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An Integrated Model for Radiology Education

Development of a Year-long Curriculum in Imaging with Focus on Ambulatory and Multidisciplinary Medicine

      Rationale and Objective

      In 2004, Harvard Medical School initiated a pilot program, the Cambridge Integrated Clerkship, in which students study the core third-year medical disciplines in a longitudinal yearlong experience. In this paper, the authors describe the design of the radiology portion of this program and compare outcomes to those of students in a traditional curriculum.

      Materials and Methods

      Students in the integrated curriculum were compared to students in traditional clerkships on the basis of Objective Structured Clinical Examination cases, final exams, fourth-year comprehensive exam scores, and choice of specialty.

      Results

      Scores on Objective Structured Clinical Examination cases and imaging final exams were not statistically different between the two groups, but Integrated Clerkship students had statistically lower scores on final exams. Integrated Clerkship students scored higher on the fourth-year radiology comprehensive exam than traditional students, but differences were not statistically significant. Choice of radiology as a specialty was not statistically different between the two groups.

      Conclusions

      Teaching radiology in an integrated yearlong curriculum is feasible, with a minimal drop in exam scores but no changes in other evaluative measures and no decrease in the choice of radiology as a specialty. The program may give students a better appreciation of the role of radiology in an ambulatory setting and in relationship to other specialties.

      Key Words

      Changes in the US health care delivery system, with shortening of hospital stays and a shift toward ambulatory care, have had a negative impact on the educational environment for medical students during many clinical rotations (
      • Irby D.M.
      Educational continuity in clinical clerkships.
      ,
      • Watson R.T.
      Rediscovering the medical school.
      ,
      • Christakis D.A.
      • Feudtner C.
      Temporary matters. The ethical consequences of transient social relationships in medical training.
      ). In the traditional hospital-based intensive-immersion model of clinical education, medical students have less time with patients and fewer substantial duties in patient care, with little emphasis on generalist or primary care skills (
      • Whitcomb M.E.
      Redesigning clinical education: A major challenge for academic health centers.
      ,
      • Rivo M.L.
      With conviction, commitment and creativity: promoting generalism and the preparation of the generalist physician.
      ). Some traditional clerkships have responded by increasing outpatient experiences or changing the proportion of time in acute care environments, but these changes may be difficult depending on the specific practice setting. In an attempt to rethink the way third-year medical students are trained, a pilot program was developed at a teaching hospital with extensive ambulatory sites, Cambridge Health Alliance, a teaching hospital of Harvard Medical School (HMS), that included a major shift away from hospital-based settings as well as integration over a yearlong period of all core disciplines, including radiology (
      • Hirsh D.
      • Gutterson W.
      • Batalden M.
      • et al.
      The Harvard Medical School Cambridge Integrated Clerkship.
      ,
      • Ogur B.
      • Hirsh D.
      • Krupat E.
      • Bor D.
      The Harvard Medical School-Cambridge Integrated Clerkship: an innovative model of clinical education.
      ).
      In this paper, we describe the methodology and evolution of the radiology component of the Cambridge Integrated Clerkship. Preliminary results comparing student outcomes on summative radiology examinations are presented, as well as information on residency selection by students in the traditional clerkship compared to the Integrated Clerkship over the past 4 years. Future plans for the program are also presented, along with a discussion of the limitations of this approach.

