Unexpected Beneﬁts of a Longitudinal Integrated Clerkship Curriculum during the COVID-19 Pandemic

This personal view regarding longitudinal integrated clerkship for medical training is based on my third-year medical curriculum experiences. The integrated model uniquely incorporates simultaneous immersion in all six core clerkships (OBGYN, pediatrics, surgery, internal medicine, psychiatry, and family medicine) rather than traditional sequential blocks. As a result, students in my cohort work with physicians in each specialty continuously throughout our third year. I will highlight what I believe are the beneﬁts to this curriculum, as well as how the longitudinal model set us apart from traditional students during the COVID-19 pandemic.


Discussion
Longitudinal clerkships in medical schools have been around in different forms for years, and its popularity is steadily rising. There are several reasons why many schools have decided to take on the challenge of offering longitudinal programs. One of them is due to the changes in patient care over the last few decades. Patient-physician relationships have evolved into a business centered model, with patient encounter face time diminished by the everincreasing demands of charting and documentation. As a result, many physicians have lost their original empathy, kindness, and compassion for the field (Noseworthy, 2019). The compassion burnout is often reinforced in traditional blocks schedules. In contrast, longitudinal clerkships provide students with the unique perspective of following patients throughout the year and observing the natural progression and impact medical conditions have on patients and their loved ones holistically (Ogur and Hirsh, 2009). For example, my curriculum consists of spending either a half or full day per clerkship per week throughout the year, except for surgery and internal medicine, which will be addressed later on. The students are assigned one or two physicians in each subject area to work with for the entirety of the year. At the end of the year, all NBME shelf exams and OSCE's are taken in a span of 6 weeks Desai R MedEdPublish https://doi.org/10.15694/mep.2020.000241.1 Page | 2 collectively.
The longitudinal integrated curriculum provides benefits that are unobtainable with conventional block curriculum. My pediatric rotation consisted of working in the same clinic for the entire year. I performed newborn exams, as well child visits for the same patient at 2, 4, 6, and even 9-months. Additionally, I witnessed and learned each of the developmental milestones firsthand. The experience allowed me to grasp key learning points for child development easily, and I was able to build personal relationships with patients and their families. Another example was in family medicine clerkship, in which I was assigned to two doctors. From the first day of participating in managing many patients' chronic conditions, to the last day leaving the clinic, I observed the struggle and triumph that patients experienced as they fought to regain control of their conditions and health. Similarly, I participated in weekly therapy sessions with same patients in my psychiatry clinic. Having the privilege to observe patients through longer periods of time provided the necessary mental framework and outlook to appreciate the complexity and multidimensional challenges that many patients face with their psychiatric problems. Lastly, working with my OB-GYN was the perfect opportunity to take advantage of a longitudinal timeline. Participating in patients' care from family planning, to weekly pregnancy checkup, and ultimately delivery was extremely rewarding. This curriculum provides a unique opportunity to reflect on the true intended nature of medical care and proper ways to establish patientphysician relationships.
Another benefit of the longitudinal clerkship lies in connections made with both physicians and their office staff. On the traditional blocks, students work with several different physicians and residents for a period of 4-8 weeks. Within this short time, not only do students need to learn all they can about the field and function responsibly as a member of the healthcare team, but they also need to establish relationships with patients and attendings. In contrast, working in the same setting for a year enables students to build trust and earn responsibilities with all healthcare staff. I felt I was integral to the team's success, rather than just a student present to learn. My efforts yielded differences in patients' lives each day, and I observed significant growth in the relationships I made. My teaching physicians became my trusted mentors, and I felt comfortable to go to them for advice on anything in life.
Despite great success the longitudinal curriculum had in many clerkships, others still benefit from traditional structures. Surgery and internal medicine take place primarily in the hospital and a vital part of the experiences come from rounding on patients. As a result, the two clerkships were designed with "immersion periods," where students would be pulled out from longitudinal schedules to focus on surgery or internal medicine for two to four weeks at a time. The combination of short blocks intertwined in an otherwise comprehensive year-long schedule played to the strength of each clerkship and provided realistic experiences for students.
As of mid-March 2020, all medical clinical rotations throughout the nation were suspended due to the COVID-19 pandemic. While students' education across the country were abruptly halted, with many lacking complete exposures to one or two core clerkships, my cohort and I stood secure in our experiences, skills, and knowledge. This contrast is particularly apparent in comparison to students from my school on other campus sites who participated in traditional block schedules. With the current educational pathway setup, medical students are not allowed to advance until they have had experiences in all six core clerkships. These students are now participating in a shortened schedule to limit clinical exposure. For example, those students who had family medicine and psychiatry clerkships left have had to spend the initial three weeks attending online lectures, and taking the family medicine shelf exam at the end, the next three weeks attending psychiatry lectures and taking that corresponding NBME, before finally getting to spend the next 6 weeks in clinic for both family medicine and psychiatry. This is in stark contrast from what they would have been doing pre-COVID. The new curriculum requires them to take shelf exams before obtaining clinical experience. On the other hand, students from longitudinal backgrounds benefited from year-long holistic learning approach and were able to handle both the transition and advance. Having completed all of the clinical requirements, my cohort and I successfully took all remaining NBME shelf exams and concluded our thirdyear medical curriculum in May 2020. I was fortunate enough to be able to move forward into my fourth year as July approached, but the same cannot be said for many others. Due to participation in a longitudinal clerkship curriculum, I felt confident to continue my educational journey in a time of uncertainty.

Take Home Messages
Traditional medical school clinical curriculum consists of 6-8 week blocks of the 6 core clerkships for the year. The longitudinal integrated curriculum differs by students participating in all 6 clerkships throughout the year, working with one or two doctors consistently. Benefits of longitudinal clerkships include building strong patient-provider relationships, observing patient conditions for longer periods of time, and becoming an integral part of the provider's healthcare team. Clerkships such as surgery and internal medicine may benefit from a mix of the traditional and longitudinal clerkship curriculum due to the nature of those specialties. The longitudinal integrated clerkship curriculum was as an unexpected blessing during the COVID19 pandemic, as our curriculum and education was minimally disrupted, compared to students on the traditional block schedule.

Notes On Contributors
Rutaa Desai is currently a 4th year medical student at Texas A&M College of Medicine. She recieved her undergraduate degree from Texas A&M Univeristy and studied STEM education. She chose to participate in the unique longitudinal integrated clerkship curriculum during her 2nd and 3rd year of medical school and is pursuing pediatrics.