Educating community health conscious physicians

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During my family medicine rotation, my very first clinical clerkship of medical school, I received the assignment of making a home visit to one of my preceptor’s patients — a man I will call Mr. Jones.

Mr. Jones had congestive heart failure, COPD, and a barrage of other chronic health problems. He was a pleasant gentleman, but had a low level of health literacy and had been doing a poor job of taking his extensive list of medications, resulting in trips to the emergency room nearly once a week. My task was to assess his situation at home in order to shed light on his lack of compliance and potentially help him stay out of the ER.

My visit to his small apartment was mostly positive, but I quickly realized that the determinants of his health conditions lay far deeper than a mere lack of adherence to the evidence-based treatment plan that had been constructed for him. Taking his beta-blocker and aspirin every day was probably far less important to him than having enough money to eat. Expecting him to follow a strict low-sodium diet seemed almost comical, given that he purchased his food at a gas station within walking distance from where he lived. Had my team possessed a better understanding of his complex social issues before, we would not have continued to increase doses for medications he obviously was not taking and pursued alternative options.

I returned to the clinic eager to share with my team the insights I gained, which I felt would be crucial to the future care of Mr. Jones. Unfortunately, I soon recognized that his needs lay far beyond what I or his primary care physician or anyone in the hospital could do for him. The system was not designed to be able to help him. I moved on from family medicine to other rotations and never saw Mr. Jones again, but I saw numerous other patients in similar conditions, and similarly felt powerless to help.

Mr. Jones’ situation was for me a very tangible reminder of a concept that was emphasized and reemphasized during various lectures in our first-year curriculum: that social, cultural, and economic factors are far more powerful in determining a person’s health outcomes than medical factors. Most medical schools now attempt to incorporate aspects of social and preventative medicine into their curricula. In our medical school, it was called “prevention course.”

However, as students move on to the wards during their clerkship years, they are awakened to the realities of our complex health care system, and those social platitudes discussed during the pre-clinical years start to seem ironic. A fundamental disconnect becomes apparent between the empathic, patient-focused, motivational interviewing model of patient care learned during the first years and the reality of patient care, with its 10-minute PCP appointments, extensive documentation on confusing EMR systems, and the shift work of exhausted residents.

Additionally, medical students may become disenchanted as they struggle to feel like a contributing member of the team, meaningfully participating in patient care. Several health system changes — structured duty hours for residents, the outsourcing of many basic tasks and procedures to specialty teams, and increased emphasis on patient autonomy and safety — have all had the effect of creating barriers to medical student involvement in direct patient care, especially on a longitudinal basis. Whereas medical students formerly played a vital role in patient care by writing notes and performing minor procedures, the current medicolegal environment has relegated medical student involvement in many situations to the level of shadowing.

Fortunately, many medical educators have begun to recognize and address these problems. They recognize that medical students, while they do not yet have the expertise or certification to allow them to practice medicine, they are equipped with one important resource that eludes residents and attending physicians: time. They have the time to employ motivational interviewing techniques, behavior coaching, and to delve into the psychosocial factors underlying the morbidity of their patients. They have the time to practice and improve empathy — the hallmark of a good doctor. One of the most well-established examples of the benefits of medical student participation in patient care comes from student-run free clinics that exist as extra-curricular service-learning opportunities at many medical schools. In one free clinic in Nashville, Tennessee, medical student-provided diabetes counseling has resulted in a significant reduction in hemoglobin A1c among patients receiving the counseling.

A few medical schools have gone one step further and begun to integrate longitudinal patient care in an ambulatory setting into the curriculum. Northwestern University Feinberg School of Medicine has developed a team-based model for longitudinal primary care education. The education-centered medical home engages groups of students from all four medical school class years in a longitudinal experience organized around principles of the patient-centered medical home. Each group of students works with a faculty preceptor to enhance care coordination for patients with chronic illnesses and high health care utilization. Students also serve as health coaches for the patients and track a variety of quality-of-care measures. Initial results from the program show high patient, student, and faculty satisfaction, as well as improvement in a variety of quality measures and an increase in students’ self-assessment of their knowledge and skills. University of Texas Medical Branch at Galveston has adopted a similar program as part of a large state-funding initiative in health care transformation and quality improvement.

Duke University School of Medicine’s Primary Care Leadership Track (PCLT) is an even more radical and revolutionary approach to direct medical student involvement in longitudinal patient care. Offered as a special scholarship program to students planning to work in primary care, PCLT replaces the traditional core clerkship year with a unique longitudinal integrated clinical year. Students spend the majority of this year following the same set of patients in an ambulatory setting, allowing them not only to build relationships with their patients but also experience continuity of care and direct investment in patient outcomes.

Additionally, students are required to contribute to community health initiatives, conduct community-engaged research, and participate in leadership training. The program began in 2011, and its first cohort of students graduate this year. More time will be needed to determine the success of the program. Nevertheless, the concept of creating physician leaders in primary care who can transform the current health system structure is an idea that is rapidly gaining popularity.

U.S. medical education is evolving as it responds to the needs of a complex health system with a very uncertain future. The biggest challenge of medical education is adequately preparing students to be able work competently within the status quo while instilling in them the passion necessary to change the status quo. Just as our clinical experiences in medical school heavily influence which specialty we select, they also influence our philosophy toward the practice of medicine. For my part, I will never forget my home visit with Mr. Jones. The experience profoundly impacted me and caused me to think more deeply about how I want to approach patient care.

Morgan Hardy is a medical student and member, AMA-MSS Committee on Global and Public Health.

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