      Materials and methods

      Initial Clerkship Design

      Beginning in 2004, HMS launched a pilot program involving eight students in an integrated curricular model for the third year of medical school (
      • Hirsh D.
      • Gutterson W.
      • Batalden M.
      • et al.
      The Harvard Medical School Cambridge Integrated Clerkship.
      ,
      • Ogur B.
      • Hirsh D.
      • Krupat E.
      • Bor D.
      The Harvard Medical School-Cambridge Integrated Clerkship: an innovative model of clinical education.
      ,
      • Hirsh D.A.
      • Ogur B.R.
      • Thibault G.E.
      • Cox M.
      Continuity as an organizing principle for clinical education reform.
      ). Students studied all HMS-required core clerkship topics (medicine, surgery, obstetrics and gynecology, pediatrics, neurology, psychiatry, and radiology) simultaneously in a longitudinal manner over a 1-year period. Each discipline developed its own longitudinal curriculum to maximize opportunities for experiential and didactic integration. Weekly multidisciplinary tutorial sessions were developed that included a spectrum of topics chosen to facilitate broad thinking about clinical scenarios, emphasis on basic science, and use of actual clinical cases from student panels (
      • Cohen P.A.
      • Hirsh D.A.
      • Ogur B.R.
      • Elvin D.M.
      • Antam A.M.
      • Bor D.H.
      A novel year-long learner centered tutorial for third-year medical students.
      ,
      • Elvin D.M.
      • Hirsh D.A.
      • Ogur B.R.
      • Cohen P.A.
      • Bor D.H.
      Teaching translation: formally incorporating basic science into a third-year medical school curriculum reinforces lessons learned.
      ). Attempts were made to distribute time proportionally for all disciplines relative to their time allotments in the traditional curriculum. The number of patients followed by students during the fourth year of the program, for which the most reliable data are available, is shown in Table 1. On average, students followed 64 patients longitudinally during the course of the year. Student institutional review board approval was obtained for evaluation of the pilot Integrated Clerkship.
      Table 1Patients Followed by Students in the Cambridge Integrated Clerkship, Year 4, by Discipline
      StudentMedicineNeurologyObstetrics/GynecologyPediatricsPsychiatrySurgeryTotal
      Number of total patients in each discipline considered to be “longitudinal,” self-reported by students, on the basis of the number, length, and quality of encounters.
      Visits
      Number of total patient visits considered to be “meaningful,” self-reported by students.
      124878151274540
      2175101720574432
      312111048449411
      4221981781892666
      5111330220125
      61766255867529
      71999824776579
      84751571149337
      99992015971523
      10209518111376482
      11181108111462414
      Average15.77.77.51311.39.464.5459
      Number of total patients in each discipline considered to be “longitudinal,” self-reported by students, on the basis of the number, length, and quality of encounters.
      Number of total patient visits considered to be “meaningful,” self-reported by students.
      The eight students in the initial year were selected by lottery from all third-year students who volunteered to participate in the pilot program. In the initial year, students received five 3-hour introductory didactic and case-based sessions covering the basics of radiology during July and August (Table 2). After this introduction, students received additional didactic instruction in imaging as it pertained to topics covered in weekly tutorial sessions. Tutorials were student-led weekly multidisciplinary 4-hour sessions with topics selected by consensus among all disciplines, including both common presenting symptoms and common diseases and disorders. A list of tutorial topics is provided in Table 3, with indications of which topics included imaging components.
      Table 2Introductory Radiology Topics in the Cambridge Integrated Clerkship, Years 1 to 4
      VariableYear 1Year 2Year 3Year 4
      Total number of sessions5542
      Total number of hours151452
      Topic list1. Introduction to chest radiography, plain films1. Chest radiography, plain films1. Course organization, chest radiography1. Course organization, overview of radiology
      2. Introduction to CT, KUB2. KUB, CT, IR2. CT, MR2. Basics of image interpretation, terminology
      3. Brain and spinal MR and CT3. Neuroimaging3. Ultrasound
      4. Ultrasound, nuclear medicine4. Ultrasound, nuclear medicine, abdominal imaging4. Other areas
      5. MSK imaging, trauma, systems and safety5. MSK imaging, safety
      CT, computed tomography; IR, interventional radiology; KUB, kidneys, ureter, and bladder; MR, magnetic resonance; MSK, musculoskeletal.
      Table 3Comparison of Tutorial Topics, Years 1 and 4, in the Cambridge Integrated Clerkship, with Indication of Those That Included Radiology
      VariableYear 1Year 4
      Total number of tutorials4341
      Tutorials with radiology30 (70%)29 (71%)
      Topic list1. Introduction to small-group learning (smoking cessation)
      Topic that included radiology.
      1. Understanding clinical research
      2. Well child/newborn
      Topic that included radiology.
      2. Introduction to small-group teaching
      Topic that included radiology.
      3. Pregnancy
      Topic that included radiology.
      3. Pediatrics, prevention
      Topic that included radiology.
      4. Jaundice
      Topic that included radiology.
      4. Geriatrics
      5. Joint pain
      Topic that included radiology.
      5. Prenatal care
      Topic that included radiology.
      6. Fever
      Topic that included radiology.
      6. Adolescence
      7. Glomerular disease
      Topic that included radiology.
      7. Personality disorders
      8. Shortness of breath
      Topic that included radiology.
      8. Lower extremity edema
      Topic that included radiology.
      9. Somatic symptoms9. Acute abdominal pain
      Topic that included radiology.
      10. Confusion10. Confusion
      Topic that included radiology.
      11. Headache
      Topic that included radiology.
      11. Pediatric fever
