Introduction

Undergraduate medical education has been described as ‘a series of transitions between phases of the journey’ towards a career in medicine [1]. Increased demand for medical student places, coupled with limited access to patients and difficulties with teaching students in secondary care, has contributed to the growth of general practice as a setting for medical education [2]. Problems with traditional secondary care placements include lack of exposure to undiagnosed patients, fragmentation of students’ supervision, limited opportunity for repeat consultations with patients and lack of relationship with tutors [3]. This has led to the adoption of an alternative approach to medical placements in which students take part in immersive clinical clerkships of longer duration in general practice [4]. Longitudinal integrated clerkships (LICs), by definition, are longer than 8 weeks duration, thereby facilitating the development of deeper relationships between students and tutors, staff and patients [5]. LICs promote a more person-centred approach to clinical medicine than traditional models, while being at least as effective in promoting knowledge acquisition [6, 7]. General practice is a popular setting for LICs as clinicians there tend to see a broader spectrum of conditions [8, 9] and place particular emphasis on doctor-patient relationship and patient-centred care [10, 11].

Student satisfaction with LIC placements tends to be high [12] and the positive impact of LICs on students choosing careers in rural and primary care medicine has been described [13,14,15]. Many students are given an opportunity to develop their own skills and build relationships with patients during the rural LIC [16]. Three principles that underpin the student experience in LICs have been described: continuity of patient care, continuity of supervision and continuity of curriculum [17]. The defining features of a LIC are that students participate in patient care over time, develop relationships with said patients’ clinicians and meet the majority of the year’s core clinical competencies through the experience [6]. Hirsh et al. outlined ‘relationship-based education’ as a core feature of LICs, whereby the student develops meaningful working relationships with other members of a practice [12], under continuous mentorship [18].

Very little has been reported on the influence of these relationships, particularly their impact on supervisors. Worley surmises that the benefits of the relationships developed in community-based clerkships are a “win-win” for all stakeholders [19] whilst Howe has suggested that supervisory responsibility can boost morale [20]. Others have been more trepidatious and have suggested that supervisors’ central roles in integrating students within clinical teams can potentially increase stress levels for general practitioners (GPs) [21].

The aim of this study is to conduct a narrative review of the literature pertaining to relationships within LICs, to understand how they come about and how they affect learning.

Methods

Search strategy

The search strategy involved searches of PubMed, ERIC (Ebsco) and EMBASE databases by entering the following keywords and MeSH terms: medical AND (‘students’/exp OR students) AND (‘experiences’/exp OR experiences) AND (‘longitudinal’/exp OR longitudinal) AND (‘clerkship’/exp OR clerkship) AND mentor (mentor* OR general practitioner) AND (‘experiences’/exp OR experiences) AND (‘longitudinal’/exp OR longitudinal) (Appendix A).

Appendix A. Search strings

Inclusion and exclusion criteria

Research papers published in peer-reviewed journals from January 2007 until September 2020 that were written in the English language were included in the search. Exclusion criteria were papers not written in the English language, research protocols, commentary pieces and studies that explored the experiences of students who were not medical students. Papers that did not pertain to experiences of mentors or medical students or specifically to LICs were also excluded. Reference lists were also searched using the search strings for relevant eligible papers.

Screening

Literature was reviewed independently by two researchers (JO’D, AO’R) using the inclusion and exclusion criteria outlined above. Any disagreement about whether a paper should be included was discussed among two researchers until consensus (JO’D, AO’R). The articles were assessed thematically for their content related to LICs. The results are presented under themes which were categorised by two researchers (JO’D, AO’R) (Fig. 1).

Fig. 1
figure 1

PRISMA diagram

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Results

The initial search yielded 2482 papers which was reduced to 2324 after the removal of duplicates. Selected papers were initially screened by title and subsequently screened on their abstract or full manuscript. Forty-three studies were selected for final review (Table 1) as they were published between January 2007 and August 2020, in English, and were focused on LICs. Four main themes were identified:

  1. 1.

    Defining relationships in LICs

  2. 2.

    Developing relationships in LICs

  3. 3.

    Relationship maintenance

  4. 4.

    Multi-stakeholder impact

Table 1 Outline of studies
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Defining relationships in LICs

Hudson described teaching as a “tradition of medical practice that goes back to Hippocrates” and a fundamental feature of this tradition is the “reciprocal benefit” of relationships formed during LICs for GP supervisors, students and community [22]. The relationships between students, supervisors and patients are central to LIC programmes, and several models for this triangular relationship have been described [23,24,25] (see Fig. 2). It has been suggested that this triangular model be expanded to encompass relationships between supervisors and the medical school and between students and the wider community [26]. Relationships between students and other practice staff are also considered important [16, 27]. For LICs in hospital settings, the central role of relationships between a hospitals’ culture, students, patients and secondary care supervisors was described [5].

