Ninety-nine years ago, Andrew Carnegie tasked noted educator Abraham Flexner with an awesome responsibility: to investigate 155 medical schools from Texas to Toronto and report on where he found outstanding medical education producing world-class physicians.
In the end, only one school met Flexner’s rigorous standards: Johns Hopkins. That report revolutionized medical training: Schools across North America adopted Johns Hopkins’ pioneering curriculum that merged the latest scientific findings with insightful clinical training to deliver first-rate compassionate patient care.
A century after Flexner’s findings, medical education is again at a crossroads. And once again, Johns Hopkins is leading the way—this time with a new curriculum that’s grounded in researchers’ ever-expanding understanding of the human genome. Developed over more than six years, in consultation with dozens of faculty members, students, and researchers, the Genes to Society program officially rolled out in August. Members of the Class of 2013 will be the first to experience the curriculum’s full spectrum.
“It will be novel in the country in that it takes a systems approach to understanding all the levels of the human being: From the genes, molecules, cells, and organs of the patient on one end, to the familial, community, societal, and environmental components on the other end,” says David Nichols, vice dean for education. By “radically integrating” every aspect of medical education, he says, the curriculum aims to produce doctors who can better serve each patient through personalized medicine (See “Post-Op,” p. 48, for more).
The curriculum is notable for putting students into extensive contact with patients from their very first day at Johns Hopkins. “We’re getting students out of the classroom pretty much from the moment they get here,” says Nichols. “They’re going to do a clinical skills course right at the beginning, and they’ll be assigned their own clinic and see patients after the first six months. That clinical experience will act as a coordinator of the subject matter they’re learning in the classroom as well, so they’ll be able to integrate the two.”
This more holistic approach to health care, he says bluntly, “is a very substantial change in our outlook and the delivery and continuity of care.”
Eight new intersession courses, each one week long, will be devoted to patient-centered topics that aren’t typically “owned” by any one department, notes Patricia Thomas, assistant dean for curriculum. “You take something like Global Health, or Pain Care, or Substance Abuse…these can be addressed as a public health problem that crosses disciplines and is solved by those disciplines working together,” she says.
She continues, “The curriculum emphasizes that wherever you go, you have to realize that you are part of a team and that you have to learn both how to contribute and to listen to what other people have to say.”
Planners note that the new curriculum moves beyond the long-held educational model, which generally classifies people as “sick” or “healthy,” with nothing in between, and redirects the discussion to, “Why is my patient at risk, and what can I do to prevent or delay the onset of this problem?” One way of broadening the view for students is through what Thomas calls “horizontal strands.” She explains, “We have faculty tracking every event in the new curriculum and ‘tagging’ it, so to speak, to see if there is an additional opportunity to teach behavioral medicine or public health or health economics as part of that topic.”
Crucial to the whole endeavor of the new curriculum is establishing better communication: not just between physicians and patients, but between faculty and students, researchers and clinicians, and policymakers and providers.
The Adopt-a-Patient program (see “What Patients Have to Teach”) provides one key channel for opening communication, by teaming fourth-year students with patients, to help aspiring doctors better see through the eyes of the sick. And a “longitudinal” clerkship requires students in their first and second year to follow patients over extended periods, not just when they’re hospitalized.
Another key improvement to the student experience: a beefed-up Colleges Advisory Program (CAP), which teams exceptional School of Medicine faculty with small groups of students (about five in each group); through both clinical instruction and informal meetings, each faculty member will serve as a mentor to those five students throughout all four years.
“In the past we had a volunteer advising program like most schools, but realistically it only worked for a small percentage of students. Our students perceived that they were largely alone trying to figure out this world of medicine,” says Robert Shochet, director of the Colleges Advisory Program. “There was a formality that created barriers to open communication and to the sharing of vulnerability and uncertainty.
“In the new version, we’re teaching in year one with their advisor, and we’ll have that same advisor over the four years working with them in the clinical skill setting episodically. So we’re starting with a strong foundation of a faculty member the student gets to know very well.”
Each of the four 30-student groups, or “colleges,” is named for a Hopkins Medicine luminary (Daniel Nathans, Florence Sabin, Helen Taussig, and Vivien Thomas), and each has a specially designed suite of rooms on the second floor of the new Anne and Mike Armstrong Medical Education Building that serves as home base during their four years.
“These new approaches to mentoring and collaborative learning,” says Nichols, “play an essential role in turning our visionary curriculum into reality.
— Mat Edelson
A New Building for a New Way of Learning
It’s no accident that the rollout of the Genes to Society curriculum this fall comes in concert with the opening of the Anne and Mike Armstrong Medical Education Building—Hopkins’ first new medical education building in 25 years.
“We realized that harnessing the full power of learning 21st-century medicine would not be possible without a new physical environment,” says David Nichols, vice dean for medical education.
In the sunlight-filled, four-story structure, which sits adjacent to the Outpatient Center, classrooms are designed for maximum flexibility, with projection capabilities on all four walls and mobile podiums for instructors. There are large lecture halls, intimate learning studios, and private study areas. To foster collegiality among students and faculty, one entire floor of the Armstrong Building is devoted to the Colleges Advisory Program. The building also boasts the latest digital communications technology, featuring everything from virtual-reality simulations to MRI images, CT scans, surgical videos, and other reference tools ready and waiting, literally, at students’ fingertips.
Facing Up—and Fessing Up—to Errors
“Mrs. Hill” paces the waiting room, her expression a storm of emotions. She’s just learned that her husband is the victim of a dangerous medical error. Without checking his chart, a health care provider in the emergency department prescribed the wrong antibiotic for his pneumonia. He has suffered a life-threatening allergic reaction and is now in intensive care, according to the “doctor” delivering this news.