      Topic that included radiology.
      12. Low back pain
      Topic that included radiology.
      12. Pelvic pain
      Topic that included radiology.
      13. Abnormal vaginal bleeding
      Topic that included radiology.
      13. Unexplained somatic symptoms
      14. Pelvic pain
      Topic that included radiology.
      14. Shortness of breath
      Topic that included radiology.
      15. Breast lump
      Topic that included radiology.
      15. Abnormal uterine bleeding
      Topic that included radiology.
      16. Lower extremity edema
      Topic that included radiology.
      16. Headache
      Topic that included radiology.
      17. Chest pain
      Topic that included radiology.
      17. Chest pain
      Topic that included radiology.
      18. Sadness, hopelessness18. Breast lump
      Topic that included radiology.
      19. Acute renal failure
      Topic that included radiology.
      19. Sadness
      20. Alcoholism
      Topic that included radiology.
      20. Pregnancy and its complications
      Topic that included radiology.
      21. Substance abuse21. Anxiety, including PTSD
      22. Asthma
      Topic that included radiology.
      22. Fluid and electrolytes
      23. COPD
      Topic that included radiology.
      23. Alcoholism and substance abuse
      24. Congestive heart failure
      Topic that included radiology.
      24. Schizophrenia
      25. Pediatric CHF
      Topic that included radiology.
      25. Diabetes mellitus
      26. Depression, anxiety26. Hypertension
      Topic that included radiology.
      27. Type 1 diabetes, diabetes in pregnancy
      Topic that included radiology.
      27. Congestive heart failure
      Topic that included radiology.
      28. Type 2 diabetes, obesity
      Topic that included radiology.
      28. HIV
      Topic that included radiology.
      29. Acid-base balance29. Colon cancer
      Topic that included radiology.
      30. Acute abdomen
      Topic that included radiology.
      30. Pediatric asthma
      Topic that included radiology.
      31. HIV
      Topic that included radiology.
      31. Pediatric leukemia
      32. Hypertension
      Topic that included radiology.
      32. Obesity
      33. TIA/CVA
      Topic that included radiology.
      33. Low back pain
      Topic that included radiology.
      34. Movement disorders34. Seizure disorders
      Topic that included radiology.
      35. Schizophrenia35. Stroke
      Topic that included radiology.
      36. Potassium balance and management36. Liver and gallbladder disease
      Topic that included radiology.
      37. Shock
      Topic that included radiology.
      37. Renal disease
      Topic that included radiology.
      38. Anemia
      Topic that included radiology.
      38. Student directed (4)
      Topic that included radiology.
      39. Renal function, salt and water management
      40. Adolescent behavior
      41. Student-led tutorials (3)
      Topic that included radiology.
      CHF, congestive heart failure; chronic obstructive pulmonary disease; CVA, cerebrovascular accident; HIV, human immunodeficiency virus; PTSD, posttraumatic stress disorder; TIA, transient ischemic attack.
      Topic that included radiology.
      During tutorials, preceptors from different disciplines as well as basic scientists discussed the topics from different perspectives. For each tutorial, a lead faculty member as well as a lead student planned the afternoon activities and selected readings for distribution online prior to the session. As noted in Table 2, 60% of tutorials included radiology components. In the final quarter of the first year, on the basis of student and faculty perceptions of a need for more time devoted to imaging, weekly radiology rounds were instituted to provide additional opportunity for discussion of general imaging principles, using cases from student panels. During rounds, radiology faculty members occasionally presented short didactic sessions based on areas of perceived deficiency.
      Each student was provided with a compact disc containing additional teaching materials, including interactive case-based modules on common imaging problems, sample multiple-choice-question (MCQ) exam items, and review modules. Students had access to online resources that had been previously used in a traditional monthlong clerkship. Students were encouraged to visit the radiology department and to shadow in six defined areas: fluoroscopy, computed tomography and magnetic resonance, ultrasound, mammography, interventional radiology, and general radiology. Students were asked to select cases from among their patient panels and prepare digital case discussions in the final quarter of the year, to be presented to the entire student group.
      In the final week of the first year of the course, students' clinic schedules were decreased to provide more flexible time to study for the final radiology exams, while still maintaining their large panels of patients. The radiology exams were identical to the exams given in a traditional 1-month radiology clerkship at one of the other university sites, to allow for comparison of scores. The final exam consisted of two parts: an MCQ-style exam concerning factual information about radiology and an online image-based exam testing interpretive skills. At the midpoint of the year, students completed two one-on-one Objective Structured Clinical Examination (OSCE) case discussions in a single evening session that consisted of digital images with a series of structured questions. These same cases had been in use in past years in a traditional 1-month radiology course and cumulated scores from past years were available for comparison for each case. During their study week, students had access to a dedicated computer learning lab as well as a selection of textbooks.
      At the beginning of the fourth year of medical school, all students at HMS are required to take a comprehensive exam that consists of OSCE stations that include radiology. Cumulated information regarding student performance on the imaging portion of this exam was available for the students in the Integrated Clerkship as well as for students at all other traditional 1-month clerkship sites at HMS.

