By Yun Tran, MD, MPH; Assistant Professor, Burnett School of Medicine at TCU; Staff Physician, Department of Family Medicine at JPS Health Network
On the last day of practice with the medical student whom I had been precepting for over two years, I couldn’t help but become emotional as I reflected on how the relatively new model of medical education called Longitudinal Integrated Clerkship (LIC) has reignited my passion for medicine.
Three years ago, I resigned from a primary care physician position in a large healthcare system. I was burned out and ready to give up medicine altogether. I enrolled in a Masters of Public Health program, thinking that I would transition away from direct patient care.
Then a phone call came just as I was in the midst of grappling with biostatistics and epidemiology. The chair of the family medicine department at TCU’s Burnett School of Medicine was looking for a course director for the first-year medical student clerkship. My name came across his desk because I had expressed interest in precepting a medical student when I was still working at the aforementioned healthcare system, which had an affiliation agreement with the new medical school. He saw that I was trained at the JPS Family Medicine residency and talked to the program director, who recommended me for the course director position.
Although I had years of experience teaching residents and medical students in the past, I had only a vague understanding of what the duty of a course director at this new medical school entailed. The medical school was two years old at the time and only provisionally accredited. However, with this position, I could see patients on a part-time basis at a county clinic. This would do beautifully while I worked on my MPH degree.
So I jumped in.
The learning curve that followed was steep and difficult, but it was also one of the most rewarding journeys I have taken in my life.
First, I had not considered fully the responsibility of crafting the course curriculum, which involved much more than simply sending students to clinics to learn from their preceptors. I was tasked to develop learning objectives, curate educational materials, and create written assignments to assess students’ learning. Fortunately, the course director before me had a curriculum that I could use as a blueprint to redesign and improve.
Second, the medical school has built based on an LIC, a concept that was foreign to me. In an LIC, throughout the first year, the students are paired with a primary care physician in the community. They go to clinic approximately every other week for a year to learn how to take a history, conduct a physical exam, and practice clinical reasoning, oral presentation, and documentation. The students concurrently take all of their other courses, including clinical skills with standardized patients. My job is to help prepare the students so that they can successfully transition into the second year, where they will have both inpatient and outpatient rotations in their eight core specialty clerkships that are longitudinal.1
Those were formidable challenges on their own, but the most intimidating prospect of my new position, in fact, was having to precept a medical student.
Recall that I was a burned-out and possibly somewhat cynical physician at the time. My fear was that I was going to discourage my student just as she started her first year of medical school. As much as I was unsatisfied with my career in medicine, I understood the need for developing the physician workforce and I still cared about people. I did not want my student to decide medicine was not for her after having me as her preceptor.
So with apprehension, I started this new phase of my career with my brand-new medical student, whose enthusiasm on her first day in the clinic motivated me to be on my best behavior. I took extra care to be a better listener when my patients talked, remembered to ask open-ended questions and wait for them to finish speaking without interruption, and summarized their problems and the plan of action while making sure that I had answered all their concerns. When my student asked me a question I was not too sure about, I acknowledged my ignorance and encouraged her to find the answer and teach me. One of her activities that day was to shadow a patient from their check-in to check-out to gain the patient’s perspective, and during her debriefing, she described how I had helped put the anxious patient at ease during the visit, and she hoped to learn to do the same.
Little did she know that her comment had put me at ease. I had not corrupted her view of medicine on her first day in the clinic. More importantly, I was not faking compassion with the patients. I truly relished being there for my patients and advising them to the best of my ability. I enjoyed the practice of medicine again!
Over the following year, my student grew to be someone who could conduct a full history and physical exam. She could also present her assessment and propose management plans. And by pending orders and having a useful chart note for me, she made me a more efficient clinician. I was also able to evaluate our course curriculum from the perspective of a preceptor. Being an MPH student at the same time also gave me a unique perspective about the needs of students, particularly adult learners. Both roles helped me tremendously as I worked to enhance the curriculum. The clinic itself also went through a transformation. At first, the nurses and medical assistants were inexperienced in navigating the intricacies of having a medical student who would be there long term, but they adapted and grew to value the partnership with the medical student as well.
When my student returned in her second year to complete her family medicine clerkship, she quickly grew to function at a sub-intern level. The patients appreciated having a medical student that they knew and frequently gave her compliments, which boosted her confidence in her ability to become an empathetic physician. I also benefited. As I witnessed my student’s development, her curiosity and eagerness to acquire knowledge, and her caring attitude, I was able to learn much more from her than information on the most up-to-date medicine that she obtained from concurrent clerkships. I also gained a sense of immense fulfillment, knowing that I had a part in putting forth into the world a physician who will be trustworthy, patient-centered, and always in pursuit of continuing education and self-improvement.
On my student’s last day with us, there was a Thanksgiving potluck at the clinic. As she was saying thanks to the staff members who had been her colleagues over the last couple of years, a surge of mixed emotions overcame me. My student would not return after that day, so there was sadness. There was also pride in how “grown up” she was. She was no longer green and unsure. Rather, she was confident, mature, responsible, while still compassionate, humble, and driven to explore and learn. Above all, there was gratitude. After two and a half years of having the privilege to serve as my student’s preceptor, not only had I not ruined her outlook on medicine, but I had also been gifted with a renewed commitment and a purposeful future.
There are many people for me to thank: My program director who recommended me; my chair, who trusted me to learn on the job and perform; and the senior leaders at the medical school, who guided me as they allowed me the freedom to put my vision of what a first-year clerkship could be into reality. I participated in the process that resulted in full accreditation of our avant-garde school, and I witnessed the construction of our school building near the historic grounds of what was once Fort Worth Medical College, the school that had graduated Dr. Frances Daisy Emery Allen, the first woman to complete medical school in Texas. I am thankful to be connected to this exciting part of Fort Worth history as our school is making history again with innovative and progressive initiatives in medical education.
I thank my medical student. She made me a better physician, a better educator, and a much better person altogether. As I have also completed my MPH degree at the same time as this transition, it feels as if I am being propelled into a new phase of my career while she begins the next step in hers. I am full of hope and optimism. I have no doubt I will feel sadness for each subsequent medical student when their time with me is concluded, but I also know that I will feel pride and gratitude over and over and that will serve as fuel for me to continue my work in healthcare.
Notes:
1. This experience changed my career and could also impact yours. Please reach out if you are interested in learning more. An LIC student in their second year may be in the pediatric clinic one morning, the psychiatry clinic in the afternoon, and the operating room the next day. For each core clerkship, they are paired with a preceptor, and they go to each clerkship every week for nearly a year. Hence, it is longitudinal, and the idea is that the student will integrate knowledge and skills from concurrent clerkships to make them better-rounded physicians, and they will not forget information like they might in block rotations. This is a curriculum design known as interleaving. Another component of LIC is for each student to have a panel of patients that they follow over many months to strengthen their ability to deliver empathetic, patient-centered care in addition to learning about disease progression over time. Patients often value these relationships with the medical students and feel more satisfied with the quality of their care.
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