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Smith, Benjamin

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    From following patients to following up: a new system for learning and patient care in a longitudinal integrated clerkship
    (2015-06-08) Smith, Benjamin
    BACKGROUND Longitudinal integrated clerkships (LICs) organize medical student learning around participation in patient care across multiple disciplines and over time. Clinical logbooks – which normally only document student activity - have a unique role in LICs, where they may connect to electronic medical records and alert students to patients’ hospital admissions and clinic visits. No logbook has been designed to facilitate the other unique kinds of contact LIC students make with patients. This study describes our pilot of a system created by a former LIC student, built from a customization of Microsoft Outlook's embedded Tasks application and designed as a place to both consolidate notes on patient contact and organize follow up. We aimed to assess the feasibility and acceptability of this system among LIC students, to describe its potential to enable following patients across disciplines and over time, and explore their use of its free text features to consolidate, integrate, and reflect on their learning about patient care in the longitudinal setting. METHODS We piloted the system with 12 students during the initial 6 months of their LIC year. Participants took part in two trainings in which they learned how to format their documentation within individual Outlook-Tasks for each patient they were following and how to customize the To-Do List interface to manage their growing lists of Outlook-Tasks. They were asked to then participate in two focus groups and submit examples of their patient notes along with a brief, semi-structured survey describing their personal use of the system. We qualitatively analyzed transcriptions of both focus groups, and confirmed the themes in the resulting codebook by review of their surveys and the Outlook-Tasks they created for patients within Outlook. RESULTS Twelve of twelve participants participated in the first focus group, 11 in the second, and nine students submitted surveys and examples of their Outlook-Tasks. All participants reported being able to create Outlook-Tasks for their patients and to review them within the customized To-Do List. Our analysis revealed that participants primarily used the system for patient-related documentation and task management, with some participants also using the system for learning and managing clerkship logistics. Participants identified the ability to set due dates and reminders as essential features, and commented additionally on customization, remote access, and the overlaps or gaps between the system and other software they used. Many participants valued the system for the organization and consolidation it provided them; for some this was a relief, for some this enabled longer-term reflection; for others this was overwhelming, with the burden of documentation potentially negatively impacting their experience. Participants varied in their experience of recording their reflections in this system, and this was further complicated by variations in their understanding of the role documentation and reflection played in their grading. Participants suggested that this system might have value to students in traditional clerkships with longitudinal patient care components. CONCLUSIONS This study identifies a potential lack of logistical tools supporting LIC students in their complex task of following patients, and offers an inexpensive and teachable system that may be able to provide such support. Participants spoke of numerous valuable uses of this system, but described powerful negative impacts on their experience related to observation of reflection and burden of expected documentation. This system should continue being explored as an additional resource for students. Educators should pay careful attention to communication with students about the relationship between their use of it and students’ grades. It may be tempting to implement this system with the goal of eliciting expressive writing from every student. Further analysis of this study with more systematic qualitative methods, longer term follow up, as well as repetition of this study with other students at other sites would better assess the benefits and harms of doing so.