      Changes in Clerkship Design in Subsequent Years

      In the second year of the program, eight students were again selected by lottery from among all students who volunteered. Students were given a radiology textbook in July, and the introductory radiology didactic sessions in July and August were shortened to 14 total hours (Table 2). Students were again requested to arrange time to shadow in radiology and to prepare cases for digital presentation in the final quarter of the year. Weekly radiology rounds began earlier in the year, in September. Students were not given time off from their other clinical assignments to study for the radiology final exams (MCQ and imaging exams), which were administered in the final quarter of the year along with other shelf exams and evaluative exercises for the other disciplines. Students completed eight one-on-one OSCE case discussions beginning in the second half of the year, completing two or three cases per 30-minute session.
      In the third year of the program, the number of students was increased to 11, again selected by lottery from all interested students. Students again received a textbook in the first week of the course, and introductory radiology sessions in July were shortened to 5 hours (Table 2). Students completed shadowing in all areas of radiology during July and August and filled out questionnaires on each area observed. Weekly radiology rounds began in August and were increased to 1.5 hours per week. In addition to bringing active cases to rounds for discussion, students were assigned specific imaging topics on a monthly basis and presented specific examples of these imaging modalities during rounds to be sure that all topics were represented. In August, no specific topics were assigned to allow general discussion of imaging principles. Topics beginning in September included chest imaging, gastrointestinal imaging, genitourinary imaging, musculoskeletal imaging, ultrasound, neuroradiology, nuclear medicine, magnetic resonance imaging, and interventional radiology. Students prepared either online case reports on one of their patients for submission to an open-source online journal (Radiology Case Reports) or presented brief didactic talks on cases at departmental grand rounds in the third quarter of the year. Each student completed eight OSCE case discussions, beginning in the second quarter of the year. Final exams (MCQ and imaging exams) were given in June, with no additional study time or decrease in clinic assignments.
      In the fourth year of the program, the number of students remained at 11. Students received a textbook in July, and introductory didactic sessions in July were shortened to two 1-hour sessions introducing general concepts of imaging, radiation safety, and the specialty of radiology (Table 2). Students demonstrated completion of all shadowing experiences in radiology by filling out a questionnaire on each area. Rounds began in August, and students were again assigned specific topics to bring to rounds on a monthly basis. Students were required to work in groups of two or three to prepare both online case reports and didactic presentations on one of their cases in the third quarter of the year. Students were encouraged to also prepare posters on their cases for a hospital-wide research poster conference in the third quarter of the year. Each student completed eight OSCE case discussions, two of which were administered online rather than in person. Each week during the first half of the year, a case of the week was posted online for discussion in weekly rounds, to coincide with the topic for each given month. Two images for description were posted online for students to e-mail written responses for individual critique on use of terminology. For five of the weekly tutorial sessions, online image previews were prepared and included in the assigned readings prior to the session. Students were e-mailed MCQ-style questions on a weekly basis in the final quarter of the year to help them prepare for final exams. Final exams (MCQ and imaging exams) were completed in the fourth quarter of the year, without extra study time.

      Comparison to Traditional Clerkship

      Total time allotted for radiology teaching by faculty members in each year of the Integrated Clerkship was tallied and compared to the time spent teaching in a traditional clerkship. There were 38 total students in the integrated program with final exam and OSCE data for evaluation. Since 2000, there were cumulated score data available for the MCQ and imaging final exams from 205 students at one HMS site in a traditional clerkship, as well as data from OSCE case discussions for 102 students in the same traditional clerkship. Comprehensive exam data were available for 23 of the students who had completed the Integrated Clerkship program and for 457 students in all other traditional clerkship sites. Residency selection data for all students at HMS were compared to those for students who completed the Integrated Clerkship.
      Statistical comparisons were performed using Student's t test and Fisher's exact test. Statistical significance was set at P < .005 to compensate for possible effects of multiple comparisons.

