The Learning Experiences of Medical Students in a Longitudinal Integrated Clerkship and Traditional Block Rotations in Taiwan: A Comparative Mixed-methods Study

10.6145/jme.202109_25(3).0001

Yaw-Wen Chang；Wen-Hui Fang；Wen-Chii Tzeng；Pauling Chu；David A. Hirsh

undergraduate medical education ； longitudinal integrated clerkship ； mix-methods research ； curriculum evaluation ； clinical learning

Journal of Medical Education

25卷3期（2021 / 09 / 01）

139 - 154

英文

Purpose: An increasing number of medical schools are implementing longitudinal integrated clerkships (LICs), but less is known about LICs in tertiary teaching hospitals. This study compares the learning experiences of LIC and traditional block rotation (TBR) students and explores the principle of educational continuity at a metropolitan tertiary teaching hospital in Taiwan. Methods: This mixed-methods study included semi-structured interviews and surveys of fifth-year medical students, including 12 LIC students, who took their clinical clerkships at Tri-Service General Hospital in the academic year 2015/16. A research assistant interviewed LIC and TBR students to explore their learning experiences. The questionnaire asked students about their sense of self-efficacy in practice, experiences of patient follow-up, and clinical supervision. The authors performed qualitative thematic analysis on interview data and analyzed the surveys quantitatively comparing the two clerkship models. Results: Qualitative analysis revealed three main themes: ＂views on the path＂, ＂support from preceptors＂, and ＂being with patients.＂ In these domains, compared to the TBRs, the LIC design appears to have offered different learning experiences to the 5th-year medical students. In the questionnaire data, the LIC students perceived higher self-efficacy on seeing how social context affects patients and their problems and reported having more opportunities to interact longitudinally with patients and preceptors. Conclusions: From the students' perspectives, LIC students had important and different opportunities to interact with their preceptors and patients compared to their TBR peers. From the view of curriculum design, this inpatient-predominant LIC program adhered to the principle of educational continuity.

