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FORUM
Third-Years Write Prescription for Ailing Clinical EducationMedical students have been known to grumble occasionally about the quality of teaching and the treatment they receive while on rotation at the hospitals. But for the first time, third-year Harvard medical students took part in a forum with educators, clinicians, and administrators to discuss these problems and propose systematic solutions. Daniel Lowenstein, who becomes dean for medical education in July, listened in via satellite from UCSF. The forum, which took place in the MEC amphitheater on Dec. 14, was part of a final project for the class's Patient–Doctor III course. Daniel Federman, current dean for medical education and one of the course's directors, urged students to "think about the system as the source of improvement." Each society chose one group to present a problem and give specific solutions. Some of the groups focused on a particular issue, such as improving student clerkship evaluations or debriefing students after their first experience with emergency resuscitation. Others spoke about needing a more defined role and better guidance for medical students in their rotations.
Emily Katz, a third-year medical student, gave a presentation for the Cannon Society criticizing aspects of clinical education. "Emily's remarks should be taken as a rather eloquent indictment of many of the issues students are facing," said Daniel Lowenstein, the incoming dean for medical education. Rebalancing PowerOne of the key concerns of students was preventing the abuse of power. The Holmes Society conducted a poll of 80 third-year students and found that half of them felt they had been mistreated by a medical professional while on rotation. Students felt that reporting these issues would negatively affect their grades, and they wanted a person they could talk to who would not be involved in grading them.Leon Goldman, associate professor of surgery and chief of compliance for CareGroup, pointed out in the subsequent response session that the nature of power relationships requires a third party and an anonymous reporting system to ensure that abuses are aired. A highlight of the forum was a speech by Emily Katz on behalf of the Cannon Society, an eloquent attack entitled "Learn Me." "We are not just griping," Katz said. "The state of teaching in the hospitals is not just less than ideal or undesirable; in many ways, it is simply unacceptable." After criticizing the lack of set objectives and roles for students, Katz then listed several suggestions for change, such as designating teaching residents who are not involved in student evaluations, and clearly defining objectives at the beginning of each rotation. "Hell, a lot of our suggestions don't even cost money and could be implemented within the month," she pointed out. Raising the Teaching MissionAfter the presentations, Lowenstein noted that "a lot of things have not changed that much," echoing a sentiment expressed by other members of the audience who had been through medical school and had many of the same complaints then. "This really comes down to the role that teaching plays in the mission of medical schools and biomedical institutions," Lowenstein said. Addressing comments about the lack of financial incentives for good teaching, he said one of his goals was to allow "people who are interested in teaching to have that role as part of their profession." (See accompanying sidebar and the Medical Education story)Although the students seemed skeptical about whether their suggestions would be followed, the opportunity to express their views was undoubtedly a step forward. "Why haven't [things] changed in the last 15 years? It would be great if they listened to us now," said Andrew Oberwager, a third-year student in the Cannon Society. Katz characterized herself as "very cautiously optimistic" about the possibility of having an effect on the system. Gordon Harper, codirector of Patient–Doctor III, said his intention in organizing the session was to encourage students to reflect on the learning process and the educational system. The forum was a step toward "helping students live and breathe the idea that they are becoming physicians who will have an important part in looking at how things happen." Uncovering Teaching Opportunities in Patient CarePriscilla Richardson, education and faculty development specialist in OB/GYN at Brigham and Women's, is a rarity in the teaching hospitals. Educational opportunities are often informal and may have a low priority in the hectic schedule of a hospital, and it is unusual to have an educator on staff. Richardson's job is to find ways to emphasize teaching, including arranging at least two grand rounds per year that focus solely on education. To bring the topic of education to the formal grand rounds setting, Richardson and Elizabeth Armstrong, HMS associate professor of pediatrics (medical education) in the Office of Educational Development, arranged a session called "Teaching in the OR." Richardson videotaped three surgeons as they operated on patients with residents and students attending. The faculty surgeons used the time to teach and