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MEDICAL EDUCATION
New Clerkship Takes Longer View of Clinical CareThis July at Cambridge Hospital, the Medical School will roll out the new Integrated Clerkship for an initial group of eight third-year students. Innovative in its interdisciplinary, comprehensive approach, the clerkship will replace traditional block rotations with a year-long immersion of each student in the illnesses, treatments, and lives of some 40 to 50 patients, beginning with their initial symptoms.
Barbara Ogur and David Hirsh have organized a year-long rotation to foster greater student understanding of the course of illness and care. (Photos courtesy of Cambridge Health Alliance) The program was developed by David Hirsh, HMS instructor in medicine, and Barbara Ogur, HMS assistant professor of medicine, who built on the educational foundations laid by HMS professors Ronald Arky, William Silen, and others. The clerkship, funded by the HMS Academy and a grant from the New York Academy of Medicine, is one of the first pilot projects in the ongoing Medical Education Reform Initiative, led by MalcolmCox, the HMS dean for medical education. It exemplifies a new model for clinical education in which students have both longitudinal and immersion experiences in patient care. At a March 31 reform initiative retreat, HMS dean Joseph Martin named five great challenges facing medical education: culturally competent care, high tuition costs and student debt levels, compensation of clinical teachers, the cultural chaos of academic health centers, and content challenges in the curriculum. The new clerkship addresses some of the challenges in educational content. "The students' principal clinical experiences will consist of caring for deliberately selected cohorts of patients longitudinally, across all venues of care, under the guidance of a team of dedicated faculty members," said Hirsh. "The patients will be selected to provide each student with the same knowledge that is recommended in national guidelines for clerkships." Students will follow about 15 patients from internal medicine, 10 from pediatrics, 5 to 10 from psychiatry, neurology, and other areas. The students will also see numerous patients outside of their longitudinal cohorts. Connecting Students with PatientsThe patient-centered clerkship is designed to give the students more opportunity and motivation to think, to ask questions, to learn, and to gain skills that will be transferable to any specialty, Ogur said. For example, managed care and increasingly less-invasive technology have combined to attenuate admissions and hasten discharge. As a result, third-year students see illnesses more as disparate snapshots, rather than as movies with a beginning, a middle, and an end.These changes have seriously diminished human contact for the students, and human contact is what medicine is about, Ogur said. Students also need more opportunity to develop their own critical faculties. "Now that many diagnoses are made on outpatients, and treatment is initiated on outpatients, many patients never make it into the hospital," she said. "I have had a succession of lung cancer patients over the last four years who were taken care of as outpatients until they had surgery." "Very often students don't see in-patients until after the diagnosis has been made," said Ogur. Patients are typically diagnosed in the ER, "and then they go upstairs for stabilization and discharge planning, and that is where the students make their acquaintance." In the case of her lung cancer patients, a student would have missed the analysis that led to the diagnosis and then to surgery or radiation. The long-term involvement with the patient will also illuminate the social and economic contributions to illness and how these may affect treatment. Clinical Skill DevelopmentThe curriculum is structured to reflect the students' developmental attainment of knowledge and skills, Hirsh explained. The students will go from history-taking, physical examinations, reading laboratory tests, and obtaining informed consent to clinical reasoning and diagnosis of important clinical syndromes to managing cases and understanding the relevant basic science and epidemiology.Weekly tutorials will address specific maladies, each session run by a faculty member with expertise in that malady. One student will research the case and propose different tests and treatment. Other experts will facilitate the discussion of the relevant basic, clinical, and social sciences to deeply understand the patient's problem and its context. Throughout the year, students will keep diaries--known as "self-reflections"--of their passages through the difficult events of third year. These might include the first time they speak to the spouse of a newly deceased patient or their first exposure to trauma. Students will also keep diaries of the cases they see. Each student will be assigned a mentor for the year, someone to oversee that student's development, to be there to answer the student's questions and concerns, and to review the student's self-reflections and case diaries. "Because we have students for the entire year, we can assist as they develop and help guide their learning and growth," Hirsh said. "We believe that by giving the students the capacity to think deeply, integrating the various sciences into their thinking, that we will enhance their curiosity," Ogur said. "By also creating strong connections with patients over time, we hope to reinvigorate that core aspect of medicine, which is to put doctors' curiosity and skills in service to their patients." --David Holzman |
