COMMENTARIES

 

Bridging education and service: The Walter Sisulu University Integrated Longitudinal Community Clerkship programme's impact on healthcare

 

 

O A Adeleke^I; K Mfenyana^II; P Yogeswaran^III; B Cawe^IV

^IMMed (Farn Med), FCFP (SA), MPhil; Department of Family Medicine and Rural Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa
^IIMPraxMed, MA; Department of Family Medicine and Rural Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa
^IIIMSc, MFamMed, FCFP (SA); Department of Family Medicine and Rural Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa
^IVMPhil, MFamMed; Department of Family Medicine and Rural Health, Faculty of Medicine and Health Sciences, Walter Sisulu University, Mthatha, South Africa

Correspondence

 

 

In December 2008, the Executive Dean of the Faculty of Medicine and Health Sciences at Walter Sisulu University (WSU) was invited by the Global Health Education Consortium (GHEC) to attend a meeting in Cuba. The meeting focused on universities that champion community training. The GHEC selected eight medical schools worldwide whose mission was 'to train doctors for service in underserved areas'. WSU was the sole South African institution invited to this meeting.

 

Community-based medical education

During the meeting facilitated by the GHEC, the participating medical schools engaged in a comparative analysis of their shared commitment to social accountability. This process led to the development of nine global principles of social accountability. Furthermore, the meeting established the Training for Health Equity Network (THEnet), a formal organisation comprising the eight pioneering institutions. A key observation shared by all these schools was the significant integration of community-based learning activities throughout their undergraduate medical curricula. At that time, WSU's community-based training accounted for 17.7% of the curriculum, well below the faculty's original target of 33.3%. This gap prompted the conception of the Integrated Longitudinal Community Clerkship (ILCC) as a strategic initiative to enhance community-based medical education.

In alignment with the philosophy of the THEnet, which emphasises significant clinical training in community settings, the WSU medical school introduced a groundbreaking curriculum innovation: the ILCC. The essential elements of such a programme are that students participate in the comprehensive care of patients over time, have longitudinal learning relationships with those patients' clinicians, and acquire core competencies across multiple disciplines simultaneously. ^[1] Approved by the Senate in April 2010 and implemented in 2014, the ILCC was designed for all fifth-year medical students. This programme requires students to engage in continuous 20-week community-based learning and service at district hospitals and clinics, predominantly located in rural areas. This immersive experience supplements the community-based education previously integrated into their earlier years of study, fostering a deeper connection to underserved communities while enhancing practical clinical skills.

Community-based learning is widely recognised for its ability to enhance medical graduates' practical experience and deepen their understanding of prevalent community health issues. This approach not only enriches students' clinical skills but also contributes to improving healthcare delivery in underserved and rural areas by bolstering the local healthcare workforce, enhancing service supervision, and ultimately elevating the quality of care provided to these populations. Introducing the ILCC at WSU has notably expanded the duration of clerkship training conducted outside tertiary hospitals, increasing the time spent in community settings from 17.7% to 33.9%. This marks a significant achievement, surpassing the faculty's initial target of 33.3%, and underscores the success of this curriculum innovation in meeting educational and community health objectives.

 

The first ILCC cohort

In 2014, the first cohort of MB ChB V students embarked on the ILCC, marking a significant milestone in their medical education. For 20 continuous weeks, these students gained hands-on clinical experience across district hospitals. The programme was warmly embraced by both the local communities and hospital management, highlighting its integral role in community healthcare. At each hospital, a designated doctor was appointed as a preceptor, responsible for co-ordinating the programme, overseeing student activities, and acting as the vital link between the hospital, the faculty and the students. This collaborative structure ensured a rich, supportive learning environment that bridged academic and clinical practice.

Clinical specialists from six departments - Internal Medicine, Surgery, Paediatrics, Obstetrics and Gynaecology, Psychiatry, and Family Medicine - regularly visited the district hospitals to enrich the ILCC experience. Each week, two specialists from these departments conducted ward rounds alongside students and hospital doctors, offering training and mentorship to doctors at district hospitals and enhancing the quality of healthcare services delivered to local communities. This aspect of the programme enriched students' education through hands-on learning and embodied the concept of service learning by providing essential support to the community.

