We welcomed Professor David Hirsh from Harvard to discuss LICs

Professor David Hirsh with, from L-R, Dr Megan Brown, Professor Gabrielle Finn, Rebecca Leckonby (MBBS student on our LIC), Dr Judith Matthews and Annie Noble-Denny (University of Bristol)

In December, Professor Gabrielle Finn from our Health Professions Education Unit (HPEU), in partnership with the school’s Academy of Primary Care, welcomed Professor David Hirsh of Harvard University Medical School’s Academy of Educators to deliver a high-profile and thought-provoking seminar on the development and success of the innovative Longitudinal Integrated Clerkship (LIC) medical education model. David was instrumental in establishing the LIC model for medical education, back in 2003, to help reconnect the patient and the student in clinical training settings. Research has demonstrated that rebuilding these relationships helps ensure better learning. Furthermore, involvement with such training can facilitate students’ advocacy role as well as increasing future doctors’ sense of duty and commitment towards their patients.

This theory draws on the 1910 radical study into US medical education by Abraham Flexner. As part of a wide-ranging reform of medical education in the US, he identified the need to support continuity of service and facilitate closeness to patients as a means to develop compassionate, patient-centred medical professionals. Similar issues had been identified by David and his team at the turn of the 21st century with evidence suggesting a decline in professionalism, “patient-centredness” and empathy of medical students, especially those entering their core clinical years. Most interestingly, this was particularly evident in medical students, rather than other healthcare professions and was most pronounced in areas of the US which were greatest underserved by medical professionals and high areas of deprivation. There was, therefore, a need to restructure the medical education model to address these issues.

The model has proved popular and LICs in US universities and other parts of the world are now over-subscribed. Students have appreciated being more involved in seeing patients both before diagnosis and after discharge through multiple connections with the same patients. This continuity in education has helped generate positive reciprocal relationships whereby the patient matters to the student and vice versa. We are witnessing similar feedback in our LIC. David outlined that to help facilitate continuity in education, a new curriculum structure was required. The curriculum was, therefore, opened up over the whole year, rather than it being delivered in the traditional clinical specialism “block” format. David suggested that it’s a peculiar quirk of medical education that students learn in discreet themes; whereas teaching in schools, more generally for example, is structured to build knowledge over the course of the year.

In addition, David highlighted some recent evidence from the US that suggests an LIC approach may actually produce measurably improved health outcomes for patients. We would hope to see similar in the UK.

In addition to David’s presentation, Dr Kevin Anderson, Director of Primary Care Education and Academic Lead for our LIC, outlined how the LIC model has been adapted in our medical school, focusing on primary care. Dr Megan Brown also presented her on-going doctoral research into the development of medical professional identities, focusing on LICs at a number of medical schools around the world.

It was great to meet David, entertain him at our York campus, and discuss our exciting ideas for the future of the LIC model at the medical school focusing on the exciting opportunities in primary care.

Professor David Hirsh with Dr Kevin Anderson and Dr Megan Brown.

Further reading

Bartlett, M, Muir, F. A new model of undergraduate clinical education. Br J Gen Pract. 2018;68:216–217.

Brown ME, Anderson K, Finn GM. A Narrative Literature Review Considering the Development and Implementation of Longitudinal Integrated Clerkships, Including a Practical Guide for Application. Journal of medical education and curricular development. 2019.

Crampton, P, McLachlan, JC, Illing, JC. A systematic literature review of undergraduate clinical placements in underserved areas. Med Educ. 2013;47:969–978.

Hauer, K.E., O’Brien, B. and Poncelet, A.N. Longitudinal, Integrated Clerkship Education: Better for Learners and Patients. Academic Medicine. 2009;84:821.

Hirsh, D., Holmboe, E. and ten Cate, O. Time to Trust: Longitudinal Integrated Clerkships and Entrustable Professional Activities. Academic Medicine. 2014;89:201-204.

Illing, JC, Crampton, PES. Collaborative relationships and learning in rural communities. Med Educ. 2015;49:852–854.

McKeown, I, Parekh, R. Longitudinal integrated clerkships in the community. Educ Prim Care. 2017;28:185–187.

Strasser, R, Hirsh, D. Longitudinal integrated clerkships: transforming medical education worldwide. Med Educ. 2011;45:436–437.

Worley, P, Couper, I, Strasser, R. A typology of longitudinal integrated clerkships. Med Educ. 2016;50:922–932.

