“The first baby I ever delivered belonged to a family I had known for 9 months.” This statement comes not from a small town doctor or longtime obstetrician, but from a medical student clerking at a busy, urban safety net. The Harvard Medical School (HMS)-Cambridge Integrated Clerkship (CIC) – based at Cambridge Health Alliance (CHA) – is a patient-centered redesign of the third-year curriculum. By enabling students to follow patients longitudinally across the course of their health care experience, the program provides benefits far exceeding the development of clinical medicine skills – a stronger sense of duty and commitment, deeper understanding of the social and economic factors involved in health care, intellectual flexibility, a sense of patient advocacy and idealism, and better patient care are just a few.
A meaningful role
The CIC was developed in response to the international call for medical education reform fueled by issues including rapidly changing health care systems and patient needs, gaps in learning and the loss of humanism due to traditional block rotations. David Hirsh, MD, director and co-founder of the CIC and an assistant professor of medicine at HMS, drills down into an underlying problem at the heart of the student-patient relationship. “Patients enter our system because they’re sick or worried about their health,” he explains. “They’re seeking to be served by a clinician. And as clinicians, we want to fulfill their needs – it brings meaning to our work. Students don’t experience that, and therefore don’t get the same passion and sense of what it’s really all about. And patients don’t see students as anything other than appendages.”
In traditional rotations, students often begin to participate in care after the diagnosis has been made, or at times even after treatment has begun. In this way, they not only learn diagnosis and treatment passively but they play a superficial role in the patient’s care – sometimes even hindering a patient who seeks quiet or rest – which erodes students’ sense of purpose. Simply put, the CIC was developed to bring meaning to the student’s role. “To have this meaningful role, students must perceive patients as their patients, and the patients must perceive the students as their own personal medical students, relevant to answering their questions, fostering their well-being, relieving their suffering,” Hirsh says.
To develop this meaningfully additive role, the CIC positions students as attending physicians’ junior colleagues. Students and their supervisors will see the same patients sequentially, and then ultimately together. In this way, each can conduct an initial assessment before the diagnosis is made, and patients benefit from two clinical opinions. “That layering of observation fills the gaps,” Hirsh says. “Students do ask provocative questions that matter. They notice if the patient isn’t writing down the next appointment or can’t procure the medicine – these little nuances that may seem simple in some ways, are providing the actual service to the patient and improve quality and access to care.”
Following your patient
The CIC is defined as a longitudinal integrated clerkship (LIC), which means students see patients longitudinally – over the entire course of an illness – within different medical specialties. While this model has grown nationally and internationally, the CIC’s use of a “streams model” is distinct. Under this model, students’ spend mornings and afternoons either working within a specialty (a different one each half day of the week), whether it be in a clinic, operating room or lab, or working on case studies of patients and reviewing skills and central topics with their peers. These learning “streams” run throughout an entire year. However, not every day in a student’s week is scheduled, which leaves moments of white space for students to follow particular patients, review their patient notes and read up on patients’ illnesses.
Because students are not tied to a particular specialty, they become intellectually flexible in their patient approach. “The point of doctoring is to approach the patient in front of you – not a particular disease,” Hirsh says. “The patient is the organizing factor, which students can follow across place and time.” Using their white space time, students join their patients in whatever part of the system they may be in at a given point in time. In fact, students are even permitted to leave their scheduled specialty time if one of their patients goes into labor or has a catastrophic health event. By participating in care across the entire course of an illness, students gain a deeper perspective on disease. As one CIC student notes in a 2009 Academic Medicine article, “Each time we see [this patient], attempting to understand her evolving health adds another piece to our medical repertoire. Each time we grow to understand a bit more about the toll that hospitalizations and chronically deteriorating health can have on a patient and her family.”
The continuity of care students provide is greater than even what is offered by physicians, who don’t follow their patients across specialties. “Students have a much fuller perspective, and the patient properly perceives that someone has woven their entire experience together, which helps patients take more interest in their own care and provides a system benefit,” Hirsh says. As he and CIC program co-founder Barbara Ogur, MD, explain in Academic Medicine, “Students often found themselves bridging gaps in the delivery system: by enabling more effective communication among providers, by translating physicians’ comments into plain language, by ensuring that patients did not get lost to follow-up, and by carefully researching clinical questions relevant to patients’ care.” In addition, because they are witness to so many transitions in care, students develop a greater understanding of the health system, even across venues.
The CIC fosters deep relationships between students and patients, which also bring an increased awareness of the social and economic factors that contribute to illness. In Academic Medicine, as one student describes the monotonous rural life that led his HIV-positive immigrant patient to drugs and alcohol, he repeatedly comments on the man’s sweet nature and exhibits sympathy for the loneliness and depression the man encounters as a foreigner in poor health. As Ogur and Hirsh note in the same article, these types of relationships enable students to understand patients’ values and social contexts and overcome stereotypes that impede empathy and accurate clinical judgment. In fact, when compared with their traditionally trained peers, CIC students felt better prepared to understand how the social context affects patient care and to work with patients from diverse backgrounds and at different stages of the life cycle.
This greater understanding of context actually develops into a sense of advocacy among many students. This advocacy manifests itself in multiple ways, ranging from individual acts of kindness toward patients and their families to speaking to hospital administrators regarding patient issues or even public policy activism. As one CIC student writes in Academic Medicine, “Since [my patient’s] death I have been supported by my preceptors to explore the ethical, personal, and public health aspects of my experience. Exploring my experience to gain insights that could improve medical care and advance social justice has been a crucial part of coming to terms with what happened, my role in it, and the reality of social injustice.”
However, the deep attachment to patients can be challenging for students. “Students have a tremendous amount of hope for their patients and can become distressed when patients aren’t getting better or they can’t do more for them,” Hirsh says. But this issue becomes even more challenging as a clinician, and the CIC helps students create boundaries and appropriate roles for themselves early on, preparing them for their work in years to come.
The CIC also changes the relationships between medical students. When patients are readmitted, they are seen by the student on call at the time – at times, someone other than their dedicated student. In these cases, on-call students often call the patient’s former student provider, and the two will consult and work with the patient as team. Gone are the typical competitive medical school relationships, replaced by a collaborative effort in line with true patient care.
While some may question whether the CIC offers the same clinical knowledge learned in a traditional program, CIC students have shown to perform as well as or better than their traditionally trained peers at HMS on measures of content knowledge and clinical skills. In fact, the CIC appears to strengthen the skills necessary for lifelong learning and safe and effective clinical practice, such as self-reflection and self-awareness. What’s more, CIC students have shown to feel better prepared than their peers in many elements of patient-centered care – including dealing with ethical dilemmas and involving patients and families in decision making – which are crucial skills for health systems of the future. According to Hirsh, “The CIC educational structure is more in line with the goals we actually seek – commitment, duty, broadened perspective, meaning, rigor, diligence, discernment. These core skills of doctoring are being taught across disciplines.”
But beyond these results, CIC students gain an intangible benefit that cannot be taught and is only noticed when lost. They retain the idealism that led them to a life of service in the first place. The patient connection serves as buffer against the cynicism often found in traditionally trained students – the loss of humanism. As Ogur and Hirsh write in Academic Medicine, “…they viewed their deep connections with patients over time as reaffirming of their potential to become the kind of doctors they had hoped to be.”
For more information about the CIC, please contact:
David Hirsh, MD
Director/Co-Founder, Cambridge Integrated Clerkship
Assistant Professor of Medicine
Harvard Medical School