      Results

      Total time allotted for radiology teaching in the traditional and integrated models is shown in Table 4. In the Integrated Clerkship, the amount of time planned for radiology in each tutorial session did not always correlate with the actual time spent. Radiology was often scheduled at the end of the tutorial afternoon and was frequently shortened if the tutorial went over time. When feasible, the assigned radiologist for the tutorial would try to attend as much of the session as possible, to be able to give an imaging perspective on the multidisciplinary discussion. However, because of scheduling constraints, the time spent by radiologists in tutorial might be as short as 30 minutes. Each year of the clerkship, faculty tutorial leaders gained sophistication in planning activities, so that the scheduled time for radiology in tutorials more accurately reflected the actual teaching time. Overall, the amount of time spent by radiology faculty members with students on the Integrated Clerkship was approximately one third more than for a traditional clerkship, as shown in Table 4.
      Table 4Comparison of the Amount of Time to Teach Radiology per Student, Traditional Clerkship Versus Cambridge Integrated Clerkship
      ClerkshipDuration of Course (wk)Total Didactic Sessions (h) per StudentTotal Observation Sessions (h)Total Contact Hours per YearDifference
      Traditional
      Based on information from a traditional required third-year course in radiology at a different site within the same school.
      440 (60) L8 (24)85
      1 (1) C
      Integrated
      Based on schedules from the fourth year of the Cambridge Integrated Clerkship program.
      4949 (74) R2 (6)114+34%
      30 (30) T
      4 (2) O
      2 (2) C
      C, case report consultation; L, lectures; O, Objective Structured Clinical Examination sessions; R, radiology rounds; T, tutorial.
      Based on information from a traditional required third-year course in radiology at a different site within the same school.
      Based on schedules from the fourth year of the Cambridge Integrated Clerkship program.
      In the third year of the program, eight of the 11 students chose to work on case reports. Three students worked on cases individually, all of which were accepted for publication in Radiology Case Reports (http://radiology.casereports.net). Two students collaborated on a case that was accepted. Three students worked on a case that they did not submit, because the intern who was involved in the case wanted to submit it to a medicine journal. In the fourth year of the program, 11 of 11 students submitted five case reports, all of which were accepted for publication.
      Final exam scores for the traditional and Integrated Clerkships are shown in Table 5. In the first year of the Integrated Clerkship, students had more time for study immediately prior to the final exams, but students' clinical schedules were not adjusted in any subsequent year. Average scores on the final MCQ exam in years 2 and 3 of the Integrated Clerkship were significantly lower than those of the students in the traditional clerkship, and the cumulated scores over all Integrated Clerkship years were significantly lower than those of the traditional students for the MCQ final exam. There were no significant differences between the Integrated Clerkship students and students in the traditional clerkship for the imaging final exam in any year, and no significant differences in cumulated scores over all Integrated Clerkship years compared to students in the traditional clerkship for the imaging final exam. Comparison of scores for the MCQ final exam and imaging final exam for traditional versus Integrated Clerkship students is shown graphically in Figure 1.
      Table 5Comparison of Final Exam Scores, OSCE Scores, and Comprehensive Exam Scores, Traditional Clerkship Versus Cambridge Integrated Clerkship
      VariableCumulated Traditional
      Cumulated from bimonthly clerkships from 2000 to 2005.
      Year 1 IntegratedYear 2 IntegratedYear 3 IntegratedYear 4 IntegratedCumulated Integrated
      Cumulated from 2004 to 2008.
      Number of students20588111138
      Final MCQ exam score81 ± 7.6, 98/5779 ± 6.6, 84/64 (.53)72 ± 5.8, 80/63 (.003)76 ± 3.7, 82/70 (.001)75 ± 7, 88/68 (.015)75 ± 6.1, 88/63 (.00001)
      Final imaging exam score82 ± 7.8, 100/6085 ± 9.3, 98/72 (.34)76 ± 7.7, 89/67 (.054)80 ± 6.3, 89/67 (.32)80 ± 5.2, 89/71 (.16)80 ± 7.5, 98/67 (.15)
      OSCE cases
      Traditional clerkship student data available from 2002 to 2004 only (n = 102).
      74 ± 8, 94/5468 ± 7.9, 82/61 (.05)72 ± 9.2, 83/57 (.46)73 ± 6.5, 81/60 (.6)80 ± 7.7, 88/59 (.05)74 ± 8.7, 88/57 (.64)
      Comprehensive exam, radiology
      Comprehensive exam represents cumulated data from 457 students from the traditional clerkship and 23 students from the Integrated Clerkship.
      68 ± 18.5, 100/5N/AN/AN/AN/A72 ± 20.3, 100/10 (.37)
      MCQ, multiple-choice-question; N/A, not available; OSCE, Objective Structured Clinical Examination.
      Data are expressed as mean ± standard deviation, maximum/minimum (P value). P values compare each year of Integrated Clerkship students and the cumulated total of Integrated Clerkship students with the cumulated traditional clerkship students.
      Cumulated from 2004 to 2008.
      Traditional clerkship student data available from 2002 to 2004 only (n = 102).
      Cumulated from bimonthly clerkships from 2000 to 2005.
      § Comprehensive exam represents cumulated data from 457 students from the traditional clerkship and 23 students from the Integrated Clerkship.
      Figure thumbnail gr1
      Figure 1Graph of final exam scores, Objective Structured Clinical Examination (OSCE) scores, and comprehensive (comp) exam scores, traditional clerkship versus Cambridge Integrated Clerkship (Int). MCQ, multiple-choice-question.
      OSCE case discussion scores for the traditional clerkship and Integrated Clerkship are shown in Table 5. In the fourth year of the program, two of the OSCE cases were converted to an online format, and these are indicated in the table. Cumulated data for these same OSCE cases were available from 3 years of students in a traditional clerkship (mid-2002 to mid-2005). OSCE case score comparison is also shown graphically in Figure 1. OSCE scores rose each year during the Integrated Clerkship. The overall average of the 4 years for the Integrated Clerkship students was not statistically different from that of the cumulated data for students in a traditional clerkship.
      Final comprehensive exam scores for fourth-year students who had completed traditional clerkships versus third-year Integrated Clerkships are shown in Table 5 and Figure 1. Yearly comparisons were performed for students in the Integrated Clerkship who took the comprehensive exam in 2004, 2005, and 2006 and showed no statistical difference compared to the cumulated traditional students who took the exam in each of these years. Because many students take extra time for research after completing their third-year courses, and before taking the comprehensive exam, it is not possible to determine which individual Integrated Clerkship students were taking the exam in any given year, so only cumulated results are presented in Table 5 and Figure 1.
      Two students from the Integrated Clerkship have chosen radiology as a career from among the 38 students who completed years 1 through 4, or 5%. Over the years from 2004 to 2008, 49 students from the total students in the match of 803 at HMS have chosen radiology as a career, or 6%. The difference between these two groups in terms of choice of radiology as a career was not statistically significant.