Fig. 2
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Dynamic relationships in a LIC

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Birden et al. reported that graduates from an LIC continued to value the relationships formed during the programme during their early years as a junior doctor [28]. However, some problems with relationships have become apparent, including social isolation in remote areas [29], loss of contact with students’ families and difficulties coping with personal problems [30]. Relationships in LICs are “not universally positive” [31, 32], chiefly due to personality clashes, though these are uncommon and tend to be managed satisfactorily [33]. Consequently, graduates of LIC programmes have advised that prospective students considering taking part should be open to close therapeutic and professional relationships [34]. Accordingly, medical schools have emphasised the importance of having a mechanism for managing relationships with GP tutors when they break down or fail to form in a therapeutic manner [35].

Developing relationships in LICs

Birden describes the role of the supervisor: to monitor students, identify deficits, give appropriate feedback, agree action plans and monitor subsequent progress. As students stay longer at a clinical site, their supervisors develop an understanding of their abilities and allow them to work with more independence, leading ultimately to an “immersive experience” for students [28]. The development of trust over time between student and GP supervisor enables students to take on a doctor-like role in a supportive environment [36, 37] (see Table 2). Supporting the student’s participation is a key role of the GP supervisor [36]. As the supervisor-student relationship grows, the students perceive the relationship as less of a hierarchy and more of a partnership [37, 38], facilitating gradual exposure to patient care [23, 39,40,41,42,43], which Latessa et al. surmise increases student opportunities for learning [44]. As trust develops over time, it leads to increased inclusion in the team and a sense of belonging [45]. Consequently, students start to identify more as an authentic member of staff and identify their mentors as clinical role models [37, 43, 46, 47]. When students have a trusting relationship with their supervisors, they interpret feedback in a more constructive way [48]. Witney et al. found that patients in rural LICs, compared with traditional block clerkships, reported more opportunities to consult with patients through the course of their illness, which helped build relationships [9]. Garne et al. reported that, as patients get to know students over time, they develop rapport which can benefit patient care [33]. Daly et al. describe how geography in LICs can be ‘a double-edged sword’, whereby rural and remote places can lead to social isolation for students, but can also provide them a more immersive experience in the community [49]. “Relationship building by students” within LICs helps learners to cross boundaries within and between communities of practices [45, 49], involving supervisors, faculty, patients, peers and communities. A key function of a supervisor is in connecting students to patients and helping students recognise that they are advocates for their patient [50]. During the LIC, students are able to build on their competencies and trust with patients and with the GP through parallel consulting [51]. Practice staff ensures that the highest quality of patient care is given, patient and student safety is ensured and that learning points can be identified for the student [51]. By having an LIC in general practice and a trusting relationship with the GP, the student can build on their clinical competencies for the future that are able to ensure any patient they will treat in the future receives the highest quality of care.

Table 2 Roles and consequences of stakeholders involved in relationships in LICs
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Relationship maintenance

It is recognised that appropriate support, supervision and opportunity for reflection are needed to optimise relationships within LICs [32, 52]. Medical schools can support relationships by investing in GP supervisors both in their professional development as supervisors and through allocation of resources, such as protected time [53]. For the process to be successful, it is imperative that medical schools identify suitable supervisors, who should then be supported in their own teaching and mentorship skills [54]. Similarly, students undertaking LICs must understand the importance of close therapeutic and professional relationships, according to graduates from a LIC-based programme [34] (see Fig. 2). Students should be orientated properly by faculty before undertaking the placement and be taught strategies to become self-directed learners who are able to capitalise on learning opportunities offered within an LIC [54]. A curricular framework such as education continuity could be used to develop effective relationships between staff and students. By having ownership of the curriculum, it can foster a learning environment that is both learner- and patient-centred, developing clinical competencies and enhancing role modelling and mentoring [17].

Multi-stakeholder impact

Hauer et al. reported that the relationships helped to “anchor [the] professional development” of students [38]. Students can improve their social skills and understanding of society by getting involved in the community [25] and community-based activities beyond the consulting room [26]. These insights facilitate the growth of empathy and a patient-centred approach [17]. Relationships developed over time with patients help students to consider the professional, ethical and personal aspects of medicine, including the family context [55]. Students perceived themselves as having an authentic role in patient care, increasing their confidence and motivation in contrast to students interviewed from traditional clerkships, who did not perceive this kind of collaborative relationship and the independence it confers [24, 46] (see Table 2).

Access to positive role models can also help students to reflect on their own well-being, which can enhance understanding of medical professionalism [56]. Further, mentors can impact the career choice of medical students [57]. It seems that the benefits of relationships continue beyond the duration of the LIC, as post-LIC students are better able to give peer-to-peer feedback regarding clinical and communication skills [58, 59] and are more likely to seek appropriate assistance concerning gaps in their knowledge [25]. Relationships formed during LICs can also influence how supervisors perceive themselves—in fact, self-perception and satisfaction were the main drivers for supervisor involvement in Walters et al. research [23]. Similarly, Teherani et al. described how collegial relationships with students enabled a shared care approach to patients [53]. As a result of the relationship between supervisors and medical schools, the former’s self-perception changed from being a solo operator to part of belonging to a bigger institution [26]. For rural general practice, LIC relationships increase morale, energy and ultimately improve patient care [60]. GP supervisors and practice managers believed that relationships with LIC students improved the ambience and increased respect and relationships between GP colleagues [43, 47, 60]. The experience of relationships within hospital-based LICs has also been mainly positive, with strengthened professional identity development, improved reflective practice and the ability to engage in inter-professional education all reported [5]. Interestingly, Connolly et al. also report the potentially damaging effect of a disengaged student within LICs, highlighting the reciprocal nature of relationships, and the importance of student engagement in the inference of relationship-based benefits within LICs [5]. Sustaining or encouraging student engagement may necessitate additional student support, and it is crucial that medical schools with LICs to consider the differences between LIC and block clerkships as experienced by students [61].

