole Baumer, HMS IV, Jack
D. Burke Jr., MD, MPH, Steve Carter, Linda 8 Association of Professors of Gynecology and students. Med Educ. 2000;34:851–857.
Chin, MS, Malcolm Cox, MD, Jules Dienstag, Obstetrics. Women’s Healthcare 20 Christakis DA, Feudtner C. Temporary
MD, Chelsea Elander Flanagan Bodnar, MD, Competencies: Sample Learning Objectives matters; the ethical consequences of transient
James Gordon, MD, Kathleen Harney, MD, for Undergraduate Medical Education. social relationships in medical training.
Carol Hulka, MD, Dennis Keefe, MBA, Judy Crofton, Md: APGO Women’s Healthcare JAMA. 1997;278:739–743.
Klickstein, MS, Katharine Kosinski, MD, David Education Office; 2001.
21 Haidet P, Stein HF. The role of
Link, MD, Joseph Martin, MD, PhD, William 9 The Curriculum Committee of the student–teacher relationship in the formation
Meikrantz, MD, PhD, Robert Meyer, MD, Association for Surgical Education. The of physicians. J Gen Intern Med.
Stephen Pelletier, PhD, Richard Pels, MD, Steven Manual of Surgical Objectives: A Symptom 2006;21(suppl 1):S16–S20.
Schwaitzberg, MD, FACS, Gary Setnik, MD, and Problem-Based Approach. Available at: 22 Harden RM, Crosby J, Davis MH, Howie PW,
FACEP, William Silen, MD, Bruce Solomon, (http://www.surgicaleducation.com/mc/ Struthers AD. Task-based learning: the
MBA, MPH, Todd Thompson, MD, Joseph page.do?sitePageId⫽28592#table1). Accessed answer to integration and problem-based
Velletri, Ronald Weintraub, MD, Tom December 16, 2006. learning in the clinical years. Med Educ. 2003;
Workman, MD, and George Thibault, MD. 10 Alliance of Medical Student Educators in 34:391–397.
Radiology. National Medical Student 23 Hansen LA, Talley RC. South Dakota’s third-
Funding for the project was provided by
Curriculum in Radiology. Available at: year program of integrated clerkships in
Cambridge Health Alliance, the New York (http://www.aur.org/amser/AMSER_national
Academy of Medicine, grant #281918, and the ambulatory-care settings. Acad Med. 1992;67:
_curriculum.html). Accessed December 16, 817–819.
Academy at HMS. Simulation-based teaching 2006.
modules were provided with support from the 24 Anderson AS, Martell JV. Comparing
Gilbert Program in Medical Simulation at 11 Council on Medical Student Education in sequential clerkships and a longitudinal
Harvard Medical School and the Center for Pediatrics. COMSEP Module Curriculum. clerkship for third-year medical students.
Medical Simulation, Cambridge, MA. Available at: (http://www.unmc.edu/ Acad Med. 1994;69:418–419.
Community/comsep). Accessed December
16, 2006. 25 Frattarelli L, Kamemoto LE Obstetrics and
gynecology medical student outcomes:
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