Please read Part 1: “A Case for Longitudinal Clerkships” prior to this article.
I: An Old Valve
There was an excitement in Dr. David Griffin’s voice that I hadn’t heard in the few days we’d known each other. Following our afternoon in clinic he walked me down to meet a longtime patient, we’ll call him Mr. Y, who was being prepped for surgery the next morning. Mr. Y had been feeling short of breath for the past year, and it was getting worse. Recently, he had started driving his golf cart to the mailbox at the end of his driveway. He was an outgoing elderly man, jolly and loud despite his precarious health. It was hard to know whether the volume of his voice was related to his cheer or his hearing-loss, but I prefer to believe it was the former.
We found Mr. Y’s room, knocked and entered. He was thrilled to see Dr. Griffin, even though we caught him while he was in the bathroom, door open, only wearing white briefs and an unbuttoned dress shirt. I was introduced without awkwardness, as the medical student that would be following his care for the next ten months. After a brief chat, we left him to finish getting ready for bed. He had a big morning ahead.
To repair severe aortic stenosis in someone of Mr. Y’s age and health, the best option is what’s known as transcatheter aortic valve replacement (TAVR). With this method, an interventional cardiologist feeds a catheter through the femoral artery — accessing this vessel at the patient’s groin — and up into the left-side of the patient’s heart. A replacement valve is fed along the line that has been positioned, and is expanded within the damaged leaflets of the native valve, crushing them to the side, leaving a functional prosthetic in its place.
II: The VALUE Clerkship
This was the second week of the VALUE program, an experiment in medical education conducted through the University of Minnesota at the Veterans Affairs Medical Center in Minneapolis. VALUE stands for “VA Longitudinal Undergraduate Medical Education.” The name does a pretty good job of explaining what it is, and, as importantly, forms a memorable acronym, which doctors to seem to enjoy.
Traditional “clerkships,” as they are known, are two- to eight-week-long clinical experiences in each of the many medical specialties taken during the third and fourth years of medical school. During these programs, students see patients and learn directly from the doctors responsible for their care. It’s a combination of structured didactic learning, self-directed experience and day-to-day grunt work. After the month-plus spent in, for example, neurology, students get comfortable thinking about common problems people seeing neurologists might have and the options for dealing with those problems … and then they move on to the next clerkship.
These immersive experiences are short and not standardized. Each clinic, hospital ward, or operating room can only accommodate a few medical students without totally derailing efficiency and patient care. Traditional clerkship experiences, therefore, are very dependent on, among other things, which physicians are working during the month of your rotation, what hospital you are assigned to, how many patients are sick during those days and with what maladies.
At the center of each traditional clerkship is the specialty in question. What goes on in a pediatric clinic? How does a general surgeon spend their days? What problems do psychiatrists address? But the VALUE program, and other programs like it, have rearranged the focus. Regardless of what specialties they may need to access, the center of the program is the patient.
The only way this model works is to make the program longitudinal, i.e. over the course of 10 months. This prolonged period allows for enough structured time in each of the disciplines. It also allows patients from a student’s cohort time to access different modalities of medicine, or to return repeatedly with a chronic disease, providing educational opportunities for students like me along the way.
III: The New Valve
After chatting with Mr. Y, Dr. Griffin and I went to find the cardiologist who would be doing the TAVR in the morning. We found Dr. Santiago Garcia looking over recent CT scans of Mr. Y’s vessels, conducting final reviews of the anatomy he would have to navigate the next day.
The following morning I stood six feet away, watching as Dr. Garcia concentrated on the delicate balance between applying enough pressure to move instruments through calcified, elderly arteries, but not so much pressure as to puncture any of the blood highways. We all had lead aprons and neck shields to guard our insides from the radiation necessary to visualize catheters as they snaked-up ancient routes through the body prone on the operating table. Occasionally, he would ask a question of one of the other half-dozen people in the room, either requesting an action from one of them, or a widget of information, all of which were vitally important to the actions he was taking to extend the man’s life by, hopefully, up to five years.
“What was the angle on his aortic arch?”
“Hand me a Kelly clamp, please.”
“I think I’m getting caught on his inguinal ligament here, do you agree?”
In just under two hours, Mr. Y’s new valve was in place, his femoral incisions were sewn up and the team walked out, smiling. There was one more TAVR scheduled for that day, and they took a deserved break while the room was prepped.
As a medical student, I had no role to play in this intricate ballet, and I was grateful for that. In medicine, and other disciplines, it is often said, “Watch one, do one, teach one.” I would probably want to watch a few more before I was ready to try replacing a patient’s heart valve.