      Discussion

      In 1910, Abraham Flexner changed the way medical students in the United States were taught, introducing the concept of medicine as a scholarly activity and mandating the association of each medical school with a university (
      • Dornan T.
      Osler, Flexner, apprenticeship and “the new medical education.”.
      ,
      • Cooke M.
      • Irby D.M.
      • Sullivan W.
      • Ludmerer K.M.
      American medical education 100 years after the Flexner report.
      ,
      • Flexner A.
      Medical education in the United States and Canada. From the Carnegie Foundation for the Advancement of Teaching, bulletin number four,1910.
      ). In the 1970s, many schools made major changes to the way the first 2 years of medical school are taught, introducing the concepts of problem-based and student-directed study on the basis of new ideas about how to optimize experiential learning (
      • Taylor D.
      • Miflin B.
      Problem-based learning: where are we now?.
      ,
      • Thurley P.
      • Dennick R.
      Problem-based learning and radiology.
      ,
      • Jones R.W.
      Problem-based learning: description, advantages, disadvantages, scenarios and facilitation.
      ,
      • Gunderman R.
      • Wood B.
      Trusting the student: learner-centered education.
      ). However few modifications have been made in the basic model of clinical education for the third and fourth years of medical school since the initial changes brought about by the Flexner report.
      In a traditional model, students form part of a team in an inpatient setting, learning to function in the acute care of patients during their clinical rotations. This model worked well in the past, when patient hospital stays were longer, but it does not work well in the current climate of short hospital stays and increased emphasis on outpatient care (
      • Christakis D.A.
      • Feudtner C.
      Temporary matters. The ethical consequences of transient social relationships in medical training.
      ,
      • Glick T.H.
      • Moore G.T.
      Time to learn: the outlook for renewal of patient-centered education in the digital age.
      ,
      • Hoffman K.G.
      • Donaldson J.F.
      Contextual tensions of the clinical environment and their influence on teaching and learning.
      ). The addition of ambulatory experiences to the traditional model deemphasizes the importance of this care venue, because students realize that the main focus remains on inpatient care. The lack of interaction among disciplines teaches students a compartmentalized model of medicine that limits their ability to see beyond a single discipline to a more holistic view of health care (
      • Shore W.B.
      • Irvine C.
      The Interdisciplinary Generalist Curriculum Project at the University of California, San Francisco.
      ). Several national reports have recently been published with detailed analyses of the many complex limitations of current clinical educational systems in the context of modern health care (
      Commonwealth Fund
      ,
      Institute of Medicine
      .
      However, in moving to an integrated model, particularly for the teaching of radiology, several questions arise. Will students be able to learn about imaging without being able to focus exclusively on the topic for an extended period of time? Will they be too distracted by the excitement of patient care to gain an appreciation of the intellectual excitement of radiology? Without dedicated time to devote to this one topic, will they be able to perform as well as students in a traditional clerkship on exams? How can a case presentation, a common feature of many monthlong clerkships, be prepared in a way that will make sense during a yearlong experience? Will students choose radiology as a career without an immersion experience? Could a yearlong reinforcement of radiology principles produce more long-term retention of the material?
      In the first year of the Integrated Clerkship, extensive introductory didactic sessions on radiology were given in the first portion of the year to attempt to maintain some immersion experience in the topic. However, as students began their clinical work, this information was rapidly forgotten, as demonstrated by student discussion and performance in weekly tutorials and radiology rounds. As a result, the introductory sessions were shortened in each subsequent year, with no apparent effect on students' performance on exams. A more gradual approach to knowledge acquisition, with a focus on actual patient imaging, seems to provide more long lasting benefits. Students are better able to integrate their newly gained imaging knowledge as their sophistication about patient care increases. In fact, students benefit greatly from the active learning of rounds based on their own patients, rather than passive didactic presentation of material. They are much more engaged in these teaching sessions and play a much more vital role in discussions than in traditional teaching sessions.
      This brings up another important challenge of teaching in a longitudinal environment. Faculty members must learn to adjust their expectations for student performance to reflect the extended time period of the course. In a 1-month clerkship, students rapidly memorize new terms and learn new skills. They may need to be told something only once, and they can retain it at least until the next teaching session or exam. However, in an integrated and longitudinal teaching environment, students need to be told the same information several times for it to become a part of their functioning long-term memories. It may not be until the final months of the year that students begin to reach the level of competency in image analysis that we have come to expect within a month in a traditional model. Faculty members teaching in this setting must have realistic expectations for students at different points in the year and must be patient in repeating and reemphasizing information in various different settings.
      Evaluation in a year-long clerkship is also a serious concern, particularly for students who are struggling. In traditional clerkships, if a student does poorly in a 1-month or 3-month rotation, he or she will have concrete feedback at the completion of that period that can be applied to later courses in the year. In a yearlong clerkship, if evaluative exercises are not incorporated early in the year, learning problems may not be detected until it is too late to help the student. Because of this concern, it is vital to begin evaluations early in the year to try to detect any learning or behavioral issues while they still can be addressed. More is at stake for struggling students, who may be at risk for failing many courses, rather than just one.
