In Medical School Shift, Meeting Patients on Day 1

On September 2, 2010, in Big Picture, Featured, by NYIT College of Osteopathic Medicine SGA

By Anemona Hartocollis for the New York Times
Published: September 2, 2010

For generations, medical students have spent two years in classrooms and laboratories, memorizing body parts and dissecting specimens, eagerly anticipating the third year when they would get to work with actual people who have actual diseases.

Upending that century-old tradition, the aspiring doctors who started their training at New York University School of Medicine last week got to meet real patients on their very first day. But not to worry — they were armed only with laptop computers, not scalpels.

“I am possibly the worst patient in the world to have,” an H.I.V.-positive tuberculosis patient told the 162 first-year students in a cavernous lecture hall in Midtown Manhattan, as they diligently jotted down notes. “I thought I had the common cold. It went on for months.”

The model of modern medical education was set by the Flexner report of 1910 and has since gone virtually unchanged: two years of foundational science — gross anatomy, biochemistry, cell biology, virology, pathology and the like — followed by two years of clinical studies.

But in the last few years, medical schools including those at N.Y.U. and Harvard have been doing some soul-searching about whether this lock-step curriculum creates doctors who lack humanity, who see patients as diseases rather than as whole people and who have what the medical literature calls “ethical erosion” — a loss of idealism, empathy, morality.

The result has been an increasing focus on clinical studies and, in a curriculum introduced by N.Y.U. last week, on fostering from the beginning more personal relationships between medical students and patients.

More than a year in the making, the N.Y.U. curriculum makes connections, professors say, between the relatively abstract science being taught in the classroom and the way it plays out in real life. It brings the progressive “hands-on” approach to education from kindergarten into higher education, said Dr. Steven B. Abramson, the medical school’s vice dean for education: instead of playing with blocks, the medical students are, with all due respect, learning to play well with patients.

By advancing some of the clinical component into the first two years, the new curriculum also gives students more time in their third and fourth years to study popular public health issues like nutrition and how diseases might affect people differently depending on race, ethnicity and socioeconomic status. For a few ambitious students, Dr. Abramson said, the new curriculum might make it possible to earn both an M.D. and a master’s degree in public health or administration in four years instead of five.

In a similar effort to connect medical students with patients sooner, the new medical school at Florida International University will place second-year students in underserved neighborhoods beginning this fall. A team of medical, nursing, social work and perhaps even law students will be assigned to a family, with the goal of understanding how factors like poverty and other stresses may complicate medical care.

At Harvard, the traditional third-year hospital rotations have been revised to foster more personal relationships with patients and to give students a sense of the continuity of care. A dozen students have been paired with faculty members to see their regular patients over an extended period of time at Cambridge Health Alliance, a system of hospitals and clinics.

“The model is intended to mimic real practice,” said Dr. David A. Hirsh, a creator of the program, which began as a pilot in 2004.

At N.Y.U. last week, new students were introduced to the “four pillars” of the school’s new curriculum: diabetes, colon cancer, tuberculosis and heart disease. These four were chosen because they are emblematic public health scourges of the 21st century, affecting large numbers of people and exacting a serious toll on the health system.

Dr. Ann Danoff, an endocrinologist who introduced the diabetes pillar, told the students in her lecture that the four-pillars concept updated the popular medical school adage “Know syphilis, know all of medicine.”

Dr. Danoff and her colleagues then proceeded to introduce the students to four patients with three of the four diseases, who could function as living case histories. Type 1 and Type 2 diabetes, colon cancer and tuberculosis were represented; heart disease was not.

As the term goes on, the students will visit clinics and hospitals once a week to meet more patients. The goal is for them to learn to listen and communicate, to use a stethoscope (traditionally delayed until the middle of the second year), and to conduct a basic physical exam, as well as to connect the diseases they see in the patients to the science they are learning in class.

On Day 1, Courtney Butler, 28, one of the guest patients, told the students how she had been told as a 13-year-old that she had Type 1 diabetes. Ms. Butler said everyone had missed her symptoms at first because, as an athlete, losing weight and being thirsty seemed normal. She shared her embarrassment at being the only child who went to the nurse’s office to check her blood sugar.

As she spoke, a student in the front row who seemed perplexed flipped open his MacBook and scanned Wikipedia entries on endocrinology, insulin pumps and finger sticks.

Was N.Y.U. putting the cart before the horse by introducing a diabetic patient before teaching students about the basics of diabetes? Dr. Abramson said later that he thought the Web surfing meant the student was engaged and would pay more attention when diabetes came up in science class.

Back in class, Dr. Craig T. Tenner, an internist, talked about the pros and cons of preventive medicine. Dr. Tenner told the students to imagine they were tied to railroad tracks.

Should they be given a pair of binoculars? “Would you want to see the train coming or not?” he said. Would they want to see it when it was two miles away? One mile away?

Then, a gastroenterologist, Dr. Michael Poles, introduced the patient, Dr. Saverio J. Senape, a retired physician with colon cancer, who ruefully confessed to having skipped his regular screenings, despite a family history of the disease.

Dr. Ellie Carmody introduced the tuberculosis pillar, telling the students that TB was not just a disease of underdeveloped countries. Then Dr. Carmody put up a slide of the locked ward at Bellevue Hospital, where tuberculosis patients who refuse to take their medications can be involuntarily confined if they are found to be a threat to public safety.

In some ways, she said, “it’s not that far from the sanatoriums.”

Her patient, a 42-year-old Navy veteran, took the stage to describe how his doctor had notified the city’s health department when he skipped his medication. “They said we’re going to lock you up, and they were not kidding,” he recalled.

He told the students that when he was hospitalized, the doctors saved his life, but the nurses saved his sanity. It was a chastening remark.

“In traditional medical education,” said a student, Hannah Kirsch, 22, “you don’t have a patient come in the first day and say, ‘Sorry, guys, it was really the nurses who carried me through.’ ”

As Dr. Danoff, a rangy former modern dancer with a tousle of gray curls, welcomed the new class, she reminisced about her own first day, in 1976, at the Medical College of Pennsylvania. It was gross anatomy class. Her first assignment was to learn all about the sternocleidomastoid, a word that seemed to encompass all the mysteries of medicine in its many syllables. (It is the columnlike muscle on either side of the neck that sticks out when you rotate your head.)

Her first patient was a cadaver.


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