Reflection on our first term of the LIC

We now approach the last few weeks of our first term doing the LIC. I thought it might be useful for others considering doing an LIC to hear some of the reasons why I have loved it at times, yet on other days have wished I’d stuck to the conventional fourth year. I hope it might help others to decide whether it’s right for them.

Part of a team

Firstly, the routine is a bit more like work. This makes me feel like I have more of a purpose than I did in third year doing conventional blocks. I enjoy being part of a team in primary care and feel I have a useful role.

I recognise that I am getting better at taking histories, identifying important information and using clinical reasoning to come up with differentials. I believe this is due to the sheer numbers of patients we see each week doing the LIC.

Equally, I believe the LIC is making me confident in summarising cases to senior colleagues in front of patients. I have found it easy to accumulate longitudinal patients and have had some positive experiences following them to appointments and continuing their care over time.

When not in primary care, we’re in hospital having teaching, following patients to appointments and spending time on the wards. I like that the Friarage is a small hospital where you can get to know staff. I feel I can walk onto any number of wards, recognise a familiar face and be supported to clerk patients and perform clinical skills. The time spent at James Cook hospital has given us a bit more exposure to some of the more acute presentations that you don’t always see in the Friarage hospital, which is helpful.

Busy schedule

I do, however, miss rotating around clinical specialties. I miss focusing in on one area of medicine and the feeling of covering a specialty thoroughly.  

In terms of logistics, the LIC involves a lot of travelling. I commute to GP three days a week, which takes up an hour of my day. This isn’t so bad, however combined with additional hospital appointments for longitudinal patients, and my commute home on the weekends, I do feel that I’m in the car a lot.

I am placed in Masham GP surgery. Whilst I feel lucky to be there because the staff are great, most the patients go to Harrogate Hospital when they’re admitted to secondary care. This means I’m travelling to a slightly less familiar hospital, where staff are unfamiliar with the LIC. I would be lying if I didn’t say this can be daunting.

Another aspect of the LIC I have found to be challenging is that you cannot entirely plan what is going to walk through the door in GP. This means that you aren’t necessary seeing patients relevant to fourth year outcomes every day. Due to a very full timetable and lack of ‘white space’, it can feel you just have no time to learn about the things we’re meant to learn about this year.

Learning curve

However we have been told about the ‘J curve’ students travel along whilst doing an LIC, where they dip before they exponentially improve in skill and knowledge. We all laugh and agree at this stage of the LIC we’re skimming the base of  the J curve!

For students considering doing an LIC, I would suggest reflecting upon the type of student you are before deciding either way. I think students considering doing the LIC need to be confident, able to manage a degree of uncertainty, flexible and motivated with regard to self-directed learning.

Eeh bah gum! Showcasing our Yorkshire LIC at Vancouver conference

The Consortium of Longitudinal Integrated Clerkships (CLIC) Conference 2019, hosted by the University of British Columbia in Canada

In the development and delivery of our LIC, we are keenly interested in exploring how such a medical education model can enhance patient-centred care, provide a richer clinical placement experience and help generate interest in working in under-doctored areas. Alongside the delivery of the LIC pilot, we have some active research themes exploring these aspects.

I was very pleased to attend the Consortium of Longitudinal Integrated Clerkships (CLIC) Conference 2019, hosted by the University of British Columbia in Canada. CLIC is a worldwide network of medical schools who are either planning or delivering LICs in a variety of different forms. Some of these have been running for more than 15 years.

An LIC in Yorkshire

It was a fascinating conference and I was pleased to share a poster about the Hull York Medical School LIC, which we believe is the first ‘immersed dispersed’ LIC in England.

Our story so far…

It was great to share ideas with colleagues from across the world as well as hearing more about the increasing body of evidence demonstrating the potential benefits of LICs as well as tips on how to avoid some of the pitfalls.

Several UK medical schools were represented including Dundee, Cardiff and Imperial who have also now established LICs.

It was also brilliant to see many LIC students (past and present) at the conference, many of whom had undertaken LIC-related research as part of their studies; hopefully we’ll be able to have some Hull York Medical School students representing us at future events! There is a student arm of CLIC – SLICC – hoping to encourage some of our own pioneering LIC students to get involved with this too.

And coming across Vancouver’s founding father… from Hull!

Also managed to squeeze in some sight-seeing; pleased to see that one of the founding fathers of Vancouver ‘Gassy Jack’ was born in Hull! It must be something about Hull and the East Riding of Yorkshire that brings out a pioneering spirit!

