I: A Very Brief History of Medical Education
Medical education has remained largely unchanged since 1889, when a young William Osler was recruited to be the chair of medicine at the newly formed Johns Hopkins Medical School in Baltimore. Borrowing principles he learned at universities in Europe, he established the Hopkins’ residency model, originally named because doctors-in-training lived in the hospitals where they apprenticed. He also recognized the importance of bringing students to the patient’s bedside during their early training, understanding that basic scientific principles are better retained when applied to real-world illness. He went so far as to have his epitaph read, “I taught medical students in the wards.”
In 1910, Abraham Flexner — a researcher at the Carnegie Foundation for the Advancement of Teaching — published a relatively scathing critique after visiting all 155 of the medical schools in the United States and Canada. He was critical of the lack of scientific grounding of medical schools’ curricula, and their focus on profits over quality education. His report helped promote the push toward analytic reasoning and evidence-based clinical practice, as well as establishing quality standards for what it means to be a medical school in North America.
Osler and Flexner inspired a monumental shift in how physicians are educated in North America, by establishing the importance of medicine based in scientific inquiry, and by devising an experiential model for medical education. Since then, U.S. medical education has been structured in a four-year curriculum, the first two years devoted to the basic sciences and the next two focused on clinical training. Though this happened more than a century ago, it was arguably the most recent structural change of any significant magnitude.
Modern trends in the practice of medicine have put strains on these core principles of medical education. The base of scientific knowledge has ballooned with the incorporation of new fields, such as genetics and molecular biology. It is now much more cumbersome to directly apply all of the necessary basic science at the patient’s bedside. Public expectations for health care have increased as medical breakthroughs have defeated disease after disease. This has made it more difficult, ethically and legally, to allow students to take an active role in their patient’s care.
Even more recently, decreased length of hospital stays and increased focus on outpatient care, while good for reducing medical expenditures and allocating resources, make it more difficult for students to see patients through the whole episode of an illness. In theory, this could lead to deficits for students in learning the full arc of diagnostic and therapeutic reasoning. Furthermore, this acceleration in the pace of clinical care puts demands on experienced clinicians that reduces the time they are able to spend on teaching and mentoring.
II: The Case for Longitudinal Clerkships
In 1971, The University of Minnesota Medical School began the Rural Physician Associate Program (RPAP). This was developed in response to the Minnesota Legislature threatening to withdraw funding from the medical school unless a program was designed to train primary care physicians to practice in rural areas of the state, places with a dangerous physician shortage. While not the primary focus, RPAP was also one of the first longitudinal clerkship models. Through the program — now in its 44th year — approximately 30 third-year University of Minnesota medical students are placed at rural hospitals for nine months, learning directly under physicians there. The program has been highly successful, with 75 percent of their trainees entering primary care specialties.
Still, longitudinal curricula are relatively rare and recent developments. In 2004, Harvard Medical School initiated a year-long program at its associated Cambridge Hospital, which eight students participated in, called the HMS-CIC. These eight were randomly selected from the pool of 18 who applied, and were then compared to the ten other applicants who took traditional clerkships. Compared to these peers, the eight who went through the longitudinal curricula did at least as well in National Board of Medical Examiners (NBME) subject exams, and scored higher on comprehensive skills assessments. The participants were also more likely to see patients before diagnosis and after discharge, and were more likely to receive thorough feedback and mentoring.
Most importantly — from my perspective — based on surveys taken before and after their third years, longitudinal students expressed more satisfaction with the curricula, and felt they were better prepared to cope with professional challenges of patient care. They also expressed decreased erosion of idealism and empathy, unfortunately a common problem these days among medical students at many universities.
Similar outcomes have been shown at other institutions, including the University of California, San Francisco, which began the year-long Parnassus Integrated Student Clinical Experiences program (PISCES) in 2005. Data from this program showed longitudinal students did at least as well as their peers on the US Medical Licensing Examination Step 2 Exam, which is the second of three national exams required to become a licensed physician.
Of note, students surveyed from the HMS-CIC program expressed that their experience was more “hectic,” and “stressful,” and felt it was equivalently “frustrating,” as their peers’ in traditional curricula. These feelings could be due to the inevitable growing pains of a new program, or could be inherent to trying to achieve comfort in multiple specialties all at once.
I’ve just completed my third year of medical school, 10 months of which was spent participating in the VA Longitudinal Undergraduate Medical Education (VALUE) clerkship, a new program at the Veterans’ Affairs Medical Center in Minneapolis, MN. Having experienced this longitudinal integrated curriculum, I suspect that the data is true, both the positives and negatives. And, for me, when it is hectic, and even stressful, I leave the VA Medical Center most days caring about the patients I have gotten to know, and feeling as though the faculty is deeply invested in the education I am receiving. I’m also able to stay grounded with moral support from the cohort of nine other bright, young medical students, who provide both humor, as well as additional learning, from what they see during their time on the wards each day.
Dr. Nacide Ercan-Feng is an endocrinologist at the Minneapolis VA, and is one of the directors of the VALUE program. She told me what surprised her most about the program thus far: “The ownership that the students have for their patients, and, likewise, the ownership that the preceptors have for the students, is remarkable.”
