The Clinical MISSILE Workshop Multi centre International Simultaneous Studies of Integrated Longitudinal Education Paul Worley, Pamela Stagg, Ian Couper, Roger Strasser, David Hirsh, Jennene Greenhill Thunder Bay, ON, October 2012
Workshop Agenda Background to MISSILE Methodology Design Group Research Steering Group Survey Small groups discussion of preliminary analyses Paul, Pamela, Jennene Report back and next steps for 2013 proof of concept study
MISSILE Collaboration Yankton CLIC Conference, 2011 Rigorous outcome evidence crucial for changing educational practice Evidence is building BUT Single institution studies have limited generalisability Utilize current global natural experiment
Four School Example Flinders, Australia Northern Ontario School of Medicine, Canada Harvard Medical School, USA University of Witwatersrand, South Africa
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G PRCC X X X X X NT X X X X X X OCEP X X X X X NOSM Can H X X X X X Harvard USA H X X X X X Wits S Afr L X X X X X
But what if other schools joined the study
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G PRCC X X X X X NT X X X X X X OCEP X X X X X NOSM Can H X X X X X Harvard USA H X X X X X Wits S Afr L X X X X X
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G PRCC X X X X X NT X X X X X X OCEP X X X X X NOSM Can H X X X X X Harvard USA H X X X X X Wits S Afr L X X X X X JCU Aust H X X X X X
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G PRCC X X X X X NT X X X X X X OCEP X X X X X NOSM Can H X X X X X Harvard USA H X X X X X Wits S Afr L X X X X X JCU Aust H X X X X X Wol g Aust H X X X X X X
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G PRCC X X X X X X NT X X X X X X OCEP X X X X X NOSM Can H X X X X X Harvard USA H X X X X X Wits S Afr L X X X X X JCU Aust H X X X X X Wol g Aust H X X X X X X UCSF USA H X X X X X
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G PRCC X X X X X NT X X X X X X OCEP X X X X X NOSM Can H X X X X X Harvard USA H X X X X X Wits S Afr L X X X X X JCU Aust H X X X X X Wol g Aust H X X X X X X UCSF USA H X X X X X Zamb Phil L X X X X X
School C try Rce Length Supervisor Location Select n Adm n H/L 2-3 /12 6/12 12/12 Gen Spec Rural Urban All Vol U/G P/G Adel Aust H X X X X X Alberta Can H X X X X X PRCC X X X X X NT X X X X X X OCEP X X X X X Harvard USA H X X X X X JCU Aust H X X X X X Minn a USA H X X X X X North Can H Dakota X X X X X NOSM Can H X X X X X South USA H Dakota X X X X X UBC Can H X X X X X UCSF USA H X X X X X UP Phil L Leyte X X X X X UWA Aust H X X X X X WAMI USA H X X X X X X X Wits S Afr L X X X X X Wol g Aust H X X X X X X WRITE USA H X X X X X WSU S Afr L X X X X X Zamb Phil L X X X X X A segment of the CLIC Viral Genome
MISSILE Collaboration >50 Participating LIC programs Methodology Design Group Volunteer collaborative approach Use collaborative methodology developed by Australian Medical Student Outcomes Database (MSOD)
MDG Preparation the key to success! Survey the program directors to identify existing research tools key factors underpinning LICs Analyse to determine priorities for research theoretical framework/s and tools for research Publish with consortium authorship
Preliminary survey Twelve questions developed by Delphi 23/48 respondents Responses analyzed by MDG Three clusters emerged
Preliminary Survey Rationales for School s adopting LICs Dimensions and diversity of LICs Observed Outcomes of LICs
Rationales for LICs School motivations Concerns for student experience Benefits to Teachers Implications for theory
School Motivations Pragmatic Elitist Distinguishing
Concerns for student experience Professional formation Common diseases and presentations Natural history and context of illness and care Meaning in learning Career choice Mentorship Continuity
Benefits for teachers Engaging with generalists Linking specialists with generalists Decrease burden of teaching More time for disciplines Mentorship Motivation
Implications for theory Adult learning theory Curriculum and assessment theory Clinical reasoning theory Workplace learning theory Identity formation theory Institutional change theory Social accountability theory
Dimensions & Diversity of LICs What is Integrated Setting-based: -Primary Care setting where patients are undifferentiated -Experiential learning in a rural setting; Community focused solutions are required Patient-based: -Undifferentiated -Followed over time -Followed through multiple settings, disciplines, events -Primary responsibility is to panel of patients
What is Integrated? Assessment concurrent assessment of knowledge, skills, attitudes spanning more than one discipline Expectations students are expected to transfer what they learn in one discipline to their practice in another discipline Interpersonal elements: -Interprofessional -Student is an integral part of the medical team
What is Longitudinal Time-based specific amount of time range from 20 wks, >3months, 6 months, 1 yr, and variable Experience-based no specific amount of time; some key features include having the opportunity to: follow patients/people, problems, and practices over time establish relationships and connection with a community see enough of all common conditions (including those that present seasonally) have the clinician, practice, health service get a net gain out of student s presence
Theoretical implications Situated Learning Social Constructivism Work integrated Learning Interprofessional Learning Theory Assessment Theory
Observed Outcomes and implications of LICs Some LICS are new, evaluations are in the early stages and ongoing. Several schools have measured overall satisfaction and exam performance with positive results.
Outcomes and Implications of LICs Workforce outcomes ALL taken internships in regional or remote hospitals Match rate Student choice of generalist careers is 3 times more interest in primary health care and rural practice Outcomes for preceptors Clinical teaching in the LIC gives experienced clinicians "a new lease on life", with a renewed sense of reward and satisfaction in their work Preceptors are re-energized in clinical practice Clinicians challenged to keep abreast of latest developments Clinicians were not able to fulfill the teaching role as fully as they would have liked Influence on faculties a nidus for innovation within the faculty trailblazers introduced new approaches to curriculum design and assessment
Outcomes and Implications of LICs Positive feedback/evaluation Overall satisfaction with the clinical clerkship Student expectation of preparedness based on clerkship objectives has been met to a greater degree in LIC vs. traditional students High level of student satisfaction with the clerkship experience (the highest of all clerkship rotations) Evaluation of students is "richer". Student and faculty satisfaction is high Influence on health services better understanding of the health care system and referral Insight into workings of practices
Different Students Outcomes in LICs Student performance outcomes More Confident and Competent clinicians Students are adventurous and tend to have increased autonomy and self reliance stress levels were higher among LIC students Assessment Outcomes Increased exam performance. Performance on MCQ's (both local and national) is at least as good as traditional students RPAP students perform comparably to their nonrpap peers (Fam Med 2010) Personal Student outcomes Practical wisdom and Passionate Professional Values Understand importance of community context Underserved Career choices
Theoretical Implications Identity theory Leadership theory Organisational theory Curriculum design Health Workforce Educational theory (eg change)
Discussion Groups Face Validity of Analyses Theoretical implications Identification of gaps Priorities for 2013 proof of concept research Report back to Workshop
Group Reports
The Clinical MISSILE studies Clinical Learning: Multi-centre International Simultaneous Studies of Integrated Longitudinal Education