“Gassy Jack” – Vancouver’s founding father, born in Hull

Next month, Hull York Medical School will welcome Professor David Hirsch for a visit, organised by our Health Professions Education Unit. Based at Harvard University, he helped to establish the LIC model and will deliver a seminar and host a discussion. There’ll be lots from this, combined with my Vancouver experience, that we can take forward in the further development of our LIC.

One month in (ish!)

Wow! How have we been here for over a month already? Time is flying by. This first month has really been all about settling in and finding our feet here in Northallerton. Things have got off to a great start.

Official Hull York Medical School LIC Merch.

GP life:

My GP is Mayford House based in Northallerton itself and it really didn’t take long to become part of their team. In the first month I spent a lot of time getting to know everyone both in the practice and in the community, with me spending a lot of afternoons with different teams such as the health visitors, palliative care nurses, district nurses, community midwife and the paramedics. This was a great way to fully integrate myself within the whole of the primary care and community setting right from the off. I am now doing 20 minutes appointments during the GP clinics with my GP alongside where I do the history taking and we both talk through the management plan and treatment options with the patients, followed by a short debrief after the patient has left which is time for me to get immediate feedback and to ask any questions. Within the next few weeks this will be changing. I will then be seeing the patients alone and the GP will join us after 15 minutes to talk through what I’ve done so far and then onto managements. As we progress through the year my knowledge will grow and I will hopefully be able to come up with a lot of the management plans and treatment options by myself. I look forward to seeing how this goes and improves through the year. 


I have already had the chance to follow a few patients through to the Friarage Hospital and to some outpatient appointments at the clinics. I can already see the benefit from seeing the patients right through from primary to secondary care, and then back to primary care. I currently have 2 longitudinal patients, both have been very keen to have me follow their journey which feels great. 

Free time:

Life in Northallerton is very chilled. Lots of time to explore the area as Emily has mentioned a few weeks ago. As well as this I’ve started road cycling and jogging and I’ve found that to be a great way to see more of the area and meet some local people. We have tried a few of the restaurants Northallerton has to offer and some of us even given blood! And of course, I’m really enjoying spending time procrasti-baking lots of sweet treats!! 

The All Saints Church in the centre of Northallerton one evening.
Baking 101.

All in all the first month or so here has been both fantastic and tiring and we are all looking forward to what the rest of the year here has to bring! 


Until next time!

Becca 🙂 x 

Part of a team

We’ve just finished week 5 of the LIC. So far so good! I’m based at Masham Surgery which is just on the edge of the Yorkshire Dales. I’m really thrilled with my practice, everyone is so nice and welcoming. Everybody knew my name by day one and seemed genuinely thrilled to have me there for the year. I really do feel like I am a member of their team already.

Doing the LIC does feel very different from anything I’ve done at medical school before. It feels a little bit more like going to work (in a good way!) This might be partly due to the routine, but also perhaps because I feel I have my own role there. I’m left to follow up my own longitudinal patients alone and organise how I do this, yet I don’t feel overwhelmed or like I cannot ask for help or advice if I were to need it. On Tuesday, for example, I had organised to attend an obstetrics appointment with one of my patients in Harrogate Hospital in the morning, prior to a midday tutorial with my GP and an afternoon clinic in Masham. I’ve been pleasantly surprised by how easy it has been to follow up patients. The majority are thrilled that you’ve taken an interest in them, and are happy for you to attend appointments with them. The staff at the appointments have also been very welcoming and interested in what I’m doing. On Tuesday I ended up staying to see a few more patients with the consultant and got some really useful teaching.

Northallerton life

With packed timetables up here we’ve been making the most of our weekends to explore the area by going on country walks and meeting some locals (the mooing kind).

Very curious cows in Osmotherley

We climbed Roseberry Topping, North Yorkshire’s rival to the Matterhorn (apparently).

We wandered along the scenic Sutton Bank with a furry friend for company.

Naomi’s dog Rafiki, who was a bit camera shy that day

Don’t worry Hull York Medical School, we did some work as well.

Local anaesthesia 101

Of course though, our Tuesday evenings are now very much dedicated to watching the Great British Bake Off.

Overall it’s been a very busy few weeks, but I’m really enjoying the time I spend at my GP surgery, which is based within Northallerton itself and is one of the largest in the area. I’ve met patients with some quite unusual conditions such as Myasthenia gravis, advanced Huntington’s disease and a little girl with mumps despite her vaccinations. Next week I’ll be set up in my own consultation room seeing patients alone, which should be a great learning experience.

