Presidential Address: On the Need for Continuity in Medical Education

Dimensions of integration, continuity and longitudinality in clinical clerkships

CONTEXT

Over the past few decades, longitudinal integrated clerkships (LICs) have been proposed to address many perceived short-coming of traditional block clerkships. This growing interest in LICs has raised broader questions regarding the role of integration, continuity and longitudinality in medical education. A study with complementary theoretical and empirical dimensions was conducted to derive a more precise way of defining these three underlying concepts within the design of medical education curricula.

METHODS

The theoretical dimension involved a thematic review of the literature on integration, continuity and longitudinality in medical education. The empirical dimension surveyed all 17 Canadian medical schools on how they have operationalised integration, continuity and longitudinality in their undergraduate programmes. The two dimensions were iteratively synthesised to explore the meaning and expression of integration, continuity and longitudinality in medical education curriculum design.

RESULTS

Integration, continuity and longitudinality were expressed in many ways and forms, including: integration of clinical disciplines, combined horizontal integration and vertical integration, and programme-level integration. Types of continuity included: continuity of patients, continuity of teaching, continuity of location and peer continuity. Longitudinality focused on connected or repeating episodes of training or on connecting activities, such as encounter logging across educational episodes. Twelve of the 17 schools were running an LIC of some kind, although only one school had a mandatory LIC experience. An ordinal scale of uses of integration, continuity and longitudinality during clerkships was developed, and new definitions of these concepts in the clerkship context were generated.

CONCLUSIONS

Different clerkship designs embodied different forms and levels of integration, continuity and longitudinality. A dichotomous view of LICs and rotation-based clerkships was found not to represent current practices in Canada, which instead tended to fall along a continuum of integration, continuity and longitudinality.

Have we lost our way?

There are many serious problems that beset society in general and medicine in particular. Some are related to the social and economic revolution that currently involves the world and will necessarily affect the practice of surgery. There is considerable evidence to indicate that one of the main battlefronts in this revolution is the practice of surgery. A review of five aspects of our current professional life has emphasized the complexity and significance of the problems with which we are confronted. It would seem that we are responsible for some of these problems and the associated confusion. In many instances, and perhaps most, it would appear that our problems and the related attempts at their solution have developed with the planning and help of other political, social, and legal groups, and often to their advantage but to the disadvantage of our patients and us. In our effort to find solutions to these problems, a vicious cycle has been established which, in turn, has produced deleterious effects and the impairment of surgical practice. As changes have been introduced in rapid succession, confusion and frustration have occurred. To eliminate confusion, committees have been appointed to solve the problems. In most instances the solutions developed by committees produced more problems which, in turn, required the appointment of still more committees which also created problems along with the development of their solutions. Consequently, the pace of academic and hospital functions has progressively increased to the point that a professional time and energy drain has been created. As the professional energy drain has increased, there has been a decrease in patient care and a breakdown of the system provided to supply this care, due in large measure to the erosion of the surgeon's time by administrative, committee, and various other nonprofessional activities. With the breakdown of hospital surgical practice, a loss of direction and a loss of control have developed.