“So this is how the great Johns Hopkins, the No. 1 hospital in the country, treats its patients? I would think that checking his chart for known antibiotic allergies is Medicine 101. What exactly is his condition now?”
“Mrs. Hill” is an actor engaged to help graduating medical students practice disclosing medical errors to family members. The student “doctor” pauses, framing her thoughts. “We had to stick a tube down his..,” she begins.
“Oh my God, he’s not breathing on his own? Why, the very thought of him fighting that tube,” Mrs. Hill chokes and begins to cry.
“He’s sedated,” the student says, handing her tissues. She assures the woman that Mr. Hill will recover, although she can’t say exactly when yet, and that the tube will be removed when the swelling in his throat goes down. Apologizing again, she also repeats that an investigation will determine how the error occurred and make sure it doesn’t happen again.
This exercise is part of TRIPLE (Transition to Residency and Internship and Preparation for Life), the two-week course in the new Genes to Society curriculum. As part of the course, small teams practice saving the life of a simulated patient who was given the wrong medicine by another provider, then take turns explaining the error to actors posing as relatives.
It’s the first time that instruction in disclosure has been a formal part of the curriculum.
Before the exercise, faculty facilitator Danelle Cayea, a geriatrician who is co-director of the basic medicine clerkship, goes over the most effective ways to admit mistakes. Disclose an error as soon as possible, she counsels, and bring a colleague along for support. Also be sure to speak clearly and use short sentences. Along with apologizing and expressing remorse, the news-bearer should also say what will be done to repair the situation and commit to doing better in the future, says Cayea.
“Even though mistakes can occur because of the system, you must often be the face of it,” Cayea tells the students. “Patients need to know that someone feels responsible for their care. They also need to know that because of what has happened, something will change in a positive way.”
— Linell Smith
What Patients Have to Teach
As he waits to hear his test results, the elderly man perches on the edge of his bed, staring into the hallway for someone to talk to. In another room, a patient struggles to sort out the visiting medical staff: Who’s the attending? Which one’s the resident? The physical therapist? Still another patient is worried about her red coat, seemingly lost in the emergency room, and wonders what else might go wrong during her stay.
Boredom, confusion, and apprehension are daily realities of life in a hospital bed, according to the medical students describing these scenes. They’re among a group of recently graduated seniors who spent several hours in patients’ rooms last spring seeking to better understand their experiences, as part of a new School of Medicine capstone course. After four years of learning how to be a doctor, it was time to review what it’s like to be a patient.
“It’s clear to the fresh medical student on the wards when a doctor is talking over a patient’s head,” notes Melissa Dattalo, now a resident in internal medicine at Johns Hopkins Bayview. “Along the way we become accustomed to new behavioral norms. By the end of medical school we have forgotten how lonely and frightening the hospital can be.”
Hopkins cardiologist Roy Ziegelstein is determined to change that. As course director for Transition to Residency and Internship and Preparation for Life (TRIPLE), he helped create this opportunity for students to briefly “adopt” patients. Other sections of the two-week course prepare graduates for situations that range from managing stress to explaining medical errors to patients and their families. (See “Facing Up—and Fessing Up—to Errors,” p. 31.)
TRIPLE, which will be a part of the school’s new Genes to Society curriculum, illustrates a key mission of the course of study: to equip students for each stage of their medical careers while also teaching them how to see illness through their patients’ eyes.
For the Adopt-a-Patient portion of TRIPLE, nurses on units randomly select patients during the time that students are assigned to visit. After spending several hours observing patients, the students write and submit essays with their impressions. (Last spring, one student even felt inspired to create a painting.)
The students also meet to share their impressions in group discussions led by faculty facilitator Jacek Mostwin. A longtime advocate for integrating reflective practices into medical education, he encourages students to perceive their adopted patients in a fresh way, by either engaging them or simply observing them. He also tells students that, when it comes to the doctor/patient relationship, “adoption” works both ways. “As a physician, you’ll become a part of your patients’ lives whether you want to or not,” he says. “And your patients will become part of an adopted family of yours as well.”
Begun two years ago with six students, TRIPLE has already received rare national recognition: a $200,000 grant from the Arthur Vining Davis Foundations for advancing humane and caring attitudes.
“Although it’s important to provide care objectively, it’s also critical to treat patients empathically and to understand the role that an illness plays in patients’ overall lives,” says David Nichols, vice dean for education. “The students in TRIPLE are very quick to pick up on what patients have to teach.”
Some Adopt-a-Patient discussions resemble lengthy repair lists. You hear about IV machines that beep incessantly, about hospital workers who neglect to knock on the door or to turn off room lights, and about inappropriate conversations that take place right outside patients’ rooms. Students also note that many patients haven’t a clue about the concept of rounds or about what doctors do between their two-minute bedside visits.
“One of my goals is to let my patients know how much I am thinking about them even when I’m not in the room,” one student tells his colleagues.
In their essays, the Hopkins medical students share many other discoveries about patients as well as reflections about them. (See “Oh, for a Shower.”)
“We’re certainly aware that our patients may be scared or in pain, but it was a new insight to me that they may also be extremely bored,” writes Emily Pfeil, now a resident in internal medicine at Hopkins Hospital.
Ziegelstein says such reflections deepen students’ understanding of their vocation as well as of their patients.
“One of the challenges of medicine is how fast-paced it is and how rarely we take time to sit down and talk about our experiences,” observes Darcy Weidemann, a pediatrics resident at Hopkins. “These practices of self-reflection and group reflection were some of my most valuable experiences.”
— Linell Smith