To finish, a nice sight I had coming back from GP one afternoon – it made the rain a bit more bearable.

That door on the far right by the cars is the entrance to our accommodation

Until next time!

Emily

First two weeks of the LIC

Not sure how it has been two weeks since we started, but here we are! These two weeks have mostly involved getting settled into our accommodation (navigating fridge and cupboard space in the kitchen), figuring out how long we can lie in bed before having to get up to get to our GP practices in time, meeting lots of lovely new people (everyone has been so friendly and helpful), and finding our way around the hospital. 

My GP practice is split into two practices – Catterick and Colburn. So far, I have sat in and observed three different GPs in clinic and been on some home visits. I have seen a huge variety of people and different presentations already, with several potential longitudinal patients. My GP runs a “walk-in” type clinic in the morning and then appointments in the afternoon. I’m definitely getting a lot of exposure to topics studied last year as well as those we study this year, which will be useful for refreshing knowledge throughout the year in preparation for 4th year exams. In hospital, we have had some teaching, including going through some scenarios using the ABCDE approach, to prepare us for our acute week in James Cook. 

Northallerton isn’t the biggest place, it’s a cute market town in North Yorkshire, which means you don’t have to go very far to be surrounded by beautiful countryside. Which I have been exploring during my runs around the area whilst the days are a bit longer – see photos below! 

Tomorrow (weather permitting) we might go on a trip to Roseberry Topping, a famous hill in the area that provides a great view from the top! So stay tuned to see some photos from there🙂

Naomi

We have LIC lift-off!

@martinveysey commenting on the great value and opportunity through the LIC to learn medicine – “Experience medicine as it really is”

Yesterday, together with Professor Martin Veysey, our MBBS Programme Director, I was really pleased to launch our exciting new LIC clinical placement at the Friarage Hospital in Northalleton. It felt like a really positive day and hopefully marks a milestone in the development and expansion of our medical programme.   It also provided a chance to reflect on the journey leading up to the day; it has been a great team effort.  

It was great to see the six Year 4 pioneering students who are starting this new pilot clinical placement. We hope the year will provide a great opportunity for them to be immersed in the whole patient journey on their clinical placements and follow the same patients over time in a variety of clinical settings.  

Giving speeches at the LIC launch
Dr Kevin Anderson (@kevvya), Director of Primary Care Education, welcoming students and tutors to the LIC.

In the morning we outlined the curriculum and how the year will differ from a standard Year 4 placement. We also went through the specialist systems that will be used to support the students’ education and our dedicated student support services.   Our Health Professions Education Unit is undertaking research on how an LIC may influence development of professional identify; Megan Brown, a PhD student, outlined this in more detail as well as the opportunities for students to become involved.

At lunch we welcomed our primary and secondary care tutors to celebrate our launch and meet the students. There was a buzz in the room with tutors and students chatting about the year ahead and reflecting on the journey of getting to this point.    It was also great to welcome and thanks Lesley Pratt from Healthwatch who has provided a really useful patient voice as part of our LIC development team.  

New scrubs

Scrubs for the LIC students
Our LIC students’ new sky blue scrubs

We also handed out scrubs for the students.  In addition to spending more time in primary care than their peers, the students will be on ward rounds and in clinics in the Friarage Hospital, and occasionally up in Middlesbrough at James Cook Hospital. For these placements the students have their own Hull York Medical School sky blue scrubs. Keep an eye out for them in either hospital.

Over the coming weeks the students will be settling into their GP clinical placements and starting their clinical procedural skills training.  We will work closely with them as they get stuck in and I look forward to hearing more about their experiences on this blog.  Please check back here soon.

Also, remember you can find out more about our LIC at www.hyms.ac.uk/LIC.

The start of the LIC is around the corner

Excited to start the LIC!

It’s been an exciting few weeks as, after a year of development, we finally approach the start of the Hull York LIC pilot. 

Our new LIC study guide is with the designer prior to printing and we’ve been having a variety of final meetings as well as running training sessions for our new batch of enthusiastic tutors.

It’s been a great a team effort and we are all looking forward to welcoming our first cohort of LIC students on their first induction on 19 August – Emily, Lucy, Rebecca, Jessica, Naomi and Ruth, I hope you are also excited about starting your LIC placement but enjoying your summer break in the meantime. 

I’m off to the Outer Hebrides now but looking forward to seeing you all on the 19 August!