Connecting with Patients over the Long Term

Photo by S. Bray Stephen Calderwood

Pilot clinical clerkships, used to sculpt the Principal Clinical Experience (PCE) launching in spring 2008, are remaking HMS’s third year. The large teaching hospitals are melding traditional immersions in the core clerkships (medicine, surgery, pediatrics, OB–GYN, neurology, psychiatry, radiology) with a year-long program that includes a multidisciplinary curriculum, faculty guidance and mentoring, assessment, and the Primary Care Clerkship, a longitudinal ambulatory-clinic experience. Cambridge Hospital continues its integrated clerkship, coordinated by David Hirsh, HMS instructor in medicine, and Barbara Ogur, HMS assistant professor of medicine. In it, students shadow patients throughout their routine care and illnesses, in and out of the hospital, focusing on longitudinal inpatient and ambulatory encounters instead of inpatient specialty immersion experiences.

The best practices within each hospital’s customized approach may wind up in their own ultimate PCE programs or be shared among institutions, but a key commonality is that students stick to one primary site for their clinical work for that year. (Students at the Longwood hospitals, Brigham and Women’s and Beth Israel Deaconess Medical Center, rely on Children’s Hospital Boston for pediatrics). And a year-long, longitudinal, multidisciplinary curriculum will ensure, for example, that “instead of learning about diabetes as a medical disease, they will learn about diabetes as a medical, surgical, pediatric, neurologic disease,” said dean for medical education Jules Dienstag.

“The ability to connect with patients over a longer term process, 12 months, allows you to understand their illness in a much broader sense,” agreed Erik Alexander, HMS assistant professor of medicine and director of BWH’s pilot, which will double last year’s 12 students when it begins its second year in July. Longitudinal tutorials at BWH will “not only be in the classroom but also at the bedside,” he said, showing students how different specialists interact with patients. BWH also focuses on evidence-based medicine, so students see “how one uses the medical literature to guide clinical decision-making and to understand the limitations of any study and how they apply to individual patients.”

Richard Schwartzstein, HMS associate professor of medicine and director of the BID pilot (eight students this year and twice that many in the planned second year), said his hospital has a transition week before the clerkships begin, in which students learn basics like hand washing and infection control and using the computer system. They also get an immersion in clinical radiology cotaught by a clinician and a radiologist, along with four sessions on “common emergencies that they’re likely to encounter on any of their rotations—chest pain, shortness of breath, low blood pressure, seizures, and altered mental status.” Students practice the evaluation and treatment of patients with these conditions in the BID simulation center.

A writing program, in which students keep portfolios of monthly self-reflections and case descriptions, is also being test-run as part of the pilot, with thrice-yearly review by faculty. “We have a much better sense of who the students are and what they’re learning because the faculty observe them over the course of the entire year,” said Schwartzstein.

Massachusetts General Hospital begins its pilot this July with 16 students. Pilot director Stephen Calderwood, HMS professor of medicine (microbiology and molecular genetics), said the hospital hired highly regarded physician-educators to assess students several times a year as they meet with patients, observing them as they step from specialty to specialty.

Students in these programs apparently appreciate the benefits. Last year, 38 students participated in PCE pilots, according to Alexander. “This year, 107 students volunteered for 68 pilot slots, the majority of the class, excited about these possibilities.”

—Rich Barlow

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