Med schools promote training that lets students follow individual patients

Third-year medical student Sophia McKinley was there when the doctor told the woman she had colon cancer. She followed the patient to visits to the cardiologist and oncologist to make sure she was healthy enough for surgery, and was by her side during the operation.

Afterward, she was part of the hospital team that cared for the woman during recovery and since has accompanied her to chemotherapy sessions. McKinley's experiences are a stark contrast to most medical students, who typically wouldn't have any more encounters with patients who leave their clinical block.

Internist Gerard Coste, MD (right), of Cambridge (Mass.) Health Alliance works with medical student Andrew Morris-Singer as part of the Harvard Medical School Cambridge Integrated Clerkship. "We are trying to break down the idea that the disciplines are the center and get the idea that the patient is the center," said David Hirsh, MD, the program's director. "It's not about the disease, it's about the person." Photo by Dr. Barbara Ogur / courtesy of Cambridge Health Alliance

"I have been with her every step of the way, and it's a process that takes months," McKinley said.

The woman is one of about 30 patients McKinley is following closely as part of the Harvard Medical School Cambridge Integrated Clerkship at Cambridge (Mass.) Health Alliance.

The program is called a longitudinal integrated clerkship -- a training model that veers away from traditional clinical block rotations. Instead of studying different disciplines in chunks, students work with physicians in core specialties continuously throughout the year while simultaneously following a panel of patients representing a wide spectrum of medical conditions.

It's a model that allows students to experience health care through the patient's perspective, said Perry Pugno, MD, MPH, vice president for education with the American Academy of Family Physicians.

Longitudinal integrated clerkships have been around in various forms for decades, but Dr. Pugno said he sees more medical schools adopting the model -- although no official count exists of how many are using it -- as they seek better ways to train the next generation of physicians.

Carol A. Aschenbrener, MD, chief medical education officer for the Assn. of American Medical Colleges, said at least 15 schools have such clerkships. "We're always looking to find optimally effective ways to give medical students and residents an experience in patient care that is as close to the real world as we can get it."

Dr. Hirsh

Under traditional clinical block rotations, medical students work in hospitals jumping from one specialty to the next every several weeks. They rarely get to know patients, said David Hirsh, MD, director and co-creator of the Harvard-Cambridge program.

With longitudinal integrated clerkships, students follow patients for an entire year to inpatient stays and outpatient appointments. The challenge to such a program is scheduling, with students balancing shadowing patients and attending scheduled clinical experiences with faculty.

"There's this constant juggling of your education, patients' needs and preceptors' needs," McKinley said.

Witnessing continuity of care

The Harvard-Cambridge program started in 2004 with the goal of improving clinical training in science and humanism, Dr. Hirsh said. A major flaw with clinical block rotations is that students can get emotionally removed from patients, causing many to lose the idealism that attracted them to medicine, he said.

"We wanted that idealism to be fostered and built in medical school, not lost," Dr. Hirsh said.

In 1910, educator Abraham Flexner published a report that shaped the structure of medical education over the past century. Patient care has changed significantly, but clinical training overall has remained the same, even though most patient care has moved from the inpatient to the outpatient setting, said Dr. Hirsh, assistant professor at Harvard Medical School.

"With the health care system structured the way it is today, people's hospital stays are very short," Dr. Aschenbrener said. "It is more difficult for medical students to see the evolution of an illness. They tend to see a snapshot."

With longitudinal clerkships, students "get to see the natural history of an illness or condition and its impact not only on the patient, but on their family," she said.

The University of California San Francisco School of Medicine started its Parnassus Integrated Student Clinical Experiences, or PISCES, program in 2007, said Ann Poncelet, MD, program co-director and professor of clinical neurology.

In addition to following patients, the program allows students to work with the same peers and faculty members throughout the year. Students are assigned an instructor in each of the seven core disciplines: internal medicine, family and community medicine, neurology, psychiatry, obstetrics-gynecology, pediatrics and general surgery.

"When you have a faculty member from each discipline for a year who is working with you consistently over that time, they really get to know you and get to know what your strengths and weaknesses are," Dr. Poncelet said.

UCSF was the first to adopt the model in the University of California system. A second program at the Fresno campus is in its second year, and a program in Oakland started in April.

Helping patients navigate care

Perhaps the oldest longitudinal integrated clerkship is the Rural Physician Associate Program at the University of Minnesota Medical School. The program started in 1971 to train physicians to work in medically underserved parts of the state by giving students the chance to train nine months in a rural health care setting, said Kathleen Brooks, MD, RPAP director and assistant professor at the school. More than 1,300 physicians have graduated from RPAP.

Several osteopathic medical colleges offer longitudinal training, said Tyler Cymet, DO, associate vice president for medical education with the American Assn. of Colleges of Osteopathic Medicine. For example, students may work in a rural clinic several hours a week throughout the year.

"The goal is to break down the silos," Dr. Cymet said. "You see several specialties at one time, so you're not learning medicine one organ system at a time."

Columbia University College of Physicians and Surgeons in New York and Bassett Healthcare Network are partnering in a new longitudinal clinical clerkship in Cooperstown, N.Y. Bassett piloted the program for three years with students from Albany Medical College. The first Columbia students will enter the program in 2012.

More than 950 students applied for the program's 10 slots the first year, said Henry Weil, MD, assistant dean for medical education at Bassett for Columbia University College of Physicians and Surgeons.

"It really gives students the opportunity to explore their interests," Dr. Weil said. "They're getting a very broad spectrum of exposure."

Students also experience the fragmentation of health care, said Dr. Pugno, of AAFP. "They really help the patient navigate the system as they learn about it themselves," he said.

Altaf Saadi, a third-year student in the Harvard-Cambridge program, said she has followed one elderly breast cancer patient since she was diagnosed. "For her to just have someone to go through the process with her meant so much. She was so scared through the whole thing. I will never forget that," Saadi said.

The clerkship model poses some challenges, said Dr. Aschenbrener of AAMC. Scheduling is complicated, and it can be difficult to find a site that can accommodate students for a prolonged period. Learning to maintain professional boundaries while working closely with patients is another challenge, Saadi said. Participating in the Harvard-Cambridge program has helped shape the kind of physician she wants to be, she said.

"A lot of times people can go through the [third] year and become disillusioned or frustrated," she said. "It's good to be part of a program that helps remind me why I entered medicine to begin with."