Discussion

Summary of main findings

This narrative review has identified that triangular relationships between students, GP supervisors and patients within LICs are the central drivers of success for this model of clinical education. These relationships are nested in a set of important supporting relationships involving other supervisors, the medical school and university, the practice clinical and administrative team as well as peers.

Comparison to existing literature

Trust and confidence developed by the student-supervisor relationship grow with time and experience and, accordingly, more exposure to patient care can gradually be facilitated, leading to deeper relationships with patients and their families [62]. A study of learning in primary care found two key inter-related elements leading to success on placement: the quality of the relationship with the GP supervisor and the development of trust between them [63]. It has been termed transformative learning, where the GP supervisor takes on a mentorship role [55] and the student takes on the role of a clinician [64]. Time and continuity are needed for these relationships to occur, both of which are emphasised by a LIC. Longitudinal clerkships can occur in other specialities such as general medicine or surgery but are often shorter in duration due to limited resources [65]. The Harvard Medical School-Cambridge Integrated Clerkship (HMS-CIC) has been taught longitudinally and based in the disciplines of internal medicine, neurology, obstetrics-gynaecology, paediatrics and psychiatry [66].

This review has not identified significant literature on strategies for dealing with poor relationships during LICs. Ellaway et al. propose that structures be in place for relationships that are more challenging [67]. Medical schools can improve their relationships with LIC sites through regular practice visits by faculty and valuing feedback from supervisors based on their experiences [68]. From a supervisors’ perspective, the ability to foster good relationships is an essential skill [69]. Hudson et al. emphasise the importance of parallel consulting [68], which often becomes time neutral as the student develops in experience and confidence [70]. It has been suggested that a benefit for GP supervisors is a steady contribution of the student to the workload through a collaborative relationship [71]. The GP supervisor-student relationship within LICs is described as “a personal and reciprocal relationship” [72].

The value of relationships between students and patients is in the increased understanding of patient experiences and opportunity to contribute meaningfully to their care [73]. Students within LICs work with and see different presentations from patients over time and work to ensure the best care is given across all healthcare settings [74]. The working relationships with patients that are developed during LICs tend to confer more understanding of the patient perspective [73]. Fortunately, positive attitudes towards the presence of students in consultations with GPs have been described by patients [75]. In addition, the relationship the student has with society or the community in which they work is considered key to retaining the rural workforce [15, 76].

The concept of connectivity has been identified in this paper as an important factor in the success of LICs, especially by Roberts et al. [45]. Possibly, the most important role of the GP supervisor, therefore, is to support students in becoming aware of their own professional boundaries [77]. This emphasis of the hidden curriculum in the formation of professional identity through positive student-GP supervisor relationships has been described [78]. Among the most important roles for a supervisor in any type of clerkship is to support students and promote their participation in patient care [79].

This review has identified two key factors regarding relationships within LICs: (i) the willingness of students to enter into mature relationships where they interact sensitively and confidently with patients and their families and (ii) the ability of students to collaborate responsibly with supervisors and accept feedback. Self-motivation and willingness to engage with learning opportunities as they arise are keys to successful clerkships [81]. We have identified feedback from supervisors as a core component in the students’ development [11].

Strengths and limitations

The strengths of this review are that this body of research adds to the emerging body of literature concerning the benefits of, and issues with, LICs. Another strength of this review concerns its novel focus—relationships within LICs—upon which the literature has not been previously synthesised. A limitation of this study is that, despite the systematic search strategy employed, relevant papers within databases not searched may have been missed. Much of the research has involved small studies that are specific to one particular school or type of programme and may not be generalizable [65].

Implications for policy and research

A cohesive approach to relationships across multiple schools is needed to establish how exactly beneficial relationships are formed and maintained during LICs, as well as how they can be supported and strengthened. Investigation of dysfunctional relationships and how to prevent and manage these is also necessary. Our recommendations include providing training for supervisors in regard to the building and maintenance of tutor-student relationships; creating orientation and pre-placement material for students to help them to understand the importance of relationships and how to engage successfully in building them; and supporting GP supervisors by providing them with ongoing training, resources and funding. Students should be given an opportunity to discuss and give feedback on their experiences on the LIC at the end of their placements to enable reinforcement of their learning experiences on their LIC. Finally, social isolation for students and tutors [29, 49] is an ongoing concern which warrants further investigation.

Conclusion

This review has identified clearly what relationships exist in LICs, the nature of these relationships, and has illuminated how they are an essential part to successful learning. For LICs to maximally benefit their stakeholders and operate sustainably over time, medical schools must support and prioritise relationship development within longitudinal clerkships.