“Teaching TLC,” the cover story of the Boston Globe Magazine earlier this year, is about the Cambridge Integrated Clerkship (CIC), the unique program where I spent my third year of medical school. In the piece, Dr. Ishani Ganguli explores some contemporary challenges in medical education and considers how the Integrated Clerkship can help train more humanistic physicians. She writes about the experiences that my classmates and I had over the course of last year, growing close to our patients over time, and highlights data from Academic Medicine showing that CIC students finish their third-year feeling both less cynical and more ready to take responsibility for patients than their colleagues in more traditional clerkships. I’m very pleased that people around Boston will be reading about the CIC and thinking about innovations in medical education.
A critique of the program raised in the article is that students don’t have enough exposure to inpatient medicine. One expert worries that the CIC “devalues what can be gained [by] being involved in acute care in the hospital, working in a team, [and] coordinating across services.” My response to this is, first, to point out that CIC students have more inpatient exposure than is typically assumed. We regularly take call on the inpatient services and, when our longitudinal patients come to the hospital, we admit them and take care of them there.
I will also concede that there are nuances of inpatient care that I have learned in my fourth year that I didn’t understand previously. But on the numerous acute care rotations I have done since the CIC, I have consistently received positive feedback on my ability to “get my head around a case,” that is, to quickly build a holistic view of a patient. Seeing the same patients at home, in clinic and in the hospital during my third year has made it natural to seek a comprehensive understanding of them and their health. In my view, delaying learning some details of inpatient medicine until my fourth year has been both a worthwhile tradeoff and a natural developmental sequence.
Medical training is so often framed around a particular hospital service or learning to be a particular kind of doctor that the patient experience is forgotten. The CIC gives students a year-long formative experience that is centered around patients. By following them closely, we develop deep empathy with our patients and, more than most medical students, share their experience of their illness. In this way, integrated clerkships allow students to learn to practice in our healthcare system while retaining clarity about its numerous shortcomings.
For instance, I’m quoted in the article saying that CIC students are able to “see how people with complex illnesses keep bouncing around, how they experience fragmentation of services.” Up-close and longitudinal exposure to this problem is essential for medical trainees. We know that five percent of patients account for fifty percent of healthcare costs and that care fragmentation plays a large role in this. If the integrated clerkship model can inspire physicians to address this issue by building better systems for care coordination, its impact will be enormous.
My personal hope is that by exposing students to patients’ lives, to the communities in which they practice and to the limitations of our healthcare system, that we’ll do more than create skilled clinicians who show more TLC. I hope we that can train more socially-conscious physicians, truly capable of addressing the big problems that American healthcare faces.
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