Trust is required in order for mentors, in any field, to allow their apprentices to fully participate in their work. This is especially true in a field with so much at stake, and one that requires such a large body of knowledge. Even the most advanced medical students will require a few weeks to prove they are competent to their supervising doctors. Until then, doctors won’t completely rely on the histories students obtain from patients, on the stitches students place in incisions, or on the conversations students have with other providers managing their patients’ care. Longitudinal programs allow trust to be built between doctor and student, maximizing the depth of learning experiences.
There is now a Consortium of Longitudinal Integrated Clerkships, composed of faculty from universities around the world devoted to developing, implementing and studying integrated longitudinal clerkships for medical students. Twenty-nine institutions in the United States, Canada, Australia and South Africa have these programs in place, many of which have more than one longitudinal option for their students. The University of Minnesota (U of M) itself has the RPAP and MetroPAP programs, with VALUE being an expansion and derivation of those previous experiments. (The U of M is also participating in the multi-center Education in Pediatrics Across the Continuum [EPAC] project, which is structured similarly to the previous three, but has slightly different goals.)
The other director of VALUE, a primary care internist at the VA named Dr. Amy Candy Heinlein, told me why she was motivated to get involved in implementing longitudinal curricula. “We know these are not worse than other clerkships. But are they better? At this point, we think so.” Ideally, physicians are evidence driven. Those involved in implementing these programs are no different. These aren’t renegade ideologues trying to overthrow an established system, but, rather, experienced educators and clinicians seeking to fix real problems they see in medical education, while patiently accumulating data that, thus far, seems to support their intuition.
Those glowing things said, there was some criticism of the clerkship’s structure from various peripheral staff, for understandable reasons. It was difficult to know where VALUE students were at any given time, sometimes making coordination difficult, and potentially making it easier to skirt responsibility for students so inclined. There was also concern that, as we prance amongst various learning experiences, VALUE students miss out on intangibles that are gained from being part of a specific medical team for a continuous chunk of time. While those worries are valid, I don’t believe they will actually hobble our medical education. It was the first year of the VALUE clerkship, and the organization of our responsibilities became more clearly communicated even within the first few months. I suspect this will only continue in future years. I also regularly remind myself that, this was a ten-month longitudinal experience, not my entire medical education. There will be ample time, in fourth year, as well as in residency, to pick up small things we may miss by participating in VALUE.
III: The VA of VALUE
The VALUE program is different from other long-term clerkships because it takes place at the VA Medical Center, a setting that lends itself well to this type of curricula. As with longitudinal programs elsewhere, our hospital has many of the core specialties all under one roof, making student access seamless to each. We have to do our pediatrics and obstetrics and gynecology rotations before or after the VALUE program, as there are not — yet — any children veterans, and there are not enough female veterans (particularly pregnant ones) to provide us with a rich experience in those fields.
Those exceptions aside, there are myriad reasons why a veteran population might need health care at higher rates than the general population, from, among others, combat exposure to chemical exposure to substance abuse and the associated complications. In addition, veterans with “service connected,” health problems are given priority when registering to receive care at the VA, and it is only these veterans who get their health care subsidized by the government. Revealingly, only 31 percent of veterans in the state of Minnesota receive their health care from the VA. As a result, students participating in the VALUE program are not seeing any perfectly healthy individuals.
Another benefit is that the Veteran’s Health Administration is federally funded. Practically, this means the VA administration is generous and financially flexible enough to give physician-mentors more time to devote to teaching. This additional time spent with VALUE students means slightly decreased patient capacity in their clinics, as more time is spent on each clinical encounter, allowing students such as myself to see the patient on our own first, before the physician joins, with time after to discuss the findings. The VALUE clerkship, therefore, has relatively low start-up costs for the University of Minnesota itself, with the University paying only for the time of some of the program administrators.
It warrants mention that the VA has been in the news in recent years for all the wrong reasons. Long patient wait-times and unscrupulous administrative behavior at certain VA locations have shone a negative light on the whole system. That said, the majority of what I have seen during my time at the Minneapolis VA has been high-quality, caring, on-time health care for veterans who need it. Perhaps there isn’t the breakneck efficiency of some private health providers. But this allows time for reflection and relationship-building. Content teachers and willing patients allow for great medical education to occur. The VA appears to me to be a truly symbiotic space, where those in need of health care, because of what they have done for our country, are paired with those who need experience providing said care, and who, in different ways, want to serve the nation too.
Veterans of war have been through things most of us will thankfully never experience, leaving their minds and bodies with scars that will never heal. From a medical student’s perspective, this is a perfect environment to see what the human body can endure physiologically, and how we as providers can facilitate healing. From a human perspective, particularly a privileged human living in a peaceful community, this is an ideal environment to see what the human mind can endure and still go on to lead a meaningful, positive life.
Concerns about a shortage of medical providers being trained coupled with simmering discontent among some trainees should motivate powers-that-be to end stagnation in medical education. The first year of the VALUE clerkship was the latest success in an expanding crop of longitudinal integrated curriculums. The initial literature supports trialing more of these programs, to provide an alternative, patient-centered model, which may leave students more satisfied with their early years of training.
For patient stories from my VALUE experience, please continue to Part 2: “Follow-Ups and Downs.”