Teaching the Art of Doctoring in a High-Tech World
By Sara Lamb, M.D., Associate Dean of Curriculum
Since 2006, the School of Medicine has been undergoing a transformation of the system of educating medical students. In response to the changing climate of medical education theory and practice, the evolving nature of health care delivery and pressures to provide more efficient, high quality care, the School of Medicine is also changing. With the emergence of electronic medical records, computers on wheels, computer terminals in patients’ rooms, doctors can be found guilty of paying more attention to their computer screen, smart phones, or iPads than to their patients. While teaching future doctors to work within systems that employ these high tech devices to streamline care, reduce costs, improve efficiency and patient safety, the School of Medicine has recognized that the doctor, the patient and their relationship are still at the center of healing.
With increased pressure to include more in an already packed four year curriculum the School of Medicine has had to become creative in weaving in elements on “doctoring” amidst the teaching and learning of gross anatomy, biostatistics, biochemistry, pharmacology, women’s health, and biomedical informatics, along with other foundational topics.
Curricula in medicine across the country have historically emphasized basic science education in the first two years with lesser emphasis on the actual art of working with patients until the latter two years of the four year curricula. The School of Medicine was not much different. Up until 2009, students had limited access to “real” patient encounters. Practicing the skills of interviewing patients, empathizing with their struggles with illness and health related tragedies was limited to a mere two weeks as part of their “Physical Diagnosis” and “Doctor Patient Relationship” courses. Starting in August 2009, the Curriculum Implementation Committee set out to emphasize the intertwining of the medical sciences, medical arts and clinical medicine throughout the four year curriculum. The importance of respect, communication, listening and empathizing with patients early and often was a central goal.
As part of the clinical medicine portion of the curriculum, students in the Class of 2013 were introduced to their first patients – hospitalized children and adults at Primary Children’s Medical Center and the University Hospital – on the first day of medical school. Patients graciously volunteered to speak to the students. The students were tasked with exploring what it is like to be hospitalized, to be ill, and to find out what advice these patients and families would give them as burgeoning young physicians that would make the health care system a better place for people to get well. Recognizing that students inherently come to medical school equipped with the sensitivity, compassion, caring and yearning to heal, the curriculum committee wanted to celebrate these skills, build upon them starting on day one and reward students for their ability to let these qualities shine through.
Following this early introduction to their “first patients,” students then have the opportunity to continue practicing interviews with actors, or “standardized patients”. Their interviews are videotaped and reviewed to illustrate ways in which body language, subtle mannerisms and communication styles all impact the doctor patient relationship. Students review their videos and critique themselves. Small groups of students are tasked with reviewing their peers’ videos. This allows clinical faculty and students to contribute to each student’s learning about how behavior impacts the relationships they will form with patients in the years to come.
Practice makes perfect, and practice is what they do – weekly. During the first semester of medical school, students practice the skills of gathering information and learning the art of the physical exam. Learning how to listen, communicate and observe are crucial skills that get regular reinforcement both within the classroom and in the clinics.
In January of the first year of the curriculum students are assigned to a primary care clinic site where they are immersed in the clinical environment. On a bimonthly basis, students in these continuity clinics work with physicians, nurses and medical assistants to learn the system of health care delivery from the community clinic perspective. These regular opportunities to interface with patients and families, interview them and hear their concerns and fears all serve to reinforce principles learned in the first semester. Throughout the remainder of the first two years, students progressively develop their interviewing skills, bedside manner, and physical exam techniques under the tutelage of University community physicians. Ultimately, this time and exposure allow students to become much more prepared for the clinical immersion that characterizes the final two years of the curriculum. Although only in the third year of its implementation, students in the new curriculum have been observed to be much more comfortable, sensitive and effective in communicating with patients and teams of health care professionals by the faculty and housestaff that traditionally help to train our students.
In addition to weaving in opportunities for clinical exposure to patients in the early portion of the curriculum, the School of Medicine has adopted a competency based mission upon which the entire curriculum is structured. Much like the competencies that underwrite the graduate medical education programs across the country, the School of Medicine has adopted similar competencies that students are expected to achieve prior to graduation from medical school. Expectations for competence in areas such as interpersonal skills and communication and professionalism serve to hold students accountable for mastery in each of these areas prior beginning their residency training programs. Inasmuch as the curriculum committee has crafted learning experiences for its students to progressively develop their skills in each of these areas, the School of Medicine has created high stakes assessments of students that are thoughtfully placed through the four year curriculum. It is through these regular, strategic and rigorous examinations that the School of Medicine assures our faculty, patients and the public that those successfully completing the curriculum at the University of Utah can interact, communicate and behave in a fashion that meets the highest standards.
New projects for students at the School of Medicine continue to come on line as the curriculum committee continues to make regular improvements in the educational program. In 2010, the Class of 2014 started their first week of medical school revisiting the Hippocratic Oath, dissecting it line for line to realize and internalize the commitments they made to the faculty, their families and their future patients. They followed this by creating their own personal oaths of professionalism, which they revisit and reflect upon at the year’s end. This fall, students in the Class of 2015 are participating in a video project wherein small groups of students meet and interview patients and families with chronic diseases in their homes. Charged with understanding their patients’ struggles with illness, and the impact it has had on their lives and livelihoods, students will learn first-hand about the ethical principle of consent and will craft a video of their encounters with these gracious patients. Later this year, the class will view their videos and celebrate what was learned, hopefully with the patients and families in attendance.
Future projects for the curriculum, which are part of the medical humanities and ethics component of the program, are under development and will involve students learning about disclosing medical errors, and working through difficult encounters with patients and families, such as delivering bad news. Much work to develop standardized patients and scenarios to help train our students to be competent in these areas before they actually have these critical conversations with real patients will be strength and of great value to our students – and to our patients.
While only three years into a new curriculum, the School of Medicine is excited about the changes that have come about in training our future physicians at the University of Utah. As our community continues to change and the demands on health care professionals evolve, our curriculum will continue to transform to meet the needs of our patients, the public and the students who will ultimately serve them. That is our goal.