When I saw Mr. Y the next day in the hospital, he was preparing to go home and happy to see me. He wondered what had gone on in the operating room the day before. I did my best to explain what I had seen, before we quickly moved on to a discussion of when he could go fishing again.
IV: Follow-Ups and Downs
Mr. Y returned to Dr. Griffin’s primary care clinic a couple of weeks after his TAVR procedure. He was there with his wife, and was doing well. He hadn’t regained all of his exercise tolerance, but a few weeks out he was walking on his own to the mailbox. His wife said he was much less fatigued, and they both seemed excited about the rest of their lives together. She asked if what I had seen made me want to be a cardiologist. I wasn’t sure how to answer.
The whole procedure was fascinating, awe-inspiring and, well … insert other grandiose adjectives here. The truth is, it made me happy to be a VALUE student. I said goodbye to the elderly couple, knowing I would see them back in the clinic at least a few more times in the coming months. And if Mr. Y needed care for a new problem, an unexpected one, as often is the case with elderly health management, I would be ready and well-versed on his recent clinical course.
Of course not all patient outcomes leave us feeling warm and satisfied. Deep, longterm investment in patients’ lives can be hard to stomach when their health takes a turn for the worse, as was the case with a man we’ll call Mr. Z. He was in the hospital before the VALUE program had even begun. The Agent Orange-related cancer in his throat had recurred, or perhaps it was a new malignancy altogether, inspired by the radiation he received to treat the first. Either way, it had invaded the tissue near his spine, and, so, was too precarious to remove surgically.
I walked into the room to introduce myself, and to ask him if there were questions he had for me, a random 26-year-old wearing a white coat. Speaking with an electronic amplifier due to the hole in his larynx, he said he didn’t think so. But I couldn’t understand him. So I asked him what he said. He shrugged and looked away.
A couple of weeks later, after we were certain an infection he had was adequately treated, and after a tube was placed through his abdominal wall into the stomach so that he could receive nutrition, Mr. Z was discharged home.
We also had placed a port in his chest, with a line sitting in his heart, to allow easy, high-throughput access to his blood stream in preparation for the chemotherapy he would receive soon.
He returned a few days before he was scheduled to meet with the oncologists, which was not a good sign. The tube we put in his stomach had fallen out at home, and the line we put in his heart had likely become infected. We rearranged a few things, delivered more antibiotics into his system, and sent him home again, crossing our fingers that the next time we saw him we could address the cancer that was necessitating all of the other care.
At the next visit, following another couple weeks of recuperation, an oncologist presented Mr. Z with his treatment options, none of them promising. Palliative chemotherapy with a high risk of reinfection, radiation therapy with a high risk of life-threatening damage to an already severely scarred neck area, or forgoing treatment altogether. He and his wife went home to discuss which option they thought would allow him an acceptable quality of life for the longest period of time.
I got a call on a Saturday, a week or so later. Mr. Z had returned to the hospital, but over the phone it didn’t seem overly urgent, just “failure to thrive,” and some increased pain in his neck. I saw him Sunday, by which point arm weakness had been added to his problem list. The Monday MRI showed an epidural abscess and osteomyelitis eating away at the vertebrae in his cervical spine, compressing his spinal cord, causing progressive paralysis and intense pain. There was nothing to be done from a surgical stand-point, as Mr. Z was too frail, too complicated and too far down a steep mountain side. He was transferred to hospice care on a different ward, downstairs, which was to be his final stop.
I wasn’t ready for such a precipitous decline in Mr. Z’s health; I knew he was likely to die before the end of the VALUE program, but I thought I’d have time to see him fight some more, time to prepare for his end, time to talk to his wife about how great of a season the Vikings had. My sentimental daydreams were dissolved, leaving only the understanding that I didn’t have many visits left with this friendly young grandfather, whose body I’d palpated, whose stool I’d asked about, whose lips I’d learned to read, whose family I’d grown to know.
Of course, this scenario more closely resembles how practicing physicians might experience the care they provide for their patients. Accepting the death of those you’ve become familiar with is part of the job, and just because it is hard doesn’t mean it should be omitted until later in training. I’m grateful for the losses a longitudinal curriculum has provided, as well as for the victories.
Longitudinal clerkships are one example of an innovation to medical education that can be reasonably attempted. Thus far, in their short history, longitudinal curricula in the third year of medical school have produced students that are more invested in the patients they are caring for, and less jaded by the churning gears medical education, while still performing as well on standardized tests as their counterparts (see the companion article “Part 1: A Case For Longitudinal Clerkships,” for more information on this).
The VALUE program is a wonderful example of their merit. I think — I hope — Mr. Y, Mr. Z and many others, would agree with me.