1. Hirsh DA, Ogur B, Thibault GE et al: "Continuity" as an organizing principle for clinical education reform. N Engl J Med 2007, 356(8):858-866.
   連結：
2. Norris TE, Schaad DC, DeWitt D et al: Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med 2009, 84(7):902-907.
   連結：
3. Worley P, Couper I, Strasser R et al: A typology of longitudinal integrated clerkships. Med Educ 2016, 50(9):922-932.
   連結：
4. Heddle W, Roberton G, Mahoney S et al: Challenges in transformation of the "traditional block rotation" medical student clinical education into a longitudinal integrated clerkship model. Educ Health (Abingdon) 2014, 27(2):138-142.
   連結：
5. Poncelet A, Bokser S, Calton B et al: Development of a longitudinal integrated clerkship at an academic medical center. Med Educ Online 2011, 16.
   連結：
6. Mylopoulos M, Kulasegaram KM, Weyman K et al: Same but Different: Exploring Mechanisms of Learning in a Longitudinal Integrated Clerkship. Acad Med 2020, 95(3):411-416.
   連結：
7. Chu TS, Weed HG, Yang PC: Recommendations for medical education in Taiwan. J Formos Med Assoc 2009, 108(11):830-833.
   連結：
8. Wu TY, Majeed A, Kuo KN: An overview of the healthcare system in Taiwan. London J Prim Care (Abingdon) 2010, 3(2):115-119.
   連結：
9. Cheng WC, Chen TY, Lee MS: Fill the gap between traditional and new era: The medical educational reform in Taiwan. Ci Ji Yi Xue Za Zhi 2019, 31(4):211-216.
   連結：
10. Ogur B, Hirsh D, Krupat E et al: The Harvard Medical School-Cambridge integrated clerkship: an innovative model of clinical education. Acad Med 2007, 82(4):397-404.
    連結：
11. Biernacki P, Waldorf D: Snowball Sampling: Problems and Techniques of Chain Referral Sampling. Sociological Methods & Research 1981, 10(2):141-163.
    連結：
12. Thomas DR: A General Inductive Approach for Analyzing Qualitative Evaluation Data. American Journal of Evaluation 2006, 27(2):237-246.
    連結：
13. O'Brien BC, Harris IB, Beckman TJ et al: Standards for reporting qualitative research: a synthesis of recommendations. Acad Med 2014, 89(9):1245-1251.
    連結：
14. Hirsh D, Gaufberg E, Ogur B et al: Educational outcomes of the Harvard Medical School-Cambridge integrated clerkship: a way forward for medical education. Acad Med 2012, 87(5):643-650.
    連結：
15. Latessa RA, Swendiman RA, Parlier AB et al: Graduates' Perceptions of Learning Affordances in Longitudinal Integrated Clerkships: A Dual-Institution, Mixed-Methods Study. Acad Med 2017, 92(9):1313-1319.
    連結：
16. Walters L, Greenhill J, Richards J et al: Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ 2012, 46(11):1028-1041.
    連結：
17. Ogur B, Hirsh D: Learning through longitudinal patient care-narratives from the Harvard Medical School-Cambridge Integrated Clerkship. Acad Med 2009, 84(7):844-850.
    連結：
18. Gaufberg E, Hirsh D, Krupat E et al: Into the future: patient-centredness endures in longitudinal integrated clerkship graduates. Med Educ 2014, 48(6):572-582.
    連結：
19. Hirsh D, Walters L, Poncelet AN: Better learning, better doctors, better delivery system: possibilities from a case study of longitudinal integrated clerkships. Med Teach 2012, 34(7):548-554.
    連結：
20. Hirsh DA, Holmboe ES, ten Cate O: Time to trust: longitudinal integrated clerkships and entrustable professional activities. Acad Med 2014, 89(2):201-204.
    連結：
21. Hauer KE, O'Brien BC, Hansen LA et al: More is better: students describe successful and unsuccessful experiences with teachers differently in brief and longitudinal relationships. Acad Med 2012, 87(10):1389-1396.
    連結：
22. Teherani A, O'Brien BC, Masters DE et al: Burden, responsibility, and reward: preceptor experiences with the continuity of teaching in a longitudinal integrated clerkship. Acad Med 2009, 84(10 Suppl):S50-53.
    連結：
23. Cuncic C, Regehr G, Frost H et al: It's all about relationships : A qualitative study of family physicians' teaching experiences in rural longitudinal clerkships. Perspect Med Educ 2018, 7(2):100-109.
    連結：
24. Beard AS, Candy AE, Anderson TJ et al: Patient Satisfaction With Medical Student Participation in a Longitudinal Integrated Clerkship: A Controlled Trial. Acad Med 2020, 95(3):417-424.
    連結：
25. Remmen R, Denekens J, Scherpbier A et al: An evaluation study of the didactic quality of clerkships. Med Educ 2000, 34(6):460-464.
    連結：
26. van der Hem-Stokroos HH, Daelmans HE, van der Vleuten CP et al: A qualitative study of constructive clinical learning experiences. Med Teach 2003, 25(2):120-126.
    連結：
27. Seabrook MA, Woodfield SJ, Papagrigoriadis S et al: Consistency of teaching in parallel surgical firms: an audit of student experience at one medical school. Med Educ 2000, 34(4):292-298.
    連結：
28. Christakis DA, Feudtner C: Temporary matters. The ethical consequences of transient social relationships in medical training. JAMA 1997, 278(9):739-743.
    連結：
29. Shahi R, Walters L, Ward H et al: Clinical participation of medical students in three contemporary training models. Med Educ 2015, 49(12):1219-1228.
    連結：
30. Stevens CD, Wilkerson L, Uijtdehaage S: Longitudinal continuity experiences can repair disconnects in the core clerkships for medical students. Acad Med 2014, 89(2):205-207.
    連結：
31. Ash JK, Walters LK, Prideaux DJ et al: The context of clinical teaching and learning in Australia. Med J Aust 2012, 196(7):475.
    連結：
32. Hauer KE, Hirsh D, Ma I et al: The role of role: learning in longitudinal integrated and traditional block clerkships. Med Educ 2012, 46(7):698-710.
    連結：
33. O'Brien BC, Poncelet AN, Hansen L et al: Students' workplace learning in two clerkship models: a multi-site observational study. Med Educ 2012, 46(6):613-624.
    連結：
34. Witte FM, Stratton TD, Nora LM: Stories from the field: students' descriptions of gender discrimination and sexual harassment during medical school. Acad Med 2006, 81(7):648-654.
    連結：
35. Wallbridge T, Holden A, Picton A et al: Does medical students' gender affect their clinical learning of gynaecological examination? A retrospective cohort study. Postgrad Med J 2018, 94(1112):325-329.
    連結：
36. Chang JC, Odrobina MR, McIntyre-Seltman K: The effect of student gender on the obstetrics and gynecology clerkship experience. J Womens Health (Larchmt) 2010, 19(1):87-92.
    連結：
37. Samuriwo R, Patel Y, Webb K et al: 'Man up': Medical students' perceptions of gender and learning in clinical practice: A qualitative study. Med Educ 2020, 54(2):150-161.
    連結：
38. Alliance for Clinical Education: Longitudinal Integrated Clerkships : Principles, Outcomes, Practical Tools, and Future Directions, First edition. edn. North Syracuse, New York: Gegensatz Press; 2016.
39. Chang YW, Hirsh DA, Fang WH et al: Patient perceptions of students in a longitudinal integrated clerkship in Taiwan: a qualitative study. BMC Med Educ 2021, 21(1):153.
40. Miles MB, Huberman AM: Qualitative data analysis : an expanded sourcebook, 2nd edn. Thousand Oaks: Sage Publications; 1994.
41. Creswell JW: Research design : qualitative, quantitative, and mixed methods approaches, 4th edn. Thousand Oaks: SAGE Publications; 2014.
42. Hirsh DA, Singh TA, Saravanan Y et al: Learning in Longitudinal Integrated Clerkships. In: A Practical Guide for Medical Teachers. Sixth edition. edn. Edited by Dent JA, Harden RM, Hunt D. Amsterdam: Elsevier Health Sciences; 2021.
43. Tesson G, Hudson G, Strasser R et al: Making of the Northern Ontario School of Medicine: A Case Study in the History of Medical Education. Montreal, QC, Canada: McGill-Queen's University Press; 2009.
44. O'Brien BC, Hirsh D, Krupat E et al: Learners, performers, caregivers, and team players: Descriptions of the ideal medical student in longitudinal integrated and block clerkships. Med Teach 2016, 38(3):297-305.