Carolyn Casey’s pager jolted her awake in wee hours of the morning: One of the Harvard medical student’s patients had checked into the hospital and needed a Caesarean section. Casey rushed off, arriving just in time to help deliver her first baby.
Later, Casey visited the mother, Camila Santans, newborn Matthew and other family members in their room at Cambridge Hospital, talking with them about breast-feeding and the gestational diabetes that had complicated the pregnancy. In the coming weeks, Casey will accompany Santans to follow-up appointments and checkups with Matthew’s pediatrician.
It’s all the kind of attentive, hands-on experience many assume is typical in a doctor’s training. In fact, it’s exceedingly rare.
Shaking up rotation system
At Harvard Medical School, as elsewhere, most students will see a dozen births or more during a three-week obstetrics rotation, but they rarely will meet a mother before she arrives at the hospital, or see her again once she leaves. On other rotations, they may see acutely ill cancer patients, but they may not be there to break the news, or follow them and their illnesses over a course of chemotherapy.
Casey and seven other third-year Harvard students are part of an experimental program that hopes to address those shortcomings by casting aside the traditional hospital rotation system. Rather than moving from specialty to specialty every few weeks for intensive blocks of training, they are following individual patients, wherever their conditions take them in the health care system.
Some patients are pregnant, others ill — either already diagnosed with complicated medical problems or picked up in the emergency room before anyone knows what is wrong.
If the patients have specialist appointments, the students accompany them, even sitting with them in the waiting room. If they need surgery, students observe and assist. In some cases, they visit patients at home. And if patients die, as has already happened in the early months of the program, students will be there for that, too.
The hope is that these relationships will both help the students become more empathetic physicians, and make the science they are supposed to be learning stick in their minds.
“We remember experiences because they are meaningful to us,” Casey said.
The experiment is one of several around the country that concern clinical training, though Harvard’s is “unique in scope,” said Dr. Michael Whitcomb, senior vice president for medical education at the Association of American Medical Colleges.
The efforts are emblematic of a growing dissatisfaction among some medical educators with the clinical training that students receive in their third and fourth years of medical school, after two years in the classroom.
That discontent stems from significant changes at the teaching hospitals where clinical training takes place. Patients once spent weeks in teaching hospitals, and students could follow them from diagnosis through treatment. Now teaching hospitals, like other medical centers, shuffle patients quickly in and out, and students get little more than a snapshot.
Teachers involved in the Harvard program say typical medical students aren’t getting the same human contact that instructors remember from their training days. Nor are students necessarily getting interdisciplinary views of illnesses, which don’t always fit neatly into categories.
Perhaps most importantly, the teachers worry students aren’t practicing the skills that, for all of the changes in medicine, are still supposed to be the focus of the third year: taking patient histories and thinking through a diagnosis.
'Best thing since peanut butter'
In the past “you had students involved in really core thinking that was going on to diagnose a patient, and you were with a patient long enough to see it actually happen,” said Dr. Barbara Ogur, one of two co-directors of the Harvard program. “That was being totally lost.” The focus in teaching hospitals now is on stabilizing patients; often a diagnosis has already been made, or the patient is discharged before it is completed, she said.
Still, the prevailing rotation system has lasted for decades because it has its virtues: it exposes students to a range of cases, is relatively easy to organize, and offers hospitals a pool of free labor. In 2000, an Association of American Medical Colleges survey found that medical schools had responded to the explosion of new drugs, technologies and treatments with a substantial retooling of the classroom portions of their curricula, Whitcomb said. But the third and fourth years of medical school had been largely untouched.
Reform has been “remarkable for its slowness,” said Dr. Kenneth Ludmerer, a historian of medical education at Washington University in St. Louis. Several similar attempts at changing clinical rotations during the 1950s failed, he said. Even as health care has become increasingly outpatient, “it’s been so convenient for hospitals to keep teaching in the hospital,” he said.
Dr. David Hirsch, Ogur’s co-director, admits some colleagues have been skeptical about the new program, and even he isn’t sure it could work on a broader basis.
“My biggest concern is scaling up,” he said. “It may be the best thing since peanut butter. But the question is, is that because we’re putting a tremendous amount of resources into only eight people?” The logistics have been tough, he said, as has been lining up the extra teaching the students need to cover material they might not otherwise see. And even if Harvard could make the system work for all 170 students in a class, that’s no guarantee poorer or larger programs could do so.
Hirsch says the key to success is picking patients who will expose the students to the widest range of experiences.
A typical example is Catalino Rodriguez, who on a recent afternoon visited student Joanna Epstein at the Windsor Street Center in Cambridge, an outpatient clinic. Rodriguez has a variety of complicated and considerably interconnected health issues: a leg injury from a workplace accident, heart problems, and most recently a dangerous infection that hospitalized him for five weeks. He also is in recovery from substance abuse.
Epstein first met Rodriguez during his hospital stay; he went to the Windsor Street Center with girlfriend and caretaker Patti Miller, who worried that a recent, small spike in his temperature could signal a recurrence of the infection. Epstein and Ogur, who joined the appointment later, concluded that it wasn’t an immediate threat but told Rodriguez to watch his temperature carefully.
“When you’re at a hospital, seeing someone you know, a friendly face, it makes you feel a little more comfortable,” Rodriguez said of Epstein. “She can speak up for you.”
Miller said Epstein also helped her deal with the stress of Rodriguez’s hospital stay. “She’s younger, she’s more our age,” she said. “I think it’s easier for us to talk to her.”
Epstein says the relationship has paid off for her, too.
“He’s actually my teacher,” Epstein says. “I tell him, he’s a Harvard professor at this point. He can add that to his resume.”
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