Once upon a time, in a rural hospital far, far away, a med student began her clerkship.
At the University of British Columbia, the Integrated Community Clerkship (ICC) provides an opportunity to spend the first clinical year of medical school in a hospital in rural British Columbia rather than a large academic center. The intent is to provide hands-on education and to encourage physicians to one day return to serve a rural community.
Applying to the ICC was a no-brainer for me. Medical education in the big city felt strange right from the start. Our preceptors didn’t know their students and in a class of around 288, I really knew only a few of my own colleagues. It made sense to retreat to a smaller town, to get to know the community around me, and to be treated like a human being. The longitudinal aspect of it was just something that came along with the decision to train rurally.
What is longitudinal education?
The industry seems to use the terms “integration” and “longitudinal” nearly interchangeably. The definitions have become one of those tortuous academic arguments that the literature is fighting to pin down. My longitudinal experience meant that I spent every day in a different specialty and continued to rotate through each specialty for the whole twelve months of third year. We had a smattering of relatively small exams throughout the year in preparation for one final cumulative multiple-choice exam — a test of endurance and sheer will, with a hint of medical knowledge.
In contrast to a traditional rotational program, I also spent a half-day every week in family practice and since our community’s general practitioners follow their patients in the hospital, I spent roughly another two hours every day rounding on our in-patients. I doubt this is a part of every “longitudinal” program, but it was certainly a focus of ours.
So, what was my experience of it?
In the beginning, every day was a chaotic frenzy to locate the right department, find a clean pair of scrubs and explain to a preceptor that I was late because the previous preceptor was quizzing me on some differential or another. All this was done while simultaneously guzzling cold coffee, switching my brain from one specialty to the next, and making first impression after exhausting first impression. I couldn’t find the ophthalmoscopes, I didn’t know how to dictate, and every question I asked or decision I made was dripping with confusion and self-doubt. This lasted three months. At least.
Winter exams came and went. Christmas break was spent on my parents’ couch with a flu followed by a URI, followed by a viral gastro and another URI.
The turning point came just as they said it would. Sometime in spring, a phenomenon common to all the ghosts of ICC past transpired. I forgot to be nervous. I walked, blind and yet confident, into any emergency room without fear of making a mistake. Well at least if I made a mistake, I knew I could identify and correct it before presenting to my attending. I was focusing my histories, nailing my exam findings, and ordering the right investigations to lock in my diagnoses.
By the time our last cumulative national board exam was written in July, I was beaten down, sleep-deprived and thirty pounds heavier than when I started. Strangers had stopped telling me that I look young for my age.
And, yes, as I hear it, this is fairly identical to the experience of my colleagues in the traditional rotational system. But there was something different — I saw the light! Not just the light at the end of the third-year tunnel, but at the end of fourth year, too! By writing that exam, I proved to myself that I was retaining my knowledge. I would be able to study for and write my qualifying exams in another year with grace and precision.
Longitudinal learning works. I didn’t ever binge and purge for exams. I didn’t engulf myself in one specialty to the exclusion of all others. Instead, I integrated surgery and medicine. I incorporated my psychiatry experiences into my emergency department skill set. I learned anaesthesia procedures that I took to obstetrics and internal. My time in radiology directly correlated to pediatrics, urology, ENT and nearly every specialty. Unbeknownst to me, I had started to become a self-motivated, well-rounded, compassionate physician.
Is it just me?
As fourth year begins, the ICC students have returned to their home sites to share stories, and our tales of woe and tearful triumph are eerily alike. We all played the underdog protagonist, who struggled with confidence and identity in the beginning, navigating spooky forests and conquering dragons on a journey of self-discovery and ultimate victory. Indeed, this story has a happy ending. Alas, it is only the first part in an epic lifelong series of tales sure to entertain!
Back to the longitudinal learning thing … Would I do it again?
In chance hallway and cafeteria reunions with classmates, I am without fail asked about my longitudinal experience and how it compares. My now well-rehearsed response includes knowing eyes, a joyful smile and vigorous nodding, but none of the details. For the sake of modesty, I don’t list the number of babies I delivered, or the uncountable surgeries for which I was primary assist, or all the medical patients I managed on my own from admission to discharge. I don’t mention the sincere thank-you’s from so many patients and their families, or the overwhelming compliments from nurses on my growth and development over the year, or the confidence that has grown from gaping nothingness, or the pride I now take in every aspect of my work. I keep it to myself, I think, because words cannot describe, because the great adventure cannot be summarized, and because my experience continues to humble me.
Whenever I am asked about my experience, I get to look back, to remind myself of where I came from, what I endured along the way and how far I still have to go. Longitudinal learning mirrors the true nature of medicine, preparing us to be insatiable lifelong learners. After my year of integrated clerkship, I am eager to turn the next corner, accept my next challenge and face the next storm with the understanding that I will become a better doctor and a better person for it.
So, would I do it again? Bring it on!