      If all exams are administered in the final month of the year, when the students have acquired their largest panels of patients and have the most active clinical duties to complete, this puts undue stress on even the best students and may compromise their performance. For this reason, as the Integrated Clerkship has evolved, exams have been spread out for various disciplines into the third and fourth quarters, rather than clustering them all in June. In a similar vein, the case report deadlines for radiology have been moved earlier each year, to encourage students to complete this task before they become absorbed in studying for exams and managing their expanded panels of patients.
      There has been a tendency as the Integrated Clerkship has evolved for each discipline to add more and more activities, evaluative exercises, and assignments for students each year. It is vital to the success of such a program to have realistic expectations for students and to be precise in estimation of the time required for students to prepare for different assignments. Radiology was initially assigned 1/12 of the time within the curriculum, but this included informal interactions with students during their clinical activities in following their patients. It became clear by the end of the first year that more scheduled and defined activities were needed, and these have been gradually added in each subsequent year. In the latest version of the curriculum, the time devoted to formally structured radiology instruction is approximately 1/12 of the total time for formal teaching, which is appropriate for a clerkship that traditionally occupies 1 month out of the third year.
      The case presentations as an assignment for students in radiology have also undergone an evolution. In the first year of the program, although case presentations were discussed as a requirement initially, they were not emphasized, and deadlines were not enforced. In each subsequent year, student assignments for preparing cases have been moved earlier and have become more concretely defined. It was felt that students would greatly benefit from the opportunity to produce publications, rather than just slide shows, with relatively little additional effort. Submission to an online journal greatly facilitated this activity, because of the ease of preparation and rapidity of turnaround. All submitted papers thus far have been accepted, after revision. The time frame of the clerkship makes this scholarly activity feasible, which would not be practical in a 1-month traditional clerkship.
      Student performance in the final exams in radiology remains significantly lower in the Integrated Clerkship than in 1-month immersion clerkships on the MCQ portion of the exam, which is not unexpected. Because this style of exam relies heavily on relatively short-term recall, which may entail last-minute memorization, scores would be expected to be higher if a student has been studying only one topic in the time immediately preceding the exam, with no patient care responsibilities. However, student performance on the OSCE cases has been equal for the Integrated Clerkship students and the traditional students in the first 3 years of the program, with steadily rising scores each year and statistically higher scores in the fourth year compared to cumulated traditional student scores. Because this format may test higher level functioning and reasoning rather than memorization, these results may be a more accurate reflection of what the students are actually likely to retain and apply in their later medical careers.
      Finally, the performance on the fourth-year comprehensive exam, which is given to both traditional and Integrated Clerkship students weeks if not months after the completion of their radiology course, may be a better reflection of actual knowledge retention. Although the differences between the Integrated Clerkship students and traditional students on the comprehensive exam radiology station are not statistically significant, there does seem to be a trend toward higher scores for the Integrated Clerkship students, which may suggest that they are indeed learning the material in a way that could have a more lasting impact on their practice.
      The percentage of students selecting radiology as a career path in the Integrated Clerkship is similar to students in traditional courses. It was initially a concern that students in the Integrated Clerkship would demonstrate a bias toward primary care specialties. However, students from this program have entered competitive residencies in surgery and other specialized fields in addition to radiology at a rate similar to students in traditional clerkships.
      The benefits of teaching radiology using actual patients known to the students are immediately obvious during each radiology rounds session. Students pay close attention to the imaging findings when they know they will have to discuss them with their medicine, surgery, or obstetric attending physicians, as well as with their patients and their families. Discussions center on the appropriate use of imaging resources and limitations of various studies rather than on the details of particular obscure diagnoses. By the end of the year, students are notably sophisticated in their approaches to imaging and show clear understanding of the role of radiologists in the multidisciplinary care of patients.
      The Integrated Clerkship model is labor intensive in terms of faculty time, requiring approximately one third more contact time per student than a traditional model. This is both an advantage (for students) and a potential disadvantage (for busy radiologists) and has been one of the major objections raised by instructors in traditional curricula to the change to an integrated program. The rewards as a teacher are tremendous, and the opportunity to interact with motivated and eager students over an entire year is unparalleled in clinical teaching settings. Robust computer systems are vital to the success of such a complex teaching enterprise. Students need considerable support to manage their many duties and must be notified when each of their patients is admitted or scheduled for exams. Records must be kept of what diagnoses are included in each student's patient panel, to ensure that students are seeing as full a range of disease as possible. Scheduling of teaching activities is extremely complex and requires sophisticated administrative support. Teaching faculty members must be willing to undergo training to function in this new system and must develop new paradigms for mentoring and evaluation of students in this unfamiliar teaching environment.
      Thus far, Harvard's Cambridge Integrated Clerkship model has not been expanded beyond a cohort of 12 students (in the current class) per year. With multiple successful programs worldwide, the longitudinal integrated model is gaining in prominence, although most existing curricula that include all core subjects remain small in size (
      • Ogur B.
      • Hirsh D.
      • Krupat E.
      • Bor D.
      The Harvard Medical School-Cambridge Integrated Clerkship: an innovative model of clinical education.
      ,
      • Hansen L.A.
      • Talley R.C.
      South Dakota's third-year program of integrated clerkships in ambulatory-care settings.
      ,
      • Halaas G.W.
