TUSM-MMC Program Longitudinal Integrated Clerkship

Evidence-level

Promising (About evidence-level criteria)

Description

Throughout the state of Maine, particularly in rural areas, there is an urgent need for medical professionals, especially in primary care.

In response, the Tufts School of Medicine's Maine Track Program was created to give students experience in rural medicine. The program launched in 2008 out of a partnership between Tufts University School of Medicine (TUSM), located in Massachusetts, and the Maine Medical Center (MMC), a large teaching hospital in Maine.

One unique aspect of the Tufts Maine Track program is its option for 3rd year clerkships. Students may choose between the traditional block model or the Longitudinal Integrated Clerkship (LIC). Students completing the traditional block schedule spend 6 to 8-week rotations at MMC in the six core clerkships (pediatrics, obstetrics & gynecology, psychiatry, internal medicine, family medicine, and surgery). The Tufts Maine Track LIC program differs in that all of the core clerkships are completed in a consecutive 9-month longitudinal rotation in a community setting, most of which are rural. Approximately half of the Maine Track students choose the LIC program.

The following rural Maine medical facilities host Tufts Maine Track LIC students:

• Western Maine Health - Stephens Memorial Hospital
• Franklin Memorial Hospital
• Mid Coast Hospital
• Pen Bay Medical Center
• Redington-Fairview General Hospital
• Lincoln County Healthcare
• Mount Desert Island Hospital
• Cary Medical Center

Maine Medical Center, located in Portland, also hosts Maine Track LIC students.

The program's innovative pedagogical approach allows students to achieve the same standards required of all TUSM students while emphasizing continuity as an underlying theme. For example:

• Continuity of patient care: Students are assigned a panel of patients whom they follow throughout their clerkship. The program's longitudinal approach allows students to be involved in the care of their patients over an extended period of time.
• Continuity of supervision and education: Students work longitudinally with a core group of faculty over the course of the clerkship. Students establish one-on-one relationships with their faculty who have a clear understanding of the students' educational trajectory, prior experiences, and abilities.

Lectures, case presentations, and group activities are conducted monthly at rotating LIC sites. Students are required to interrupt their 9-month experience to travel to the group sessions and to MMC for most of their exams.

This video explains more about the TUSM-MMC partnership, highlighting the first class of medical students to enter the Main Track program:

The Tufts Maine Track LIC program originally received support from a 2010-2013 Federal Office of Rural Health Policy Rural Health Workforce Development grant, but is now self-funded.

Services offered

• Each host hospital is responsible for securing housing for the students, including internet access and snow removal services.
• Every rural training site has a designated site director who works with other site directors to create a full, instructive experience for each student.
• Twenty students in each Maine Track class are given an annual scholarship of $25,000, which significantly reduces their overall tuition costs.
• TUSM and MMC offer ongoing faculty development at each training site.
• Unlike many LIC programs around the nation, the Tufts Maine Track LIC program offers all six core clerkships at most sites.

Results

• To date, 362 physicians over 10 classes have graduated from the Maine Track Program.
• 45% of alumni who have completed training report they are now practicing in Maine.
• 47% of all Maine Track graduates have chosen a specialty related to primary care (family medicine, internal medicine, and pediatrics).
• To date, scholarships have been awarded to a total of 281 Maine Track students. This substantial financial support from scholarships continues to open doors for Maine students, allowing them to learn and serve in the communities that helped raise them.
• 27% of Maine Track graduates have matched to Maine Medical Center for their residency training.
• Since 2013, the number of medical school applications from Maine residents has almost tripled.
• Approximately 50% of Tufts Maine Track students are placed in the LIC Program for their core clerkship year.

Despite the smaller size of many of the participating hospitals, the wide range of experiences available at each site has deflated the argument that core medical education cannot be completed in rural areas. Preceptors and site directors have additionally attested to seeing their students develop a sense of ownership of their patients and their care, largely due to the hands-on experience that rural practices offer.

The Tufts Maine Track program not only benefits students, but also the attending physicians and their host sites. Physicians report that their students' inquiries have kept their medical perspectives fresh and minds sharp. Several TUSM faculty have accepted positions at rural training sites because of the opportunity to teach medical students, benefiting the students, facilities, and rural communities. Host sites have also expressed that becoming an academic teaching center has energized staff as they practice with the enhanced purpose of creating an optimal learning environment for their students.

Evaluations of similar LIC programs that have been implemented at medical schools across the country indicate that students who participate in LIC generally perform as well, or better than, those who follow a more traditional training program (see The Harvard Medical School-Cambridge Integrated Clerkship: An Innovative Model of Clinical Education).

To find out more about the Tufts Maine Track LIC program:

• Bing-You R.G., Bates P.W., Epstein S.K., Kuhlik A.B., & Norris T.E. (2010). Using Decentralized Medical Education to Address the Workforce Needs of a Rural State: A Partnership Between Maine Medical Center And Tufts University School of Medicine, Rural and Remote Health 10(2), 1-11.
• Bing-You R.G., Trowbridge R.L., Kruithoff C., & Daggett Jr J.L. (2013) Unfreezing the Flexnerian Model: Introducing Longitudinal Integrated Clerkships in Rural Communities, Rural and Remote Health 14(3).
• Rural Health Workforce Development Program: Giving Medical Students the Opportunity to Experience Practicing in Rural Maine, Rural Case Study Report
• TUSM & Maine Medical Center Celebrate Third Class of "Maine Track MD" Students, Tufts Now
• Maine Track Program Sees Third Crop of Students Successfully Matched, The Tufts Daily
• Off the Beaten Track, Maine the Magazine
• Medical school students learn to focus on whole patient, Boothbay Register

Challenges

• As is common with LIC programs, the "fire hose" approach of studying all six core specialties simultaneously makes the initial adjustment to clinical medicine difficult for students.
• Since most rural host sites are assigned only two students, it is difficult for students to measure their rate of advancement in comparison to their peers.
• The distance from program administrators and fellow medical school students has resulted in some students feeling isolated in their rural host site locations.

Replication

• Ensure that there is a strong core of services provided at each host hospital in order to provide exposure to a variety of medical fields.
• Choose host sites where there is more than one physician so that teaching responsibilities may be shared.
• Check that logistical arrangements are in place, including student support services such as access to medical care from clinicians who do not serve as preceptors.
• Connect with other LIC programs. Tools and resources can be shared to strengthen curriculum.
• Allow adequate time for planning. The Maine Track program spent two years preparing for the program before launching.
• Expect a period of adjustment. Since the Tufts Maine Track LIC program model is very different from traditional methods, it may be exhausting for preceptors and students at first. This adjustment time is normal and will become increasingly easier.

Contact Information

Dr. Marybeth Ford, Director
TUSM-MMC Longitudinal Integrated Clerkship
207.662.7066
Marybeth.Ford@mainehealth.org