 

Expansion and learning activities

The success of the inaugural cohort paved the way for the programme's expansion to additional district hospitals. Positive feedback from students, hospital management and the community underscored the mutual benefits of the initiative, highlighting its value for all stakeholders involved.

The programme later integrated a Quality Improvement Project into the ILCC block to enhance students' research skills. This initiative enabled students to collaborate with hospital staff to identify and improve key service delivery areas. Upon completion, the projects were formally presented to hospital management, hospital staff, academic staff and community representatives, fostering a collaborative approach to healthcare improvement and reinforcing the students' role in advancing quality care in underserved areas.

Formative assessments in the ILCC programme include a monthly Oral Patient-Based Assessment, where students present a patient they have managed in collaboration with the clinical team over the preceding 4 weeks. These presentations comprehensively cover the patient's journey from admission to discharge, and include follow-up and ongoing care plans. Assignments and patient portfolios are submitted electronically, and all formative assessments are recorded on digital rubrics, making the programme largely 'paperless'. At the conclusion of the block, a modified Objective Structured Clinical Examination (OSCE) is administered as the summative assessment, ensuring a rigorous evaluation of student competence

To ensure that students gain comprehensive exposure to a wide variety of patients and clinical conditions, they are required to document each patient encounter and record the supervising clinician's involvement using mobile devices. This 'patient mix' offers valuable insights into the diverse clinical conditions encountered across the facilities, as well as the supervision provided during consultations. According to Dolmans et al.,^[2] the effectiveness of clinical rotations depends on the supervision provided and the patient mix. Additionally, students track and document the management of chronic communicable and non-communicable diseases, including the level of control achieved for these conditions. These data are shared with the clinical team, enhancing the quality of patient care and fostering collaborative improvement in healthcare delivery.

The ILCC has significantly expanded over the years, with students now assigned to 16 hospitals across the province. To maintain uniformity across all sites, students engage in asynchronous learning activities through the university's learning management system. Additionally, they participate in synchronous online seminars and expert-led resource sessions, ensuring a cohesive and interactive learning experience, regardless of location.

 

Conclusion

The ILCC programme has inspired medical graduates not only to return and serve these hospitals during their community service but, for some, to extend their commitment to serve as medical officers in these rural hospitals. It has produced socially responsible graduates who are responsive to the needs of rural and marginalised communities.^[31 Remarkably, many of these graduates have become dedicated preceptors, further strengthening the programme's impact. This initiative has highlighted the profound value of community-based medical education, creating a dynamic ecosystem that benefits students, hospitals and communities alike. It illustrates the tangible, long-term advantages of integrating real-world experience into medical training. As demonstrated by Gaufberg et al.,^[4] the benefits of integrated longitudinal clerkships are sustained over time among graduates.

 

References

1. Dornan T, Tan N, Boshuizen H, et al. How and what do medical students learn in clerkships; Experience based learning (ExBL). Adv Health Sci Educ 2014;19(5):721-749. https://doi.org/10.1007/s10459-014-9501-0        [ Links ]

2. Dolmans DH, Wolfhagen IH, Essed GG, Scherpbier AJ, van der Vleuten CP. The impacts of supervision, patient mix, and numbers of students on the effectiveness of clinical rotations. Acad Med 2002;77(4):332-335. https://doi.org/10.1097/00001888-200204000-00016        [ Links ]

3. Coetzee F, van Schalkwyk S, Couper I. Exploring how longitudinal integrated clerkships at Stellenbosch University influence the career journeys of medical graduates. Afr J Health Prof Educ 2023;15(3):e570. https://doi.org/10.7196/ajhpe.2023.v15i3.570        [ Links ]

4. Gaufberg E, Hirsh D, Krupat E, et al. Into the future: Patient-centredness endures in longitudinal integrated clerkship graduates. Med Educ 2014;48(6):572-582. https://doi.org/10.1111/medu.12413        [ Links ]

 

 

Correspondence:
O A Adeleke
oadeleke@wsu.ac.za

Received 10 April 2025
Accepted 11 August 2025