      The Rural Physician Associate Program: successful outcomes in primary care and rural practice.
      ,
      • Lewin L.O.
      • Papp K.K.
      • Hodder S.L.
      • et al.
      Performance of third-year primary-care-track students in an integrated curriculum at Case Western Reserve University.
      ,
      • Mihalynuk T.
      • Bates J.
      • Page G.
      • Fraser J.
      Student learning experiences in a longitudinal clerkship programme.
      ,
      • Schauer R.W.
      • Schieve D.
      Performance of medical students in a nontraditional rural clinical program, 1998-1999.
      ,
      • Oswald N.
      • Alderson T.
      • Jones S.
      Evaluating primary care as a base for medical education: the report of the Cambridge community-based clinical course.
      ,
      • Worley P.
      • Silagy C.
      • Prideaux D.
      • Newble D.
      • Jones A.
      The parallel rural community curriculum: an integrated clinical curriculum based in rural general practice.
      ). Larger partial integrations across only a few disciplines (primary care, medicine-surgery, or neurology-psychiatry) have been reported (
      • Rabinowitz H.K.
      • Babbott D.
      • Bastacky S.
      • et al.
      Innovative approaches to educating medical students for practice in a changing health care environment: the National UME-21 project.
      ,
      • Blue A.V.
      • Griffith III, C.H.
      • Stratton T.D.
      • et al.
      Evaluation of students' learning in an interdisciplinary medicine-surgery clerkship.
      ,
      • Pipas C.F.
      • Peltier D.A.
      • Fall L.H.
      • et al.
      Collaborating to integrate curriculum in primary care medical education: successes and challenges from three US medical schools.
      ,
      • Roberts L.W.
      • Franchini G.
      • Fielder K.
      An integrated psychiatry-neurology clerkship within a problem-based learning curriculum.
      ), including radiology (
      • Lowitt N.R.
      Assessment of an integrated curriculum in radiology.
      ,
      • Chew F.S.
      Distributed radiology clerkship for the core clinical year of medical school.
      ). Integration has generally been easier in the first 2 years of medical school than in the clinical years, without the complexity of patient care issues to be resolved (
      • Muller J.H.
      • Jain S.
      • et al.
      Lessons learned about integrating a medical school curriculum: perceptions of students, faculty and curriculum leaders.
      ). In settings outside the United States, an integrated clinical model is being used for larger cohorts of students (
      • Worley P.
      • Prideaux D.
      • Strasser R.
      • Magarey A.
      • March R.
      Empirical evidence for symbiotic medical education: a comparative analysis of community- and tertiary-based programmes.
      ). Follow-up of students from these new types of training programs is being initiated to assess graduates' perceptions and performance during internship, residency, and practice to determine whether an integrated approach may have longer term effects on such things as job satisfaction, academic productivity, or patient outcomes.
      Our study is limited by the small number of students who have completed the program thus far and the fact that students were not randomly assigned to the program. This may have biased the results both in terms of student level of interest (although it would seem likely that students selecting this program might be less interested in radiology, rather than more interested), as well as selecting for students who might be more highly motivated or more willing to be creative in their approach to their own education. There is also a possible Hawthorne effect (
      • Kohli E.
      • Ptak J.
      • Smith R.
      • et al.
      Variability in the Hawthorne effect with regard to hand hygiene performance in high- and low-performing inpatient care units.
      ) within this group because students know that they are being closely monitored. Because the curriculum has been changed each year, comparisons among different groups of students within the program are of limited validity. This educational approach may not be easily generalizable to all academic settings, and there are definite potential barriers to implementation of such a complex and labor-intensive curriculum in departments without financial resources to support the additional teaching time required and the robust information technology support that is needed. Another potential limitation of this study concerns the reuse of exam questions and OSCE cases over time, which may lead to forward feeding of information from one student group to another and artifactual elevation of scores. However, over the past 5 years, there has not been a noticeable increase in OSCE or exam scores in the traditional clerkship to suggest that this is playing a large role. In terms of OSCE-style exercises, although they are designed to be as objective as possible, such case discussions are still subject to the bias of the examiner, because the way in which questions are asked can have an influence on students' responses.
      Future plans for a clerkship of this type could focus on optimizing use of radiologists' time and might include the development of more digital material to supplement weekly tutorial sessions, the development of more online OSCE cases to decrease the amount of individualized time needed for this exercise and to increase the objectivity of the scoring, and expansion of the e-mail question bank. If contact time could be limited to weekly rounds, this would facilitate potential to expand a program of this type to encompass larger student groups. However, the absence of a voice for imaging in interdisciplinary tutorial discussions would be a serious loss. Having a radiologist present for as many tutorials as possible gives students a graphic demonstration of the essential role of radiology in a wide variety of clinical settings. Better integration of students into daily radiology departmental routines should also be a goal, developing roles for students at various observation sites that would benefit learners, teachers, and patients.
      The changes in health care in the United States in the 21st century require changes in medical educational methods. The inpatient setting is no longer conducive to early clinical education, for a number of reasons. Students at the beginning of their training need better opportunities to learn about disease progression over time, the long-term effects of treatment, and interdisciplinary care. Students must gain an appreciation of the vital role of ambulatory care in modern medicine if we are to encourage them to choose careers in primary care. And all primary care givers need a deep understanding of the role of radiologists in the health care system. A longitudinal integrated model of medical education may provide a better venue for training the doctors of the future. Radiology should play a vital role in this educational process.

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