involve the students—discussing the case, outlining expectations, thinking out loud, and giving the students feedback. Richardson and Armstrong showed the tape to an audience of students, residents, and faculty to open a discussion about how to incorporate teaching in a clinical setting. "What I think is important is that we look at integrating teaching—from the clerkship, through the residency, through the faculty," Richardson says. Realistically, clinical faculty members have little time to teach, so her approach is to show them ways to incorporate teaching into their activities at various levels. Richardson was among the hospital administrators attending the student forum on Dec. 14, where students brought up some of the same issues that she addresses in her role at the hospital. "The students were right on," she says. "Their feedback really created a sense of urgency about the educational mission of the teaching hospitals." Program Begins Teaching Residents to TeachResidents play a crucial role in the education of medical students, although most are not trained to be teachers. Now that gap is being addressed by the Resident-as-Teacher Program, under way in the Departments of Medicine and Pediatrics at HMS-affiliated hospitals. Daniel Federman, dean for medical education at HMS, who initiated the program at Harvard, says it is long overdue, especially since today a number of "system" problems add stress to the resident–student relationship. For example, in addition to heavy resident workloads, there is less time for students and residents to get to know each other, largely due to shorter clinical rotations and conflicting schedules. Forward MotionThe program stems from a large collaborative project involving the medical schools of Harvard, the University of Chicago, and Columbia University. It has been supported by the Harvard Macy Institute with subsequent funding from the Gold Foundation. At HMS, the program's leaders are Federman; Janet Hafler, associate director for faculty development; Elizabeth Rider, clinical instructor in pediatrics; and William Kormos, instructor in medicine.In a survey of 120 residents, most indicated considerable interest in the program and a lack of previous training. In fact, 70 and 81 percent of pediatric and medical house staff, respectively, indicated they had not previously participated in any formal programs to improve their clinical teaching skills. The surveys were distributed to both residents and students to help evaluate the need for a resident teaching curriculum. Students generally thought residents' teaching skills could be improved and indicated they viewed residents as important role models. To develop the program, its leaders met with teams from each HMS-affiliated medicine and pediatrics site, comprising residency program directors, clerkship heads, and chief residents. During four half-day retreats, they discussed the importance of a teaching curriculum, program designs, methods for evaluating the teaching effort, and other relevant topics. The pediatrics and medicine departments developed teaching programs unique to the needs of each institution. Many programs focus on feedback skills, leadership skills, the student–teacher relationship, and teaching strategies. Others include awards, one-on-one mentoring about teaching, and methods to evaluate teaching. Some sites are scheduling workshops, while others have incorporated teaching programs into pre-existing retreats and house staff meetings. Elements of StructureThe program's developers believe it will substantially improve communication and teaching skills and, therefore, the relationship between students and residents. According to Rider, "Communication is important. Establishing clear learning goals and expectations between resident and student early on in the relationship enhances the learning experience in many ways." She believes that having specific guidelines in place will facilitate the learning process for the student and clarify the resident's role.John D'Orazio, a pediatric chief resident at Massachusetts General Hospital, who helped develop the program, agrees. He says, "The resident-as-teacher curriculum is largely about improving communication skills in the workplace. Issues of how to interact with each other and work together effectively constantly arise on the wards and in the clinics." Federman believes one simple recipe can be incorporated into residents' daily lives that will not even require extra time: 1. Think out loud; 2. Stick to basics; and 3. Be kind. Elaborating on these concepts, he says that residents should do their best to continually communicate with students about what they are doing with a patient. Also, they need not cite the latest research article or feel they have to launch into didactic presentations. They need only concentrate on what they do best and what students appreciate most: history taking, physical examination, and case formulation. Federman says the Resident-as-Teacher Program is not a panacea, since systemwide problems will not go away overnight. But it is a step in the right direction. Soon similar programs will be developed in other departments at affiliated hospitals. —Lorene Leiter |
